DM CKD 糖尿病慢性腎病第四期以下, eGFR < 30 藥物選擇

糖尿病慢性腎病第四期以下, eGFR < 30 藥物選擇

BG二甲雙胍
台灣, eGFR < 30 不建議使用

加拿大規定血清肌酸酐濃度超過 1.5 毫 克/毫升的病人，不適用 metformin

SU磺醯尿素
Glipizide 2.5~20 mg/day不須調整劑量
glimepiride 1-8mg/day 低劑量使用 1mg qd
Gliclazide 80-160 bid 或緩釋劑 30-120mg qd  不須調整劑量
gliqidone 45-60 mg/day 不須調整劑量

Meglitinides

Repaglinide 0.5-4mg 隨餐服用, 低劑量使用
Nateglinide 60-120mg 隨餐服用 , 低劑量使用

DPP4i

sitagliptin (Januvia) 2.5 mg QD (四分之一量)
Saxagliptin (Onglyza ) 2.5mg qd (半量)

Linagliptin (Trajenta) 不須調整劑量

Vildagliptin (Galvus) 50mg qd 

TZD

pioglitazone 15-45 mg qd 不須調整劑量
rosiglitazone 4-8 mg qd 不須調整劑量

eGFR < 45 禁止使用SGLT2i. 

Canaglu®可拿糖膜衣錠 canagliflozin 

dapagliflozin/Forxiga 福適佳 

empagliflozin/Jardiance 恩排糖膜衣錠

甲狀腺疾病與糖尿病

參考資料 Thyroid Hormone Effects on Diabetes Jennal L. Johnson, MS, RNC, FNP, BC-ADM, CDE

Diabetes Spectrum 2006 Jul; 19(3): 148-153.

甲狀腺疾病造成的碳水化合物代謝影響, 可能會導致糖尿病失控, 雖然不是每次血糖都受影響, 但甲亢患者有可能因為血糖上升過快, 造成葡萄糖耐受試驗異常, 過多的甲狀腺素會增加消化道吸收. 增加胰島素阻抗及胰島素降解. 
The effect on carbohydrate metabolism can potentially lead to disruptions in diabetes control. Although the glucose level does not always change, there can be an abnormal response to glucose tolerance testing in hyperthyroidism because glucose rises faster than normal.7 Additionally, excessive thyroid hormones increase the rate of digestive tract absorption and thyroid hormone levels and therefore increase insulin resistance and insulin degradation.

甲亢症肝醣合成與降解增加, 造成肝醣貯積下降, 葡萄糖吸收增加, 葡萄糖利用率與產生增加, 周邊組織攝入葡萄糖速率增加, 導致葡萄糖試驗時峰值上升. 胰島素需求量增加, 如果沒有適當解決, 會失去代償. 導致DKA, 此外, 尚未被診斷的DM患者, 甲亢症會增加胰島素阻抗而出現糖尿病, 在甲亢症治療過程, 可能需增加血糖藥物, 直到甲狀腺功能穩定且血糖穩定. 
In hyperthyroidism, glycogen synthesis and degradation increase, leading to decreased glycogen levels.3 Glucose absorption is increased, as well as utilization and production. Peripheral tissues have increased rates of glucose uptake that can lead to the aforementioned exaggerated glucose peak during a timed glucose test. Insulin requirements are increased, and, if not addressed adequately, control can decompensate, leading to diabetic ketoacidosis. Additionally, in patients with undetected diabetes, hyperthyroidism can unmask diabetes because glucose levels can be abnormally elevated because of increased insulin resistance.3 Increased dosages of diabetes medications may be necessary in those already treated, until thyroid function is stabilized and resultant glucose stabilization occurs.

甲狀腺低下症, 肝臟分泌肝醣減少, 降解也減少, 導致肝醣貯積增加, 腸胃道吸收葡萄糖下降, 周邊組織葡萄糖利用率下降, 葡萄糖新生的受質減少. 胰島素半衰期增加, 胰島素濃度下降, 胰島素分泌下降. 導致胰島素需求量降低, 如果外源性胰島素沒有減少, 會導致低血糖. 

