2020 糖尿病血糖控制 第二型糖尿病的藥物治療建議

9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020

American Diabetes Association  Diabetes Care 2020 Jan

PHARMACOLOGIC THERAPY FOR TYPE 2 DIABETES
Recommendations
第二型糖尿病建議使用 metformin 作為起始治療
9.4 Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. A

開始治療後, 應持續使用 metformin , 除非病患無法忍受副作用, 或有禁忌症, 其他抗糖尿病藥物, 包括胰島素, 可以與 metformin 合併使用
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

有些病患在剛開始治療的時候, 可以早期使用組合式療法, 可以延緩治療失敗
9.6 Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. A

有些狀況應早點使用胰島素: 有代謝症狀 (體重減輕), 有高血糖症狀, A1C > 10%, 血糖 > 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

應以病患為中心選擇藥物, 考量心血管疾病, 低血糖風險, 體重, 費用, 發生副作用機率, 以及病患選擇
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

糖尿病患, 如果已有動脈粥狀硬化, 或是動脈粥狀硬化風險高, 或心臟衰竭, 可考慮使用 SGLT2i 或 GLP1RA, 這兩類藥物有助於心血管疾病, 對於心血管疾病益處與 A1C 數值無關.
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

第二型糖尿病如需大幅度降低血糖, 使用口服藥物無法達到血糖治療目標, 可考慮使用 GLP1RA, 優先順位在胰島素之前.
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

第二型糖尿病如果血糖無法達到治療目標, 需即早考慮合併其他藥物治療
9.11 Intensification of treatment for patients with type 2 diabetes not meeting treatment goals should not be delayed. B

每 3-6 個月需重新評估藥物組合及服藥習慣, 將會影響治療的其他因素列入考量
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

第十二章 老年人的血糖控制目標  Recommendations

如果過去健康, 沒有其他慢性疾病, 認知功能正常, 日常生活功能正常, 控制 A1C < 7.5%
如果有多重慢性共病症, 認知功能障礙, 功能異常, 血糖控制目標可以較寬鬆, A1C < 8.0-8.5%
12.5 Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.5% [58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less-stringent glycemic goals (such as A1C <8.0–8.5% [64–69 mmol/mol]). C

老人的血糖控制目標可以稍微寬鬆, 但應避免高血糖引起症狀, 或急性高血糖併發症風險,
12.6 Glycemic goals for some older adults might reasonably be relaxed as part of individualized care, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided in all patients. C

老年人的糖尿病併發症篩檢應客製化, 多注意可能會導致功能異常的併發症
12.7 Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to functional impairment. C

高血壓治療目標應根據每個病患訂定各別目標
12.8 Treatment of hypertension to individualized target levels is indicated in most older adults. C

治療其他心血管疾病危險因子, 對於老人應客製化, 考量其預期壽命, 視情況給予降血脂治療及aspirin 治療.
12.9 Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit. Lipid-lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E