心血管疾病中降糖药物治疗的选择__培训课件.ppt

MANAGEMENT GUIDELINESCombination Therapy in Type 2 Diabetes:Pragmatic Approach Early combination of insulin secretagogue + insulin sensitizer Most simple and cost effective: Combination of selective sensitizers If target HbA1c 7% not achieved: Try triple therapy? Continue oral agent(s) + Insulin Rx at PM or HS using Insulin Pen once-daily Sulfonylurea (AM) + Metformin (PM) 5-20 Combination Therapy in Type 2 Diabetes:Decision Considerations HbA1c efficacy Reductions from baseline Reaching target Synergy of mechanisms of action Side effects and toxicity profile Frequency and severity of hypoglycemia Effect on weight gain Avoiding polypharmacy and complex regimens Compliance and convenience Cost 5-1a 糖尿病患者缺乏抗氧化因子，同时内皮功能异常 维生素 E 和 C : 在一组大系列的研究中T2DM患者是缺乏的。 (Sundaram, et al. Clin Sci 1996;90:255-60) 浙江114例糖尿病患者和100例健康人 糖尿病组的血浆维生素C、维生素E和β－胡萝卜素平均含量显著降低 随着病程延长，患者血浆维生素C、维生素E和β－胡萝卜素逐渐降低； 病程与维生素E 、 β－胡萝卜素水平相关最密切。 顾惠娟等,实用新医学.2000,2(9).-769-770 抗氧化剂对内皮功能异常的作用 通过去铁铵的铁螯合作用影响冠状动脉的血管舒缩功能  (Nitenberg, et al. Circulation 1998;97:736-43) 黄酮类对于毛细血管通透性的影响 (Valensi, et al. Diabet Med 1996;13:882-8) (Cohen-Boulakia, et al. Metabolism 2000;49:880-5) 维生素C 可以直接逆转NIDDM患者血流障碍导致的依赖内皮的舒血管作用的异常 (Ting, et al. JCI 1996;97:22-8) 对于1型DM用维生素 E 3个月， 可以使血流障碍导致的依赖内皮的舒血管作用恢复正常  (Skyrme-Jones, et al. Circulation 1999;100: I-756) α硫辛酸 : 对糖尿病神经病变的益处  (Cameron, et al. Diabetologia 1994;37:449-59) Liver Increased Glucose Production Adipose Tissue Increased Lipolysis Increased Free Fatty Acids Pancreatic Beta Cells Decreased Insulin Secretion Thiazolidinedinones (TZDs) Increase Glucose Uptake Skeletal Muscle Decreased Glucose Uptake Defective Insulin Secretion Insulin Resistance Small Intestine Carbohydrate Absorption Hyperglycemia Glucotoxicity Sulfonylureas and Nonsulfonylurea Secretagogues Increase Insulin Secretion TZDs Biguanides D