胡仁明-糖尿病課件

Classificationofdiabetes(ADA-1997)Type1

(beta-celldestruction,usuallyleadingtoabsoluteinsulindeficiency)

AutoimmuneIdiopathicType2

(mayrangefrompredominantlyinsulinresistancewithrelativeinsulindeficiencytoapredominantlysecretorydefectwithorwithoutinsulinresistance)

Otherspecifictypes

Gestationaldiabetes**第一頁(yè)第二頁(yè)，共104頁(yè)。Otherspecifictypes

Geneticdefectsofbeta-cellfunctionGeneticdefectsininsulinactionDiseasesoftheexocrinepancreasEndocrinopathiesDrug-orchemical-inducedInfectionsUncommonformsofimmune-mediateddiabetesOthergeneticsyndromessometimesassociatedwithdiabetes第二頁(yè)第三頁(yè)，共104頁(yè)。Pathogenesis

第三頁(yè)第四頁(yè)，共104頁(yè)。PathologyType1DM：inflammationofpancreasType2DM：amyloidosisofpancreasLargevessel：atherosclerosisKidney：diffuseornodularglomerularsclerosisRetina：arteriolarsclerosis、microaneurysm、exudates、newvesselformationNerve：axondegeneration、myelinolysis第四頁(yè)第五頁(yè)，共104頁(yè)。Pathophysiology

第五頁(yè)第六頁(yè)，共104頁(yè)。AbnormalitiesinmetabolismCarbohydrate：anabolism

，catabolism

、utilizationLipid：anabolism

，catabolism

，ketoplasiaprotein：anabolism

，catabolism

，glyconeogenesis第六頁(yè)第七頁(yè)，共104頁(yè)。Insulinsecretioncurve:normalanddiabetics第七頁(yè)第八頁(yè)，共104頁(yè)。ClinicalPresentation

第八頁(yè)第九頁(yè)，共104頁(yè)。Naturalhistoryoftype2DMAfterthediagnosisoftype2diabetes:IRconstantlyexistsInsulinsecretionabilitygraduallydeclines:WhenFPGreachsthediagnosticcriteria，insulinsecretionabilityhasalreadydeclinedby50%WhenFPG≥7.0mmol/L，-cellinsulinsecretionabilityWhenFPG≥1011.0mmol/L，-Cinsulinsecretionabilityhasalreadynearedabsolutedeficiency第九頁(yè)第十頁(yè)，共104頁(yè)。Modelsoftheonsetoftwophrasesoftype2DMNGTIGR(IFG、IGT)

DM

cellexhaustionInsulinresistanceInsulinresistance第十頁(yè)第十一頁(yè)，共104頁(yè)。WHOplasmaglucoseguidelineIGTIFGNGTDM75gOGTT2hPG

(mmol/L)FPG(mmol/L)7.06.1FPG7.811.1IGT第十一頁(yè)第十二頁(yè)，共104頁(yè)。Comparisonoftype1andtype2DM

type1DMtype2DMUsualageofonset<30years>40yearsModeofonsetacutechronicweightnormaloverweightorobesityorweightlosssymptomspolyuria,polydipsia,similarbutusuallyweightlosslessseverepresentationAcutecomplicationsoftenfewChroniccomplicationsLargevesseldiseaselessthentype2DMleadingcauseofdeathRenaldiseaseleadingcauseofdeath5%

10%Insulinandc-peptideloworlackpeakvaluedelayed,highordeficiencyImmunemarkerusually+usually-Therapyinsulindependenceoralantidiabeticagentsareavailable第十二頁(yè)第十三頁(yè)，共104頁(yè)。ChroniccomplicationsMacrovasculardiseaseMicroangiopathyDiabeticretinopathyDiabeticrenaldiseaseDiabeticneuropathyDiabeticdermatopathyInfection第十三頁(yè)第十四頁(yè)，共104頁(yè)。MechanismofcomplicationsActivationofpolyol（orsorbitol）pathway

