18 歲以下第1型糖尿病童的血糖建議控制目標為空腹血糖 90-130 mg/dl，睡前血糖 90-150 mg/dl，HbA1c ＜ 7.5%，並再次強調指標需個別化調整
Type 2 Diabetes Glucose Management Goals
Glycemic targets
美國內分泌臨床醫師協會AACE 建議可將A1C目標值設定在 6.5 以下.
美國糖尿病學會ADA則建議將一般成人A1C目標設定在 7.0 以下
(ADA也建議, 在選擇性的病患, 可將控制目標設為6.5以下例如沒有其他疾病, 預期還有很長的生命, 低血糖風險低, 容易達成目標)
糖化血色素控制目標, 需根據病患特性考量, 多數病患, 建議控制 A1C ≤7.0 %
老年人或有其他共病症的患者, 或預期壽命有限的患者, A1C 標準可上調.
●Glycated hemoglobin (A1C) – Target A1C levels in patients with type 2 diabetes taking insulin should be tailored to the individual, balancing the reduction in microvascular complications (figure 1) with the risk of hypoglycemia and insulin-associated weight gain. A reasonable goal of therapy for most patients might be an A1C value ≤7.0 percent (using an assay aligned to the Diabetes Control and Complications Trial [DCCT] in which the upper limit of normal is 6.0 percent). The A1C goal should be set somewhat higher for older patients, patients with comorbidities, and those with a limited life expectancy. (See "Glycemic control and vascular complications in type 2 diabetes mellitus".)
空腹血糖, 健康人如果要讓A1C小於7, 空腹血糖值通常在 80-130 之間, 老年人如果有慢性腎病, 有低血糖風險, 這些病患的A1C目標值可調高, 空腹血糖標準也可以上調至 150.
●Fasting blood glucose (FBG) – In general, for healthy young and middle-aged adults to achieve an A1C goal ≤7.0 percent, an FBG of 80 to 130 mg/dL (4.4 to 7.2 mmol/L) is usually necessary, but slightly higher levels may suffice [2,3]. In older patients, those with chronic kidney disease, or those with other risk factors for hypoglycemia, in whom the A1C goal is set higher, a higher FBG target (eg, 150 mg/dL) may be used.
美國內分泌臨床醫師協會AACE 建議根據病患的年齡, 共病症, 低血糖風險等等因素來制訂A1C 目標值. 如果身體狀況良好, 可將A1C目標設定在 6.5 以下.
T2D Pharmacotherapy
In patients with T2D, achieving the glucose and A1C targets requires a nuanced approach that balances age, comorbidities, hypoglycemia risk, and many other factors described above (4). The AACE supports an A1C goal of ≤6.5% (48 mmol/mol) for most patients or >6.5% if the lower target cannot be achieved without adverse outcomes. Significant reductions in the risk or progression of nephropathy were seen in the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) study, which targeted an A1C <6.5% in the intensive therapy group versus standard approaches. In ADVANCE, the starting A1C was 7.5% (58 mmol/mol), and rates of hypoglycemia were higher in the intensive therapy group (173). In the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial, intensive glycemic control significantly reduced the risk and/or progression of retinopathy, nephropathy, and neuropathy (174,175). However, in ACCORD, which involved older and middle-aged patients with long-standing T2D who were at high risk for or had established ASCVD and a baseline A1C >8.5% (69 mmol/mol), patients randomized to intensive glucose-lowering therapy (A1C target of <6.0% [42 mmol/mol]) had increased mortality (176). The excess mortality occurred only in patients whose A1C remained >7% (53 mmol/mol) despite intensive therapy, and this critical distinction is sometimes forgotten when the risk and benefits of intensive therapy are discussed. In the standard therapy group (A1C target 7 to 8% [53 to 64 mmol/mol]), mortality followed a U-shaped curve with increasing death rates at both low (<7%) and high (>8%) A1C levels (177). ACCORD showed that cardiovascular autonomic neuropathy may be another useful predictor of cardiovascular risk (178). A combination of cardiovascular autonomic neuropathy and symptoms of peripheral neuropathy increase the odds ratio to 4.55 for ASCVD and mortality (179). In the Veterans Affairs Diabetes Trial (VADT), which had a higher A1C target for intensively treated patients (1.5% lower than the standard treatment group), there were no between-group differences in ASCVD endpoints, cardiovascular death, or overall death during the 5.6-year study period (176,180). After approximately 10 years, however, VADT patients participating in an observational follow-up study were 17% less likely to have a major cardiovascular event if they received intensive therapy during the trial (P<.04; 8.6 fewer cardiovascular events per 1,000 person-years), while mortality risk remained the same between treatment groups
The hemoglobin A1C (A1C) target should be individualized based on numerous factors, such as age, life expectancy, comorbid conditions, duration of diabetes, risk of hypoglycemia or adverse consequences from hypoglycemia, patient motivation, and adherence. Glycemic control targets include fasting and postprandial glucose as determined by self-monitoring of blood glucose (SMBG). In recent years, continuous glucose monitoring (CGM) has become more available for people with T2D and has added a considerable degree of clarity for the patient's and clinician's understanding of the glycemic pattern.
An A1C level of ≤6.5% (48 mmol/mol) is considered optimal if it can be achieved in a safe and affordable manner, but higher targets may be appropriate for certain individuals and may change for a given individual over time.
Severe hypoglycemia occurs more frequently with intensive glycemic control in RCTs where insulin and/or sulfonylureas (SUs) are utilized (173,176,180,182,183). In ACCORD, severe hypoglycemia may have accounted for a substantial portion of excess mortality among patients receiving intensive therapy, although the hazard ratio for hypoglycemia-associated deaths was higher in the standard treatment group (183).
Taken together, this evidence supports individualization of glycemic goals (see Comprehensive Type 2 Diabetes Management Algorithm—Glycemic Control Algorithm) (4). In adults with recent T2D onset and no clinically significant ASCVD, an A1C ≤6.5% (48 mmol/mol), if achieved without substantial hypoglycemia or other unacceptable consequences, may reduce the lifetime risk of micro- and macrovascular complications. A broader A1C range may be suitable for older patients and those at risk for hypoglycemia. A less stringent A1C >6.5% is appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced renal disease or macrovascular complications, extensive comorbid conditions, or long-standing T2D in which the A1C goal has been difficult to attain despite intensive efforts, so long as the patient remains free of polydipsia, polyuria, polyphagia, or other hyperglycemia-associated symptoms. Therefore, selection of glucose-lowering agents should consider a patient's therapeutic goal, age, and other factors that impose limitations on treatment, as well as the attributes and adverse effects of each regimen. Regardless of the treatment selected, patients must be followed regularly and closely to ensure that glycemic goals are met and maintained.
ADA關於A1C 的建議
A1C GOALS
For glycemic goals in older adults, please refer to Section 12 “Older Adults.” For glycemic goals in children, please refer to Section 13 “Children and Adolescents.” For glycemic goals in pregnant women, please refer to Section 14 “Management of Diabetes in Pregnancy.”
Recommendations
6.4 A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol). A
6.5 Providers might reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. C
6.6 Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. B
6.7 Reassess glycemic targets over time based on the criteria in Fig. 6.1 or, in older adults, Table 12.1. E
However, on the basis of physician judgment and patient preferences, select patients, especially those with little comorbidity and long life expectancy, may benefit from adopting more intensive glycemic targets (e.g., A1C target <6.5% [48 mmol/mol]) if they can achieve it safely without hypoglycemia or significant therapeutic burden.
沒有留言:
張貼留言