安立澤病例(劉洲君)

安立澤聯(lián)合用藥的選擇江蘇省中西醫(yī)結(jié)合醫(yī)院內(nèi)分泌代謝病院區(qū)劉洲君CasereportTreatmentexperienceSummaryContentsPartI

CasereportGeneraldataandbriefhistoryGenderMaleAge50OccupationClerkChiefcomplaintElevatedbloodglucosefor4yearsHistoryofpresentillnessBGwastestedinhighlevel4yearsago,hetook

metforminandglimepirideorally,FBG8-9mmol/L.Oneyearago,hewasdiagnosedwithT2DM,diabeticperipheralvasculardiseaseinourdepartment,thenhewastreatedwithmetforminandglargine,withoutdietarytherapy.Glargine16uqn,metformin0.5bidoftheadmissionwithoutpolydipsia,polyuria,weightloss.BriefhistoryPastmedicalhistoryNohistoryof

hypertension,CHDExposurehistoryofinfectiousdiseasesUnremarkableAllergichistoryNoPersonalhistorySmokingcessationfor4yeas,abstinencefor2monthsFamilyhistoryHismotherhasT2DMPhysicalexaminationT36.5oCP74bpmR16BP115/75Ht1.83mWt93kgBMI27.77Kg/m2WC97cmNootherpositivesignsLaboratorydataBRTURTWBC4.16X109/LGlu++RBC4.15X1012/Lketone+Hb138g/LPro--N53%L40%EKGNormalLaboratorydataBloodglucoseHepaticandrenalfunctionRBG15.5mmol/LALT10IU/LFPG12.13mmol/LAST10IU/LPPG19.3mmol/LBUN3.96mmol/LHbA1c9.7%Cr65mmol/LUA322μmol/LLaboratorydataLipidprofileTC4.85mmol/LTG2.86mmol/LHDL0.89mmol/LLDL3.17mmol/LMicroalbuminuria/Cr1.89mg/gImagestudies

Fundoscopy:nodiabeticretinopathyAbdomenUS:mildfattyliver,gallstoneDopplerforarteryoflowerextremity:arteriosclerosiswithmultipleplaqueformationCarotidUS:softplaquesformationinbilateralcommoncarotidsinusesHistorysummaryOnsetsecretivelyinmiddleage,

nopronetospontaneousketosiswithSUstreatmentFamilyhistoryofDMOverweight,WC>90cmComplicatedbyseveralriskfactors(peripheralvasculardisease,dyslipidemia)Combinedwithfattyliver,gallstoneTheBGispoorcontrolledthoughcombinationtherapywithglargineandMETDiagnosisT2DMDiabeticperipheralvasculardiseaseDyslipidemiaFattyliverGallstone

MetabolicsyndromeFurthertreatment？IntensivelifestylemodificationAddinginsulindosage？AGI？SUs？TZD?Newdrug：DPP-4inhibitor

DPP-4inhibitormarkedlyreduceHbA1c

levelPhungOJetal.

JAMA.2010;303:1410-1418.-2.0-1.5-1.0-0.500.5SUsGLNTZDAGIDPP-4iGLP-1

RA-0.79（-1.15,-0.43）-0.71（-1.24,-0.18）-1.00（-1.62,-0.38）-0.65（-1.11,-0.19）-0.79（-0.94,-0.63）-0.99（-1.19,-0.78）AverageHbA1creducing

level（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%DPP-4inhibitorwithrarelyoccurrenceofhypoglycemiaPhungOJetal.

JAMA.2010;303:1410-141.0102050SUsGLNTZDAGIDPP-4iGLP-1

RA2.63（0.76,9.13）7.92（1.45,43.21）2.04（0.50,8.23）0.60（0.08,4.55）0.67（0.30,1.50）0.94（0.42,2.12）incidenceofhypoglycemia（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%DPP-4inhibitorwithnearlynoaffectsonthebodyweight-5-2.502.55SUsGLNTZDAGIDPP-4iGLP-1

RA1.99（0.86,3.12）0.91（0.35,1.46）2.30（1.70,2.90）-1.80（-2.83,-0.77）-0.09（-0.47,0.30）-1.76（-2.90,-0.62）Averageofweightchange（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%PhungOJetal.

JAMA.2010;303:1410-1418.IncretintherapyisfailuretoincreasetheCVDriskinT2DM

0.010.1110100Sitagliptin(100mgqd)Vildagliptin(50mgbid)Alogliptin(25mgqd)Saxagliptin

(2.5-10mgqd)exenatide(5/10μgbid)HighCVDriskpatientsVildagliptin(50mgbid)Alogliptin(25mgqd)incidenceIncretinvs.control0.6%1.32%0.28%0.7%0.86%3.72%0.46%0.9%1.64%0.50%1.4%1.10%5.08%0.60%RRBettertreatmenteffectWorsetreatmenteffect

vs.controlSchweizer,etal.DiabetesObesMetab.2010.White,etal.ADA.2010;Poster:391-P.Ratner,etal.CardiovascDiabetol.2011.WilliamsHerman,etal.BMCEndocrDisord.2010.Frederich,etal.PostgradMed.2010..DemandingofnewdrugsSafty(hypoglycimia,CVDrisk)文本3complianceValidity(short/longterm)cost-effectiveCefaluWT.DiabetesCare..2012Jun;35(6):1201-3.CerielloA,etal.Diabetologia..2012Oct;55(10):2853-2855.InzucchiSE,etal.Diabetologia.

2012Apr20.HOMAimprovementaftercombinationtherapyofonglyzaandMETDeFronzoRA,etal.DiabetesCare.

2009

Sep;32(9):1649-55.HOMA-2βvariationcomparetobasline(%)5mgSaxagliptin+METn=166Placebo+METn=180Arandomized,double-blind,placebocontrol

study，743

individualswithT2DM，treatedwithMET,baselineHbA1c7.0%-10.0%,βcellfunctionvariationpre-andpost-treatmentwithsaxagliptinorplaceboafter24weeksTreatmentplanlifestyleinterventionDietaryandexerciseinstruction,diabeticeducationMedicaltherapy1.Glargine

20Uqn2.MET

0.5Bid3.Plusonglyza

5mg/dayBGmonitoringDatefastingpostmealpremealpostmealpremealpostmealremarks5-0515.513.3Glargine20uqn5-0612.618.418.614.85-0810.115.514.212.2Glargine20uqn+

MET0.5bid+onglyza

5mgqd5-1214.612.311.3Glargine23uqn+

MET0.5bid+onglyza

5mgqd5-137.211.912.715.28-156.58.07.68.5Glargine20uqn+

MET0.5bid+ongl