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首页 糖尿病治疗指南2007及其解读

糖尿病治疗指南2007及其解读.pdf

糖尿病治疗指南2007及其解读

ak472828
2009-01-17 0人阅读 举报 0 0 暂无简介

简介:本文档为《糖尿病治疗指南2007及其解读pdf》,可适用于自然科学领域

StandardsofMedicalCareinDiabetesAMERICANDIABETESASSOCIATIONCONTENTSICLASSIFICATIONANDDIAGNOSIS,pSAClassificationBDiagnosisIISCREENINGFORDIABETES,pSIIIDETECTIONANDDIAGNOSISOFGESTATIONALDIABETESMELLITUS,pSIVPREVENTIONDELAYOFTYPEDIABETES,pSVDIABETESCARE,pSAInitialevaluationBManagementCGlycemiccontrolAssessmentofglycemiccontrolaSelfmonitoringofbloodglucosebACGlycemicgoalsApproachtotreatmentDMedicalnutritiontherapyEDiabetesselfmanagementeducationFPhysicalactivityGPsychosocialassessmentandcareHReferralfordiabetesmanagementIIntercurrentillnessJHypoglycemiaKImmunizationVIPREVENTIONANDMANAGEMENTOFDIABETESCOMPLICATIONS,pSACardiovasculardiseaseHypertensionbloodpressurecontrolDyslipidemialipidmanagementAntiplateletagentsSmokingcessationCoronaryheartdiseasescreeningandtreatmentBNephropathyscreeningandtreatmentCRetinopathyscreeningandtreatmentDNeuropathyEFootcareVIIDIABETESCAREINSPECIFICPOPULATIONS,pSAChildrenandadolescentsBPreconceptioncareCOlderindividualsVIIIDIABETESCAREINSPECIFICSETTINGS,pSADiabetescareinthehospitalBDiabetescareintheschoolanddaycaresettingCDiabetescareatdiabetescampsDDiabetescareatcorrectionalinstitutionsEEmergencyanddisasterpreparednessIXHYPOGLYCEMIAANDEMPLOYMENTLICENSURE,pSXTHIRDPARTYREIMBURSEMENTFORDIABETESCARE,SELFMANAGEMENTEDUCATION,ANDSUPPLIES,pSXISTRATEGIESFORIMPROVINGDIABETESCARE,pSDiabetesisachronicillnessthatrequirescontinuingmedicalcareandpatientselfmanagementeducationtopreventacutecomplicationsandtoreducetheriskoflongtermcomplicationsDiabetescareiscomplexandrequiresthatmanyissues,beyondglycemiccontrol,beaddressedAlargebodyofevidenceexiststhatsupportsarangeofinterventionstoimprovediabetesoutcomesThesestandardsofcareareintendedtoprovideclinicians,patients,researchers,payors,andotherinterestedindividualswiththecomponentsofdiabetescare,treatmentgoals,andtoolstoevaluatethequalityofcareWhileindividualpreferences,comorbidities,andotherpatientfactorsmayrequiremodificationofgoals,targetsthataredesirableformostpatientswithdiabetesareprovidedThesestandardsarenotintendedtoprecludemoreextensiveevaluationandmanagementofthepatientbyotherspecialistsasneededFormoredetailedinformation,refertorefs–TherecommendationsincludedarediagnosticandtherapeuticactionsthatareknownorbelievedtofavorablyaffecthealthoutcomesofpatientswithdiabetesAgradingsystem(Table),developedbytheAmericanDiabetesAssociation(ADA)andmodeledafterexistingmethods,wasutilizedtoclarifyandcodifytheevidencethatformsthebasisfortherecommendationsThelevelofevidencethatsupportseachrecommendationislistedaftereachrecommendationusingthelettersA,B,C,orEICLASSIFICATIONANDDIAGNOSISAClassificationIn,ADAissuednewdiagnosticandclassificationcriteria()in,modificationsweremaderegardingthediagnosisofimpairedfastingglucose(IFG)()Theclassificationofdiabetesincludesfourclinicalclasses:●Typediabetes(resultsfrom�celldestruction,usuallyleadingtoabsoluteinsulindeficiency)●Typediabetes(resultsfromaprogressiveinsulinsecretorydefectonthebackgroundofinsulinresistance)●Otherspecifictypesofdiabetesduetoothercauses,eg,geneticdefectsin●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●Therecommendationsinthisarticlearebasedontheevidencereviewedinthefollowingpublication:Standardsofcarefordiabetes(TechnicalReview)DiabetesCare:–,OriginallyapprovedMostrecentreviewrevision,OctoberAbbreviations:ABI,anklebrachialindexAMI,acutemyocardialinfarctionARB,angiotensinreceptorblockerCAD,coronaryarterydiseaseCBG,capillarybloodglucoseCHD,coronaryheartdiseaseCHF,congestiveheartfailureCKD,chronickidneydiseaseCMS,CentersforMedicareandMedicaidServicesCSII,continuoussubcutaneousinsulininfusionCVD,cardiovasculardiseaseDCCB,dihydropyridinecalciumchannelblockerDCCT,DiabetesControlandComplicationsTrialDKA,diabeticketoacidosisDMMP,diabetesmedicalmanagementplanDPN,distalsymmetricpolyneuropathyDPP,DiabetesPreventionProgramDRI,dietaryreferenceintakeDRS,DiabeticRetinopathyStudyDSME,diabetesselfmanagementeducationDSMT,diabetesselfmanagementtrainingECG,electrocardiogramESRD,endstagerenaldiseaseETDRS,EarlyTreatmentDiabeticRetinopathyStudyFDA,FoodandDrugAdministrationFPG,fastingplasmaglucoseGDM,gestationaldiabetesmellitusGFR,glomerularfiltrationrateHRC,highriskcharacteristicICU,intensivecareunitIFG,impairedfastingglucoseIGT,impairedglucosetoleranceMNT,medicalnutritiontherapyNDEP,NationalDiabetesEducationProgramNPDR,nonproliferativediabeticretinopathyOGTT,oralglucosetolerancetestPAD,peripheralarterialdiseasePDR,proliferativediabeticretinopathyPPG,postprandialplasmaglucoseRDA,recommendeddietaryallowanceSMBG,selfmonitoringofbloodglucoseTZD,thiazolidinedioneUKPDS,UKProspectiveDiabetesStudyDOI:dcS©bytheAmericanDiabetesAssociationPositionStatementSDIABETESCARE,VOLUME,SUPPLEMENT,JANUARY�cellfunction,geneticdefectsininsulinaction,diseasesoftheexocrinepancreas(suchascysticfibrosis),anddrugorchemicalinduced(suchasinthetreatmentofAIDSorafterorgantransplantation)●Gestationaldiabetesmellitus(GDM)(diagnosedduringpregnancy)SomepatientscannotbeclearlyclassifiedastypeortypediabetesClinicalpresentationanddiseaseprogressionvaryconsiderablyinbothtypesofdiabetesOccasionally,patientswhootherwisehavetypediabetesmaypresentwithketoacidosisSimilarly,patientswithtypemayhavealateonsetandslow(butrelentless)progressionofdiseasedespitehavingfeaturesofautoimmunediseaseSuchdifficultiesindiagnosismayoccurinchildren,adolescents,andadultsThetruediagnosismaybecomemoreobviousovertimeBDiagnosisRecommendations●TheFPGisthepreferredtesttodiagnosediabetesinchildrenandnonpregnantadults(E)●UseoftheACforthediagnosisofdiabetesisnotrecommendedatthistime(E)CriteriaforthediagnosisofdiabetesinnonpregnantadultsareshowninTableThreewaystodiagnosediabetesareavailable,andeachmustbeconfirmedonasubsequentdayunlessunequivocalsymptomsofhyperglycemiaarepresentAlthoughthegoralglucosetolerancetest(OGTT)ismoresensitiveandmodestlymorespecificthanfastingplasmaglucose(FPG)todiagnosediabetes,itispoorlyreproducibleandrarelyperformedinpracticeBecauseofeaseofuse,acceptabilitytopatients,andlowercost,theFPGisthepreferreddiagnostictestItshouldbenotedthatthevastmajorityofpeoplewhomeetdiagnosticcriteriafordiabetesbyOGTT,butnotbyFPG,willhaveanACvalue�TheuseoftheACforthediagnosisofdiabetesisnotrecommendedatthistimeHyperglycemianotsufficienttomeetthediagnosticcriteriafordiabetesiscategorizedaseitherIFGorimpairedglucosetolerance(IGT),dependingonwhetheritisidentifiedthroughanFPGoranOGTT:●IFG�FPGmgdl(mmoll)tomgdl(mmoll)●IGT�hplasmaglucosemgdl(mmoll)tomgdl(mmoll)Recently,IFGandIGThavebeenofficiallytermed“prediabetes”Bothcategories,IFGandIGT,areriskfactorsforfuturediabetesandcardiovasculardisease(CVD)Intheabsenceofunequivocalhyperglycemia,thesecriteriashouldbeconfirmedbyrepeattestingonadifferentdayTheOGTTisnotrecommendedforroutineclinicalusebutmayberequiredintheevaluationofpatientswithIFG(seetext)orwhendiabetesisstillsuspecteddespiteanormalFPG,aswiththepostpartumevaluationofwomenwithGDMIISCREENINGFORDIABETESRecommendations●Screeningtodetectprediabetes(IFGorIGT)anddiabetesshouldbeconsideredinindividuals�yearsofage,particularlyinthosewithaBMI�kgmScreeningshouldalsobeconsideredforpeoplewhoare�yearsofageandareoverweightiftheyhaveanTableADAevidencegradingsystemforclinicalpracticerecommendationsLevelofevidenceDescriptionAClearevidencefromwellconducted,generalizable,randomizedcontrolledtrialsthatareadequatelypowered,including:●Evidencefromawellconductedmulticentertrial●Evidencefromametaanalysisthatincorporatedqualityratingsintheanalysis●Compellingnonexperimentalevidence,ie,“allornone”ruledevelopedbyCenterforEvidenceBasedMedicineatOxfordSupportiveevidencefromwellconductedrandomizedcontrolledtrialsthatareadequatelypowered,including:●Evidencefromawellconductedtrialatoneormoreinstitutions●EvidencefromametaanalysisthatincorporatedqualityratingsintheanalysisBSupportiveevidencefromwellconductedcohortstudies●Evidencefromawellconductedprospectivecohortstudyorregistry●EvidencefromawellconductedmetaanalysisofcohortstudiesSupportiveevidencefromawellconductedcasecontrolstudyCSupportiveevidencefrompoorlycontrolledoruncontrolledstudies●Evidencefromrandomizedclinicaltrialswithoneormoremajororthreeormoreminormethodologicalflawsthatcouldinvalidatetheresults●Evidencefromobservationalstudieswithhighpotentialforbias(suchascaseserieswithcomparisontohistoricalcontrols)●EvidencefromcaseseriesorcasereportsConflictingevidencewiththeweightofevidencesupportingtherecommendationEExpertconsensusorclinicalexperienceTableCriteriaforthediagnosisofdiabetesSymptomsofdiabetesandacasualplasmaglucose�mgdl(mmoll)CasualisdefinedasanytimeofdaywithoutregardtotimesincelastmealTheclassicsymptomsofdiabetesincludepolyuria,polydipsia,andunexplainedweightlossORFPG�mgdl(mmoll)FastingisdefinedasnocaloricintakeforatleasthORhplasmaglucose�mgdl(mmoll)duringanOGTTThetestshouldbeperformedasdescribedbytheWorldHealthOrganization,usingaglucoseloadcontainingtheequivalentofganhydrousglucosedissolvedinwaterPositionStatementDIABETESCARE,VOLUME,SUPPLEMENT,JANUARYSotherriskfactorfordiabetes(Table)Repeattestingshouldbecarriedoutatyearintervals(E)●Screenforprediabetesanddiabetesinhighrisk,asymptomatic,undiagnosedadultsandchildrenwithinthehealthcaresetting(E)●Toscreenfordiabetesprediabetes,eitheranFPGtestorhOGTT(gglucoseload)orbothareappropriate(B)●AnOGTTmaybeconsideredinpatientswithIFGtobetterdefinetheriskofdiabetes(E)ThereisamajordistinctionbetweendiagnostictestingandscreeningBothutilizethesameclinicaltests,whichshouldbedonewithinthecontextofthehealthcaresettingWhenanindividualexhibitssymptomsorsignsofthedisease,diagnostictestsareperformed,andsuchtestsdonotrepresentscreeningThepurposeofscreeningistoidentifyasymptomaticindividualswhoarelikelytohavediabetesorprediabetesSeparatediagnostictestsusingstandardcriteriaarerequiredafterpositivescreeningteststoestablishadefinitivediagnosisasdescribedaboveTypediabetesGenerally,peoplewithtypediabetespresentwithacutesymptomsofdiabetesandmarkedlyelevatedbloodglucoselevelsBecauseoftheacuteonsetofsymptoms,mostcasesoftypediabetesaredetectedsoonaftersymptomsdevelopWidespreadclinicaltestingofasymptomaticindividualsforthepresenceofautoantibodiesrelatedtotypediabetescannotberecommendedatthistimeasameanstoidentifyindividualsatriskReasonsforthisincludethefollowing:)cutoffvaluesforsomeoftheimmunemarkerassayshavenotbeencompletelyestablishedinclinicalsettings)thereisnoconsensusastowhatactionshouldbetakenwhenapositiveautoantibodytestresultisobtainedand)becausetheincidenceoftypediabetesislow,testingofhealthychildrenwillidentifyonlyaverysmallnumber(�)whoatthatmomentmaybe“prediabetic”Clinicalstudiesarebeingconductedtotestvariousmethodsofpreventingtypediabetesinhighriskindividuals(eg,siblingsoftypediabeticpatients)Thesestudiesmayuncoveraneffectivemeansofpreventingtypediabetes,inwhichcasetargetedscreeningmaybeappropriateinthefutureTypediabetesTypediabetesisfrequentlynotdiagnoseduntilcomplicationsappear,andapproximatelyonethirdofallpeoplewithdiabetesmaybeundiagnosedIndividualsathighriskshouldbescreenedfordiabetesandprediabetesCriteriafortestingfordiabetesinasymptomatic,undiagnosedadultsarelistedinTableTheeffectivenessofearlydiagnosisthroughscreeningofasymptomaticindividualshasnotbeendetermined()ScreeningshouldbecarriedoutwithinthehealthcaresettingEitheranFPGtestorhOGTT(gglucoseload)isappropriateThehOGTTidentifiespeoplewithIGT,andthus,morepeopleareatincreasedriskforthedevelopmentofdiabetesandCVDItshouldbenotedthatthetwotestsdonotnecessarilydetectthesameindividuals()ItisimportanttorecognizethatalthoughtheefficacyofinterventionsforprimarypreventionoftypediabeteshavebeendemonstratedamongindividualswithIGT(–),suchdataamongindividualswithIFG(whodonotalsohaveIGT)arenotavailableTheFPGtestismoreconvenienttopatients,morereproducible,lesscostly,andeasiertoadministerthanthehOGTT(,)Therefore,therecommendedinitialscreeningtestfornonpregnantadultsistheFPGAnOGTTmaybeconsideredinpatientswithIFGtobetterdefinetheriskofdiabetesTheincidenceoftypediabetesinadolescentshasincreaseddramaticallyinthelastdecadeConsistentwithscreeningrecommendationsforadults,onlychildrenandyouthatincreasedriskforthepresenceorthedevelopmentoftypediabetesshouldbetested()(Table)TheeffectivenessofscreeningmayalsodependonthesettinginwhichitisperformedIngeneral,communityscreeningoutsideahealthcaresettingmaybelesseffectivebecauseofthefailureofpeoplewithapositivescreeningtesttoseekandobtainappropriatefollowuptestingandcareor,conversely,toensureappropriaterepeattestingforindividualswhoscreennegativeThatis,screeningoutsideofclinicalsettingsmayyieldabTableCriteriafortestingfordiabetesinasymptomaticadultindividualsTestingfordiabetesshouldbeconsideredinallindividualsatageyearsandabove,particularlyinthosewithaBMI�kgm*,and,ifnormal,shouldberepeatedatyearintervalsTestingshouldbeconsideredatayoungerageorbecarriedoutmorefrequentlyinindividualswhoareoverweight(BMI�kgm*)andhaveadditionalriskfactors:●arehabituallyphysicallyinactive●haveafirstdegreerelativewithdiabetes●aremembersofahighriskethnicpopulation(eg,AfricanAmerican,Latino,NativeAmerican,AsianAmerican,PacificIslander)●havedeliveredababyweighing�lborhavebeendiagnosedwithGDM●arehypertensive(�mmHg)●haveanHDLcholesterollevel�mgdl(mmoll)andoratriglyceridelevel�mgdl(mmoll)●havePCOS●onprevioustesting,hadIGTorIFG●haveotherclinicalconditionsassociatedwithinsulinresistance(eg,PCOSoracanthosisnigricans)●haveahistoryofvasculardisease*MaynotbecorrectforallethnicgroupsPCOS,polycysticovarysyndromeTableTestingfortypediabetesinchildrenCriteria●Overweight(BMI�thpercentileforageandsex,weightforheight�thpercentile,orweight�ofidealforheight)Plusanytwoofthefollowingriskfactors:●Familyhistoryoftypediabetesinfirstorseconddegreerelative●Raceethnicity(NativeAmerican,AfricanAmerican,Latino,AsianAmerican,PacificIslander)●Signsofinsulinresistanceorconditionsassociatedwithinsulinresistance(acanthosisnigricans,hypertension,dyslipidemia,orPCOS)●MaternalhistoryofdiabetesorGDMAgeofinitiation:ageyearsoratonsetofpuberty,ifpubertyoccursatayoungerageFrequency:everyyearsTest:FPGpreferredClinicaljudgmentshouldbeusedtotestfordiabetesinhighriskpatientswhodonotmeetthesecriteriaPCOS,polycysticovarysyndromeStandardsofMedicalCareSDIABETESCARE,VOLUME,SUPPLEMENT,JANUARYnormalteststhatareneverdiscussedwithaprimarycareprovider,lowcompliancewithtreatmentrecommendations,andaveryuncertainimpactonlongtermhealthCommunityscreeningmayalsobepoorlytargeted,ie,itmayfailtoreachthegroupsmostatriskandinappropriatelytestthoseatlowrisk(theworriedwell)oreventhosealreadydiagnosed(,)Onthebasisofexpertopinion,screeningshouldbeconsideredbyhealthcareprovidersatyearintervalsbeginningatage,particularlyinthosewithBMI�kgmTherationaleforthisintervalisthatfalsenegativeswillberepeatedbeforesubstantialtimeelapses,andthereislittlelikelihoodofanindividualdevelopinganyofthecomplicationsofdiabetestoasignificantdegreewithinyearsofanegativescreeningtestresultTestingshouldbeconsideredatayoungerageorbecarriedoutmorefrequentlyinindividualswhoareoverweightandhaveoneormoreoftheotherriskfactorsfortypediabetesIIIDETECTIONANDDIAGNOSISOFGDMRecommendations●Screenfordiabetesinpregnancyusingriskfactoranalysisand,ifappropriate,useofanOGTT(C)●WomenwithGDMshouldbescreenedfordiabetes–weekspostpartumandshouldbefollowedupwithsubsequentscreeningforthedevelopmentofdiabetesorprediabetes(E)RiskassessmentforGDMshouldbeundertakenatthefirstprenatalvisitWomenwithclinicalcharacteristicsconsistentwithahighriskforGDM(eg,thosewithmarkedobesity,personalhistoryofGDMordeliveryofapreviouslargeforgestationageinfant,glycosuria,polycysticovarysyndrome,orastrongfamilyhistoryofdiabetes)shouldundergoglucosetestingassoonaspossible()AnFPG�mgdloracasualplasmaglucose�mgdlmeetsthethresholdforthediagnosisofdiabetesandneedstobeconfirmedonasubsequentdayassoonaspossibleunlessunequivocalsymptomsofhyperglycemiaarepresentHighriskwomennotfoundtohaveGDMattheinitialscreeningandaverageriskwomenshouldbetestedbetweenandweeksofgestationTestingshouldfollowoneoftwoapproaches:●Onestepapproach:performadiagnosticgOGTT●Twostepapproach:performaninitialscreeningbymeasuringtheplasmaorserumglucoseconcentrationhafteragoralglucoseload(glucosechallengetest)andperformadiagnosticgOGTTonthatsubsetofwomenexceedingtheglucosethresholdvalueontheglucosecha

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糖尿病治疗指南2007及其解读

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