Formationofnon-enzymesaccharificationproductsChangeofhemodynamicsActivationofPKCMicroangiopathytheory第十四頁(yè)第十五頁(yè)，共104頁(yè)。HyperglycemiaistheessentialreasonfordiabeticcomplicationsDCCT

DiabetesControlandComplicationsTrialUKPDSUnitedKingdomProspectiveDiabetesStudy第十五頁(yè)第十六頁(yè)，共104頁(yè)。UKPTS：resultsHbA1c0.9%，（intensivetherapyvsroutinetherapy）Intensivetherapygroup:diabetisassociatedcomplications12%，andthefatalnessofmicrovascularcomplications25%。Itcannotevidentlyreducetheincidenceofgreatvesseldisease,suchasmiocardialinfarctionandstrock.Moststimulatingfindings：Biguanidescanpreventorslowtheonsetand/orprogressionofdiabeticcomplicationsinoverweightpatientsTightcontrolofhypertensioncanpreventorslowtheonsetand/orprogressionofdiabeticcomplicationsby24%（144/82mmHgvs154/87mmHg），strokeby44%，microvascularcomplicationsby37%。第十六頁(yè)第十七頁(yè)，共104頁(yè)。Epidemiologyofdiabetes

MacrovasculardiseaseDiabeticsareeasytogetatherosclerosisMonckeberg’ssclerosis41.5％Intimalarteriosteogenesis29.3％Coronaryheartdisease、cerebrovasculardisease：24timesRiskofmiocardialinfarction：10timesRiskofstroke:3.8times，especiallyinwomenRiskoflowerlimbamputation：15times，fatalness第十七頁(yè)第十八頁(yè)，共104頁(yè)。HypertensioninDMMorbidityratediabetes:20%

40%DiabetesinEU(35-54years):30%

50%DiabetesinChina:29.2%pathogenesisaortosclerosisArteriolaresistanceHypertensionassociatedwithDNRenalhypertensioncausedbystenosisofrenalartery第十八頁(yè)第十九頁(yè)，共104頁(yè)。Diabeticretinopathy－leadingcourseofnewcasesofblindnessPathogeny：stateofillness、courseofdisease、ageofonset<5years：eyegrounddiseaseisnotcommon<10years：50％eyegrounddisease<20years：80

90％eyegrounddisease

DiabeticRetinopathy第十九頁(yè)第二十頁(yè)，共104頁(yè)。Classifications(China)BackgroundretinopathyⅠmicroaneurysms、dotsofhemorrhagesⅡyellowandwhitehardexudates,haemorrhagesⅢwhitesoftexudates,haemorrhagesspotsProliferativeretinopathyⅣnewvesselformation、haemorrhageintothevitreousⅤnewvesselformationandfibrosisⅥretinaldetachment第二十頁(yè)第二十一頁(yè)，共104頁(yè)。DiabeticnephropathyDNistheleadingcauseofESRD(end-stagerenaldisease)Almost40％ofType1DMdiedofuremiaIncidenceofDNintype2DMisabout20％InEU，DNaccountsfor1/3ofdialysisandkidneytransplantationcasesInChina,DNalsoaccountsforquitealotofdialysesandkidneytransplantations第二十一頁(yè)第二十二頁(yè)，共104頁(yè)。Stagesofdiabeticnephropathy(1)stageIincreasedkidneyDMalreadyfiltrationdiagnosisedGFR↑↑enlargedkidneys(B-ultrasonic)GFR>130ml/minStageIIclinicallysilentphaseDM2

5yearGFR↑20

40％renalenlargement， withcontinuedglomerularhypertrophy,hyperfiltrationandhypertrophyexpansionofthemesangialmatrix thickeningoftheglomerularbasementmembraneresultinginglomerulosclerosis

StageIIIconcealedDNmicroalbuminuriaDM5

10yearmicroalbuminuria1/5patientswithhypertension(20-200μg/minretinopothy↑,or30

300mg/24h)proteinuria0.15

0.5g/24hGFR>or=normal第二十二頁(yè)第二十三頁(yè)，共104頁(yè)。Stagesofdiabeticnephropathy(2)StageIVOvertNephropathy

