糖尿病繼續教育課程 個案討論會 醫師組 · ADA-EASD Position Statement: Management of...
Transcript of 糖尿病繼續教育課程 個案討論會 醫師組 · ADA-EASD Position Statement: Management of...
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2014.07.18
PM 13:30 ~16:30
主講人: 林君璐醫師
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1. 請討論此個案A1C Target的設定, 若未達標該如何處理。
2. 請討論如何在使用了OADs之後加入胰島素的治療。
3. 請討論Human Insulin與Insulin analogue
的異同與優缺點。
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請討論此個案A1C Target的設定, 若未達標該如何處理。
以上皆是!
6.5%
7.0% 7.5%
8.0%
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ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM
Glycemic Targets
- HbA1c < 7.0%
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
PG = plasma glucose
Diabetes Care, Diabetologia. 19 April 2012
Do You Agree ?
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ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM
Individualization is key !
PG = plasma glucose Diabetes Care, Diabetologia. 19 April 2012
Tighter targets
(6.0 - 6.5%)
younger, healthier
Looser targets
(7.5 - 8.0%+)
older, comorbidities, hypoglycemia prone
Avoidance of hypoglycemia !!!
Q: What else?
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糖尿病被診斷
胰島beta細胞 剩餘功能<50%
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胰島 b-細胞
胰島素分泌
功能受損
神經傳導物質
功能障礙
葡萄糖攝取減少
胰島 a-細胞
昇糖素分泌
增加
脂解作用
增強
葡萄糖重吸收
增加
HGP增加
Incretins
作用減弱
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請討論如何在使用了OADs之後加入胰島素的治療。
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Years
0 4 10 8 6 2
Glycemic control continues to deteriorate
UKPDS Group. Lancet. 1998;352:837-53
Turner R. C. et al. JAMA 1999; 281: 2005-2012.
• A1C <7%
Year 3: 47-53%; Year 9: 20-28%
Monotherapy
After 4 years:
Initial A1C < 7%: 68% A1C > 8.0%
Cook, M. N. et al Diabetes Care 2005 28: 995-1000
Sulfonylurea and Metformin
5
Hem
oglo
bin
A1c (%
)
Chlorpropamide
Metformin
Glibenclamide Insulin
Conventional
6
7
8
9 pre A1C level 10% (———), 9.0–9.9% (———)
8.0–8.9% (— - —), 4.0–7.9% (- - - -)
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8.2
7.7
8.8
7.6
7.1
9.1
5
6
7
8
9
10
A1
C %
0
35 Months*
27 Months*
Goal:A1C:<7%
Modified: Monotherapy switched to another agent or additional agent added. *Mean number of months until a new or additional treatment was started
Adapted from Brown JB, et al. Diabetes Care 2004;27:1535–40
First HbA1c on treatment
Last HbA1c before switch or addition
Best HbA1c on treatment
Before Starting Insulin, Patients Spend an Estimated 10 Years Above Target
Metformin monotherapy
Sulfonylurea monotherapy
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Sequential insulin strategies in type 2 diabetes ADA and EASD
Inzucchi SE. et.al. Diabetes Care 2012
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請討論Human Insulin與Insulin analogue的異同與優缺點。
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西元1922-1923年,班庭和貝斯特從狗和牛的胰臟萃取出胰島素,而開啟用胰島素治療糖尿病病人的新紀元
後來則從豬的胰臟萃取胰島素,比較不會產生抗體
然後是利用基因工程的方法,在大腸桿菌或酵母菌合成人類胰島素(HRI), 以後這種基因工程合成的胰島素變成正規使用的胰島素
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Before insulin was discovered in 1921, everyone with type 1 diabetes died within
weeks to years of its onset….
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Normal Blood Glucose Levels
Blood Glucose (mmols) 10-
8-
6-
4-
2-
0
8am noon 6pm 2am 4am 8am
Time
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Blood Glucose (mmols)
8am noon 6pm 2am 4am 8am
Time
R or H + N in AM R or H + N at Supper
10-
8-
6-
4-
2-
0
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Four injections/day
Blood Glucose (mmols)
8am noon 6pm 2am 4am 8am
Time
R or H at every meal N or U once or twice/day
10-
8-
6-
4-
2-
0
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Basal Bolus Injection
Blood Glucose (mmols) 10-
8-
6-
4-
2-
0
8am noon 6pm 2am 4am 8am
Time Blood Glucose (mmols)
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問題1: 請討論此個案若很少運動,有哪些方法
可增加病人動機。
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解釋運動對糖尿病的效益及好處 將運動計畫付諸實踐 以漸進的方式輔導病人 以階段性行為改變模式,輔導病患養成長期規律運動的習慣
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1.增加血中葡萄糖的利用率 2.降低糖化血紅素 3.提昇胰島素的敏感度 4.適當調整口服降血糖藥及胰島素的需求量 5.減少高胰島素血症 6.增加葡萄糖轉送蛋白的功能
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1.我懶得運動。 2.工作忙沒時間運動。 3.過去有運動,因為…,所以就沒繼續運動。 4.我很少運動,有一次去爬山回來後腳痛了一星期就沒再去運動了。
5.因為膝蓋退化,所以沒在運動。 6.糖尿病有吃藥控制了,還需要運動嗎?
