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1、ADA糖尿病诊疗标准更新要点2024IA刖言2023年12月11日ADA发布了最新2024版糖尿病诊疗标准,主要内容涉及ADA当前所有的临床实践建议,共包括17部分内容:(1)改善诊疗并促进群体健康;(2)糖尿病诊断和分类;(3)预防或延缓糖尿病及相关合并症;(4)综合医学评估和合并症评估;(5)促进积极健康行为以改善结局;(6)血糖目标和低血糖;(7)糖尿病技术;(8)2型糖尿病的预防和治疗:肥胖和体重管理;(9)降糖药物治疗;(10)心血管疾病和风险管理;(Il)慢性肾病和风险管理;(12)视网膜病变、神经病变和足部诊疗;(13)老年患者;(14)儿童和青少年患者;(15)妊娠期糖尿病;(
2、16)院内糖尿病管理;(17)糖尿病倡导。新版指南纳入了更多循证医学证据,本文梳理了新指南的第一至四部分的更新要点。一糖尿病的诊断与分类要点1建议根据糖化血红蛋白或血糖标准诊断糖尿病,血糖标准包括空腹血糖(FPG)值、75克口服葡萄糖耐量试验(OGTT)的2小时血糖(2-hPG)值,还是伴有典型高血糖症状/危象标准的随机血糖值。在没有明确的高血糖(例如,高血糖危象)的情况下,需要进行一次验证性诊断试验(表2)o新指南将AlC置于的诊断试验的顶部,以强调其在诊断糖尿病和糖尿病前期时的临床实践地位。并且强调了在发现异常血糖结果时进行确诊测验的重要性(图1、表1)。Recommendations2.
3、1aDiagnosediabetesbasedonAlCorplasmaglucosecriteria,eitherthefastingplasmaglucose(FPG)value,2-hplasmaglucose(2-hPG)valueduringa75-goralglucosetolerancetest(OGTT)zorrandomglucosevalueaccompaniedbyclassichyperglycemicsymptoms/crisescriteria(Table2.1).A2.1bIntheabsenceofunequivocalhyperglycemia(e.g.,hy
4、perglycemiccrises),diagnosisrequiresconfirmatorytesting(Table2.1).A图1Table 2.1- riteriaforthediagnosisofdiabetesinnonpregnantindividualsAlC6.5%(48mmol/mol).Thetestshouldbeperformedinalaboratoryusingamethod外atisNGSPcertifiedandstandardizedtotheDCCTassay.*1 ORFPG126mg/dL(7.0mmolL).Fastingisdefinedasno
5、caloricintakeforatleast8h.*OR2-hPG200mg/dL(11.1mmolL)duringOGTT.ThetestshouldbeperformedasdescribedbytheWHO,usingaglucoseloadcontainingtheequivalentof75ganhydrousglucosedissolvedinwater.,ORInanindividualwithclassicsymptomsofhyperglycemiaorhyperglycemiccrisis,arandomplasmaglucose2mg/dL(11.1mmolL).Ran
6、domisanytimeofthedaywithoutregardtotimesincepreviousmeal.DCCTDiabetesControlandComplicationsTrial;FPG,fastingplasmaglucose;OGTT,oralglucosetolerancetest;NGSf*NationalGlycohemoglobinStandardizationProgram;WHO,WorldHealthOrganization;2-hPG,2-hplasmaglucose,lntheabsenceofunequivocalhyperglycemia,diagno
7、sisrequirestwoabnormaltestresultsobtainedatthesametime(e.g.,AlCandFPG)orattwodifferenttimepoints.表1.糖尿病诊断标准Table 2.2- riteriadefiningprediabetesinnonpregnantindividualsAlC5.7-6.4%(39-47mmol/mol)ORFPG1mg/dL(5.6mmolL)to125mg/dL(6.9mmolL)(IFG)OR2-hPGduring75-gOGTT140mg/dL(7.8mmolL)to199mg/dL(11.0mmolL)
8、(IGT)Forallthreetests,riskisntinuous,extendingbelowthelowerlimitoftherangeandbecomingdisproportionatelygreateratthehigherendoftherange.FPG,fastingplasmaglucose;IFG,impairedfastingglucose;IGTimpairedglucosetolerance;OGTT,oralglucosetolerancetest;2-hPG,2-hplasmaglucose.表2.糖尿病前期(未怀孕个体)诊断标准要点2新指南新增为新诊断的
