第一步是控制早餐前空腹血糖, 如果早上AC glucone正常, 而A1C 仍超標, 進行第二步
第二步是控制每餐前的血糖, 如果餐前血糖已經達標, 但 A1C 仍超標, 進行第三步
第三步是控制每餐後的血糖, 如果餐後血糖高, 則追加餐前速效胰島素
Insulin Initial dose
Insulin detemir= IDet
Insulin degludec= IDeg
glargine = Gla
第二型糖尿病的胰島素初始劑量相似, (不管是否有服用口服藥, 或以 insulin 替代口服藥, 或使用胰島素做為起始治療方式), 有很多流程圖被發表, 在此提供一種簡易保守的流程.
睡前施打 NPH 或 IDet, 如果病患早上 7-8 AM 測空腹血糖, 往前推 9-10 小時, 施打時間為晚上 10 點.
睡前或早上施打 GLA or IDeg
Gla與IDeg 可以在一天的任何時間施打, 施打 Gla or IDeg 的時間可根據病患喜好做決定, 以提高順從性.
NPH, IDet, Gla 起始劑量都是 0.2u/kg/day., 最低劑量從 10u/day 開始,
IDeg 的起始劑量是 10u/day, 皮下注射
如果空腹血糖 FBG 超過 250, 或已知病患有很高的胰島素阻抗, 初始劑量可以更高
每天測量 FBG, 每三個月測 A1C, 調整藥物劑量
已經使用基礎胰島素, A1C 仍超標, 可測量每餐之前的血糖值
午餐前血糖高 --> 早上施打速效胰島素
晚餐前血糖高--> 早上餐前打NPH 或 午餐前打速效胰島素
睡前血糖高 --> 晚餐前打速效胰島素
For patients with type 2 diabetes, the initial dose of insulin (whether in addition to oral agents, in place of oral agents, or as initial treatment) is similar . Many algorithms have been published; one simple and conservative algorithm is presented here (algorithm 1). We start with bedtime NPH or detemir, taken at 10:00 PM if the person is testing his or her FBG at 7:00 or 8:00 AM, or bedtime or morning glargine or degludec. Since glargine and degludec can be administered any time of day, the timing of daily insulin glargine or degludec is based on patient preference to facilitate adherence. The initial dose for NPH, detemir, or glargine is 0.2 units per kg (minimum 10 units) daily. The initial dose for insulin degludec is 10 units subcutaneously once daily. If FBG levels are very elevated (>250 mg/dL [13.9 mmol/L]), or if a patient is known to be very insulin resistant, initial doses can be higher. Subsequent modifications can be made according to daily measurement of FBG and every three month A1C values.
組合療法- 同時使用口服抗糖尿病藥物與注射胰島素, 藉由不同作用機轉, 達到降血糖的目標, 將胰島素所需總劑量減至最低, 避免體重上升.
加入胰島素治療後, Metformin 通常繼續服用, 其他可以繼續使用的藥物包括, SU, TZD, GLP-RA, DPP-4 inhibitors, SGLT2 inhibitors, 但組合治療的好處, 要與複雜處方及昂貴花費做權衡,
SU 通常逐漸減量停用. 尤其是開始使用隨餐胰島素之後.
●Combination therapy – The rationale for combination oral hypoglycemic drug and insulin therapy is that using glucose-lowering medications with different mechanisms of action may achieve goal glycemia while minimizing total insulin requirements and weight gain [38]. Metformin is often continued with the addition of insulin. Other agents including sulfonylureas, thiazolidinediones, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose co-transporter 2 (SGLT2) inhibitors can also be continued when insulin is added, although the putative advantages of doing so must be balanced against the downside of regimen complexity (polypharmacy) and increased cost. Sulfonylureas are usually tapered and stopped, especially when prandial insulin is started.
胰島素單一療法- 使用胰島素單一療法可能比口服藥搭配胰島素便宜 (metformin 不貴), 但可能導致輕微體重上升(取決於所選藥物), 低血糖事件更多, 少數可能很嚴重
病患開始使用胰島素之後, 或者基礎胰島素劑量調整適當之後, 口服藥物可停用,
較早停藥可能造成血糖短暫上升, 直到胰島素調整至適當劑量之後.
●Insulin monotherapy – Switching to insulin monotherapy may be cheaper than combined oral agent-insulin therapy depending on the combination used (metformin is very inexpensive) but may result in slightly more weight gain, depending on the combination, and more episodes of hypoglycemia, few of which are severe [38]. The oral agent may be discontinued when insulin is initially added or after the patient is on adequate basal insulin. The former approach may be associated with elevations in glucose levels until the dose of injected insulin is sufficient to achieve metabolic control.
胰島素劑量調整, 根據 FBG 和 A1C 數值調整, 對於多數第二型糖尿病患, 單獨使用基礎胰島素就可以維持良好血糖控制, 因為身體自己產生的胰島素可以控制飯後血糖波動,
但對於飯後高血糖導致的 A1C 持續上升, 可能需加上餐前胰島素, 與第一型糖尿病治療相似
使用餐前胰島素需自我監測血糖, 不僅是FBG, 例如, 施打餐前胰島素的時候, 測每餐前的血糖, 來調整餐前劑量(餐前劑量應該是指長效胰島素/基礎胰島素)
Titrating dose — The basal insulin regimen is adjusted based on FBG and A1C values. For many patients with type 2 diabetes, basal insulin alone is often adequate for good glycemic control since endogenous insulin secretion will control the postprandial excursions. However, patients with type 2 diabetes and persistently elevated A1C due to postprandial hyperglycemia may require additional pre-meal insulin, similar to treatment for type 1 diabetes. Pre-meal insulin regimens will require self-monitoring of glucose levels other than just fasting levels (ie, before the meals when rapid-acting insulin is used to help determine and subsequently adjust preprandial dosing).
沒有留言:
張貼留言