MedPage：加拿大新指南称糖尿病患者40岁时应该使用他汀类药物

根据加拿大最新指导原则，所有糖尿病患者到40岁时应该开始服用他汀类药物，55岁时服用降血压药物，尽管他们在当时没有其它危险因素。

准则委员会主席、多伦多圣迈克尔医院的Alice Cheng博士说，该指导原则也建议那些年龄30岁以上、患糖尿病至少15年的患者也应该开始使用他汀类药物。

Cheng对MedPage Today说，“在加拿大，仅13%的2型糖尿病患者在血糖、血压和LDL胆固醇控制3个方面达标，很明显，这中间仍有护理差距，我们需要找到解决的方法。那就是这些指导原则介入的地方。”

据ADA医疗事务前任主席、北卡罗来纳大学教堂山分校的Sue Kirkman博士所说，尽管加拿大糖尿病协会(CDA)的建议稍微更激进一些，但是与美国糖尿病协会(ADA)的建议没有太大不同。

ADA建议40岁及以上、至少有一种其它危险因素的糖尿病患者使用他汀类药物：“主要考虑到大多数糖尿病患者在这个年龄都有高血压，这与CDA指导原则是相同的，” Kirkman对Medpage Today说道。

CDA指导原则建议55岁及以上患者服用ACE抑制剂和血管紧张素受体阻断剂(ARB)与ADA的情况类似。ADA呼吁有高血压、微量白蛋白尿或心血管疾病的糖尿病患者服用降血压药物：“这将可能覆盖55岁及以上的大多数人，”Kirkman说。

但是她警告，多项临床试验显示这些药物不能预防蛋白尿的发生，并且怀疑CDA指导原则中建议使用降血压药物的根据。

加利福尼亚Tarzana美国代谢研究所主任和美国临床内分学家协会前任主席Yehuda Handelsman博士对建议使用ACE/ARB也“不那么热情”。

“我仅用于治疗有高血压或明显终末器官疾病的患者，”Handelsman对MedPage Today说。“一位健康的60岁糖尿病患者，既没有高血压，也没有肾脏或心脏损害，我不会去处理。”

Cheng博士承认仅仅根据年龄推荐使用ACE/ARB是D级共识水平证据，正如推荐30岁没有长期疾病的患者使用他汀类药物一样。

推荐1型糖尿病患者40岁时使用他汀类药物也是D级共识水平证据，但是对于2型糖尿病患者来说是A级1类水平证据。

Cheng警告，因为建议30岁使用他汀类药物可能会涉及到育龄妇女，所以只有当与患者就妊娠计划讨论后或“有可靠的避孕措施”才应该推荐使用，同时应该明确妊娠期禁忌症。

“他汀类药物在妊娠期是Ⅹ类药物，我们知道糖尿病妇女中大约一半的妊娠是无计划的，所以有此担忧，”Kirkman说道。

Cheng说，准则委员会120名专家对新的指导原则有多种意见。“在治疗和避免过度治疗方面总是有选择犯错的人，但是在另一方面，也有那些宁愿过度治疗一些患者也不愿错过任何一个的人，” Cheng说道。“该指南建议在某些地方是中立的，使得大多数实践理性化。”

加拿大指导原则不同于美国版本的另一点是建议使用HbA1c 6% 到6.4%诊断前驱糖尿病；ADA使用的切点较低，为5.7%。

Cheng说，“直到现在，我们才有界定前驱糖尿病的A1c值范围。”

她补充道，社会也在更新推广指南的方法，在线版本将为医生和患者提供数字化工具。例如，她说，患者将能够使用在线计算器计算他们的心血管风险和他们预防用药的需要。

行动要点：

注意：这些指导原则来自加拿大糖尿病协会，与前一版本比较，对于那些凭经验性药物治疗、超过一定年龄的患者来说，包含了更多积极的建议。这些建议大多是基于共识，不是确凿的证据。