9、成人疑似1型糖尿病的筛查提供了一个结构化的框架(图2)。200 pmol/L2OOOO pmol/LEl600 pmol/L200 pmol/LIType 1diabetesType 2diabetes图2.成人疑诊1型糖尿病筛查流程图要点3对症状前1型糖尿病的筛查可以通过检测胰岛素、谷氨酸脱竣酶(GAD)、胰岛抗原2(IA-2)或锌转运蛋白8(ZnT8)的自身抗体来完成。有多个确认的胰岛自身抗体是临床糖尿病的危险因素。血糖异常检测可用于进一步预测近期风险。当鉴定出多个胰岛自身抗体时,应考虑转诊到专门的中心进行进一步评估和/或考虑临床试验或批准的治疗方法,以潜在地延缓临床糖尿病的发展(图3)。
10、Recommendations2.6 Screeningforpresymptomatictype1diabetesmaybedonebydetectionofautoantibodiestoinsulin,glutamicaciddecarboxylase(GAD),isletantigen2(IA-2)zorzinctransporter8(ZnT8).B2.7 Havingmultipleconfirmedisletautoantibodiesisariskfactorforclinicaldiabetes.Testingfordysglycemiamaybeusedtofurtherf
11、orecastnear-termrisk.Whenmultipleisletautoantibodiesareidentified,referraltoaspecializedcenterforfurtherevaluationand/orconsiderationofaclinicaltrialorapprovedtherapytopotentiallydelaydevelopmentofclinicaldiabetesshouldbeconsidered.B2.8 Standardizedisletautoantibodytestsarerecommendedforclassificati
12、onofdiabetesinadultswhohavephenotypicriskfactorsthatoverlapwiththosefortype1diabetes(eg,youngerageatdiagnosis,unintentionalweightloss,ketoacidosis,orshorttimetoinsulintreatment).E要点42019年冠状病毒(新冠肺炎)感染和新发的1型糖尿病之间可能的联系。正在服用糖皮质激素、他汀类药物、曝嗪类利尿剂、抗艾滋病毒药物以及第二代抗精神病药物人群会增加糖尿病前期和2型糖尿病风险,新指南强调这类人群筛查糖尿病的必要性(图4)。2
13、.15 bInpeoplewhoareprescribedsecond-generationantipsychoticmedications,screenforprediabetesanddiabetesatbaselineandrepeat12-16weeksaftermedicationinitiationorsooner;ifclinicallyindicated,andannually.B2.16 PeoplewithHIVshouldbescreenedfordiabetesandprediabeteswithanFPGtestbeforestartingantiretroviral
14、therapy,atthetimeofswitchingantiretroviraltherapand3-6monthsafterstartingorswitchingantiretroviraltherapy.Ifinitialscreeningresultsarenormal,FPGshouldbecheckedannually.E要点6强调在急性胰腺炎发作后或慢性胰腺炎患者中筛查糖尿病的重要性。新指南建议:在急性胰腺炎发作后3-6个月内筛查糖尿病患者,此后每年筛查一次;每年对慢性胰腺炎患者进行糖尿病筛查(图5)。Recommendation2.17 Screenpeoplefordiab
15、eteswithin3-6monthsfollowinganepisodeofacutepancreatitisandannuallythereafter.Screeningfordiabetesisrecommendedannuallyforpeoplewithchronicpancreatitis.E图5要点7由于敏感性较低,不建议将AlC作为囊性纤维化相关糖尿病(CFRD)的筛查试验,但它在临床实践中被广泛使用,并且AIC值6.5%(48mmol/mol)与CFRD的诊断相符合。2.19 AlCisnotrecommendedasascreeningtestforCFRDduetolow
16、sensitivity.However;avalueof6.5%(48mmol/mol)isconsistentwithadiagnosisofCFRD.B图6二、预防或延缓糖尿病及相关并发症新指南建议:在临床前1型糖尿病患者中,每6个月检测A1C用以监测疾病进展,每年进行75克口服葡萄糖耐量试验(即空腹和2小时血糖);根据基于年龄、自身抗体数量和类型以及血糖指标的个人风险评估修改监测频率。强调检测1型糖尿病高危人群的重要性(图7)。3.2Inpeoplewithpreclinicaltype1diabetes,monitorfordiseaseprogressionusingAlCapproxima