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手把手教你正確掌握二甲雙胍的臨床地位與使用時(shí)機(jī)。 糖尿病患者心血管事件發(fā)生風(fēng)險(xiǎn)顯著增高，長(zhǎng)期以來(lái)受到內(nèi)分泌、心血管領(lǐng)域醫(yī)師廣泛關(guān)注。作為一種臨床應(yīng)用已有60多年歷史的降糖藥，二甲雙胍已成為全球糖尿病防控的核心藥物。因此，正確認(rèn)識(shí)、合理使用二甲雙胍對(duì)心血管醫(yī)師來(lái)說(shuō)同樣至關(guān)重要。 近期，《二甲雙胍臨床應(yīng)用專家共識(shí)》（下文簡(jiǎn)稱“共識(shí)”）?2018版正式公布。基于近年來(lái)不斷涌現(xiàn)的二甲雙胍相關(guān)研究新證據(jù)，共識(shí)做出部分更新與修訂，為廣大臨床醫(yī)師提供重要的學(xué)術(shù)參考。我們將依據(jù)專家共識(shí)，對(duì)每部分內(nèi)容進(jìn)行具體解讀，今天先跟小編一起來(lái)了解“二甲雙胍的臨床地位與使用時(shí)機(jī)”。 表：二甲雙胍的臨床地位與使用時(shí)機(jī) T2DM治療的一線首選和全程用藥， 二甲雙胍當(dāng)仁不讓！ 共識(shí)推薦，如無(wú)禁忌癥和不耐受，二甲雙胍是治療T2DM的首選全程用藥，且應(yīng)一直保留在糖尿病治療方案中。那么，二甲雙胍為何能夠在眾多降糖藥中脫穎而出，讓共識(shí)為它打Call呢？ 首先，二甲雙胍兼具短期和長(zhǎng)期降糖療效，單獨(dú)使用可有效降低T2DM患者的空腹血糖（FPG）和餐后血糖（PPG）。研究表明二甲雙胍可使中國(guó)新診斷T2DM患者的HbA1c降低1.8%，且不受體重影響?[1]。基線HbA1c水平一致時(shí)，最佳有效劑量（2000 mg/d）的二甲雙胍降糖療效優(yōu)于其他口服降糖藥?[2]。二甲雙胍緩釋片與普通片的療效相似。 其次，二甲雙胍單藥治療效果不佳者，聯(lián)合其他口服降糖藥可進(jìn)一步獲得明顯的血糖改善。與使用其他口服降糖藥作為一線治療相比，以二甲雙胍作為一線治療的患者，加用第二種口服降糖藥或啟動(dòng)胰島素聯(lián)合治療的開始最晚，后續(xù)需要調(diào)整治療方案的概率也最低[3, 4]。二甲雙胍聯(lián)合胰島素可進(jìn)一步降低HbA1c、減少胰島素用量、增加體重并降低低血糖風(fēng)險(xiǎn)[5-8]。 再次，二甲雙胍具有心血管保護(hù)作用。二甲雙胍的長(zhǎng)期治療與新診斷的T2DM患者、已存在心血管疾病的T2DM患者的心血管事件發(fā)生風(fēng)險(xiǎn)降低顯著相關(guān)[9]。此外，薈萃分析顯示，二甲雙胍可降低糖尿病患者的全因死亡率[9, 10]。 最后，二甲雙胍良好的安全性和耐受性是其長(zhǎng)期應(yīng)用的保障。單獨(dú)使用時(shí)不增加低血糖發(fā)生的風(fēng)險(xiǎn)，胃腸道反應(yīng)多為一過(guò)性、不導(dǎo)致腎臟損害，長(zhǎng)期使用不增加高乳酸血癥或乳酸酸中毒發(fā)生風(fēng)險(xiǎn)?[11-13]。與其他降糖藥物相比，二甲雙胍具有良好的成本-效益比。 不超重、不肥胖的T2DM患者， 也應(yīng)該首選二甲雙胍！ 回顧性和前瞻性臨床研究結(jié)果均顯示，二甲雙胍在肥胖、超重、正常體重的T2DM患者中療效相當(dāng)。因此，體重不是能否使用二甲雙胍治療的決定因素，無(wú)論對(duì)于超重、肥胖或體重正常的患者，國(guó)內(nèi)外主要糖尿病指南均將二甲雙胍推薦為治療T2DM的首選用藥?[14, 15]。 防范糖尿病于未然，二甲雙胍也有功！ 值得一提的是，除治療效果成績(jī)斐然外，大量證據(jù)尚顯示二甲雙胍可以有效且安全地降低糖尿病前期人群發(fā)展為T2DM的發(fā)生率?[16]、減少患者體重增加且10年內(nèi)醫(yī)療花費(fèi)更低?[17, 18]，但我國(guó)尚未批準(zhǔn)二甲雙胍應(yīng)用于糖尿病的預(yù)防。 鑒于大量研究證據(jù)表明二甲雙胍具有確切的降糖效果和包括改善心血管結(jié)局在內(nèi)的多重優(yōu)勢(shì)，專家共識(shí)仍然力薦二甲雙胍作為首選和全程用藥奮戰(zhàn)于T2DM治療一線。 下期預(yù)告： 二甲雙胍的作用機(jī)制 參考文獻(xiàn)： [1]Ji L, Li H, Guo X, et al. Impact of baseline BMI on glycemic control and weight change with metformin monotherapy in Chinese type 2 diabetes patients: phase IV open-label trial. PloS one. 2013; 2: e57222. [2]Esposito K, Chiodini P, Bellastella G, et al. Proportion of patients at HbA1c target <7% with="" eight="" classes="" of="" antidiabetic="" drugs="" in="" type="" 2="" diabetes:="" systematic="" review="" of="" 218="" randomized="" controlled="" trials="" with="" 78="" 945="" patients.="" diabetes,="" obesity="" &="" metabolism.="" 2012;="" 3:=""> [3]Berkowitz SA, Krumme AA, Avorn J, et al. Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study. JAMA internal medicine. 2014; 12: 1955-62. [4]Ji L, Lu J, Weng J, et al. China type 2 diabetes treatment status survey of treatment pattern of oral drugs users. Journal of diabetes. 