重磅更新:2019年ADA糖尿病诊疗标准(中文版·中)

2018-12-24 海南医学院第一附属医院内分泌科 王新军 王转锁译 海医附院内分泌

美国糖尿病协会制定(海南医学院第一附属医院内分泌科 王新军 王转锁译)

间歇扫描动态血糖监测仪的使用

7.19间歇扫描连续血糖监测器的使用可被认为是对需要频繁进行葡萄糖检测的成人糖尿病患者进行自我血糖监测的替代品。C

自动胰岛素输注

7.20在儿童(>7岁)和成人1型糖尿病患者中可以考虑使用自动胰岛素输注系统来改善血糖控制。

8.  2型糖尿病治疗的肥胖管理

8.1 每次就诊时应该计算BMI并记录在病历中。B

8.2准备减重的超重和肥胖的2型糖尿病患者,应该处方饮食、体力活动和行为治疗,以减轻体重的>5%。A

8.3这种干预措施应该是高强度的(6个月内≥16次),专注于饮食、体力活动和行为治疗,以每天减少500~750千卡热量。A

8.4饮食应该个体化,因为如果提供相同的热量限制,即使蛋白质、碳水化合物和脂肪的含量不同,但在减轻体重方面的效果是相同的。A

8.5对达到短期体重减轻目标的患者,应该处方长期(≥1年)全面体重维持计划。这种计划应该提供至少每月随访一次,鼓励持续监测体重(每周或更频繁),持续减少膳食热量,参加高水平的体力活动(200~300分钟/周)。A

8.6为达到体重减轻>5%的目标,处方极低热量饮食(≤800千卡/天)短期(3个月)高强度的生活方式干预应该谨慎,并应严密监测。为保持体重减轻,这种计划应该结合长期全面体重维持咨询。B

8.7超重或肥胖的2型糖尿病患者选择降糖药物时,考虑对体重的作用。E

8.8在可能的情况下,减少增加体重的药物。E

8.9对某些BMI≥27kg/m2的2型糖尿病患者,减肥药物配合饮食、体力活动和行为咨询或许是有效的。必须权衡潜在的益处和潜在的药物风险。A

8.10如果3个月后患者对减肥药物的应答<5%,或者任何时间有安全性和耐受性的问题,应该考虑停止用药或更改药物及治疗方案。A

8.11对于BMI>40 kg/m2(亚裔美国人BMI>37.5kg/m2)的成人2型糖尿病患者(无论血糖水平和降糖药物如何)以及BMI35.0-39.9 kg/m2(亚裔美国人BMI 32.5-37.4 kg/m2)尽管通过生活方式和药物治疗血糖仍然控制不佳者,应该建议代谢手术。A

8.12对于BMI 30.0-34.9 kg/m2(亚裔美国人BMI27.5-32.4 kg/m2)尽管通过口服或注射药物治疗(包括胰岛素)血糖仍然控制不佳者,应该考虑代谢手术。B

