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1、胰岛素泵治疗,LES TEAM,2005 Medtronic Diabetes China basic Pump Therapy Training program,内容,强化血糖控制的重要性 胰岛素泵发展历史 胰岛素泵基本理论 胰岛素泵治疗优势 胰岛素泵治疗适应症 装泵前的准备和教育,为什么血糖要保持在正常范围内？,糖尿病的发病率,总计: 2080万人口 占总人口的7.0% 患糖尿病,资料来源： 2005, CDC 网站,美国2005年20岁以上人群中糖尿病的总发病率， 按年龄分组评估,2.5,2.0,1.5,1.0,0.5,0.0,20-39,40-59,60+,百分比,年龄分组,*Base
2、d on DCCT dataSkyler J. Endocrinol Metab Clin North Am. 1996;25:243-254.,Relative Risk of Progression of Diabetic Complications as a Function of Mean A1C*,Diet,糖尿病病程,7,6,9,8,HbA1c (%),10,更积极的血糖控制策略,胰岛素强化治疗,胰岛素强化治疗,糖尿病的慢性并发症是造成病人致死、致残的重要原因，其中分为微血管病变、大血管病变及神经病变，其病变的发生与发展与高血糖状态有着极其密切的关系，特别是微血管病变和神经病变，所
3、以严格控制血糖显得尤其重要，而胰岛素强化治疗是达到严格血糖控制的重要手段。,胰岛素泵的应用背景,八十年代 “强化治疗”的概念开始被应用： 是指每天不同时间段应有不同的胰岛素用量相对应，饮食及运动等应与胰岛素用量保持平衡，同时经常监测血糖，以使血糖控制在接近正常范围内。,胰岛素泵的应用背景,九十年代 一些大型临床试验结果证实强化治疗的优势： 美国DCCT 日本Kumamoto 英国UKPDS,强化治疗对糖尿病并发症的 相关风险性,1DCCT Research Group. N Engl J Med. 1993;329:977986. 2DCCT Research Group. Diabetes.
4、 1995;44:968983. 3Ohkubo Y, et al. Diabetes Res Clin Pract. 1995;28:103117. 4UK Prospective Diabetes Study Group (UKPDS) 33: Lancet. 1998;352:837853.,*Not statistically significant in intervention analysis.,Skyler, J: Chronic Complications of Diabetes Endo Met Cl N Am, vol 25, 2, p.243- 254, June 19
5、96 Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986. *Endocrine Practice 2002, 8 (supp 1), pg. 7. AACE recommends less than or equal to 6.5 HbA1c. Minshall M, Roze S, Palmer A, et al. Treating diabetes to accepted standards of care: a 10-year projection of the estima
6、ted economic and health impact in patients with type 1 and type 2 diabetes in the US. Clin Ther. 2005;27:940950.,DCCT 研究结果 A1C 和糖尿病慢性并发症的相对危险度,1,3,5,7,9,11,13,15,6,7,8,9,10,11,12,眼部病变,肾脏病变,神经损害,A1C,并发症的相对危险度,( “可能高X” 倍 ),美国A1C平均水平控制在 7.8-8.6%,AACE 推荐 控制目标 为 6.5%,EDIC 1型糖尿病和心血管事件,从19831989年间共有1,425 名
7、1型糖尿病患者入选， 以达到A1C6.5%的控制目标,积极的A1C控制目标,1375 名DCCT 患者继续进入 EDIC研究， 所有患者转入积极的A1C控制目标,主要终点：心血管事件*, 非致死性心梗，卒中和心血管死亡 次要终点：微血管和神经系统的长期预后,传统的A1C 控制目标,双盲,积极的A1C控制目标,观察,DCCT 研究,EDIC 研究,研究设计,Nathan, David M; Cleary, Patricia A.; Raskin, Philip; Zinman, Bernard. Intensive Diabetes Treatement and Cardiovascular D
8、isease in Patients with Type 1 Diabetes. New England Journal of Medicine, Dec. 22, 2005, Vol 353, No. 25, pg. 2643 - 2653.,0.12,0.08,0.10,0.06,0.04,0.02,0.00,0,3,4,5,6,9,10,11,12,13,14,15,16,17,18,19,20,21,强化治疗,常规治疗,自入选起的年份,与常规治疗相比， 强化治疗降低心血管疾病的风险达42%,任何预定义心血管事件 的累积发生率,(95的可信区限 , 9 63%; P = 0.02),Na