2015; 2: 166-73. [5]Hemmingsen B, Christensen LL, Wetterslev J, et al. Comparison of metformin and insulin versus insulin alone for type 2 diabetes: systematic review of randomised clinical trials with meta-analyses and trial sequential analyses. Bmj. 2012: e1771. [6]Strowig SM, Aviles-Santa ML, Raskin P. Comparison of insulin monotherapy and combination therapy with insulin and metformin or insulin and troglitazone in type 2 diabetes. Diabetes care. 2002; 10: 1691-8. [7]Kooy A, de Jager J, Lehert P, et al. Long-term effects of metformin on metabolism and microvascular and macrovascular disease in patients with type 2 diabetes mellitus. Archives of internal medicine. 2009; 6: 616-25. [8]Guo L, Chen L, Chang B, et al. A randomized, open-label, multicentre, parallel-controlled study comparing the efficacy and safety of biphasic insulin aspart 30 plus metformin with biphasic insulin aspart 30 monotherapy for type 2 diabetes patients inadequately controlled with oral antidiabetic drugs: The merit study. Diabetes, obesity & metabolism. 2018; 12: 2740-2747. [9]Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. The New England journal of medicine. 2008; 15: 1577-89. [10]Campbell JM, Bellman SM, Stephenson MD, et al. Metformin reduces all-cause mortality and diseases of ageing independent of its effect on diabetes control: A systematic review and meta-analysis. Ageing research reviews. 2017: 31-44. [11]Wright AD, Cull CA, Macleod KM, et al. Hypoglycemia in Type 2 diabetic patients randomized to and maintained on monotherapy with diet, sulfonylurea, metformin, or insulin for 6 years from diagnosis: UKPDS73. Journal of diabetes and its complications. 2006; 6: 395-401. [12]Rachmani R, Slavachevski I, Levi Z, et al. Metformin in patients with type 2 diabetes mellitus: reconsideration of traditional contraindications. European journal of internal medicine. 2002; 7: 428. [13]Cryer DR, Nicholas SP, Henry DH, et al. Comparative outcomes study of metformin intervention versus conventional approach the COSMIC Approach Study. Diabetes care. 2005; 3: 539-43. [14]Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus Statement by the American Association Of Clinical Endocrinologists And American College Of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm - 2018 Executive Summary. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2018; 1: 91-120. [15]Introduction: Standards of Medical Care in Diabetes-2018. Diabetes care. 2018; Suppl 1: S1-S2. [16]Li CL, Pan CY, Lu JM, et al. Effect of metformin on patients with impaired glucose tolerance. Diabetic medicine : a journal of the British Diabetic Association. 1999; 6: 477-81. [17]Diabetes Prevention Program Research G. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes care. 2012; 4: 723-30. [18]Diabetes Prevention Program Research G. Long-term safety, tolerability, and weight loss associated with metformin in the Diabetes Prevention Program Outcomes Study. Diabetes care. 2012; 4: 731-7. |
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