糖尿病神經(jīng)病變甲古胺系列

1、糖尿病神經(jīng)病變甲古胺系列Contents主要內(nèi)容糖尿病相關(guān)的學(xué)會(huì)組織糖尿病定義糖尿病流行病學(xué)糖尿病分類糖尿病臨床表現(xiàn)糖尿病診斷標(biāo)準(zhǔn)糖尿病神經(jīng)病變概述Neuropathy screening and treatment Standards of Medical Care in Diabetes-2007 ADARoleplay2糖尿病相關(guān)的學(xué)會(huì) Some Association about Diabetes中華醫(yī)學(xué)會(huì)糖尿病學(xué)分會(huì)(CDS)“Chinese Diabetes Society”歐洲糖尿病研究學(xué)會(huì)(EASD)“European Association for the Study of

2、Diabetes”美國(guó)糖尿病協(xié)會(huì)(ADA)“American Diabetes Association”美國(guó)國(guó)家糖尿病資料組(NDDG)“National Diabetes Data Group”美國(guó)國(guó)立衛(wèi)生研究院(NIH)“National Institutes of Health”國(guó)際糖尿病聯(lián)盟(IDF)“International Diabetes Federation”世界衛(wèi)生組織(WHO)“World Health Organization”3糖尿病Diabetes mellitus糖尿病(diabetes, DM)糖尿病是一組以胰島素分泌缺陷和（或）胰島素生物作用障礙導(dǎo)致的慢性血糖

3、水平增高為主要特征的代謝疾病群，包括糖、蛋白質(zhì)、脂肪、水及電解質(zhì)等的代謝紊亂，嚴(yán)重時(shí)常導(dǎo)致酸堿平衡失常 特征：高血糖、糖尿、葡萄糖耐量減低及胰島素釋放試驗(yàn)異常三多一少：多食、多飲、多尿、體重減少*ADA已將原先的Diabetes mellitus簡(jiǎn)略為Diabetes4糖尿病流行病學(xué)Epidemiology of Diabetes全球T2DM發(fā)病率最高的是太平洋島國(guó)瑙魯(Naura)和美國(guó)皮瑪(Pima)印地安人*附注：此數(shù)據(jù)摘自5目前世界DM人數(shù)最多的3個(gè)國(guó)家依次為：印度、中國(guó)、美國(guó)中國(guó)有超過(guò)5千萬(wàn)糖尿病患者1996年全國(guó)調(diào)查數(shù)據(jù)：糖尿病患病率3.21%IGT患病率4.81%2001年CDS

4、全國(guó)住院DM患者并發(fā)癥調(diào)查數(shù)據(jù)：T1DM神經(jīng)病變患病率：44.9%T2DM神經(jīng)病變患病率：61.8%總發(fā)病率：60.3%糖尿病流行病學(xué)Epidemiology of Diabetes附注：此數(shù)據(jù)摘自6糖尿病分類Classification of DiabetesADA 2007版糖尿病診療標(biāo)準(zhǔn)：1型糖尿病(T1DM)2型糖尿病(T2DM)其他特殊型糖尿病妊娠糖尿病(GDM) 注：ADA-美國(guó)糖尿病學(xué)會(huì)7臨床表現(xiàn)Clinical manifestations代謝紊亂癥候群“三多一少”：多飲、多食、多尿、體重減少并發(fā)癥和(或)伴發(fā)病各種急慢性并發(fā)癥，有的以肢端麻木等周圍神經(jīng)病變而就診神經(jīng)系統(tǒng)損害發(fā)

