糖尿病诊疗标准更新要点2024.docx

糖尿病诊疗标准更新要点20242023年12月11日，ADA发布了最新2024版糖尿病诊疗标准，主要内容涉及ADA当前所有的临床实践建议，共包括17部分内容：（1）改善诊疗并促进群体健康；（2）糖尿病诊断和分类；（3）预防或延缓糖尿病及相关合并症；（4）综合医学评估和合并症评估；（5）促进积极健康行为以改善结局；（6）血糖目标和低血糖；（7）糖尿病技术；（8）2型糖尿病的预防和治疗：肥胖和体重管理；（9）降糖药物治疗；（10）心血管疾病和风险管理；（11）慢性肾病和风险管理；（12）视网膜病变、神经病变和足部诊疗；（13）老年患者；（14）儿童和青少年患者;（15）妊娠期糖尿病；（16）院内糖尿病管理；（17）糖尿病倡导。新版指南纳入了更多循证医学证据，本文梳理了新指南的第十至十七部分的更新要点。一、慢性肾病和风险管理要点1新指南纳入了ACE抑制剂或血管紧张素受体阻滞剂在预防肾脏疾病进展和减少心血管事件方面的作用（图1）。11.4aInnonpregnantpeoplewithdiabetesandhypertension,eitheranACEinhibitororanangiotensinreceptorblocker（ARB）isrecommendedforthosewithmoderatelyincreasedalbuminuria（UACR30-299mg/gcreatinine）Bandisstronglyrecommendedforthosewithseverelyincreasedalbuminuria（UACR300mg/gcreatinine）and/oreGFR<60mL/min/1.73m2topreventtheprogressionofkidneydiseaseandreducecardiovascularevents.A对于慢性肾脏病（CKD）G3期（30mlmin1.73m2<egfr<60mlmin1.73m2）或更高期的糖尿病肾病患者，膳食蛋白质摄入量的目标是每天0.8gkg。对于一些透析患者,蛋白质摄入量建议每天1.0-1.2gkg（图2）o11.7Forpeoplewithnon-dialysisdependentstageG3orhigherCKD,dietaryproteinintakeshouldbeaimedtoatargetlevelof0.8g/kgbodyweightperday.AForindividualsondialysis,1.0-1.2g/kg/dayofdietaryproteinintakeshouldbeconsideredsinceproteinenergywastingisamajorprobleminsomeindividualsondialysis.B图2要点3新指南总结了改善糖尿病合并慢性肾脏疾病患者预后的整体方法（图3）。二、视网膜病变.神经病变和足部诊疗要点4因为糖尿病引发视力损失，建议受影响的个体咨询有关视觉康复护理的可行性和覆盖范围，并由经验丰富的视觉康复专业人员提供或推荐接受全面的视觉障碍评估(图4)。Recommendations12.15Peoplewhoexperiencevisionlossfromdiabetesshouldbecounseledontheavailabilityandscopeofvisionrehabilitationcareandprovided,orreferredfor;acomprehensiveevaluationoftheirvisualimpairmentbyapractitionerexperiencedinvisionrehabilitation.E12.16Peoplewithvisionlossfromdiabetesshouldreceiveeducationalmaterialsandresourcesforeyecaresupportinadditiontoself-managementeducation(e.g.,glycemicmanagementandhypoglycemiaawareness).E三.老年患者对于患有糖尿病的老年人，建议采用个性化的血糖目标，比如认知功能比较强或其他功能状态稳定的老年糖尿病患者应将糖化血红蛋白目标定为7%-7.5%,否则应放宽至小于8%并考虑降低引起低血糖的药物的强度，或换用低血糖风险较低的药物类别(图5a5b)Recommendations13.8aOlderadultswithdiabeteswhoareotherwisehealthywithfewandstablecoexistingchronicillnessesandintactcognitivefunctionandfunctionalstatusshouldhavelowerglycemicgoals(suchasAlC<7.0-7.5%<5358mmolmol).C13.8bOlderadultswithdiabetesandintermediateorcomplexhealthareclinicallyheterogeneouswithvariablelifeexpectancy.Selectionofglycemicgoalsshouldbeindividualized,withlessstringentgoals(suchasAlC<8.0%<64mmolmol)forthosewithsignificantcognitiveand/orfunctionallimitations,frailt½severecomorbidities,andalessfavorablerisk-to-benefitratioofdiabetesmedications.C13.8cOlderadultswithverycomplexorpoorhealthreceiveminimalbenefitfromstringentglycemiccontrol,andcliniciansshouldavoidrelianceonglycemicgoalsandinsteadfocusonavoidinghypoglycemiaandsymptomatichyperglycemia.C图5b要点6在个体化的血糖目标范围内，对于那些治疗可能带来伤害和/或负担大于好处的患者，建议减低糖尿病药物的强度。此外，可以考虑简化复杂的治疗计划，特别是胰岛素，以降低低血糖和多药联用的风险，减轻治疗负担，前提是在使用个性化血糖目标的情况下能够达到治疗目标（图6a、6b）o对于已明确患有或处于高风险的包括动脉粥样硬化性心血管疾病、心力衰竭和/或慢性肾脏疾病在内的2型糖尿病老年患者，治疗方案应涵盖减少心肾风险的药物，而不仅仅局限于血糖控制（图6b）。13.16aInolderadultswithdiabetes,deintensifyhypoglycemia-causingmedications(e.g.,insulin,sulfonylureas,ormeglitinides)orswitchtoamedicationclasswithlowhypoglycemiariskforindividualswhoareathighriskforhypoglycemia,usingindividualizedglycemicgoals.B13.16bInolderadultswithdiabetes,deintensifydiabetesmedicationsforindividualsforwhomtheharmsand/orburdensoftreatmentmaybegreaterthanthebenefits,withinindividualizedglycemicgoals.E图6a13.16cSimplificationofcomplextreatmentplans(especiallyinsulin)isrecommendedtoreducetheriskofhypoglycemiaandpolypharmacyanddecreasethetreatmentburdenifitcanbeachievedusingtheindividualizedglycemicgoals.B13.16dInolderadultswithtype2diabetesandestablishedorhighriskofatheroscleroticcardiovasculardisease,heartfailure,and/orchronickidneydisease,thetreatmentplanshouldincludeagentsthatreducecardiorenalrisk,irrespectiveofglycemia.A在为超重或肥胖的2型糖尿病的青少年选择降糖或其他药物时，应考虑服药行为和药物对体重的影响（图7）。14.69Whenchoosingglucose-loweringorothermedicationsforyouthwithoverweightorobesityandtype2diabetes,considermedication-takingbehaviorandthemedications,effectonweight.E要点8肾病患者蛋白质摄入量应达到推荐的每日摄入量0.85-1.2gkgd（视年龄而定）（图8）。Recommendations14.78Proteinintakeshouldbeattherecommendeddailyallowanceof0.85-1.2g/kg/day（accordingtoage）.E图8五.妊娠期糖尿病要点9建议妊娠期糖尿病患者进行空腹、餐前和餐后血糖监测，以达到最佳的血糖水平。血糖目标为空腹血糖<95mgdL(<5.3mmolL),餐后Ih血糖<140mgdL(<7.8mmolL)或餐后2h血糖<120mgdL(<6.7mmolL)(图9)。Recommendations15.7Fasting,preprandial,andpostprandialbloodglucosemonitoringarerecommendedinindividualswithdiabetesinpregnancytoachieveoptimalglucoselevels.Glucosegoalsarefastingplasmaglucose<95mg/dL(<5.3mmolL)andeither1-hpostprandialglucose<140mg/dL(<7.8mmolL)or2-hpostprandialglucose<120mg/dL(<6.7mmolL).B要点10推荐CGM用于与妊娠的1型糖尿病患者。实时CGM可以降低妊娠合并1型糖尿病的大胎龄儿和新生儿低血糖的风险（图10)o15.10CGMisrecommendedinpregnanciesassociatedwithtype1diabetes.AWhenusedinadditiontobloodglucosemonitoring,achievingtraditionalpre-andpostprandialgoals,real-timeCGMcanreducetheriskforlarge-for-gestationalageinfantsandneonatalhypoglycemiainpregnancycomplicatedbytype1diabetes.A胰岛素是治疗妊娠期糖尿病高血糖的首选药物。二甲双服和格列本版单独或联合使用不应作为一线药物，因为两者都会通过胎盘影响到胎儿（图11）。15.15InsulinisthepreferredmedicationfortreatinghyperglycemiainGDM.Metforminandglyburide,individuallyorincombination,shouldnotbeusedasfirst-lineagents,asbothcrosstheplacentatothefetus.AOtheroralandnoninsulininjectableglucose-loweringmedicationslacklongtermsafetydata.E图11六、院内糖尿病管理要点12对于持续性高血糖的治疗，应开始或加强胰岛素和/或其他疗法，对于非重症患者（非重症监护室）患者，应以180mgdL（10.0mmol.L）的门槛开始治疗（在24小时内两次确认）（图12）。Recommendations16.4 InsulinAand/orothertherapiesBshouldbeinitiatedorintensifiedfortreatmentofpersistenthyperglycemiastartingatathresholdof180mg/dL(10.0mmolL)(confirmedontwooccasionswithin24h)fornoncriticallyill(non-ICU)individuals.A建议对大多数高血糖重症患者设定血糖目标在140-180mg/dL(7.8-10.0mmol/L)o对于特定危重病人,可能考虑更为严格的血糖目标，例如110-140mg/dU6.1-7.8mmolL)z前提是在不引起明显低血糖的情况下(图13a、13b)o16.5 aOncetherapyisinitiated,aglycemicgoalof140-180mg/dL(7.8-10.0mmol/L)isrecommendedformostcriticallyill(ICU)individualswithhyperglycemia.A图13a16.5bMorestringentglycemicgoals,suchas110-140mg/dL(6.1-7.8mmolL)zmaybeappropriateforselectedcriticallyillindividualsandareacceptableiftheycanbeachievedwithoutsignificanthypoglycemia.B对于因心力衰竭住院的2型糖尿病患者，在急性病情康复后，如果没有禁忌症，建议在住院期间和出院时开始或继续使用钠-葡萄糖共转运体2抑制剂（图14）。Recommendation16.11Forpeoplewithtype2diabeteshospitalizedwithheartfailure,itisrecommendedthatuseofasodiumglucosecotransporter2inhibitorbeinitiatedOrcontinuedduringhospitalizationandupondischarge,iftherearenocontraindicationsandafterrecoveryfromtheacuteillness.A图14