DM10

25yearalbuminuria>300mg/d60

70％patientsproteinuria>0.5g/d，withhypertentioGFR↓(whenUAER=100andedemamg/24h,GERbegintodecrease，about1ml/min/month)retinopathy↑↑

StageVend-stagerenaldisease,ESRDDM15

30yearalbuminuriaazotemic→uremiaGFR<1/3ofnormal第二十三頁(yè)第二十四頁(yè)，共104頁(yè)。Classificationofdiabetesneuropathy（1）Peripheralneuropathy

symmetricmultipleperipheralneuropathysensibilitymultipleneuropathynumbnesstype

paintypenumbness-paintypesensomotormultipleneuropathyacuteorsub-acutemotormultipleneuropathyasymmetricsingleormultipleperiphearalneuropathymemberortorsomononeuralcranialnervesdiseaseradiculopathyproximalmotorneuropathyautonomicneuropathyAutonomicneuropathydiabeticmyelopathydiabeticspinalataxiaspinalmuscularatrophyCerebropathyHypoglycemiacerebropathydiabeticcomacerebrovasculardisease第二十四頁(yè)第二十五頁(yè)，共104頁(yè)。DiabeticsensabilitymultipleneuropathymorecommoninfemaleAverageageofonsetis58.7yearCourseofDM>15yearsSymptomsofsenseNumbnesstype：largemedullatedfibersPaintype：littlemedullatedfibersandnonmedullatedfibersNumbness-paintype第二十五頁(yè)第二十六頁(yè)，共104頁(yè)。

NervoussymptomexaminationparasthesiaLowerlimbspallestheticdisturbanceordissapearTendonreflexlowordissappearSensorystaxiaParatrophysymptomsCharcotarthropathy、ischemicgangrenosisandfootulcer第二十六頁(yè)第二十七頁(yè)，共104頁(yè)。DiabeticautonomicneuropathyPupildiseaseCardiovascularparafunctionFixedheartratePosturalhypertensionSuddencardiacdeathGestrophageal,diarrheaNeuropathicbladder,erectilefailureAbnormalsweating第二十七頁(yè)第二十八頁(yè)，共104頁(yè)。Glucosuria：associatedwithrenalthresholdofsugar(onlyforclue)KetonuriaBloodsugar：plasmaglucose，PODHBA1c：2

3monthsbloodsugarlevelFructosamine：2

3weeksbloodsugarlevelOGTT：2hourspecimenInsulinandC-peptidereleasetestLaboratorytests第二十八頁(yè)第二十九頁(yè)，共104頁(yè)。Diagnosis第二十九頁(yè)第三十頁(yè)，共104頁(yè)。CriteriafordiagnosingdiabetesFPGRandomOGTTplasmaglucose2hPGmmol/Lmmol/Lmmol/LDM≥7.0≥11.1≥11.1IGRIFG6.1≤FPG<7.0IGT7.8≤FPG<11.1Normal<6.1<7.8第三十頁(yè)第三十一頁(yè)，共104頁(yè)。CharacteristicsofnewdiabeticdiagnosticcriteriaFPG<6.1mmol/Lisnormalfastingglucose，OGTT2hPG<7.8mmol/Lisnormalglucosetolerance；Impairedfastingglucosecorrespondingwithimpairedglucosetolerance(IFG)：6.1mmol/L≤FPG<7.0mmol/L；ThecutoffvalueofFPGdeclinefrom7.8mmol/Lto7.0mol/L.thecutoffvaluesofOGTT2hrPGandrandomplasmaglucoselevelarestill11.1mmol/L；FPGistheinitialscreeningtestofdiabetes，OGTTisnotrecommendedforroutinediagnosticuse.ThediagnosesofGestationaldiabetesisnotchanged第三十一頁(yè)第三十二頁(yè)，共104頁(yè)。PracticalproblemsindiagnosisSymptoms＋randomplasmaglucose≥11.1mmol/LFPG：≥7.0mmol/LOGTT：2hPG≥11.1mmol/LAsymtomaticpersonstestsshouldberepeatedtheonce第三十二頁(yè)第三十三頁(yè)，共104頁(yè)。latentautoimmunediabetesmellitusinadults（LADA）AdultonsetSymptomsareevidentSecretionfunctionofcellislowGADApositiveHLA-DQBchainisnonaspartatehomozygote第三十三頁(yè)第三十四頁(yè)，共104頁(yè)。Management第三十四頁(yè)第三十五頁(yè)，共104頁(yè)。GoalsGoodmetabolismcontrol（bloodsugar、bloodlipid、HBA1Cetc）RelievesymptomsKeepinggoodphysiologicstateandasociallifeGoodqualityoflivePreventthedevelopmentofacutecomplicationsofdiabetes（hypoglycemia、DKA、hyperosmolarnonketoticsyndrome、lacticacidosis）Preventingthedevelopmentordelayingtheprogressionofthechroniccomplicationsofdiabetes第三十五頁(yè)第三十六頁(yè)，共104頁(yè)。PrincipleoftreatmentEarlyLife-longsynthesisindividual第三十六頁(yè)第三十七頁(yè)，共104頁(yè)。Goalsofcontrol