8.13代谢手术应该在具有多学科团队的有治疗糖尿病和肠外科经验的大医院进行。C

8.14手术后的患者应该接受长期生活方式支持,并定期监测微量营养素和营养状态,根据国家和国际学会的代谢手术术后管理指南进行。C

8.15进行代谢手术的患者应该进行全面的心理健康评估。B

8.16接受代谢手术的患者,应该评估是否需要持续的精神卫生服务,以帮助他们适应手术后的医疗和社会心理变化。C

9. 血糖控制的药物治疗

1型糖尿病的药物治疗

9.1 大多数1型糖尿病患者应该用MDI注射(基础和餐时胰岛素)或连续皮下胰岛素输注(CSII)方案治疗。A

9.2大多数1型糖尿病患者应该使用速效胰岛素类似物以减少低血糖风险。A

9.3考虑教育大多数1型糖尿病患者如何根据碳水化合物摄入量、餐前血糖和预期运动量调整餐前胰岛素剂量。E

9.4成功应用持续皮下胰岛素输注的患者,应该持续应用到65岁。E

2型糖尿病的药物治疗

9.5如果没有禁忌证且能够耐受,二甲双胍是2型糖尿病起始治疗的首选药物。A

9.6二甲双胍一旦启动,只要它是耐受的,没有禁忌,应长期使用;其他药物,包括胰岛素,应添加到二甲双胍。A

9.7长期使用二甲双胍或许与生化维生素B12缺乏有关。在用二甲双胍治疗的糖尿病患者,尤其是那些伴有贫血或周围神经病变的患者,应该考虑定期监测维生素B12的水平。B

9.8如有明显高血糖症状和/或A1C水平≥10%和/或血糖≥16.7mmol/L,胰岛素应考虑早期使用(用或不用其他药物)。E

9.9在A1C在≥1.5%靶目标时,新诊断的2型糖尿病患者考虑起始两药联合治疗。E

9.10应该采用以病人为中心的方法来指导药物选择。考虑因素包括伴发疾病(动脉粥样硬化性血管疾病、心力衰竭、慢性肾脏疾病)、低血糖风险、对体重的影响、成本、副作用的风险以及患者的偏好。E

9.11在已确诊动脉粥样硬化性血管疾病的2型糖尿病患者中,推荐使用已证实具有心血管疾病益处的钠-葡萄糖共转运体2抑制剂或胰高血糖素样肽1受体激动剂作为抗高血糖方案的一部分。A

9.12在动脉粥样硬化性心血管疾病合并心力衰竭的高危患者或合并心力衰竭的患者中,首选钠-葡萄糖共转运体2抑制剂。C

9.13对于患有2型糖尿病和慢性肾脏疾病的患者,考虑使用钠-葡萄糖共转运体2抑制剂或胰高血糖素样肽1受体激动剂,以降低慢性肾脏疾病进展或/和心血管事件的风险。C

9.14在大多数需要注射性药物以获得更大降糖效果的患者中,和胰岛素相比,优先选择胰高血糖素样肽1受体激动剂。B

9.15对于没有达到血糖目标的2型糖尿病患者,不应推迟药物强化治疗。B

9.16药物治疗方案应定期重新评估(每3-6个月一次),并根据需要调整以纳入新的患者因素。E

10. 心血管疾病和危险因素管理

高血压/血压控制

10.1糖尿病患者每次就诊时均应测量血压。血压升高的患者(≥140/90),应该多次测量,包括非同日重复测量确诊高血压。B

10.2所有高血压糖尿病患者都应该在家监测自己的血压。B

10.3对于糖尿病和高血压患者,血压目标应该通过共同的决策过程来个性化,该决策过程考虑心血管风险、抗高血压药物的潜在副作用以及患者的偏好。C

10.4心血管高危患者(确诊动脉粥样硬化性心血管疾病或10年心血管风险>15%)的糖尿病和高血压患者,如果可以安全达标,<130/80mmHg的血压目标可能是合适的。C

10.5心血管事件风险较低的糖尿病和高血压患者(10年心血管风险<15%),血压控制目标为<140/90mmHg。A

10.6为优化长期产妇健康,减少胎儿生长受损,糖尿病合并慢性高血压的妊娠女性的血压控制目标建议为120-160/80-105mmHg。E

10.7血压>120/80 mmHg的患者应进行生活方式干预,包括超重或肥胖者减轻体重;包括减少钠和增加钾摄入的阻断高血压的膳食疗法(DASH)的膳食结构;酒精摄入适度;以及增加体力活动。B

10.8明确的诊室血压≥140/90 mmHg的患者,除接受生活方式治疗外,应立即启动药物治疗,并及时调整药物剂量使血压达标。A

10.9明确的诊室血压≥160/100 mmHg的患者,除接受生活方式治疗外,应立即启动两种药物联合治疗或应用在糖尿病患者具有心血管获益证据的单片复方制剂。A

10.10高血压的治疗应包括减少糖尿病患者心血管事件的药物:ACEI、ARB、噻嗪样利尿剂(thiazide-like diuretics)、二氢吡啶类CCB。A