9、than, David M; Cleary, Patricia A.; Raskin, Philip; Zinman, Bernard. Intensive Diabetes Treatement and Cardiovascular Disease in Patients with Type 1 Diabetes. New England Journal of Medicine, Dec. 22, 2005, Vol 353, No. 25, pg. 2643 - 2653.,1,2,7,8,n = 1,341,a,a,0.12,0.08,0.10,0.06,0.04,0.02,0.00,0
10、,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,强化治疗,常规治疗,糖尿病强化治疗有效降低 首发非致命性大血管并发症的风险达57%,a,a,非致命性心肌梗塞、卒中或因心血管疾病而死亡的累积发生率,(95%的可信区限, 1279 %; P = 0.02),Nathan, David M; Cleary, Patricia A.; Raskin, Philip; Zinman, Bernard. Intensive Diabetes Treatement and Cardiovascular Disease in Patients wi
11、th Type 1 Diabetes. New England Journal of Medicine, Dec. 22, 2005, Vol 353, No. 25, pg. 2643 - 2653.,n=1,341,自入选起的年份,EDIC 1型糖尿病和心血管事件,首个证实早期积极治疗控制A1C与传统治疗相比可降低心血管事件的长期研究 所有心血管事件风险降低42% 非致死性心梗、卒中和心血管死亡风险降低57% 这些风险的降低要比迄今为止在高血压或是血脂控制研究中所观察到的风险降低都更为显著 这些有益的心血管结果是因为A1C的降低而引起的 控制A1C所起的作用占心血管事件降低的97,结论,N
12、athan, David M; Cleary, Patricia A.; Raskin, Philip; Zinman, Bernard. Intensive Diabetes Treatement and Cardiovascular Disease in Patients with Type 1 Diabetes. New England Journal of Medicine, Dec. 22, 2005, Vol 353, No. 25, pg. 2643 - 2653.,MI Microvascular endpoints,80 ,Adapted from Stratton IM e
13、t al. BMJ. 2000;321:405-412.,UKPDS:Cardiovascular Risk Increases With Increasing Glycemia,Stratton IM, et al. BMJ. 2000;321:405-412.,UKPDS 流行病学资料 2型糖尿病患者A1C 和并发症风险,微血管并发症 大血管并发症,微血管终点,A1C每降低1% 危险度降低14%,P0.0001,0,.,5,1,5,0,5,6,7,8,9,1,0,1,1,危险度比值,校正后的A1C平均值,致死性和非致死性心梗,A1C每降低1% 危险度降低21%,P0.0001,0,.,5,
14、1,5,0,5,6,7,8,9,1,0,1,1,校正后的A1C平均值,危险度比值,糖尿病相关的死亡,任何糖尿病相关的终点,校正后的A1C平均值,危险度比值,0,.,5,1,5,0,5,6,7,8,9,1,0,1,1,A1C每降低1% 危险度降低21%,P0.0001,0,.,5,1,10,0,5,6,7,8,9,1,0,1,1,A1C每降低1% 危险度降低37%,P0.0001,校正后的A1C平均值,危险度比值,UKPDS流行病学资料 2型糖尿病患者A1C 和并发症风险,0,10,20,30,40,50,60,70,80,5,6,7,8,9,10,11,校正后每1000患者年的发生率 (%),
15、心梗,微血管终点,校正后的A1C均值 (%),Stratton IM, et al. BMJ. 2000;321:405-412.,A1C无阈值!,*AAFP: goals for self-monitoring of blood glucose. American Diabetes Association. Diabetes Care. 2003;26(suppl 1):S33S50. American College of Endocrinology. Endocr Pract. 2002;8(suppl 1):4082. American Academy of Family Physicians. SMBG monograph. Available at: http:/www.aafp.org/smbgmonograph.xml. Accessed October 13, 2004.,