goodaveragebad

PBG(mmol/L) fasting4.4-6.1

7.0>7.0non-fasting4.4-8.0

10.0>10.0HBA1c(％) <6.56.5-7.5>7.5 BP(mmHg)<130/80>130/80-<140/90 >140/90 BMI(Kg/m2)M<25M<27

27 F<24F<26F

26TC

(mmol/L)

<4.5

4.5

6.0 HDL-c(mmol/L)

>1.11.1-0.9<0.9 TG

(mmol/L)

<1.5 <2.2

2.2 LDL-C

(mmol/L)<2.5 2.6-4.40 >4.0第三十七頁(yè)第三十八頁(yè)，共104頁(yè)。ControlactualityofDMinChina26centers、3965patients28％patientsmeasureHbA1c：8.12.6%，52％>7.5％FPG：9.23.7mmol/L，55%>7.8mmol/LDetermingrateofmicroalbumininurine：20％第三十八頁(yè)第三十九頁(yè)，共104頁(yè)。DiabetesManagementPlanPatienteducationHealthnutritiontherapyExercisetherapyDrugtherapyMonitoringofbloodglucose第三十九頁(yè)第四十頁(yè)，共104頁(yè)。PhasestherapyofDMEarlyreactionPatienttherapyMedicalnutritiontherapyExercisetherapySingledrugtherapydeclineofcurativeeffectCombineddrugtherapySecondaryfailure、distinctinsufficiencyofinsulinInsulintherapy第四十頁(yè)第四十一頁(yè)，共104頁(yè)。PrinciplesofmedicalnutritiontheraphyrationalcontroloftotalcalorificvalueGoal：KeepidealbodyweightLossweightforobesepatientAddweightforleanpatientStandardbodyweight＝height（cm）－105male：（height－100）×0.9female：（height－100）×0.85Bodymassindex（BMI）：weight（kg）/height2（m2）第四十一頁(yè)第四十二頁(yè)，共104頁(yè)。Adult-onsetdiabetesthermalenergysupplyperday（therm/kgstandardweight）