5、病率為47-91%反應(yīng)性低血糖餐后3-5小時(shí)的低血糖體檢/手術(shù)發(fā)現(xiàn)高血糖8診斷標(biāo)準(zhǔn)Criteria for the diagnosis of diabetes1999年WHO診斷標(biāo)準(zhǔn) 1999年WHO診斷標(biāo)準(zhǔn)1.有糖尿病癥狀和隨機(jī)血糖11.1mmol/L。“隨意”是指一天內(nèi)任何時(shí)間，無(wú)論進(jìn)食與否。糖尿病癥狀包括多尿、多飲和不可解釋的體重減輕。FPG:空腹血糖，“空腹”是指至少8h未進(jìn)食（未攝入能量）3.OGTT試驗(yàn)2hPG 11.1mmol/L。試驗(yàn)需按WHO要求用75g無(wú)水葡萄糖溶于水對(duì)無(wú)癥狀者應(yīng)隔日復(fù)測(cè)9診斷標(biāo)準(zhǔn)Criteria for the diagnosis of diabetes1

6、999年WHO診斷標(biāo)準(zhǔn)糖尿病前期(Pre-Diabetes)空腹血糖受損(IFG)and糖耐量減低(IGT)and附注： 2006年WHO/IDF將糖尿病前期(Pre-Diabetes)改稱為高血糖中間狀態(tài)(Intermediate Hyperglycemia)10診斷標(biāo)準(zhǔn)Criteria for the diagnosis of diabetes2007年ADA診斷標(biāo)準(zhǔn)糖尿病前期(Pre-Diabetes)空腹血糖受損(IFG)and糖耐量減低(IGT)and11IFG診斷標(biāo)準(zhǔn)Criteria for the diagnosis of diabetesbetween WHO and ADA

7、WHOFPG= andOGTT ADAFPG= andOGTT 12IFG診斷標(biāo)準(zhǔn)Criteria for the diagnosis of diabetesfrom Chinese Diabetes Society(CDS)降低IFG的下限診斷切割點(diǎn),即從6.1 mmol/L降至IFG上限的診斷切割點(diǎn)不變,仍為87% sensitivity in detecting DPN. 聯(lián)合應(yīng)用多于一項(xiàng)以上的臨床檢查方法診斷遠(yuǎn)端對(duì)稱性多神經(jīng)病變的敏感性87%55D. Neuropathy screening and treatment (171,172)D.糖尿病神經(jīng)病變篩查與治療Diagnosis

8、of neuropathy神經(jīng)病變的診斷Loss of 10-g monofilament perception and reduced vibration perception predict foot ulcers. 10g單絲壓力覺(jué)的喪失和音叉振動(dòng)覺(jué)的降低預(yù)示著足部潰瘍的發(fā)生A minimum of one clinical test should be carried out annually, and the use of two tests will increase diagnostic ability.每年必須最少使用一項(xiàng)臨床檢查來(lái)檢測(cè)神經(jīng)病變，二項(xiàng)臨床檢查可以提高診斷率Foc

9、al and multifocal neuropathy assessment requires clinical examination in the area related to the neurological symptoms.局灶性和多病灶性神經(jīng)病變的判定需要神經(jīng)系統(tǒng)癥狀相關(guān)區(qū)域的檢查來(lái)實(shí)現(xiàn)56D. Neuropathy screening and treatment (171,172)Diabetic autonomic neuropathy糖尿病性自主神經(jīng)病變Major clinical manifestations of diabetic autonomic neuropat

10、hy include resting tachycardia, exercise intolerance, orthostatic hypotension,constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, “brittle diabetes,” and hypoglycemic autonomic failure.糖尿病自主神經(jīng)病變的常見臨床表現(xiàn)包括：靜息時(shí)心動(dòng)過(guò)速、運(yùn)動(dòng)不耐受、便秘、胃輕癱、勃起機(jī)能障礙、泌汗功能障礙、神經(jīng)血管功能

11、受損，“脆性糖尿病”、低血糖性自主神經(jīng)功能衰竭Cardiac autonomic neuropathy may be indicated by resting tachycardia (100 bpm), orthostasis (a fall in systolic blood pressure20 mmHg upon standing), or other disturbances in autonomic nervous system function involving the skin, pupils, or gastrointestinal and genitourinary sy

