糖尿病治療的新策略 - tma.tw

1 / 2 0 1 0 1 A m e r i c a n D i a b e t e s Association, ADA Clinical Practical Recommendations (1) guidelines NICE Guidelines(2) 2 0 1 0 A D A 2006 2009 (3,4) 2009 2010 1. 1 type 1 diabetes, T1DM 2.

2 2 type 2 diabetes, T2DM 3. AIDS 4. fasting plasma glucose, FPG 75 oral glucose tolerance test, OGTT 2 1997 glycated hemoglobin, A1C 1 A1C 2009 ADA (6) A1C A1C 2 A1C A1C A1C A1C 1 d1 A1C a 2 FPG 126 mg/dL mmol/L b 3 OGTT 200 mg/dL mmol/L c 4 200 mg/dL mmol/L a A1C DCCT(5)

3 NGSP b 8 c OGTT 75 d 1~3 A1C % mg/ 2 A1C 7 458459162010, , 1. A 1 C 7 % T 1 D M T 2 D M A 1 C 7 % m i c r o v a s c u l a r disease 2. T 2 D M A 1 C 7 % macrovascular disease 3. ADVANCE study 4. A1C 7% A1C 7% (1) (2) (3) A 1 C intensive glycemic control A1C s t a n d a r d g l y c e m i c control A1C UK Prospective D i a b e t e s S t u d y, U K P D S (8) The Diabetes Control and Complications Trial, D C C T (9) a c t i o n i n diabetes and vascular disease, ADVANCE (10)

4 Action to control cardiovascular risk in diabetes, ACCORD (11) Veterans Affairs Diabetes Trial, VADT (12) DCCT A1C 7% A1C 9% 60% 41% DCCT 9 42% 57% UKPDS(8) A1C 7% A1C 10 25 % 1 10 legacy effect ACCORD(14) 10 A1C 35% A 1 C 6 % A1C 3 22% A1C 8% 2008 2 ADVANCE(10) A1C 6.

5 5 % 6 . 3 % 8 ACCORD 2 A1C ACCORD vs. 21% 10% VADT(12) A1C 12 90 458459172010, , 1. 2 130 mmHg 80 mmHg 2. 1 3 0 - 1 3 9 m m H g 8 0 - 8 9 mmHg 3 3.

6 Lifestyle therapy 7 % Dietary Approaches to Stop Hypertension, DASH 4. 140 mmHg 90 mmHg 5. A C E I A R B 130/80 mmHg GFR 30 mL/ t h i a z i d e G F R 3 0 m L / loop 6. 7. ACEI ARB 8. 110-129/65-79 mmHg ACEI ARB ACEI ARB - renin-angiotensin system, RAS A C E I A C E I d i h y d r o p y r i d i n e A RB A R B ACEI ARB (13) ADVANCE(10) ACEI perindopril indapamide 1.

7 LDL < 100 mg/dL HDL >50 mg/dL TG <150 mg/dL 2 2. n-3 stanols/sterols 150 3. Statin statin 40 LDL>100 mg/dL 4. LDL<100mg/dL 5. LDL<70mg/dL 6. L D L 3 0 -40% LDL 7. TG<150mg/dL, HDL>40 mg/dL HDL>50 mg/dL 8. statin s t a t i n H P S - D M s i m v a s t a t i n 31% LDL 34% CARDS atrovastatin 40% LDL 35% 4S-DM simvastatin 36% LDL CARE-DM spravastatin 27% LDL 13% fenofibrate 1.

8 T1DM T2DM 10 10% 75-162 mg aspirin 5 0 460461182010, , 60 2 . aspirin 3. 75-162 mg aspirin 4. a s p i r i n clopidogrel 75mg/day 5. aspirin clopidogrel 1 a s p i r i n (14) 4 5 - 7 9 5 5 - 7 9 a s p i r i n J PA D POPADAD aspirin ATT Anti-Thrombotic Trialists (15) aspirin 12% RR 95% CI 14% 32% aspirin 12% RR 95% CI 13% RR 95% CI aspirin Aspirin 1-5/1000/ aspirin 50 60 10 5% 1.

9 2. 5 T1D M 3 T2DM 3. serum creatinine CKD 4 4. micro-or macroalbuminuria ACEI ARB 5. T1DM ACEI T 2 D M A C E I ARB macroalbuminuria > 1 . 5 m g / d L T2DM ARB ACEI ARB 6. CKD 7. ACEI ARB 8.

10 3 24 g/mg creatinine <30 microalbuminuria 30-299 macroabluminuria, clinical 300 Stage GFR mL/ 1 GFR 902 GFR 60-893 GFR 30-594 GFR 15-295 <15 4 chronic kidney disease, CKD 16 460461192010, , 9. 2 0 - 4 0 % ESRD >300 mg/24h 3 T2DM (8) UKPDS RAS A C E I A R B ARB T2DM ESRD ACEI ARB 2 0 1 0 A D A 2 0 0 9 1 (3) DPP-4 dipeptitidyl-peptidase 4 4 ADA NICE (2)