低血糖对2型糖尿病患者的影响课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,DRAFT FOR INTERNAL TRAINING USE ONLY,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,1,低血糖及其对,2,型糖尿病患者的影响,北京同仁医院内分泌科,杨毅,2,内容,低血糖的定义及其症状,2,型糖尿病患者中低血糖的发病率,低血糖是,2,型糖尿病患者,通过充分的血糖控制后达到,阳性结果的障碍,基于肠促胰岛,激,素的治疗,方法,为,充分控制,血糖,并,降低低血糖风险提供新选择,3,美国糖尿病学会对低血糖的定义,低血糖有如下症状特征,血糖水平低,神经低血糖症状和,/,或神经症状,摄入碳水化合物后症状缓解,所有具有潜在危害的异常低血糖,都称之,为低血糖症,对于使用促胰岛素分泌剂或胰岛素治疗的患者，血糖水平,3.9 mmol/L(,70mg/dL),为低血糖,American Diabetes Association.,Diabetes Care.,2005;28(5):12451249.,4,低血糖的症状,神经症状,1,2,神经低血糖症状,1,2,肾上腺素能症状,心悸,震颤,焦虑,/,觉醒,类胆碱样症状,出汗,饥饿感,感觉异常,认知障碍,行为改变,精神运动异常,抽搐,昏迷,1,型和,2,型糖尿病控制不佳，,1,型糖尿病血糖的严格控制以及老龄是影响血糖阈值的因素,2,3,1.,Cryer PE.,J Clin Invest,.2007;117(4):868870.,2.,Cryer PE.,Diabetes Care,.2003;26(6):19021912.,3.,Meneilly GS et al.,J Clin Endocrinol Metab,.1994;78(6):13411348.,5,5,低血糖的发病率,1993-2005,年间因低血糖急诊,a,的总人数达,5,百万,1,25%,的患者入院,72%,的患者第一诊断为低血糖,其中大约,44%,的病例发生于,65,岁以上的老人,老年患者不容易出现症状性低血糖,2,a,患者为,1,、,2,型糖尿病,.ICD-9,诊断编码,:251.0(,低血糖昏迷,),251.1(,其他指定的低血糖,),251.2(,低血糖,非特定,),270.3(,亮氨酸诱导的低血糖,),775.0(,糖尿病母亲出生婴儿低血糖,),and 775.6(,新生儿低血糖,).ICD-9,编码,250.8,还包括,(,有其他特定表现的糖尿病,),但除以下联合诊断编码以外,:259.8,272.7,681.xx,682.xx,686.9x,707.xx,709.3,730.0,730.2,和,731.8.,1.Ginde AA et al.,Diabetes Care.,2008;31:511,513.,2.,Matyka K et al.,Diabetes Care,.1997;20(2):135,141.,6,2,型糖尿病患者低血糖症状的发病率,1.,Reproduced with permission of Springer Verlag.Lundkvist J et al.,Eur J Health Econom,.2005;6(3):197202.Permission conveyed through Copyright Clearance Center,Inc.,2.,Asia RECAP-DM Study Group.7th IDF Western Pacific Region Congress,Wellington,New Zealand.Poster No.P45.,3.,lvarez Guisasola F et al.,Diabetes Obes Metab,.,2008;10(suppl 1):2532.,自发报告发生,低血糖事件的患者,%,亚洲和欧洲其他研究中,应用口服制剂治疗,2,型糖尿病的患者自发报告低血糖的发生率结果相似,2,3,任何胰岛素,(n=133),仅用口服制剂,(n=176),所有患者,(N=309),0,10,20,30,40,50,60,最近,1,月内低血糖症状的发生率,1,7,1,型和,2,型糖尿病的低血糖发病率与病程相关,1.,Reproduced with permission of Springer Verlag.UK Hypoglycemia Study Group.,Diabetologia,.2007;50(6):11401147.Permission conveyed through Copyright Clearance Center,Inc.,2.,NIDDK 2007.Available at http:/diabetes.niddk.nih.gov/dm/pubs/statistics/.Accessed December 12,2008.,(n=46),(n=54),(n=103),(n=85),(n=75),由于,2,型糖尿病患者占所有诊断为成人糖尿病的,90%95%,2,，故低血糖事件在,2,型糖尿病患者中发生的绝对数比,1,型糖尿病患者更多。