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CSE 2016掠影:从指南到实践,全面加强糖尿病管理

2016-09-20 志文 中国医学论坛报

由中华医学会内分泌学分会主办的第十五次全国内分泌学学术会议(CSE 2016)近期在北京召开。本次会议内容丰富,专题报告和讨论、病例讨论、演讲比赛等各种学术内容精彩纷呈,我们精选了9月1日一场关于二肽基肽酶4(DPP-4)抑制剂“从过去到未来”的内容与您分享。从指南到临床看DPP-4抑制剂的疗效及安全性陈璐璐教授华中科技大学同济医学院附属协和医院陈璐璐教授从指南谈起,指出目前DPP-4抑制剂在糖尿

由中华医学会内分泌学分会主办的第十五次全国内分泌学学术会议(CSE 2016)近期在北京召开。本次会议内容丰富,专题报告和讨论、病例讨论、演讲比赛等各种学术内容精彩纷呈,我们精选了9月1日一场关于二肽基肽酶4(DPP-4)抑制剂“从过去到未来”的内容与您分享。

从指南到临床看DPP-4抑制剂的疗效及安全性

陈璐璐教授

华中科技大学同济医学院附属协和医院陈璐璐教授从指南谈起,指出目前DPP-4抑制剂在糖尿病管理中地位获指南充分认可。2016美国临床内分泌医师学会/美国内分泌学会(AACE/ACE)2型糖尿病管理流程推荐DPP-4抑制剂可作为一线治疗药物,建议降糖药选择优先考虑最小化低血糖及体重增加风险。2016年我国发表基于肠促胰素治疗药物临床应用的快速建议指南,推荐DPP-4抑制剂可作为一线治疗药物选择。

二甲双胍与DPP-4抑制剂联合机制互补。一系列研究揭示,在2型糖尿病(T2DM)患者中,DPP-4抑制剂与传统口服降糖药(格列吡嗪、格列美脲、阿卡波糖等)相比疗效确切,DPP-4抑制剂组低血糖发生率低、不增加体重,不引起胃肠道不良反应。关于二甲双胍单药控制不佳T2DM患者的非劣效性研究显示,加用西格列汀与加用格列吡嗪降低糖化血红蛋白(HbA1c)的疗效相似,西格列汀组低血糖发生率更低(5%对32%)、体重减轻(-1.5 kg对+1.1 kg,图1)。药物经济学研究显示,与格列美脲或阿卡波糖相比,DPP-4抑制剂西格列汀治疗T2DM远期效果更具成本效果。


不同的DPP-4抑制剂之间也存在差异。酶抑制率比较研究显示,用药5天后,西格列汀100 mg每日1次(91.7%)达到的24小时谷值DPP-4抑制率显著高于沙格列汀5 mg 每日1 次(73.5%)或维格列汀50 mg每日1次(28.9%);西格列汀每日1次和维格列汀每日2次从第2天服药前到末次服药24小时后,显示出了持续的最大抑制(>90%,图2)。心血管安全性方面,TECOS研究显示,西格列汀与安慰剂相比在心血管复合终点方面具有非劣效性[11.4%对11.6%,风险比(HR)=0.98,P<0.001],且不增加因心衰入院风险HR=1.0,P=0.98),更少患者需加用其他降糖药(HR=0.72,P<0.001)或起始胰岛素治疗
(HR=0.70,P<0.001)。


陈教授总结,DPP-4抑制剂已成为一线推荐或二甲双胍后的二线推荐。在T2DM患者中,DPP-4抑制剂疗效确切,不良反应少,且具成本效果。DPP-4抑制剂中西格列汀具有更好的酶抑制率,心血管及其他安全性数据良好。

从中国T2DM患者达标挑战看西格列汀/二甲双胍固定复方制剂应用前景

王卫庆教授

上海交通大学医学院附属瑞金医院王卫庆教授介绍,我国仅约三分之一T2DM 患者血糖控制达到HbA1c<7.0%。影响血糖达标的因素很多,包括疾病特点(中长病程患者多、大量患者合并心血管疾病、β细胞功能差)、药物治疗因素(早期联合比例低、药物不良反应影响达标)、患者依从性低(患者对多种药物治疗和胰岛素的接受度低、患者对治疗方案维持时间不足)。

针对疾病特点,是否需要创新机制的药物来保护β细胞功能、延缓疾病进展并且具有心血管安全性?一项为期2年的研究显示,与二甲双胍+格列吡嗪相比,二甲双胍+西格列汀可改善胰岛功能、增加胰岛素敏感性。另一研究报告,治疗6年时,应用二甲双胍+西格列汀的患者起始应用胰岛素的比例低于应用二甲双胍+磺脲类者(26.6%对34.1%)。我国台湾一项研究显示,与加用磺脲类相比,在二甲双胍基础上加用DPP-4抑制剂可降低全因死亡(HR=0.63)、主要心脏不良事件(HR=0.68)、缺血性卒中(HR=0.64,图3)和低血糖风险(HR=0.43)。针对药物治疗因素,是否要选择更强效安全的药物进行早期积极联合治疗?机制互补的西格列汀与二甲双胍组成的固定复方制剂(推荐50 mg/850 mg,每日2次)为T2DM治疗提供了新选择。一项在166例中国新诊断的肥胖T2DM患者进行的研究显示,治疗24周时,接受西格列汀/二甲双胍固定复方制剂+低热量饮食者较应用甘精胰岛素+二甲双胍者HbA1c 降低幅度更大(-2.89%对-2.25%)、达标率更高(图4)。且研究证实,西格列汀/二甲双胍可降低体重,低血糖和胃肠道不良事件少。针对患者依从性,是否需要选择让患者更方便使用的药物以提高依从性?回顾性研究已发现,与自由联合治疗相比,应用固定复方制剂者依从性提高、糖尿病相关月费用和总体月费用均降低。



总之,T2DM管理面临来自疾病、治疗及患者等方面的诸多挑战,应对策略应包括早期积极联合治疗、选择机制优势互补且可改善治疗依从性的药物。西格列汀/二甲双胍固定复方制剂是T2DM的良好选择。

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    2017-02-20 sjzlzc015
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    2016-10-12 1e0d99ddm02(暂无匿称)

    总结的很好!

    0

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    2016-10-12 1e0d99ddm02(暂无匿称)

    分享一下!

    0

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    2016-09-21 jiangxianchen

    学习啦

    0

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    2016-09-20 医路开来

    学习啦,,,

    0

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