10.11为使血压控制达标,常需联合应用多种降压药物。但不联用ACEI和ARB,ACEI或ARB也不与直接肾素抑制剂联用。A

10.12尿白蛋白肌酐比值≥300mg/g(A)或30-299mg/g(B)的糖尿病患者高血压治疗的建议首选最大耐受剂量的ACEI或ARB。如果一类药物不能耐受,应该用另一类药物替代。B

10.13如果应用ACEI、ARB类或利尿剂,每年至少监测一次血肌酐/ eGFR和血钾。B

10.14应用包括利尿剂在内的三种降压药物未达标的高血压患者,应考虑应用盐皮质激素受体拮抗剂治疗。B

血脂管理

10.15生活方式干预,主要是减轻体重(如有指征);应用地中海饮食或停止高血压膳食方法(DASH)饮食模式;减少饱和脂肪和反式脂肪;增加膳食ω-3脂肪酸、黏性纤维和植物固醇/甾醇的摄入量;以及增加体力活动应被推荐以改善脂质分布并降低患上高血压的糖尿病患者的动脉硬化性心血管疾病风险。A

10.16对甘油三酯水平升高(≥1.7 mmol/L)和/或HDL胆固醇降低(男性<1.0 mmol/L,女性<1.3 mmol/L)的患者,应该强化生活方式干预并优化血糖控制。C

10.17未服用他汀或其他调脂药物的成人在首次诊断、初次医学评估、以后每5年(如果年龄在40岁以下)检查血脂是合理的,如有必要时增加监测频度。E

10.18在启动他汀或其他降脂药物治疗时,起始或改变治疗药物4-12周后,和以后每年检测血脂,或许有助于监测治疗应答和治疗的依从性。E

10.19无论任何年龄,糖尿病合并ASCVD或10年心血管风险>20%的患者,均应在生活方式干预的基础上使用高强度他汀治疗。A

10.20对年龄<40岁且伴有其他ASCVD危险因素的患者,考虑在生活方式干预的基础上使用中等强度的他汀治疗。C

10.21无ASCVD的40~75岁A和>75岁B的糖尿病患者,在生活方式干预的基础上使用中等强度的他汀治疗。

10.22伴有多种ASCVD危险因素的糖尿病患者,考虑高强度他汀类药物治疗是合理的。

10.23不能耐受预期强度他汀类药物的患者,应使用最大耐受剂量他汀类药物。E

10.24糖尿病合并ASCVD患者,如果最大耐受他汀类药物剂量LDL-C仍≥1.8mmol/L时,考虑在评估进一步减少动脉粥样硬化性心血管疾病风险的可能性后,考虑增加其他降低LDL-C的药物(如依折麦布或PCSK9抑制剂),考虑药物特异性、副作用和患者偏好。由于价格较低,依折麦布可能是首选的。A

10.25妊娠期间禁用他汀。B

10.26对空腹甘油三酯≥5.7 mmol/L的患者,评估继发性因素,并考虑药物治疗以减少胰腺炎的风险。C

10.27在患有中度高甘油三酯血症(空腹或非空腹甘油三酯2.3-5.7 mmol/L)的成年人中,临床医生应处理和治疗生活方式因素(肥胖和代谢综合征)、继发性因素(糖尿病、慢性肝病或肾脏疾病和/或肾病综合征、甲状腺功能减退)和升高甘油三酯的药物。C

