1、 内容概括1.背景资料背景资料2.糖尿病危害性糖尿病危害性3.诊断及监测诊断及监测4.治疗概论治疗概论5.住院病人治疗原则住院病人治疗原则1.背景资料背景资料 1.根据循证医学原则制定根据循证医学原则制定,内容参考近内容参考近5年来年来国际上出版的指南、国际上出版的指南、meta分析、及相关刊分析、及相关刊物。物。2.根据不同地区、不同医疗资源制定根据不同地区、不同医疗资源制定3个等个等级标准。级标准。三个等级医疗标准Standard Care Minimal Care Comprehensive Care 2.糖尿病危害性糖尿病危害性 1.发病人数日益增长。发病人数日益增长。无论是在发达国家
2、还是在发展中无论是在发达国家还是在发展中国家，均明显增加。其中国家，均明显增加。其中90%90%为为2 2型糖尿病型糖尿病。（见下图）。（见下图）2.发展中国家增长的速度超过了发达国家。（发展中国家增长的速度超过了发达国家。（200%200%比比45%45%），），2121世纪世纪DM DM 将在中国、印度等发展中国家流行将在中国、印度等发展中国家流行 。3.DM DM 的主要并发症已经成为病人致残和早亡的主要原的主要并发症已经成为病人致残和早亡的主要原因，因，每年全球约每年全球约 3 000 000 人口因糖尿病而死亡。人口因糖尿病而死亡。4.2 2型糖尿病占我国糖尿病人群的型糖尿病占我国糖
3、尿病人群的90%90%以上，它的血管并以上，它的血管并发症使人们丧失劳动能力发症使人们丧失劳动能力,预期寿命缩短预期寿命缩短8-128-12年。年。P.Zimmet et al.Bulletin of the International Diabetes Federation 48:13,2003 A much quoted paper by Haffner et al,suggested that people with Type 2 diabetes have a CV risk equivalent to non-diabetic people with previous CVD。Haf
4、fner SM,Lehto S,R鰊nemaa T,Pyorala K,Laakso M.Mortality from coronary heart disease in subjects with type 2diabetes and in nondiabetic subjects with and without prior myocardial infarction.N Engl J Med 1998;339:229-34.糖尿病急性并发症及大血管和微血管等慢性并发症，致糖尿病急性并发症及大血管和微血管等慢性并发症，致死、致残率高，一旦发生，难以逆转，降低病人的生活死、致残率高，一旦发生
5、，难以逆转，降低病人的生活质量，缩短寿命。质量，缩短寿命。3.诊断及监测诊断及监测提倡早期诊断 早期诊断的意义；早期诊断的意义；Type 2 diabetes has a long asymptomatic pre-clinical phasewhich frequently goes undetected.At the time of diagnosis,over half have one or more diabetes complications.Retinopathy rates at the time of diagnosis range from 20%to 40%.Of peo
6、ple with Type 2 diabetes,the proportion who areundiagnosed ranges from 30%to 90%.SM,Meyer LC,Neil HAW,Ross IS,Turner RC,Holman RR.Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors.UKPDS 6.Diabetes Res 1990;13:1-11.Har
7、ris MI,Klein R,Welborn TA,Knuiman MW.Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis.Diabetes Care 1992;15:815-19.UKPDS Group.UK Prospective Diabetes Study 30:Diabetic retinopathy at diagnosis of type 2 diabetes and associated risk factors.Arch Ophthalmol 1998;116:297-303.早期诊断早期诊断的方法
8、早期诊断的方法-目前全球根据各地区约有目前全球根据各地区约有30%-90%糖尿病漏糖尿病漏诊率诊率.For diagnosis,an oral glucose tolerance test(OGTT)should be performed in people with a fasting plasma glucose 5.6 mmol/l(100 mg/dl)and 7.0 mmol/l(126 mg/dl);Where a random plasma glucose level 5.6 mmol/l(100 mg/dl)and 11.1 mmol/l(200 mg/dl)is detecte
9、d on opportunistic screening,it should be repeated fasting,or an OGTT performed.诊断标准:WHO-1999 criteriaHealth Organization.Definition,Diagnosis and Classification of Diabetes Mellitus and its Complications.Report of a WHO Consultation.Part 1:Diagnosis and Classification of Diabetes Mellitus.Geneva:WH
10、O 诊断标准的解释诊断标准的解释:糖尿病诊断是依据空腹、任意时间或OGTT中2小时血糖值空腹指至少8小时内无任何热量摄入任意时间指一日内任何时间，无论上次进餐时间及食物摄入量OGTT是指以75克无水葡萄糖为负荷量，溶于水内口服(如用1分子结晶水葡萄糖，则为82.5克。OGTT的方法的方法:早餐空腹取血(空腹8-14小时后），取血后于5分钟内服完溶于250-300ml水内的无水葡萄糖75克（如用1分子结晶水葡萄糖，则为82.5克）试验过程中不喝任何饮料、不吸咽、不做剧烈运动，无需卧床从口服第一口糖水时计时，于服糖后30分钟、1小时、2小时及3小时取血（用于诊断可仅取空腹及2小时血）控制指标水平
11、血糖控制水平；血糖控制水平；HbA1c 6.5%Equivalent target levels for capillary plasma glucose levels are 6.0 mmol/l(110 mg/dl)before meals,and 8.0 mmol/l(145 mg/dl)1-2 h after meals.血脂控制水平血脂控制水平Reassess at all routine clinical contacts to review achievement of lipid targets:LDL cholesterol 2.5 mmol/l(95 mg/dl),trig