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1.糖尿病患者每次運動45-60分鐘,中等費力強度的有氧運動。
2.活動型態:選擇適合的有氧運動如快走、跑步、游泳、自行車等。
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3.頻率:每週5-7天。 4.時間:每次至少10分鐘以上,每天累積時間達30鐘以上。
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5.強度:年齡推估最大心跳率的50-70% 。 6.欲增加運動量時,建議先增加每次運動時間再著量。
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1.盡量避免餐前運動。 2.避開胰島素作用高峰期運動及注射部位適當選擇。
3.避免血糖持續過高的狀態下運動。 4.預防激烈運動的低血糖。 5.調整運動時間及運動前點心量。
2012糖尿病核心教材課程
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6.生病時不要勉強運動。 7.避免單獨在偏遠地方運動。 8.配戴識別卡。 9.隨身攜帶點心預防低血糖。 10.配合胰島素種類及劑量調整運動時間及強度。
2012糖尿病核心教材課程
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雨天 室內:健身中心、游泳池。 家中:計步器原地慢跑、健身器材、運動光碟、放音樂跳舞。
天冷 勿太早出門/家中先做暖身操/洋蔥式穿衣/極端氣候視個別狀況不可勉強。
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太熱 調整時間/早晚太陽不大時 室內運動:賣場/捷運地下街/社區健身房
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問題2: 請問此個案是否需要留意低血糖,請討
論低血糖發生之原因與處理措施。
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自主神經 中樞神經 不明原因 發抖、顫動、
冒汗
思考緩慢、注意力不集中、暈眩
飢餓感 噁心
心悸 脈搏加速
視力模糊 口齒不清
四肢無力
體溫變化 四肢刺激感
動作不協調 麻木感
頭痛
呼吸困難
疲倦、嗜睡
感覺不對勁
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藥物 飲食 運動
2012糖尿病核心教材課程
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藥物方面 經常改變劑量
注射時間不規律
食量減少時未減少胰島素劑量
胰島素劑量不正確
血糖監測不足
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飲食方面 忽略正餐/點心
延誤正餐/點心
飲食時間不規律
醣類份量不固定
沒有預備醣類食物
飲酒而無進食可能會導致低血糖
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運動方面 沒有補充醣類食物
每日或每週活動量大幅變化
未察覺熱量需求有明顯的增加
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第一級-嚴重低血糖:
無法自行處理者,血糖值<50mg/dl
第二級-中度低血糖:
•可自行處理者,血糖值<70mg/dl,有
低血糖症狀發生
•可自行處理者,血糖值<70mg/dl,無 低血糖症狀發生
第三級-輕度低血糖:
可自行處理者,血糖值>70mg/dl,有低
血糖症狀發生
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牛奶(低脂或脫脂)240mL 果汁汽水120-180cc 蜂蜜一湯匙 糖包3小包(每包5公克) 葡萄糖片(3-4錠) 急救片(3片)
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問題1: 請討論此個案的熱量需求與含醣類食物
的份量及餐次分配。
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身高:170公分、體重:74公斤 理想體重:63.6公斤±10% BMI:25.6 過重 保全業(白天班)很少運動偶散步
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成年人熱量估算(依實際體重為基礎)
20大卡/公斤體重: 肥胖、非常不活動的人與長期節食者
25大卡/公斤體重: 年齡大於55歲、活動的女性與慣於久坐的男性
30大卡/公斤體重: 活動的男性、非常活動的女性
40大卡/公斤體重: 非常活動的男性、運動員
成年人熱量估算方式
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2014/8/7 55 每日飲食不需低於1200卡熱量
每天活動量 體重正常者所需熱量 體重過重或肥胖者所需熱量
輕度工作 30大卡×目前體重(公斤) 20~25大卡×目前體重(公斤)
中度工作 35大卡×目前體重(公斤) 30大卡×目前體重(公斤)
重度工作 40大卡×目前體重(公斤) 35大卡×目前體重(公斤)
每日熱量需求
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問題1: 熱量需求: 7420~25=1480~1850 大卡/天 BEE(IBW)1.251=1784 大卡/天 BEE(ABW)1.251-(300~500) =1462~1662 大卡/天 1600~1700 大卡/天
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問題1: 含醣類食物份量: 主食類:11份 低脂奶類:1份 水果類:2份 豆魚肉蛋類:5份 蔬菜類:3份 油脂類:5份 (1670 大卡/天 CHO:54.4% PT:16.5% FAT:29.1%)
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問題1: 含醣類食物餐次分配:
早餐 早點 午餐 午點 晚餐 晚點
主11 3 4 4
奶1 1
果2 1 1
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問題2: 請討論此個案平時的飲食問題,有哪些
可先加強衛教?
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早餐06:00:菜包或肉包小的兩顆+黑芝麻粉一包
早點09:00:菜包或肉包一顆 午餐12:00:水餃15顆+酸辣湯或青菜蛋花湯 午點15:00乳酪餅乾3~4片 晚餐19:00:池上便當(秋刀魚)+水果(蕃茄或蓮霧一顆或香蕉一根)
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1.早餐06:30:涼麵一盒 2.早點10:00:孔雀餅乾5~6片 3.午餐12:00:涼麵或咖哩飯 4.午點15:00:孔雀餅乾5~6片 5.晚餐19:00控肉便當+無糖綠+偶爾水果(水梨幾片或一個或香蕉一根)
6.宵夜23:00麥片粥(即時)一包
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問題2: 可先說明均衡低熱量飲食以控制體重 可先加強含醣類食物定時定量的概念 可先教導簡單的含醣類食物份量代換 可先強調高纖維蔬果攝取的飲食原則
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