10.28联合应用他汀和贝特未能提供除他汀类药物单药治疗之外的额外的心血管获益,通常不予推荐。A

10.29联合应用他汀和烟酸未能提供除他汀类药物单药治疗之外的额外的心血管益处,且或许可以增加卒中风险,一般不予推荐。A

抗血小板药物

10.30确诊ASCVD的糖尿病患者用阿司匹林(剂量75~162mg/d)作为二级预防治疗。A

10.31确诊ASCVD但对阿司匹林过敏的糖尿病患者,应该使用氯吡格雷(75mg/d)。B

10.32急性冠脉综合征患者,双联抗血小板治疗(低剂量阿司匹林和P2Y12抑制剂)一年是合理的A,继续治疗或许也有益处。B

10.33心血管风险增加的1型或2型糖尿病患者,在与患者沟通获益与出血风险之后,可以考虑阿司匹林一级预防(75~162 mg/d)。

冠心病

10.34对于无症状的患者,不推荐常规筛查冠状动脉疾病,因为只要对ASCVD危险因素给予治疗,常规筛查并不能改善结局。A

10.35以下患者考虑筛查冠心病:非典型心脏症状(如不能解释的呼吸困难、胸部不适);血管疾病相关的症状和体征,包括颈动脉杂音、短暂性脑缺血发作、卒中、跛行或周围动脉疾病;或心电图异常(如Q波)。E

10.36确诊ASCVD的糖尿病患者,考虑ACEI或ARB治疗以降低心血管事件的风险。B

10.37既往发生心肌梗死的患者,应该在心梗后持续使用β-受体阻滞剂至少2年。B

10.38病情稳定的充血性心力衰竭(CHF)患者,如果eGFR>30mL/min,可以应用二甲双胍。CHF 病情不稳定或因CHF住院的患者,应避免使用二甲双胍。B

10.39在2型糖尿病伴ASCVD的患者,推荐使用已证实具有心血管疾病益处的SGLT-2抑制剂或GLP-1受体激动剂作为抗高血糖方案的一部分。A

10.40在ASCVD合并心力衰竭高危因素或确诊心力衰竭的患者中,首选SGLT-2抑制剂。C

11. 微血管并发症和足病

慢性肾脏疾病

11.1病程≥5年的1型糖尿病患者、所有2型糖尿病患者及所有伴有高血压的患者,至少每年定量评估尿白蛋白(如随机尿的尿白蛋白/肌酐比值)和估算肾小球滤过率(eGFR)。B

11.2优化血糖控制,以减少糖尿病肾脏疾病风险或延缓其进展。A

11.3对于患有2型糖尿病和慢性肾脏疾病的患者,考虑使用钠-葡萄糖共转运体2抑制剂或胰高血糖素样肽1受体激动剂,以降低慢性肾脏疾病进展、心血管事件或两者的风险。C

11.4优化血压控制,以减少糖尿病肾脏疾病风险或延缓其进展。A

11.5对非透析依赖的糖尿病肾脏疾病患者,蛋白质摄入量应该大约是0.8g/kg公斤体重(建议每日允许量),对于透析的患者,应该考虑较高水平的蛋白质摄入量。B

11.6非妊娠合并糖尿病和高血压患者,建议ACEI或ARB类用于治疗中度升高尿白蛋白排泄(30–299 mg/d)B和强烈推荐用于尿白蛋白排泄>300mg/d的患者和/或eGFR<60 ml/min/1.73 m2的患者。A