workintension Bodilyform

inbedlightphysicalmiddleheavylaborphysicalphysicallaborlaborlean20

253540>40normal15

20303540obesity1520

253035第四十二頁(yè)第四十三頁(yè)，共104頁(yè)。

Nutritionprinciplesofdiabetics

ModerateweightcontrolThedistributionoftotalcalorficvalue：carbohydrate55%

60%fat20%

25%1/5、2/5、2/5protein15%

20%DrinklimitationAvoiding‘diabetic’foods(whichcontainsorbitolorfrucotose)Aspartameisanacceptablecalorie-freesweetenersalt<10g/d，(<3g/dayifhypertensive)第四十三頁(yè)第四十四頁(yè)，共104頁(yè)。Calculationprotein：0.81.2/kgstandardweightfat：0.61.0/kgstandardweightcarbohydrate：totalcalorificvalue－caloriesofproteinandfat第四十四頁(yè)第四十五頁(yè)，共104頁(yè)。ExercisetherapyBenefitsGlycaemiccontrolIncreaseβcellsensitivitytoglucoseBloodlipidWeightreductionEstimationofquantityofexercise：heartrate<170－age(year)第四十五頁(yè)第四十六頁(yè)，共104頁(yè)。DrugtherapySulfonylureasBiguanidesα-glucosidaseinhibitorsTniazolidinedionesMeglitinidesInsulinDry-combinationtherapy第四十六頁(yè)第四十七頁(yè)，共104頁(yè)。Sulfonylureas:modeofactionTheprincipalactionofthesedrugsistostimulateendogenousinsulinsecretionfromthepancreaticβ-cellsNottoincreasesynthesisofinsulinAlsotoincreaseβ-cellssensitivitytoglucoseandexertsomeinfluenceindiminishinginsulinresistance.第四十七頁(yè)第四十八頁(yè)，共104頁(yè)。Sulfonylureas（SU）：firstchoiceofnon-obesityT2DM

GeneralnamedurationofactionpotencymeritsmainsiteofexcretionTolbutamide(D860)shortweakcheaprenalGlyburide(micronase)longstrongaffirmedhypoglycemiaeffectsinloweringbloodglucoselevels cheaprenalGliclazide(diamicvon)mediumstrongpreventandrenalglipizide(minidiab)shotstrongaffirmedeffectsrenalGliquidone(glurenorm)shotweeknotrenal(only5%)Glipizide(tonbac)longstronggoodcompliancelowincidenceofhypoglycemia第四十八頁(yè)第四十九頁(yè)，共104頁(yè)。TherapeuticeffectsofSUPrimaryfailuretorespondtoSUoccursin20%to25%ofpatientsFPGand2hPGHbA1c1%

2％Astheperiodoftreatmentprogresses,effectsdecline：Secondaryfailureoccursattherateof10%to15%peryearAfter5years，onlyhalfofthepatientscankeepidealbloodglucosecontrol. UKPDS：firstyear:bloodglucose，insulinthen:bloodglucoseinsulinthe6thyear:returnedtothestatebeforetherapy第四十九頁(yè)第五十頁(yè)，共104頁(yè)。IndicationsandcontraindicationsofSUIndicationsPoorcontrolofT2DMbyweightcontrolandphysicalactivityPoorcontrolofT2DMbybiguanidesand

-CombinedwithinsulinContraindicationsT1DMAcuteorchronicdiabeticcomplicationsEmergencyDysfunctionofliverorkidneyPregnantorbleedingwomen第五十頁(yè)第五十一頁(yè)，共104頁(yè)。SideeffectsofSUHypoglycemia，mostcommoninOldpatientsLong-termpharmaceuticsSymptomsofdigestivetractLiverdysfunctionTetterChangeofhematology第五十一頁(yè)第五十二頁(yè)，共104頁(yè)。Biguanides：firstchoiceofobesitytype2DM

GenericnamedosagemeritsNB

phenformin<75mg/dcheaplacticacidosis（降糖靈） restrainoxygenicmetabolismlowerenergyofoxygenicmetabolismdimethylbiguanide<1.5g/dlowgastrointestinalside-effectsreaction（降糖片）

第五十二頁(yè)第五十三頁(yè)，共104頁(yè)。MechanismsofactionofbiguanidesIncreasingβcellsensitivitytoglucoseEnhancingglucoseuptakeandutilizationbymuscleReducingHGPbyinhibitinggluconeogenesis.DecreasingintestinalglucoseabsorptionDoNotstimulatingendogenousinsulinsecretionfromβcellDoNotcausinghypoglycemiawhenusedsingly第五十三頁(yè)第五十四頁(yè)，共104頁(yè)。indicationsandcontraindicationsofBiguanidesIndicationsObesityT2DMPoorcontrolbySUPoorcontrolbyinsulin，includingT1DMSimpleobesityPolycysticovarysyndromeContraindicationsAllergicreactionsRenaldysfunction，serumcreatinine>1.4mg/dlAcuteorchronicacidosisHeart、lungdisease：hypoxia、acidosisinclinationHypohepatiaSeveregastroenteropathyPregnancy第五十四頁(yè)第五十五頁(yè)，共104頁(yè)。SideeffectsofBiguanidesDiarrheaAnaphylaxisOvertmacies：commoninelderlypatientsLacticacidosis第五十五頁(yè)第五十六頁(yè)，共104頁(yè)。Inhibiting

