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1、1,老年糖尿病患者的治疗策略,李诗洋,糖尿病患病人数 (20-79岁) 排名前10位的国家/地区 单位:百万,最新IDF流行病学数据显示： 20102030年糖尿病在全球迅速流行,中国糖尿病患病人数已居世界第一,Diabetes Atlas, 5th edition, IDF, 2011.,China in 2010,11.6% prevalence of diabetes in adults in China in 2010 based on cross-sectional study of 98,658 adults in China in 2010 estimated prevalenc
2、e any diabetes in 11.6% (12.1% in men and 11% in women) prediabetes in 50.1% Reference - JAMA 2013 Sep 4;310(9):948, editorial can be found in JAMA 2013 Sep 4;310(9):916,我国老年人群糖尿病患病率显著增加,我国老年人的标准大于等于60岁,中华内科杂志. 2014;53(3):243-251,Background,Diabetes mellitus type 2 is a common endocrine disorder cha
3、racterized by variable degrees of insulin resistance and deficiency, resulting in hyperglycemia. It is often identified through routine screening beginning in middle age, or through targeted screening of adults with risk factors such as obesity, metabolic syndrome, polycystic ovary syndrome, a histo
4、ry of gestational （妊娠期的）diabetes, or other concerning familial, clinical, or demographic characteristics.,Also called,diabetes mellitus type II type 2 diabetes type II diabetes non-insulin-dependent diabetes mellitus (NIDDM) adult-onset diabetes（成人型） insulin-resistant diabetes,Who is most affected,p
5、ersons with obesity(2) mean age at diagnosis of type 2 diabetes in United Stated decreased from 52 years in 1988-1994 to 46 years in 1999-2000 (Ann Fam Med 2005 Jan-Feb;3(1):60full-text) diabetes prevalence similar in men and women globally, but slightly higher in men 60 years old and in women at ol
6、der ages (Diabetes Care 2004 May;27(5):1047full-text) American Indians/Alaska Natives (AI/ANs) have higher prevalence of diabetes from 1994 to 2002, age-adjusted prevalence of diabetes among United States adults increased from 4.8% to 7.3%, but among AI/AN adults, from 11.5% to 15.3% (MMWR Morb Mort
7、al Wkly Rep 2003 Aug 1;52(30):702full-text) from 1994 to 2004, age-adjusted prevalence of diagnosed diabetes in AI/ANs 35 years old increased from 0.85% to 1.71%; prevalence in 2004 increased with age from 0.22% at age 15 years to 4.68% at ages 25-34 years (MMWR Morb Mortal Wkly Rep 2006 Nov 10;55(4
8、4):1201full-text),Likely risk factors,Prediabetes impaired fasting glucose（空腹血糖受损） - plasma glucose 110-125 mg/dL (6.1-6.9 mmol/L) using WHO criteria, or 100-125 mg/dL (5.6-6.9 mmol/L) using ADA criteria impaired glucose tolerance （糖耐量减低）- 2-hour plasma glucose 140-199 mg/dL (7.8-11 mmol/L) during 7
9、5 g oral glucose tolerance test (WHO and ADA criteria) HbA1c 5.7%-6.4% (ADA criteria),Likely risk factors,obesity metabolic syndrome polycystic ovary syndrome（多囊卵巢综合征） gestational diabetes mellitus (GDM)（妊娠期糖尿病）,Diagnostic criteria,fasting plasma glucose 126 mg/dL (7 mmol/L) (after no caloric intake
10、 for 8 hours) symptoms of hyperglycemia（高血糖） with random plasma glucose 200 mg/dL (11.1 mmol/L) 2-hour plasma glucose 200 mg/dL (11.1 mmol/L) during a 75 g oral glucose tolerance test HbA1c 6.5% (HbA1c may not be accurate for diagnosis if there is pregnancy, hemoglobinopathy(血红色异常), certain anemias（
11、贫血）, or abnormal erythrocyte（红细胞） loss or replacement) Repeat testing for confirmation in the absence of unequivocal （明确的）hyperglycemia. (WHO/IDF 2006 PDF) WHO Consultation Report 2011 PDF,Additional testing and evaluation,a fasting lipid profile liver transaminases serum creatinine, estimated glome
12、rular filtration rate, spot urine microalbumin（微量蛋白） to creatinine ratio a dilated eye exam to detect retinopathy（视网膜）a Semmes-Weinstein monofilament （震动阈值）exam to detect peripheral neuropathy （周围神经病变）,Individualize glycemic goals,Strong recommendation targets in adults with type 2 diabetes are HbA1
13、c 7% in most nonpregnant adults and 6% in pregnant women with preexisting（既往） diabetes,Consider individualized lipid goals and blood pressure goals; generally recommended targets in adults with type 2 diabetes are low-density lipoprotein (LDL) cholesterol 100 mg/dL (2.6 mmol/L) and blood pressure 13
14、0/80 mm Hg or 140/90 mm Hg (Weak recommendation).,Provide support for dietary management, maintaining physical activity, and diabetes self-management education and support (Strong recommendation),Prescribe glucose-lowering medications,Prescribe glucose-lowering medications if there is inadequately i
15、mproved hyperglycemia with lifestyle modifications (Strong recommendation),Metformin（二甲双胍） is the first-line drug of choice for type 2 diabetes (Strong recommendation). The initial dosing is 500 mg twice daily or 850 mg once daily. Increase dose by 500 mg/day weekly or 850 mg/day every other week. T
16、he maximum dose is 1 g twice daily or 850 mg 3 times daily.,Add a second drug if glycemic goals are not met on the maximal tolerated dose of metformin monotherapy (Strong recommendation) and a third drug if glycemic goals are not met on a 2-drug combination;,In hospitalized patients: Avoid the sole use of sliding scale insulin in the hospitalized patients (Strong recommendation). For noncritically ill patients, subcutaneous （皮下）insulin suggested in patients with persisten