11.7当使用ACE抑制剂、ARBs或利尿剂时,定期监测血清肌酐及血钾水平观察是否发生肌酐升高或血钾变化。B

11.8用ACEI或ARB治疗的有白蛋白尿的患者持续监测尿白蛋白/肌酐比值以评估糖尿病肾脏疾病的进展是合理的。E

11.9糖尿病患者如果血压和尿白蛋白/肌酐比值(<30mg/g)及估算肾小球滤过率正常,不推荐应用ACEI或ARB作为糖尿病肾脏疾病的一级预防。B

11.10当估计GFR(eGFR)<60 ml/min/1.73 m2时,评估和处理慢性肾脏疾病(CKD)的潜在并发症。E

11.11当估计GFR(eGFR)<30 ml/min/1.73 m2时,应该转诊进行肾脏替代治疗评估。A

11.12当肾脏疾病病原不明确、治疗困难或者肾脏疾病进展较快时,应该立即把患者转诊给有经验的肾病专科医生。B

糖尿病视网膜病变

11.13优化血糖控制以降低视网膜病变的风险或延缓其进展。A

11.14优化血压和血脂控制以降低视网膜病变的风险或延缓其进展。A

11.15 成人1型糖尿病患者在糖尿病发病后的5年内,应该接受眼科医师或验光师散瞳后综合性眼检查。B

11.16  2型糖尿病患者确诊后应该接受眼科医师或验光师散瞳后综合性眼检查。B

11.17如果每年进行一次或多次眼科检查没有视网膜病变的证据,并且血糖控制良好,则可考虑每1-2年进行一次检查。如果存在任何程度的糖尿病性视网膜病变,则应该由眼科医生或验光师至少每年进行散瞳视网膜检查。如果视网膜病变进展或视力受到威胁,则需要增加检查的频率。B

11.18使用验证的眼科医师或验光师通过远程阅片视网膜摄影远程医学程序,并在有指征时及时转诊进行全面的眼科检查,可以是糖尿病视网膜病变的合适筛选策略。B

11.19计划怀孕或已经怀孕的1型或2型糖尿病的妇女应咨询糖尿病视网膜病变发生和/或进展风险。B

11.20在1型或2型糖尿病患者,眼科检查应在妊娠前或妊娠早期(前三个月)进行,随后每3个月和产后1年监测患者的视网膜病变程度。B

11.21有任何程度黄斑水肿、严重非增殖性糖尿病视网膜病变(增殖性糖尿病视网膜病变的前兆)或任何增殖性糖尿病视网膜病变(PDR)的患者,应该立即转诊给有处理和治疗糖尿病视网膜病变丰富经验的眼科医师。A

11.22高危增殖性糖尿病视网膜病变和部分严重非增殖性糖尿病视网膜病变的患者,传统的标准治疗、全视网膜激光光凝治疗可以降低失明的危险。A

11.23玻璃体内注射抗血管内皮生长因子(VEGF)雷尼珠单抗治疗非劣于传统的全视网膜激光光凝治疗,对增值性糖尿病视网膜病变也有指征,以减少失明的风险。A

11.24玻璃体内注射抗血管内皮生长因子可用于中心型糖尿病性黄斑水肿,该病灶位于中心凹下方,可能威胁阅读视力。A

11.25由于阿司匹林不增加视网膜出血的风险,视网膜病变的存在不是用于心脏保护的阿司匹林治疗的禁忌证。A

神经病变

11.26所有2型糖尿病确诊时和1型糖尿病确诊5年后应该筛查糖尿病周围神经病变(DPN),以后至少每年筛查一次。B

11.27评估远端对称性多神经病变应包括详细病史、温度觉、针刺觉(小纤维功能)、用128-Hz音叉评估振动觉(大纤维功能)。所有糖尿病患者应进行10g尼龙丝试验以明确足溃疡和截肢的风险。B

11.28存在微血管和神经病变并发症的患者应该评估自主神经病变的症状和体征。E

11.29优化控制血糖可预防或延缓1型糖尿病患者神经病变A,并可延缓2型糖尿病神经病变的进展。B

11.30评估和治疗患者以减轻糖尿病周围神经病变相关的疼痛B和自主神经病变的症状,从而改善生活质量。E

11.31治疗糖尿病神经病变性疼痛的初始治疗建议使用普瑞巴林、度洛西汀或加巴喷丁。A

足部治疗

11.32对所有糖尿病患者每年进行全面的足部检查,以确定溃疡和截肢的危险因素。B

11.33有感觉丧失或先前溃疡或截肢的患者应在每次就诊时应进行足部检查。C

11.34询问以前溃疡、截肢、Charcot足、血管成形术或血管外科治疗、吸烟、视网膜病变、肾脏透析的病史,并评估目前神经病变的症状(疼痛、烧灼、麻木感)和血管疾病(下肢疲劳、跛行)。B

