ADA糖尿病诊疗标准更新要点2024.docx

ADA糖尿病诊疗标准更新要点2024IA刖言2023年12月11日ADA发布了最新2024版糖尿病诊疗标准，主要内容涉及ADA当前所有的临床实践建议，共包括17部分内容：（1）改善诊疗并促进群体健康；（2）糖尿病诊断和分类；（3）预防或延缓糖尿病及相关合并症；（4）综合医学评估和合并症评估;（5）促进积极健康行为以改善结局；（6）血糖目标和低血糖；（7）糖尿病技术；（8）2型糖尿病的预防和治疗：肥胖和体重管理；（9）降糖药物治疗；（10）心血管疾病和风险管理；（Il）慢性肾病和风险管理；（12）视网膜病变、神经病变和足部诊疗；（13）老年患者；（14）儿童和青少年患者；（15）妊娠期糖尿病；（16）院内糖尿病管理；（17）糖尿病倡导。新版指南纳入了更多循证医学证据，本文梳理了新指南的第一至四部分的更新要点。一糖尿病的诊断与分类要点1建议根据糖化血红蛋白或血糖标准诊断糖尿病，血糖标准包括空腹血糖（FPG）值、75克口服葡萄糖耐量试验（OGTT）的2小时血糖（2-hPG）值，还是伴有典型高血糖症状/危象标准的随机血糖值。在没有明确的高血糖（例如，高血糖危象）的情况下,需要进行一次验证性诊断试验（表2)o新指南将AlC置于的诊断试验的顶部，以强调其在诊断糖尿病和糖尿病前期时的临床实践地位。并且强调了在发现异常血糖结果时进行确诊测验的重要性(图1、表1)。Recommendations2.1aDiagnosediabetesbasedonAlCorplasmaglucosecriteria,eitherthefastingplasmaglucose(FPG)value,2-hplasmaglucose(2-hPG)valueduringa75-goralglucosetolerancetest(OGTT)zorrandomglucosevalueaccompaniedbyclassichyperglycemicsymptoms/crisescriteria(Table2.1).A2.1bIntheabsenceofunequivocalhyperglycemia(e.g.,hyperglycemiccrises),diagnosisrequiresconfirmatorytesting(Table2.1).A图1Table 2.1- riteriaforthediagnosisofdiabetesinnonpregnantindividualsAlC6.5%(48mmol/mol).Thetestshouldbeperformedinalaboratoryusingamethod外atisNGSPcertifiedandstandardizedtotheDCCTassay.*1 ORFPG126mg/dL(7.0mmolL).Fastingisdefinedasnocaloricintakeforatleast8h.*OR2-hPG200mg/dL(11.1mmolL)duringOGTT.ThetestshouldbeperformedasdescribedbytheWHO,usingaglucoseloadcontainingtheequivalentof75ganhydrousglucosedissolvedinwater.,ORInanindividualwithclassicsymptomsofhyperglycemiaorhyperglycemiccrisis,arandomplasmaglucose2mg/dL(11.1mmolL).Randomisanytimeofthedaywithoutregardtotimesincepreviousmeal.DCCTDiabetesControlandComplicationsTrial;FPG,fastingplasmaglucose;OGTT,oralglucosetolerancetest;NGSf*NationalGlycohemoglobinStandardizationProgram;WHO,WorldHealthOrganization;2-hPG,2-hplasmaglucose,lntheabsenceofunequivocalhyperglycemia,diagnosisrequirestwoabnormaltestresultsobtainedatthesametime(e.g.,AlCandFPG)orattwodifferenttimepoints.表1.糖尿病诊断标准Table 2.2- riteriadefiningprediabetesinnonpregnantindividualsAlC5.7-6.4%(39-47mmol/mol)ORFPG1mg/dL(5.6mmolL)to125mg/dL(6.9mmolL)(IFG)OR2-hPGduring75-gOGTT140mg/dL(7.8mmolL)to199mg/dL(11.0mmolL)(IGT)Forallthreetests,riskisntinuous,extendingbelowthelowerlimitoftherangeandbecomingdisproportionatelygreateratthehigherendoftherange.FPG,fastingplasmaglucose;IFG,impairedfastingglucose;IGTimpairedglucosetolerance;OGTT,oralglucosetolerancetest;2-hPG,2-hplasmaglucose.表2.糖尿病前期（未怀孕个体）诊断标准要点2新指南新增为新诊断的成人疑似1型糖尿病的筛查提供了一个结构化的框架(图2)。<200 pmol/L2OOOO pmol/LEl<200 pmol/L>600 pmol/L>200 pmol/LIType 1diabetesType 2diabetes图2.成人疑诊1型糖尿病筛查流程图要点3对症状前1型糖尿病的筛查可以通过检测胰岛素、谷氨酸脱竣酶(GAD)、胰岛抗原2(IA-2)或锌转运蛋白8(ZnT8)的自身抗体来完成。有多个确认的胰岛自身抗体是临床糖尿病的危险因素。血糖异常检测可用于进一步预测近期风险。当鉴定出多个胰岛自身抗体时，应考虑转诊到专门的中心进行进一步评估和/或考虑临床试验或批准的治疗方法，以潜在地延缓临床糖尿病的发展(图3)。Recommendations2.6 Screeningforpresymptomatictype1diabetesmaybedonebydetectionofautoantibodiestoinsulin,glutamicaciddecarboxylase(GAD),isletantigen2(IA-2)zorzinctransporter8(ZnT8).B2.7 Havingmultipleconfirmedisletautoantibodiesisariskfactorforclinicaldiabetes.Testingfordysglycemiamaybeusedtofurtherforecastnear-termrisk.Whenmultipleisletautoantibodiesareidentified,referraltoaspecializedcenterforfurtherevaluationand/orconsiderationofaclinicaltrialorapprovedtherapytopotentiallydelaydevelopmentofclinicaldiabetesshouldbeconsidered.B2.8 Standardizedisletautoantibodytestsarerecommendedforclassificationofdiabetesinadultswhohavephenotypicriskfactorsthatoverlapwiththosefortype1diabetes(eg,youngerageatdiagnosis,unintentionalweightloss,ketoacidosis,orshorttimetoinsulintreatment).E要点42019年冠状病毒（新冠肺炎）感染和新发的1型糖尿病之间可能的联系。