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1、ADA2024糖尿病诊疗标准更新要点(第二部分)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;(11)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
2、病;(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五至十部分的更新要点。一促进积极健康行为以改善结局要点1新指南建议糖尿病患者考虑采用地中海饮食计划。这种饮食模式富含单不饱和脂肪、多不饱和脂肪和长链脂肪酸,例如鱼类、坚果等食物。这有助于患者降低心血管疾病风险并改善葡萄糖代谢(图1)。5.20CounselpeoplewithdiabetestoconsideraneatingplanemphasizingelementsofaMediterraneaneatingpattern,whichisrichinmonounsaturatedandpo
3、lyunsaturatedfatsandlong-chainfattyacidssuchasfattyfish,nuts,andseeds,toreducecardiovasculardiseaseriskAandimproveglucosemetabolism.B要点2成年糖尿病患者饮酒不要超过推荐的每日限量(成年女性每天喝一杯,成年男性每天喝两杯)。新指南建议戒酒者不要为了改善健康状况而开始饮酒,即使是适量饮酒也不建议(图2)。5.23Adviseadultswithdiabeteswhoconsumealcoholtonotexceedtherecommendeddailylimits(
4、onedrinkperdayforadultwomenandtwodrinksperdayforadultmen).CAdviseabstainerstonotstarttodrink,eveninmoderation,solelyforthepurposeofimprovinghealthoutcomes.C图2要点3新指南强调至少每年对所有糖尿病患者进行抑郁症状筛查,并更频繁地筛查那些自我报告有抑郁史的人(图3)。Recommendations5.41Conductatleastannualscreeningofdepressivesymptomsinallpeoplewithdiabet
5、esandmorefrequentlyamongthosewithaself-reportedhistoryofdepression.Useage-appropriate,validateddepressionscreeningmeasures,recognizingthatfurtherevaluationwillbenecessaryforindividualswhohaveapositivescreen.B要点4新指南建议糖尿病患者练习促进睡眠的行为或习惯(例如,保持一致的睡眠时间表,限制在下午摄入咖啡因)(图4)。5.51Counselpeoplewithdiabetestopract
6、icesleep-promotingroutinesandhabits(e.g.,maintainingconsistentsleepscheduleandlimitingcaffeineintheafternoon).A图4二、血糖目标和低血糖要点5在个体化的血糖目标范围内,对于低血糖风险较高的患者,应停用引起低血糖的药物(胰岛素、磺眼类或格列奈类药物),或改用低血糖风险较低的药物种类。针对需要制定个体化血糖目标范围的患者,若治疗的危害和/或负担可能大于益处的患者,应该减少降糖治疗药物(图5)o6.8aDeintensifyhypoglycemia-causingmedications(in
7、sulin,sulfonylureas,ormeglitinides)zorswitchtoamedicationclasswithlowerhypoglycemiarisk,forindividualswhoareathighriskforhypoglycemia,withinindividualizedglycemicgoals.B6.8bDeintensifydiabetesmedicationsforindividualsforwhomtheharmsand/orburdensoftreatmentmaybegreaterthanthebenefits,withinindividual
8、izedglycemicgoals.B图5要点6新指南建议:低血糖高危人群推荐使用持续葡萄糖监测(CGM)(图6)。6.11dUseofCGMisbeneficialandrecommendedforindividualsathighriskforhypoglycemia.A图6要点7新指南总结了预防低血糖的组成部分及其推荐频率(表1)。Table6.7-Componentsofhypoglycemiapreventionforindividualsatriskforhypoglycemiaatinitial,follow-up.andannualvisitsHypoelycemUpreven
9、tionactionInitialvisitEveryfollow-upvisitAnnualvisitHypoglycemlahistoryassessmentHypoglycemiaawarenessassessmentCognitivefunctionandotherhypoglycemiariskfactorassessmentStructuredpatienteducationfoehypogtycomiapreventionandtreatmentConsiderationofcontinuousglucosemonitoringneedsRecvaluationofdiabete
10、streatmentplanwithdeintnsficatk)nfSlmpllftcdtionroragentmodificationasappropriatettGlucagonprescriptknandtrainingforcksecontactsforInsulin-treatedindividualsorthoseathighhypoglycemicriskTralnirtorMstablishawaroneofhy0glc9miat八Thelistedfrequenciesaretherecommendedminimum;actionsforhypoglycemiaprevent
11、ionshouldbedonmoroftnasneededbscdonCIlngljudgment,lndkatdwithrecurrenthypoglycenMceventsoratinitiationofmedicationwithahighriskforhypoglycemia,tIndicatedwithanylevel2or3hypogtcemia,IntercurrentHlnessvorInitiatinginteractingmedications,tlndicatdwhenimpairedhypoglycemiaawarenessisdetected.表1高危人群预防低血糖组
12、成部分及其推荐频率三、糖尿病技术要点8对于使用个人CGM的糖尿病患者,应在住院期间临床合适的情况下继续使用CGM,并根据机构方案进行确认性护理点血糖测量,以进行胰岛素剂量调整和低血糖的评估(图8)。Recommendations7.33InpeoplewithdiabetesusingpersonalCGM,theuseofCGMshouldbecontinuedwhenclinicallyappropriateduringhospitalization,withconfirmatorypoint-of-careglucosemeasurementsforinsulindosingandhyp
13、oglycemiaassessmentandtreatmentunderaninstitutionalprotocol.B图8四.2型糖尿病的预防和治疗:肥胖和体重管理要点9新指南建议:根据患者的病史、生活环境、喜好等,对肥胖症患者进行个体化初始治疗(即生活方式和营养疗法、药物或代谢手术)。如有必要,可考虑结合不同治疗方法(图9)。8.6Individualizeinitialtreatmentapproachesforobesity(i.e.zlifestyleandnutritionaltherapy,pharmacologicagents,ormetabolicsurgery)Abase
14、donthepersonsmedicalhistory,lifecircumstances,preferences,andmotivation.CConsidercombiningtreatmentapproachesifappropriate.E图9要点10将胰高血糖素样多肽I(GLP-I)受体激动剂或具有更好减重效果的双重葡萄糖依赖型促胰岛素多肽(GIP井口GLP-1受体激动剂作为糖尿病患者肥胖管理的首选药物(图10)。8.17Inpeoplewithdiabetesandoverweightorobesity,thepreferredpharmacotherapyshouldbeaglu
15、cagon-likepeptide1receptoragonistordualglucosedependentinsulinotropicpolypeptideandglucagon-likepeptide1receptoragonistwithgreaterweightlossefficacy(i.e.zSemaglutideortirzepatide),especiallyconsideringtheiraddedweight-independentbenefits(e.g.,glycemicandCardiometabolic).A图10要点11越来越多证据表明代谢手术治疗对肥胖症和2型糖尿病患者(BMI30.0kgf或27.0kgf亚洲人群)的长期益处(图11)。Recommendations8.19ConsidermetabolicsurgeryasaweightandglycemicmanagementapproachinpeoplewithdiabeteswithBMI30.0kgm2(or27.5kgm2inAsianAmericanindividuals)whoareotherwisegoodsurgicalcandidates.A五降糖药物治疗要点12对于