甲狀腺低下症治療過程, 血糖可能呈現穩定狀態, 但經過治療之後, 當甲狀腺功能正常, 可能導致血糖濃度上升, 影響血糖控制

In hypothyroidism, liver secretion of glycogen decreases, but so does degradation, leading to increased levels of glycogen. Absorption of glucose from the gastrointestinal tract is slowed, and glucose utilization is slowed in the peripheral tissues. The availability of gluconeogenic substrate is decreased. Additionally, the insulin half-life is prolonged, insulin levels are lower, and insulin secretion is reduced, which may lead to reduced insulin requirements. If exogenous insulin is not decreased, hypoglycemia may occur. It is likely that glucose levels will stabilize during hypothyroidism treatment. But when thyroid function is normalized, this may lead to higher blood glucose levels and adverse effects on glycemic control.

潛伏結核感染治療處方

 參考資料: 疾管署 第十章「潛伏結核感染 (LTBI)」有關LTBI治療處方說明
結核病診治指引-第10章潛伏 結核感染10905修正版
https://www.cdc.gov.tw/Uploads/6b5c1be7-5666-4dea-aabe-0ecbd5826c7d.pdf

3HP 3HR 4R 9H

已服用3HP治療轉換處方建議表

高三酸甘油脂治療 TG levels between 150-885 mg/dL

參考資料: uptodate 

TG過高如果合併LDL超過目標值, 應使用 statin 治療. 

中高劑量 statin 例如 atorvastatin 80 mg qd 或 rosuvastatin 20-40 mg qd. 可以降低 TGs 25-30%, 在TG超過 800mg/dL 的患者甚至可以降 40% 

如果已經使用最大能忍受的statin劑量仍無法將LDL控制在目標值, 可加上 ezetimibe. 

高心血管疾病風險患者, 包括已經確診心血管疾病患者, 糖尿病患, 十年內發生心血管疾病機率>10% 的族群

高心血管疾病風險患者, 如果經過上述治療, TG仍超過 150, 可考慮加上 Fenofibrate 或 icosapent ethyl (或 niacin, 但較少用). 沒有胰臟炎病史的人, 可先服用魚油萃取物 icosapent ethyl, 如果曾有胰臟炎, 可選用 fenofibrate. 如果是高心血管疾病風險患者, 已經服用 fenofibrate, TG仍過高, 可再加上 icosapent ethyl 

icosapent ethyl=Vascepa= 魚油成份處方藥, 魚油中萃取高純度EPA(二十碳五烯酸)

The following is our initial approach to patients with TG levels between 150 and 885 mg/dL 

●All patients should adopt lifestyle modifications similar to those recommended for individuals at high risk of ASCVD . 
All patients not at their LDL-C goal should be treated with a statin.

Statins typically lower TG levels by 5 to 15 percent; however, high-intensity statin therapy can lower TGs by 25 to 30 percent in patients with fasting TGs <400 mg/dL. Larger reductions in TGs of 40 percent have been reported in patients with fasting TGs as high as 800 mg/dL with treatment with a moderate- to high-dose high-intensity statin (atorvastatin 80 mg daily, rosuvastatin 20 or 40 mg daily) [125,126]. Goals for the treatment of LDL-C are presented elsewhere.

●For patients who are not at LDL-C goal with maximally tolerated statin dose, we add ezetimibe.

●For patients with a TG level >150 mg/dL who have been managed with the above approach and who are at high risk of cardiovascular disease, we consider adding a drug that lowers non-HDL-C through effects of VLDL (eg, fenofibrate, icosapent ethyl, or rarely niacin) to further lower TG. High cardiovascular risk includes patients with known ASCVD or diabetes and those with a 10-year risk of a cardiovascular disease event >10 percent. 

For these high-risk patients we usually start with icosapent ethyl. However, if the patient has a history of pancreatitis, we might start with fenofibrate. If after adding either icosapent ethyl or fenofibrate the TG level remains >150 mg/dL, we consider adding the other drug based on clinical circumstances. For example, if the cardiovascular risk is high and we had started with fenofibrate, we consider adding icosapent ethyl.