12、stems.靜息時(shí)心動(dòng)過(guò)速（100bpm）、靜息狀態(tài)（站立時(shí)收縮壓下降超過(guò)20mmHg以上）、或者其他一些自主神經(jīng)功能的紊亂包括皮膚、瞳孔、胃腸和泌尿生殖系統(tǒng)等可能提示心臟自主神經(jīng)病變的存在57D. Neuropathy screening and treatment (171,172)Diabetic autonomic neuropathy糖尿病性自主神經(jīng)病變Gastrointestinal disturbances (e.g., esophageal enteropathy, gastroparesis, constipation, diarrhea, fecal incontinenc

13、e) are common, and any section of the gastrointestinal tract may be affected. Gastroparesis should be suspected in individuals with erratic glucose control.胃腸道功能紊亂(如：食道性腸病、胃輕癱、便秘、腹瀉、大便失禁)是最常見的，同時(shí)胃腸道的任何部位都有受累的可能。血糖控制不穩(wěn)定的病人應(yīng)該首先懷疑胃輕癱的可能Diabetic autonomic neuropathy is also associated with genitourinary

14、 tract disturbances, including bladder and/or sexual dysfunction. 糖尿病自主神經(jīng)病變同樣也可伴隨泌尿生殖系統(tǒng)功能紊亂，包括膀胱功能和性功能障礙 In men, diabetic autonomic neuropathy may cause loss of penile erection and/or retrograde ejaculation.在男性，糖尿病自主神經(jīng)病變可能引起陰莖勃起功能障礙和逆行射精58D. Neuropathy screening and treatment (171,172)Symptomatic tr

15、eatments對(duì)癥治療The first step in management of patients with DPN should be to aim for stable and optimal glycemic control.治療糖尿病患者遠(yuǎn)端對(duì)稱性多神經(jīng)病變的第一步是穩(wěn)定和理想的血糖控制Most patients will require pharmacological treatment for painful symptoms: many agents have efficacy confirmed in published randomized controlled tri

16、als, though none are specifically licensed for the management of painful-DPN. See Table 10對(duì)于疼痛的癥狀絕大多數(shù)患者都需要藥物治療，發(fā)表的隨機(jī)控制試驗(yàn)證實(shí)許多治療方法都是有效的，但是還沒(méi)有一種被特別批準(zhǔn)專門用于治療DPN疼痛癥狀的藥物（見表10）59D. Neuropathy screening and treatment (171,172)Symptomatic treatments對(duì)癥治療三環(huán)類藥物抗驚厥劑P物質(zhì)抑制劑5-羥色胺和去甲腎上腺素再攝取抑制劑阿米替林去甲替林丙米嗪加巴噴丁卡馬西平普加巴林辣

17、椒辣素60D. Neuropathy screening and treatment (171,172)Treatment of autonomic neuropathy自主神經(jīng)病變的治療A wide variety of agents are used to treat the symptoms of autonomic neuropathy, including metoclopramide for gastroparesis and several medications for bladder and erectile ysfunction. These treatments are

18、frequently used to provide symptomatic relief to patients.多種多樣的治療方法或藥物被用于治療糖尿病自主神經(jīng)病變的癥狀，包括甲氧氯普胺治療胃輕癱、多種藥物治療膀胱和勃起功能障礙。上述這些治療方法經(jīng)常被用于改善病人的癥狀A(yù)lthough they do not change the underlying pathology and natural history of the disease process, their use is recommended due to the impact they may have on the quality of life of the patient.即使這些治療不能改變潛在的病理變化和疾病的自然進(jìn)程，但由于這些治療能改善病人的生活質(zhì)量，故還是推薦使用的 61Summary總結(jié)DPN篩查非常重要，在診斷DM時(shí)及以后至少每年篩查一次篩查的常用方法有：針刺痛覺(jué)、溫度覺(jué)、音叉振動(dòng)覺(jué)（使用128Hz音叉）、10-g單絲壓力覺(jué)以及踝反射強(qiáng)調(diào)自主神經(jīng)病變的各種表現(xiàn)，提高醫(yī)務(wù)保健人員的注意以防止對(duì)糖尿病神經(jīng)病變的漏診治療DPN的第一步也