一例2型糖尿病的循證醫(yī)學

1、一例2型糖尿病的循證醫(yī)學 臨床八年 杜敏 044171 1 病例患者，男性，53歲，2型糖尿病史4年余，常規(guī)服用磺脲類藥物控制，飲食無特殊注意，血糖控制不穩(wěn)定，多尿，多飲，多食，體重減輕明顯，視物模糊，長時間站立后有雙腿麻木脹痛，無頭暈。既往體健，無其他相關疾病史。體檢及實驗室檢查：雙足無明顯異常，空腹血糖7.1mmol/L，血壓150/90 mmHg，未進行眼底檢查。2 提出問題該患者可確診為2型糖尿病。根據(jù)WHO1999年提出的糖尿病分型，共分為四型：1型糖尿病、2型糖尿病、其他特異型和妊娠糖尿病。關于糖尿病的治療和控制目標是：1糾正代謝紊亂，消除糖尿病癥狀，維持良好的營養(yǎng)狀況及正常的生活

2、質量和工作能力 2 防止糖尿病急性代謝紊亂發(fā)生 3預防和延緩慢性并發(fā)癥的發(fā)生和發(fā)展UKPDS對2型糖尿病的的治療目標是：在強調嚴格控制血糖的基礎上，全面控制代謝紊亂和慢性并發(fā)癥，保護B細胞功能，延緩疾病的進展。該患者病程中長，血糖控制不佳，未出現(xiàn)嚴重并發(fā)癥，但有一些末梢神經(jīng)及眼底的病變早期表現(xiàn)，對該患者的治療應針對其現(xiàn)在的情況。為提出適合的治療方法及對其后續(xù)發(fā)展作出評估，應回答下面幾個問題：1 該患者現(xiàn)行的藥物治療是否合理？是否需要使用胰島素？2 如何延緩2型糖尿病并發(fā)癥的出現(xiàn)？3 證據(jù)檢索與評價經(jīng)驗的證據(jù)研究表明2型糖尿病人的發(fā)病與肥胖、高熱量飲食、體力活動不足密切相關。飲食治療室糖尿病治療

3、的基礎，應計算其理想體重：身高（cm）105，根據(jù)體力勞動的輕重每千克體重每天攝入105167kj熱量不等。并且控制碳水化合物的攝入，約占總量的50%-60%。應進行有規(guī)律的運動，每次30-60分鐘，限于有氧運動。胰島素適應癥包括所有1型糖尿病患者和部分發(fā)生并發(fā)癥及特殊狀態(tài)下的2型糖尿病患者：該患者無明顯胰島素適應癥，可以暫時不使用?；请孱愃幬镏饕谴碳ひ葝uB細胞分泌胰島素，對于2型糖尿病血糖可以起到控制作用，但其的副作用是可以引起低血糖，并且有可能發(fā)生繼發(fā)性失效。臨床上可配合其他藥物使用。糖尿病多并發(fā)大血管，微血管和神經(jīng)病變，以及感染性疾病。預防最有效的方法就是控制血糖，使血糖穩(wěn)定保持在正常

4、范圍內或正常高值。文獻的證據(jù) 雖然對于治療有成體系的理論基礎，但單憑經(jīng)驗或許不能代表是對該患者最佳的治療方法。 使用pubmed，搜索關鍵詞“type 2”and“diabetes mellitus”and“ therapy”，限定為humans搜索到數(shù)萬的文獻，限定時間為近3個月，檢索到91篇文獻。篩選相關文獻，閱讀，可得到以下文獻證據(jù)：使用胰島素對患者的脂糖代謝，并發(fā)癥都有很好的作用，對于控制糖尿病的作用是口服降糖藥難以比擬的。但是何時使用胰島素，各方爭論很大。多數(shù)研究結果提示，使用胰島素應以藥物治療的效果，和患者糖尿病并發(fā)癥的發(fā)生與否進行評斷。如果藥物治療效果有所減退，血糖控制不佳的早期

5、，或血管、神經(jīng)已存在初期病變時就應考慮聯(lián)合使用胰島素治療，而非等到藥物已失效或慢性并發(fā)癥癥狀已產(chǎn)生再使用。循證醫(yī)學的證據(jù)檢索pubmed，clinical queries，檢索詞為(diabetes mellitus AND 2 type AND insulin) AND (randomized controlled trialPublication Type OR (randomizedTitle/Abstract AND controlledTitle/Abstract AND trialTitle/Abstract)， limited：humans、Mate-Analysis.共檢索到7

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27、:18A-25A; discussion 25A-26A.15: Cardiovascular mortality and morbidity in type-2 diabetes mellitus.Schernthaner G.Diabetes Res Clin Pract. 1996 Jul;31 Suppl:S3-13. 證據(jù)評價1 關于2型糖尿病人使用胰島素的問題2型糖尿病人不僅有胰島素抵抗也有胰島素的缺乏，使用胰島素可以補充病人缺少的胰島素并且能夠改善糖尿病患者脂代謝，對于糖尿病的并發(fā)癥也有一定得預防作用。該病人使用的是磺脲類的降糖藥，該藥的一個重要副反應就是低血糖，通過循證的搜索，我們發(fā)現(xiàn)，使用胰島素的低血糖反應發(fā)生率低于使用磺脲類藥物，Meta分析發(fā)現(xiàn)，聯(lián)合使用胰島素和磺脲類藥物相對于單獨使用磺脲類藥物，對