糖尿病臨床照護指引 - ttpc.mohw.gov.tw

1 : , , T2DM World wide epidemic3 Zimmet, Nature 2001 India:2000:32 mill2020: 81 mill : , , : , , : , , Categories of increased risk for diabetes151617 : , , 1. Glycemic control 2. minimize microvascular complications 3. minimize macrovascular complications and treatment of CVD risk factor19treatment of CVD risk factor 1. Glycemic control 2. minimize microvascular complications 3. minimize macrovascular complications and treatment of CVD risk factor20treatment of CVD risk factor 1. Glycemic control 2. minimize microvascular complications 3. minimize macrovascular complications and treatment of CVD risk factor22treatment of CVD risk factorDiabeticRetinopathyLeading causeof blindnessin adults1,2 CardiovascularStroke2- to 4-fold increase in cardiovascular mortality and stroke5 Type 2 diabetes is associated with serious complicationsin adults1,2 DiabeticNephropathyLeading cause of end-stage renal disease3,4 CardiovascularDiseaseDiabeticNeuropathyL eading cause ofnon-traumatic lower extremity amputations7,88/10 individuals with diabetes die from CV events61UK Prospective Diabetes Study Group.

2 Diabetes Res1990; 13:1 11. 2 Fong DS, et al. Diabetes Care2003; 26 (Suppl. 1):S99 S102. 3 The Hypertension in Diabetes Study Group. J Hypertens1993; 11:309 317. 4 Molitch ME, et al. Diabetes Care2003; 26 (Suppl. 1):S94 S98. 5 Kannel WB, et al. Am Heart J1990; 120:672 RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes2nd Edition, 1997. Blackwell Sciences. 7 King s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8 Mayfield JA, et al. Diabetes Care2003; 26 (Suppl. 1):S78 S79. 1% HbA1c (P< )Diabetes-related deathsUKPDS: HbA1c 120140160 Any diabetes endpoint Microvascular endpoint Myocardial infarcationAdjusted incidence per 1000 person years (%)N=4585 Incidence of ComplicationsRelative RiskN=3642 Type 21%Myocardial infarctionsMicrovascular complicationsAmputations or deaths from peripheral vascular disorders020406080100567891011 Data adjusted for age, sex, and ethnic group, expressed for white men aged 50 54 years at diagnosis and with mean duration of diabetes of 10 years.

3 Adapted with permission from Stratton IM et al. UKPDS 35. BMJ2000;321:405 incidence per 1000 person years (%)Mean HbA1c (%)Type 1 1. Glycemic control 2. minimize microvascular complications 3. minimize macrovascular complications and treatment of CVD risk factor26treatment of CVD risk factorADAA1 CFPGPPG< % 70-130 mg/dl<180 mg/dlRecommendations for Adults with Diabetes28BP< 130/80 mmHgLDL-CHDL-CTG< 100 mg/dl> 40 mg/dl< 150 mg/dlDiabetes Care2006; 29(s1): Type 2 DM practice guidelineOAD (Oral antidiabetic agents OAD) Sulfonylureas Meglitinide glinides Benzoic acid repaglinide D- D-phenylalanine nateglinide Biguanide metformin 36 Biguanide metformin Thiazolidinediones glitazones pioglitazone - ( -glucosidase inhibitors acarbose Incretin hormone (DPP-4 inhibitor) 3738 SaxagliptinVildagliptinLinaglipitin 39 Plasma insulin levelsNPHR egularAspart, Lispro, GlulisineProfiles Human Insulin and Insulin AnalogsBasal InsulinPrandial Insulin024681012141618202224 Plasma insulin levelsHoursGlargineDetemir414243.)

4 , , Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS) (counterregulatory hormones) Glucagon Catecholamines Cortisol Growth hormone Corticosteroids Diuretics Sympathomimetic agents - DKA and HHS ( ) In DKA In DKA In HHS DKA: >250 mg/dl pH < or bicarbonate < 15 mEq/l ketonuira, ketonemia ketonuira, ketonemia HHS > 600 mg/dl pH > and bicarbonate > 15 mEq/l effective serum osmolality >320 mOsm/kg/H2O dehydration hyperglycemia electrolyte imbalances dehydration hyperglycemia electrolyte imbalances : , , : , , : , , Thank you !