,至少,发生,1,次严重低血糖的比例,1,0.0,0.2,0.4,0.6,0.8,1.0,磺脲类治疗,5,年胰岛素治疗,15,年胰岛素治疗,2,型糖尿病,1,型糖尿病,8,2,型糖尿病低血糖的危害,2,型糖尿病患者发生低血糖与使用胰岛素和磺酰脲类药物有关,1,严重低血糖容易引起临床重视，但轻到中度低血糖可能是无症状的并且可能会被漏报,2,3,即使是无症状的低血糖也对患者有危害,4,老年患者比年轻患者发生低血糖相关事件的几率更高,5,1.,Asian-Pacific Type 2 Diabetes Policy Group.4th Edition.2005;158.,2.,Chico A et al.,Diabetes Care.,2003;26(4):11531157.,3.,Canadian Diabetes Association Clinical Practice Guidelines Expert Committee.,Can J Diabetes,.2008;32(suppl 1):S62S64.,4.,California Healthcare Foundation.,J Am Ger Soc.,2003;51(5,suppl):S265S280.,5.,Matyka K et al.,Diabetes Care.,1997;20(2):135141.,9,无症状性低血糖可能被漏报,在连续血糖监控的糖尿病人中，超过,50%,出现过无症状性低血糖,(,未识别出,),1,其他研究者也有类似发现,2,3,1.,Copyright 2003 American Diabetes Association.,Chico A et al.,Diabetes Care.,2003;26(4):11531157.Reprinted with permission from the,American Diabetes Association.,2.,Weber KK et al.,Exp Clin Endocrinol Diabetes,.2007;115(8):491494.,3.,Zick R et al.,Diab Technol Ther,.2007;9(6):483492.,0,25,50,75,100,所有糖尿病患者,1,型糖尿病,患者,患者比例,%,2,型糖尿病,患者,55.7,62.5,46.6,发生,1,次未识别的低血糖事件的患者,%,n=70,n=40,n=30,10,严重低血糖的影响和并发症,血糖水平,10,20,30,40,50,60,70,80,90,100,110,1,2,3,4,5,6,mg/dL,mmol/L,1.,Landstedt-Hallin L et al.,J Intern Med,.1999;246:299307.,2.,Cryer PE.,J Clin Invest,.2007;117(4):868870.,增加心律失常风险,1,进行性神经低血糖症,2,延长心脏复极化,QTc,和,QTd,猝死,认知受损,行为异常,抽搐,昏迷,脑死亡,11,严重并持续的低血糖增加死亡率,葡萄糖为大脑的代谢功能所必需,1,由于大脑自己不能合成葡萄糖，脑组织需要依靠糖循环提供能量,1,当动脉中葡萄糖水平下降,血液到大脑的葡萄糖传输将变慢，从而使脑组织的代谢受限，甚至脑死亡,1,低血糖导致,6%-10%,的,1,型糖尿病患者死亡,2,3,致命性的低血糖并不仅限于,1,型糖尿病,4,致命的磺酰脲类相关性低血糖也有报道,.,5,1.,Cryer,PE et al.,Diabetes Care,.2003;26(6):19021912.,2.,DCCT/EDIC Study Research Group.,N,Engl,J Med,.2007;356:18421852.,3.,Skrivarhaug T et al.,Diabetologia,.2006;49:298305.,4.,Cryer,PE.,J,Clin,Invest,.2006;116(6):14701473.,5.,