Thrasher James
Medical Investigations, Inc, Little Rock, Ark.
Am J Med. 2017 Jun;130(6S):S4-S17. doi: 10.1016/j.amjmed.2017.04.004.
Choices for the treatment of type 2 diabetes mellitus (T2DM) have multiplied as our understanding of the underlying pathophysiologic defects has evolved. Treatment should target multiple defects in T2DM and follow a patient-centered approach that considers factors beyond glycemic control, including cardiovascular risk reduction. The American Association of Clinical Endocrinologists/American College of Endocrinology and the American Diabetes Association recommend an initial approach consisting of lifestyle changes and monotherapy, preferably with metformin. Therapy choices are guided by glycemic efficacy, safety profiles, particularly effects on weight and hypoglycemia risk, tolerability, patient comorbidities, route of administration, patient preference, and cost. Balancing management of hyperglycemia with the risk of hypoglycemia and consideration of the effects of pharmacotherapy on weight figure prominently in US-based T2DM recommendations, whereas less emphasis has been placed on the ability of specific medications to affect cardiovascular outcomes. This is likely because, until recently, specific glucose-lowering agents have not been shown to affect cardiorenal outcomes. The Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes 6 (SUSTAIN-6) recently showed a reduction in overall cardiovascular risk with empagliflozin, liraglutide, and semaglutide treatment, respectively. Moreover, empagliflozin has become the first glucose-lowering agent indicated to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease. Results from cardiovascular outcomes trials have prompted an update to the 2017 American Diabetes Association standards of care, which now recommend consideration of empagliflozin or liraglutide for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease because these agents have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
随着我们对2型糖尿病（T2DM）潜在病理生理缺陷的理解不断深入，T2DM的治疗选择也日益增多。治疗应针对T2DM的多种缺陷，并遵循以患者为中心的方法，该方法需考虑血糖控制以外的因素，包括降低心血管风险。美国临床内分泌医师协会/美国内分泌学会以及美国糖尿病协会推荐初始治疗方法包括生活方式改变和单药治疗，首选二甲双胍。治疗选择的依据是血糖疗效、安全性，特别是对体重和低血糖风险的影响、耐受性、患者合并症、给药途径、患者偏好和成本。在美国的T2DM治疗建议中，平衡高血糖管理与低血糖风险以及考虑药物治疗对体重的影响是重点，而对特定药物影响心血管结局的能力则较少强调。这可能是因为直到最近，特定的降糖药物尚未显示出对心肾结局有影响。2型糖尿病患者清除多余葡萄糖的恩格列净心血管结局事件试验（EMPA-REG OUTCOME）、糖尿病患者中利拉鲁肽的作用及心血管结局评估试验（LEADER）以及评估司美格鲁肽对2型糖尿病患者心血管及其他长期结局的试验（SUSTAIN-6）最近分别显示，恩格列净、利拉鲁肽和司美格鲁肽治疗可降低总体心血管风险。此外，恩格列净已成为首个被批准用于降低患有T2DM和已确诊心血管疾病的成年人心血管死亡风险的降糖药物。心血管结局试验的结果促使2017年美国糖尿病协会护理标准进行更新，现在推荐对于长期T2DM控制不佳且已确诊动脉粥样硬化性心血管疾病的患者考虑使用恩格列净或利拉鲁肽，因为这些药物在添加到标准治疗中时已显示可降低心血管和全因死亡率。