12、lyceride 2.3 mmol/l(1.0 mmol/l(39 mg/dl).血压控制水平血压控制水平Aim to maintain blood pressure below 130/80 mmHgAccept that even 140/80 mmHg may not be achievable with 3 to 5 antihypertensive drugs in some people.Revise individual targets upwards if there is signi.cant risk of postural hypotension and falls.每年
13、全面检测一次检测原则及目的 General principles include:annual review of control and complications;an agreed and continually updated diabetes care plan;and involvement of the multidisciplinary team in delivering that plan,centred around the person with diabetes.临床血糖监测方法 HbA1c performed every 2 to 6 months dependin
14、g on level and stability of blood glucose control,and change in therapy.Site-of-care capillary plasma glucose monitoring at random times of day is not generally recommended.自我血糖监测方法 Self-monitoring of blood glucose(SMBG)should be available to those;For all newly diagnosed people with Type 2 diabetes
15、;those on insulin treatment;to provide information on hypoglycaemia;to assess glucose excursions due to medications and lifestyle changesto monitor changes during intercurrent illness.SMBG can be considered in relation to:outcomes(a decrease in HbA1c with the ultimate aim of decreasing risk of compl
16、ications)safety(identifying hypoglycaemia)process(education,self-empowerment,changes in therapy).对尿糖监测的评价Urine glucose testing is cheap but has limitations.Urine free of glucose is an indication that the blood glucose level is below the renal threshold,which usually corresponds to a blood glucose le
17、vel of about 10.0 mmol/l(180 mg/dl).Positive results do not distinguish between moderately and grossly elevated levels,and a negative result does not distinguish between normoglycaemia and hypoglycaemia.4.治疗概论治疗概论生活方式干预治疗 目的：通过调整生活方式，如饮食、运动等更好地控制血糖、血通过调整生活方式，如饮食、运动等更好地控制血糖、血压、血脂等危险因素。压、血脂等危险因素。关于饮食；
18、专家指导下制定个体营养需求方案专家指导下制定个体营养需求方案;严格限制高热量、高脂食物、食盐及酒精等；严格限制高热量、高脂食物、食盐及酒精等；根据降糖药（口服药及胰岛素）及运动量调整饮食量。根据降糖药（口服药及胰岛素）及运动量调整饮食量。关于运动：Encourage increased duration and frequency of physical activity(where needed),up to 30-45 minutes on 3-5 days per week,or an accumulation of 150 minutes of physical activity pe
19、r week.生活方式干预治疗利益Randomized controlled trials and outcome studies of medical nutrition therapy(MNT)in the management of Type 2 diabetes have reported improved glycaemic outcomes(HbA1c decreases of 1.0-2.0%,depending on the ration of diabetes).In a meta-analysis of non-diabetic people,MNT restricting
20、 saturated fats to 7-10%of daily energy and dietary cholesterol to 200-300 mg daily resulted in a 10-13%decrease in total cholesterol,12-16%decrease in LDL cholesterol and 8%decrease in triglycerides.A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to 2.4 g
21、/day decreased blood pressure by 5/2 mmHg in hypertensive subjects.beside,that weight loss,increased physical activity,a low-fat diet that includes fruits,vegetables and low-fat dairy products,reducing blood pressure.生活方式干预治疗利益A meta-analysis of exercise(aerobic and resistance training)reported an H
22、bA1c reduction of 0.66%,independent of changes in body weight,in people with Type 2 diabetes.In long-term prospective cohort studies of people with Type 2 diabetes,higher physical activity levels predicted lower longterm morbidity and mortality and increases in insulin sensitivity.Interventions incl
23、uded both aerobic exercise(such as walking)and resistance exercise(such as weight-lifting).口服药物治疗时机；时机；Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.双胍类应用要点Begin with metformin unless evidence or isk of renal impairment,titrating t
