Recommendations
建議Metformin 做為起始藥物,
9.4 Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. A
開始使用metformin後, 如果病患可容忍且沒有禁忌症, 應持續使用, 其他藥物, 包含胰島素, 可與 metformin 並用
9.5 Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. A
對於特定病患, 可考慮早期使用組合治療, 可以延緩治療失敗的時間
9.6 Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. A
有些狀況建議早期使用胰島素: 有進行性異化作用(大分子分解為小分子,體重減輕), 有高血糖症狀, 或 A1C > 10%, 或血糖超過 300.
9.7 The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. E
以病患為中心的治療策略選擇藥物, 考量因素包括: 心血管共病症, 低血糖風險, 體重增減, 副作用機率, 以及病患喜好.
9.8 A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include cardiovascular comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences (Table 9.2 and Figure 9.1). E
第二型DM病患如果已經確診動脈粥粥狀硬化的心血管疾病, 或有心血管疾病危險因子, 慢性腎病, 心衰竭, 可考慮 SGLT2i 或 GLP1RA, 這兩類藥物對心血管疾病有益處.
9.9 Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit (Table 9.1, Table 10.3B, Table 10.3C) is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors (Figure 9.1). A
第二型DM病患, 如果血糖需降低的幅度大於口服藥物的降血糖作用, 選擇 GLP1RA 優於胰島素.
9.10 In patients with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, glucagon-like peptide 1 receptor agonists are preferred to insulin when possible. B
第二型DM病患如果沒有達到治療目標, 應及早使用組合治療
9.11 Intensification of treatment for patients with type 2 diabetes not meeting treatment goals should not be delayed. B
應常規檢視病患的處方, 及病患用藥行為 (每 3-6 個月), 根據特定因素調整藥物
9.12 The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment (Fig. 4.1 and Table 9.1). E
美國糖尿病學會/歐洲糖尿病共識研究, 建議以病患為中心的治療策略, 考量治療效果與病患的關鍵因子, 來選擇最適合的治療方式
1. 已罹患重要的共病症(例如動脈粥狀硬化的心血管疾病 ASCVD), 具 ASCVD 危險因子, 慢性腎病, 心衰竭
2. 低血糖風險
3. 是否影響體重
4. 副作用
5. 費用
6. 病患喜好(例如有人堅持不打胰島素)
The American Diabetes Association/European Association for the Study of Diabetes consensus report “Management of Hyperglycemia in Type 2 Diabetes, 2018” and the 2019 update (33,34) recommend a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose (Fig. 9.1). This includes consideration of efficacy and key patient factors: 1) important comorbidities such as atherosclerotic cardiovascular disease (ASCVD) and indicators of high ASCVD risk, chronic kidney disease (CKD), and heart failure (HF) (see Section 10 “Cardiovascular Disease and Risk Management,” https://doi.org/10.2337/dc20-S010, and Section 11 “Microvascular Complications and Foot Care,” https://doi.org/10.2337/dc20-S011), 2) hypoglycemia risk, 3) effects on body weight, 4) side effects, 5) cost, and 6) patient preferences.
不管用哪一種藥, 都要對病患強調, 改變生活習慣以促進健康,
Lifestyle modifications that improve health (see Section 5 “Facilitating Behavior Change and Well-being to Improve Health Outcomes,” https://doi.org/10.2337/dc20-S005) should be emphasized along with any pharmacologic therapy. Section 12 “Older Adults” (https://doi.org/10.2337/dc20-S012) and Section 13 “Children and Adolescents” (https://doi.org/10.2337/dc20-S013) have recommendations specific for older adults and for children and adolescents with type 2 diabetes, respectively; Section 10 “Cardiovascular Disease and Risk Management” (https://doi.org/10.2337/dc20-S010) and Section 11 “Microvascular Complications and Foot Care” (https://doi.org/10.2337/dc20-S011) have recommendations for the use of glucose-lowering drugs in the management of cardiovascular and renal disease, respectively.
抗糖尿病藥物與腎功能考量
Metformin eGFR < 30 禁用
SGLT2i 需根據腎功能調整劑量
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