DESIGNING AN INSULIN REGIMEN 基礎胰島素與隨餐胰島素

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DESIGNING AN INSULIN REGIMEN

臨床醫師應該要對幾種糖尿病的治療很熟悉, 始終如一的使用.
We advise clinicians to familiarize themselves with a limited number of regimens 養生之道 (to facilitate addressing 對病患說  patient preferences個人偏好, lifestyle [meal and activity patterns], etc) and use them consistently.

經過適當調整劑量後, 不同胰島素對於降血糖的效果差異不大.
在現實的治療, 基礎胰島素的劑量經常使用不足,
多數的研究僅能提供各種胰島素的降血糖效果, 對於不同種類的胰島素, 微細血管及大血管併發症或死亡率的資訊未能提供. 對於降低A1C的差異, 有時候會被不良反應(低血糖)抵銷.
The glycemic differences achieved among different insulin regimens, assuming that they are adequately titrated, are modest. However, basal insulin is frequently suboptimally titrated in actual clinical practice [19]. The majority of the studies provide information on lowering of glycemia but do not provide information regarding the effects of various insulin regimens on microvascular or macrovascular complications or mortality. When differences in A1C levels have been found, they are sometimes offset by adverse events such as hypoglycemia.

對於即將使用胰島素的病患, 建議選擇基礎胰島素, 而非隨餐胰島素, 基礎胰島素可以改善夜間血糖及空腹血糖, 餐前胰島素可以降低餐後血糖波動,
基礎胰島素與隨餐胰島素, 何者更能改善小血管併發症仍未知.
不同種類的胰島素對於心血管併發症的影響並無差異.
Insulin initiation — For patients who are initiating insulin (in addition to oral agents, in place of oral agents, or as initial treatment), we suggest initiating basal, rather than prandial, insulin. Basal insulin will improve nocturnal and fasting blood glucose (空腹血糖 FBG), whereas prandial (pre-meal) bolus insulin will decrease postprandial glucose excursions. Whether a basal or a prandial strategy is more effective in improving microvascular complications remains uncertain. The type of insulin regimen (basal or prandial) does not appear to affect cardiovascular outcomes.

使用基礎胰島素做為起始治療, 優點是方便, 簡單, 尤其是第一次使用胰島素的病患, 雖然基礎胰島素與隨餐胰島素, 針對治療目標積極調整劑量之後, 對於降低  A1C 的結果相似, 基礎胰島素的病患滿意度較高, 低血糖機率較低
Initiation of insulin therapy with a basal insulin has the advantage of convenience and simplicity in patients who are using insulin for the first time. Although basal and prandial insulin are similarly effective in improving A1C when insulin doses are aggressively titrated to achieve glycemic goals, basal insulin is associated with greater patient satisfaction and less frequent hypoglycemia [20,21]. As examples:

隨機研究, 收錄經過 metformin 及 SU 治療後, 血糖仍控制不良的患者, 共收錄 415位, , 一天打一次 insulin glargine 與隨餐胰島素 lispro 比較, 最後降低 A1C 的結果相近(1.7 VS 1.9), 兩組之中, A1C 降低至6.5~7.0 的人數比例, 分別是 27% VS 30%, 基礎胰島素的病患滿意度較高, 低血糖事件較少
●In a randomized trial of once-daily insulin glargine versus prandial insulin lispro in 415 patients who were inadequately controlled with metformin and a sulfonylurea, there were similar improvements in A1C (mean decrease of 1.7 and 1.9 percent, respectively) and target A1C concentrations between 6.5 and 7.0 percent were achieved by 27 and 30 percent of subjects, respectively [20]. Basal insulin was associated with greater patient satisfaction and less hypoglycemia.

這篇研究標題是第二型糖尿病患, 高血糖對於急性心肌梗塞後的心血管結果之影響, 簡稱 HEART2D 研究, 實驗設計是為了評估隨餐血糖 lispro 與基礎胰島素 NPH BID 或 insulin glargine QD, 對於病患心血管結果的影響, 總共收錄 1115 位心肌梗塞之後的病患, 實驗開始時, 有 50% 病患使用 metformin 和 SU, 單獨使用或兩個並用, 其他病患則使用胰島素做為單一治療. 追蹤2.7年後, 因為兩者沒有太大差異使得研究提早結束, 兩組對於 A1C 分別降到 7.7% VS 7.8%, 對於 cardiovascular outcomes 心血管結果的影響差異不大

cardiovascular event 心血管事件包括: 心血管死亡, 非致死性心肌梗塞, 非致死性中風, 冠狀動脈血管重建, 因急性冠心症住院)
(cardiovascular death, nonfatal MI, nonfatal stroke, coronary revascularization, or hospitalization for an acute coronary syndrome).)

●The Hyperglycemia and its Effect After Acute Myocardial Infarction on Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus (HEART2D) trial was designed to evaluate the effects of prandial (lispro) or basal (NPH twice daily or insulin glargine once daily) insulin on cardiovascular outcomes in 1115 patients after myocardial infarction (MI) [18]. At baseline, 50 percent of the patients were taking metformin, sulfonylureas, or both, whereas the remaining patients were treated with insulin monotherapy. At a mean follow-up of 2.7 years, the trial was stopped early due to lack of efficacy. There was no difference between the prandial and basal groups in A1C (7.7 versus 7.8 percent). The cardiovascular outcomes are reviewed above.