正在服用糖皮质激素、他汀类药物、曝嗪类利尿剂、抗艾滋病毒药物以及第二代抗精神病药物人群会增加糖尿病前期和2型糖尿病风险，新指南强调这类人群筛查糖尿病的必要性（图4）。2.15 bInpeoplewhoareprescribedsecond-generationantipsychoticmedications,screenforprediabetesanddiabetesatbaselineandrepeat12-16weeksaftermedicationinitiationorsooner;ifclinicallyindicated,andannually.B2.16 PeoplewithHIVshouldbescreenedfordiabetesandprediabeteswithanFPGtestbeforestartingantiretroviraltherapy,atthetimeofswitchingantiretroviraltherap½and3-6monthsafterstartingorswitchingantiretroviraltherapy.Ifinitialscreeningresultsarenormal,FPGshouldbecheckedannually.E要点6强调在急性胰腺炎发作后或慢性胰腺炎患者中筛查糖尿病的重要性。新指南建议：在急性胰腺炎发作后3-6个月内筛查糖尿病患者，此后每年筛查一次；每年对慢性胰腺炎患者进行糖尿病筛查（图5）。Recommendation2.17 Screenpeoplefordiabeteswithin3-6monthsfollowinganepisodeofacutepancreatitisandannuallythereafter.Screeningfordiabetesisrecommendedannuallyforpeoplewithchronicpancreatitis.E图5要点7由于敏感性较低，不建议将AlC作为囊性纤维化相关糖尿病(CFRD)的筛查试验，但它在临床实践中被广泛使用，并且AIC值6.5%(48mmol/mol)与CFRD的诊断相符合。2.19 AlCisnotrecommendedasascreeningtestforCFRDduetolowsensitivity.However;avalueof6.5%(48mmol/mol)isconsistentwithadiagnosisofCFRD.B图6二、预防或延缓糖尿病及相关并发症新指南建议：在临床前1型糖尿病患者中，每6个月检测A1C用以监测疾病进展，每年进行75克口服葡萄糖耐量试验（即空腹和2小时血糖）；根据基于年龄、自身抗体数量和类型以及血糖指标的个人风险评估修改监测频率。强调检测1型糖尿病高危人群的重要性（图7）。3.2Inpeoplewithpreclinicaltype1diabetes,monitorfordiseaseprogressionusingAlCapproximatelyevery6monthsand75-goralglucosetolerancetest（i.e.zfastingand2-hplasmaglucose）annually;modifyfrequencyofmonitoringbasedonindividualriskassessmentbasedonageznumberandtypeofautoantibodies,andglycemicmetrics.E图7对于年龄8岁的2期1型糖尿病患者，应考虑注射Teplizumab（图8）oRecommendation3.15Teplizumab-mzwvinfusiontodelaytheonsetofsymptomatictype1diabetes（stage3）shouldbeconsideredinselectedindividualsaged>8yearswithstage2type1diabetes.Managementshouldbeinaspecializedsettingwithappropriatelytrainedpersonnel.B图82022年11月17日，美国食品药品监督管理局（FDA）批准Teplizumab用于延缓1型糖尿病2期成人和儿童（大于8岁）的1型糖尿病3期发病。三、综合医学评估和合并症评估要点9新指南新增建议：对于糖尿病患者，骨骼健康作为常规护理的一部分，应根据危险因素和合并症评估老年糖尿病患者的骨折风险（图9）。Recommendations4.9 Fractureriskshouldbeassessedinolderadultswithdiabetesasapartofroutinecareindiabetesclinicalpractice,accordingtoriskfactorsandcomorbidities.A4.10 Monitorbonemineraldensityusingdual-energyX-rayabsorptiometryofhigh-riskolderadultswithdiabetes（aged>65years）andyoungerindividualswithdiabetesandmultipleriskfactorsevery2-3vears.A图9每2-3年使用双能X射线骨密度仪监测患有糖尿病（年龄>65岁）的高危老年人和患有糖尿病合并多种危险因素的年轻人的骨密度（图9）。临床医生在选择降糖方案时，应考虑对骨骼健康的潜在不利影响。建议优先使用对骨骼具有公认安全性的药物（图10）。4.11 Cliniciansshouldconsiderthepotentialadverseimpactonbonehealthwhenselectingpharmacologicaloptionstolowerglucoselevelsinpeoplewithdiabetes.Prioritizingmedicationswithaprovensafetyprofileforbonesisrecommended,particularlyforthoseatelevatedriskforfractures.A4.12 Tbreducetheriskoffallsandfractures,glycemicmanagementgoalsshouldbeindividualizedforpeoplewithdiabetesatahigherriskoffracture.CPrioritizeuseofglucose-loweringmedicationsthatareassociatedwithlowriskforhypoglycemiatoavoidfalls.E图10为了减少跌倒和骨折的风险，糖尿病患者的血糖管理目标应该个体化（图10）。