24、he dose over early weeks to minimize discontinuation due to gastro-intestinal intolerance.Monitor renal function and risk of signi.cant renal impairment eGFR 7.5%(confirmed)on maximal oral agents.可继续联用可继续联用 metformin.Additionally continue sulfonylureas when starting basal insulin therapy.-Glucosidas
25、e inhibitors may also be continued.目标血糖：目标血糖：Aim for pre-breakfast and pre-main-evening-meal glucose levels of 6.0 mmol/l(40 yr old(or all with declared CVD).a statin at standard dose for all 20 yr old with microalbuminuria or assessed as being at particularly high risk.in addition to statin,fenofib
26、rate where serum triglycerides are 2.3 mmol/l(200 mg/dl),once LDL cholesterol is as optimally controlled as possible.consideration of other lipid-lowering drugs(ezetimibe,sustained release nicotinic acid,concentrated omega 3 fatty acids)in those failing to reach lipidlowering targets or intolerant o
27、f conventional drugs.全面控制心血管危险因素 小剂量应用抗血小板药物小剂量应用抗血小板药物Provide aspirin 75-100 mg daily(unless aspirin intolerant or blood pressure uncontrolled)in people with evidence of CVD or at high risk.Arrange smoking cessation advice in smokers contemplative of reducing or stopping tobacco consumption.5.住院病人治
28、疗原则住院病人治疗原则导致患者住院的因素 Hospitalcare for people with diabetes may be required for metabolic emergencies,in-patient stabilization of diabetes,diabetesrelated complications,intercurrent illnesses,Surgical procedures,and labour and delivery.Prevalence of diabetes in hospitalized adult patients is 12-25%or
29、 more.住院治疗的重点Evaluate blood glucose control,and metabolic and vascular complications(in particular renal and cardiac status)prior to planned procedures;provide advice on the management of diabetes on the day or days prior to the procedure.Ensure the provision and use of an agreed protocol for in-pat
30、ient proceduresand surgical operations.Aim to maintain near-normoglycaemia without hypoglycaemia by regular quality-assured blood glucose testing and intravenous insulin delivery where needed,generally using a glucose/insulin/potassium infusion.住院治疗的重点Ensure awareness of special risks to people with
31、 diabetes during hospital procedures,including risks from:neuropathy(heel ulceration,cardiac arrest)intra-ocular bleeding from new vessels(vascular and other surgery requiring anticoagulation)drug therapy(risks of acute renal failure causing lactic acidosis in people on metformin,for example with ra
32、diological contrast media)急症处理原则Provide access to intensive care units(ICU)for life-threatening illness,ensuring that strict blood glucose control,usually with intravenous insulin therapy,is a routine part of system support for anyone with hyperglycaemia.Provide protocol-driven care to ensure detect
33、ion and immediate control of hyperglycaemia for anyone with a presumed acute coronary event or stroke,normally using intravenous insulin therapy with transfer to subcutaneous insulin therapy once stable and eating.后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用资料仅供参考，实际情况实际分析主要经营：课件设计，文档制作，网络软件设计、图文设计制作、发布广告等秉着以优质的服务对待每一位客户，做到让客户满意！致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求The user can demonstrate on a projector or computer,or print the presentation and make it into a film to be used in a wider field
