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[ADA2012]糖尿病前期的药物治疗:生活方式改变及二甲双胍足够了吗?NO
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作者:国际糖尿病网 2012/8/16 13:33:00    加入收藏
内容概要:德克萨斯大学健康科学中心内分泌科主任,曾荣获得ADA的Banting和EASD的Bernard奖,37年糖尿病、内分泌疾病和肾病临床经验,在同行评议杂志发表600余篇文章。

  《国际糖尿病》:您是认为糖尿病前期患者使用二甲双胍和生活方式改变有何局限性?
  Prof. DeFronzo:迄今已经发表的所有研究中,二甲双胍或磺脲类药物应用1年后,胰岛β细胞开始衰竭,导致HbA1c增高。DPP研究中,二甲双胍组糖尿病发生风险降低了31%,饮食控制和体育锻炼组降低了58%。而在任何一项采用TZD类药物开展的研究中,该比例均能达到60%~70% ,GLP-1类药物甚至更高。尽管二甲双胍可以使糖尿病发生率降低31%,但是胰岛β细胞功能仍然在衰竭。问题是二甲双胍不能阻止病情进展。如果使糖尿病前期患者采用饮食控制和体育锻炼,结果会不同,但是患者的依从性很难保证,一旦项目结束,他们就会恢复到以前的生活方式中去,因此从长期效果来看,生活方式改变这种方法没有作用。
  《国际糖尿病》:您认为糖尿病前期患者还有哪些治疗选择?
  Prof. DeFronzo:目前糖尿病前期患者的最佳选择是低剂量吡格列酮联合低剂量的二甲双胍。从长期效果来看,我认为治疗糖耐量受损(IGT)的最佳药物是GLP-1类似物。目前从实用的角度来看,人们不会为了治疗“糖尿病前期”状态而选择利拉鲁肽注射。但我相信,每周一次的艾塞纳肽长效缓释型Bydureon和即将上市的只需每月一次注射的新药将会是理想的选择。这类药物的胰岛β细胞保护作用最强。目前仅有3.5年的数据资料,但是我确信即使超过3.5年,这类药物依然有很好的作用。另一巨大的问题是费用。我们不得不面对药物有效性与患者承受能力之间权衡的困境。
  In every study that has been published, after the first year on metformin or sulfonylureas, the beta cells start to fail and then the A1C goes up. In the DPP Study where they were using metformin, there did seem to be a 31% decreased risk for developing diabetes, and with diet and exercise to was 58%. In every TZD study that rate has been 60%-70%, and with GLP-1s it is even higher. Even though metformin decreased the incidence by 31%, the beta cells are still dying. The problem is that metformin doesn’t stop the process. If you can get people to diet and exercise, then it is a different story. But it is very difficult to get people to adhere to the regimen, and once they are out of the program then they go back to their old ways and lifestyle. So on a long-term basis, it simply does not work.
  I think that the optimum choice at this point is the low dose pioglitazone plus low dose metformin. On a long-term basis, the best drugs for treating people with IGT are the GLP-1 analogs. Right now, from a practical standpoint, people are not going to take a shot of Liraglutide once a day for “prediabetes” because of its administration route. But I think that Exenatide, which is a once-a-week dosage, and the new drugs that are coming which are once-a-month, will be ideal choices. These drugs have the most powerful effect in preserving beta cell function. I am quite certain that they will work beyond three and a half years, but that data is not yet available. The other big issue is cost. So we have face the dilemma of balancing efficacy versus what people can afford.
 

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