与糖尿病相关的拓展阅读：

• Diabetes Care：维生素D缺乏不能预测糖尿病患者心血管风险
• Diabetes care：女性糖尿病患者死亡风险高于男性
• Diabetes Care：网络教程改善青少年糖尿病预后
• 自体荧光测糖尿病微血管病变
• Diabetes Care：青少年肥胖者发生糖尿病风险高于成人
• Hypertension：无糖尿病患者ACEI与小剂量噻嗪利尿剂联用对胰岛素作用影响不大
更多信息请点击：有关糖尿病更多资讯

Guidelines Urge Statins at 40 for Diabetics
All patients with diabetes should start taking statins when they turn 40 and blood pressure drugs when they turn 55, even if they have no other risk factors at the time, according to new Canadian guidelines.

The guidelines also recommend that those over 30 who have had diabetes for at least 15 years also should start on statins, according to Alice Cheng, MD, of St. Michael's Hospital in Toronto, who is chair of the guideline committee.

"In Canada, only 13% of patients with type 2 diabetes achieve all three targets in glucose, blood pressure, and LDL cholesterol control," Cheng told MedPage Today. "Clearly, there's still a care gap, and we needed to find ways to address it. That's where these guidelines come in."

Though the recommendations from the Canadian Diabetes Association (CDA) are slightly more aggressive, they are not so far from those of the American Diabetes Association (ADA), according to Sue Kirkman, MD, of the University of North Carolina at Chapel Hill and former chair of medical affairs for ADA.

ADA recommends statins for diabetics ages 40 and up who have at least one other risk factor: "Given that most people with diabetes have hypertension at that age, it isn't that different from the CDA guidelines," Kirkman told MedPage Today.

It's a similar situation for the ACE inhibitor and angiotensin receptor blocker (ARB) recommendation in those ages 55 and up. ADA calls for blood pressure drugs in diabetes patients with hypertension, microalbuminuria, or cardiovascular disease: "That would likely cover most people ages 55 and up," Kirkman said.

But she cautioned that several trials have shown that these drugs don't prevent the onset of albuminuria, and questioned the basis of the blood pressure drug recommendation in the CDA guidelines.

Yehuda Handelsman, MD, director of the Metabolic Institute of America in Tarzana, Calif., and immediate past president of the American Association of Clinical Endocrinologists, was also "slightly less enthusiastic" about the ACE/ARB recommendations.

"I would only treat if there is hypertension or clear end-organ disease," Handelsman told MedPage Today. "A healthy 60-year-old with diabetes but no hypertension and no kidney or heart damage, I would not treat."

Cheng acknowledged that the ACE/ARB recommendation based on age alone is grade D, consensus-level evidence, as is the recommendation for statins in 30-year-olds who've had long-standing disease.

Starting statins at 40 is also grade D, consensus-level evidence for those with type 1 diabetes -- but it is grade A, level-1 evidence for those with type 2 disease.

Cheng cautioned that since the statin recommendation in 30-year-olds likely involves women of child-bearing age, they should only be recommended after discussions with patients about pregnancy plans or "in the presence of reliable contraception," and should definitely be contraindicated during pregnancy.

"Statins are category X in pregnancy, and we know that about half of pregnancies among women with diabetes are unplanned, so there's that concern," Kirkman said.

Among the guideline committee of 120 experts, Cheng said there was a range of opinion on the new recommendations.

"There will always be those who choose to err on the side of undertreating and avoiding overtreatment, but at the other end of the spectrum you have those who prefer to overtreat some [patients] and not miss any," Cheng said. "[The recommendation] is somewhere in the middle, and makes the most practical sense."

Another area in which the Canadian guidelines differ from their American counterpart is in the recommendation of using an HbA1c of 6% to 6.4% to diagnose pre-diabetes; ADA puts the cutoff lower, at 5.7%.

"We didn't have a definition of pre-diabetes using A1c until now," Cheng said.

She added that the society has also updated the way it is rolling out the guidelines, using an online version that will include digital tools for both the clinician and patient. For instance, she said, patients will be able to use an online calculator to calculate their vascular risk and their need for preventive medications.