Rodbard Helena W
Endocrinology and Metabolic Consultants, Rockville, MD, USA.
J Fam Pract. 2013 Dec;62(12 Suppl CME):S5-11.
The ADA/EASD and AACE guidelines emphasize the importance of individualizing treatment to best meet each patient's situation. Metformin remains the preferred choice as initial therapy for most patients. The 2009 AACE algorithm elevated the role of incretin-based therapies (GLP-1R agonists and DPP-4 inhibitors) relative to previous algorithms and this has been endorsed by subsequent algorithms and guidelines. The incretin-based therapies and insulin therapy should be considered with very high priority. Either incretin-based therapy or insulin therapy can be used as monotherapy or in combination with other agents. The GLP-1R agonists are especially useful when attempting to reduce the risk of hypoglycemia and when assisting the patient to achieve weight loss. Insulin therapy is especially useful when the HbA1c level is >9.0% or when symptoms of glucotoxicity are present. Insulin is the recommended treatment when other agents fail to achieve the desired target levels for HbA1c, FPG, and PPG. The combination of a GLP-1R agonist with basal insulin can provide better glycemic control than either agent alone, with less weight gain and glycemic outcomes for combined therapy with a long-acting basal insulin analog and a glucagon-like peptide-1 receptor agonist a markedly lower incidence of hypoglycemia than with use of basal insulin alone.
美国糖尿病协会（ADA）/欧洲糖尿病研究协会（EASD）和美国临床内分泌医师协会（AACE）指南强调个体化治疗的重要性，以最好地满足每个患者的情况。二甲双胍仍然是大多数患者初始治疗的首选药物。2009年AACE算法提高了基于肠促胰素的疗法（胰高血糖素样肽-1受体激动剂和二肽基肽酶-4抑制剂）相对于以前算法的地位，这一点已得到后续算法和指南的认可。基于肠促胰素的疗法和胰岛素治疗应被高度优先考虑。基于肠促胰素的疗法或胰岛素治疗都可以用作单一疗法或与其他药物联合使用。当试图降低低血糖风险以及协助患者实现体重减轻时，胰高血糖素样肽-1受体激动剂特别有用。当糖化血红蛋白（HbA1c）水平>9.0%或存在糖毒性症状时，胰岛素治疗特别有用。当其他药物未能达到HbA1c、空腹血糖（FPG）和餐后血糖（PPG）的目标水平时，胰岛素是推荐的治疗方法。胰高血糖素样肽-1受体激动剂与基础胰岛素联合使用比单独使用任何一种药物都能提供更好的血糖控制，体重增加更少，长效基础胰岛素类似物与胰高血糖素样肽-1受体激动剂联合治疗的血糖结果显示低血糖发生率明显低于单独使用基础胰岛素。