-glucosidaseDelayingthedigestionofglucose2hPGNotstimulatingthesecretionofInsulinα-glucosidaseinhibitors:modeofaction第五十六頁(yè)第五十七頁(yè)，共104頁(yè)。TherapeuticeffectsofAcarbose2hPGFPGHbA1cabout1％.WhenusedincombinationwithSU,HbA1c:about2％SeruminsulinslightlydeclinedWeightnotafewpatientsWhenusedasmonotherapy,itdonotcausehypoglycemiaWhenusedincombinationwithotheroralantidiabeticagents,itmaycausehypoglyceiaIfhypoglycemiahappens,patientshouldbetreatedbyglucose.Otherkindsofsugarareineffective第五十七頁(yè)第五十八頁(yè)，共104頁(yè)。Indicationsandcontraindicationsof

α-glucosidaseinhibitorsIndicationsLightcasesusingdrugseparatelyorcombinedIGTintervention，securityContraindicationsAllergicreactionsSeveregastroenteropathyDysfunctionofrenalandliverAcutecomplicationsEmergencyPregnantandbreastfeedingwomen第五十八頁(yè)第五十九頁(yè)，共104頁(yè)。thiazolidinedion（TZD）：insulinsensitizersInsulinsensitizers;agonistattheperoxisomeproliferator-activatedreceptor

（PPAR

）;increaseglucoseutilizationinperipheraltissues.Reducinginsulinresistance，hyperglycemiaandhyperlipaemiaandhypertensioncanbeimprovedatvariesdegreesForT2DM:usedasmonotherapyorincombinationwithSU,insulin.WhenusedincombinationwithSUorinsulin,hyperglycemiaWithoutinsulin，itcannotreducehyperglycemiaLiverfunctionshouldbemonitoredfrequently.Stopusingitincaseliverdysfunctionisfound.Incidenceofedema:4

5%ItmaycauseHbslightly↓第五十九頁(yè)第六十頁(yè)，共104頁(yè)。Meglitinides：repaglinideStimulatePancreaticinsulinsecretion（similarwithSU）：specificcombinitionwith36KDaproteinKpathwaycloseStimulatingthefirstphrasesecretionofinsulinAction:rapidonset，shortduration，suppressingpostloadhyperglycemiaquicklySitesofexcretion:kidney8%，fecal92%Usedasmonotherapyorincombinationwithbiguanides，α-glucosidaseinhibitorsIncidenceofhypoglycemiaislow第六十頁(yè)第六十一頁(yè)，共104頁(yè)。FactorsinchoosingoralantidiabeticagentsageweightBloodglucoselevelFunctionofliverandkidneyCharacteristicofdrugcosts第六十一頁(yè)第六十二頁(yè)，共104頁(yè)。ChooseoforalantihyperglucemicagentsOlderpatients：shorttermSUObesityorhyperinsulinismpatients：biguanidesoracarbose2hPG：α－glucosidaseConcentrationofplasmaglucose：>270

300mg/dl.thesymptomsofhypertensionareevident.InsulintherapyisavailableImpairedliverandkidneyfunction：avoidusingOHALean、fastingandafter-excitationinsulinall：insulin第六十二頁(yè)第六十三頁(yè)，共104頁(yè)。Drug-CombinedtherapyReasonabledietandpoorplasmaglucosecontrolbymonotherapySU、biguanides、TZDandα-glucosidaseinhibitorsallcanbeusedincombinationwitheachotherSmalldosagecombinedwithofallkindsofdrugs;enhancingeffectsofreduceglucaemia;sideeffectsofsingleagentsOralagentswithinsulinDrugsofthesameclasscannotbeusedinacombinedway.第六十三頁(yè)第六十四頁(yè)，共104頁(yè)。Insulintherapy第六十四頁(yè)第六十五頁(yè)，共104頁(yè)。IndicationsofinsulinType1DMType2DMAcutecomplicationsSeverechroniccomplicationsofdiabetesEmergencySeveredysfunctionofliverorkidneyGestationandbleedingwomenWithouttoleranceOHA，curativeeffectofOHA，SUinvalidationDistinctleanWithdiseasestreatedbyglucocorticoidSomespecifictypesofDM：secondarypancreasdisease、endocrinopathies、geneticdiabetes第六十五頁(yè)第六十六頁(yè)，共104頁(yè)。ObstaclestousingInsinT2DM