11.35检查应包括皮肤视诊、评估足部畸形、神经评估包括10g尼龙丝试验和针刺或振动觉试验或评估踝反射,和血管评估包括下肢和足部血管搏动。B

11.36  有跛行症状或足背动脉搏动减弱或消失的患者应转诊进一步进行踝臂指数和血管评估。C

11.37对于足溃疡及高危足患者(如透析患者和Charcot足、有足溃疡史或截肢患者),推荐多学科管理。B

11.38对吸烟、有下肢并发症史、保护性感觉缺失(LOPS)、畸形或外周动脉疾病的患者,应该转诊给足病专家进行持续性预防治疗和终生监护。C

11.39对所有糖尿病患者都应给予综合的足部自我管理的教育。B

11.40对高危糖尿病患者,包括严重神经病变者,足畸形或有截肢病史者,建议使用专业的治疗鞋。B

12. 老年人

12.1对老年糖尿病患者考虑进行医学、功能、心理和社会老年领域的评估,以确定治疗目标和治疗方案。C

12.2在日常生活的基本和结构活动受限的老年患者筛查老年人综合征或许是合适的,因为这可影响到糖尿病的自我管理。C

神经认知功能

12.3  65岁及以上的糖尿病患者应该每年筛查及早期检测轻度认知功能受损、痴呆和抑郁。B

低血糖

12.4老年糖尿病患者应该避免低血糖。应该通过调整血糖目标和药物干预来筛查和管理低血糖。B

治疗目标

12.5老年人健康状况良好,较少伴有慢性疾病,机能和认知完整应该设定较低的血糖目标(A1C<7.5%),而多种并存的慢性病,认知障碍或功能较差,应设定较宽松的血糖目标(A1C<8.0-8.5%)。C

12.6对一些老年患者放宽血糖控制目标是合理的,使用个体化标准,但所有患者应避免导致症状或急性高血糖并发症风险的高血糖。C

12.7老年患者筛查糖尿病并发症应该个体化。应特别注意导致功能障碍的并发症。C

12.8在大多数老年患者,应该治疗高血压达到个体化的目标。C

12.9考虑患者获益时间窗,老年患者其他心血管危险因素应该予以个体化治疗。降脂和阿司匹林治疗在预期寿命至少等于一级或二级预防试验时间段的患者或许获益。E

生活方式治疗

12.10 建议老年人优化营养和蛋白质摄取;应该鼓励所有能够安全地从事这些活动的老年人进行定期运动,包括有氧活动和耐力训练。B

药物治疗

12.11在低血糖风险增加的老年人中,首选低血糖风险低的降糖药物。B

12.12在老年人中糖尿病的过度治疗是常见的,应该避免。B

12.13如果可以在个体化A1C目标内实现,则建议对复杂方案进行去强化(或简化)以降低低血糖的风险。B

护理机构和家庭护理的治疗

12.14考虑长期护理机构的糖尿病教育,改善老年人糖尿病的管理。E

12.15居住在长期护理设施的糖尿病患者,需要仔细评估建立血糖目标,根据他们的临床和功能状态,进行合适的降糖药物的选择。E

临终治疗

12.16如果老年糖尿病患者需要姑息治疗,则可能不需要严格的血压控制,停止治疗可能是适当的。同样,血脂管理的强度可以放宽,停止降脂治疗可能是适当的。E

12.17全面舒适,预防令人痛苦的症状,并保持生活质量和尊严是临终糖尿病管理的主要目标。E

(未完。。)

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    2018-12-26 般若傻瓜
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    2018-12-26 xxxx1054
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    2018-12-25 wxl882001

    了解一下

    0

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    2018-12-25 医者仁心5538

    学习了

    0

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    2018-12-24 misszhang

    谢谢MedSci提供最新的资讯

    0

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