oldnotion：NIDDMThedoctorusesOHAonlyanddoesnotseetheneedtouseIns.ThepatientdoesnotwanttouseInforfearofdevelopinginsulindependenceafteruseingit.HyperinsulinismcanleadAStoCVD？hypoglycemia，BW↑第六十六頁(yè)第六十七頁(yè)，共104頁(yè)。國(guó)內(nèi)常用胰島素一覽表產(chǎn)品名生產(chǎn)廠家種屬來源包裝(U/瓶)短效胰島素普通胰島素(RI)上海生物制藥廠豬400U/瓶?jī)?yōu)泌林R禮來基因重組400U/瓶諾和靈-R諾和諾德基因重組400U/瓶Lispro禮來基因重組400U/瓶中效胰島素優(yōu)泌林N禮來基因重組400U/瓶諾和靈-N諾和諾德基因重組400U/瓶NPH徐州生化制藥廠豬400U/瓶混合胰島素優(yōu)泌林70/30禮來基因重組400U/瓶(人工合成)諾和靈-30R諾和諾德基因重組400U/瓶諾和靈-30R諾和諾德基因重組300U/瓶長(zhǎng)效胰島素PZI上海生物制藥廠豬400U/瓶第六十七頁(yè)第六十八頁(yè)，共104頁(yè)。DifferencesbetweenhumanandanimalinsulinDifferenceinpharmacodynamic：CloseactionintensityHumaninsulin:absorptionisfast，timeofonsetofeffectisearlyDifferenceinimmunogenicity:AntigenicitofhumaninsulinisweakerthananimalinsulinAfterusehumaninsulin,antibodytiterofbloodinsulinislowerSynthesizedinsulin：lispro（28proline29proline）Quickabsorption,shorteffecttime第六十八頁(yè)第六十九頁(yè)，共104頁(yè)。Shot-termintensiveinsulin

therapyforT2DMIndications：monotherapyorcombinationtherapyoforalantihyperglycemiatherapyfailtoachieveglucosetargets，overthyperglycemia，fastingandpostprandialC-peptideMethod：useinsulin2timesperday：NPH/R70/30prebreakfastandpresupper，adjustthedosagewiththemonitoringresultsofbloodsugar.useinsulin4timesperday：RIpremeal、NPHbeforesleepPeriodoftreatment：severalweeksormonthes第六十九頁(yè)第七十頁(yè)，共104頁(yè)。Shot-termintensiveinsulin

therapyforT2DM

Estimationofinitialdosage：0.2

0.4U/KgweightperdayModeoftherapyRIbeforemeals：RI—RI—RI—O，beforebreakfast＞beforesupper＞beforedinerRIbeforethreemeals+RIbeforesupper：RI—RI—RI—RIRIbeforethreemeals+NPHbeforesupper:RI—RI—RI/NPHRIbeforethreemeals+NPHbeforesleep：RI—RI—RI—NPHmixedinsulin（RI/NPH）beforethreemeals（2/3beforebreakfast，1/3beforesupper），theproportion:10R—50RNPH/R70/30beforebreakfastandsupper第七十頁(yè)第七十一頁(yè)，共104頁(yè)。SecondaryfailureofOHA:combinationwithinsulinFPG

oralanti-hyperglycemiaagents+NPHbeforesleepPPG

NPHbeforebreakfast+oralanti-hyperglycemiaagentsFPG

PPG