Gastaldi Giacomo, Lucchini Barbara, Thalmann Sebastien, Alder Stephanie, Laimer Markus, Brändle Michael, Wiesli Peter, Lehmann Roger
Endocrinology and Diabetes, University Hospital Geneva, Geneva, Switzerland.
Endocrinology and Diabetes, Regional Hospital Locarno, Locarno, Switzerland.
Swiss Med Wkly. 2023 Apr 1;153:40060. doi: 10.57187/smw.2023.40060.
As a first step, the authors emphasise lifestyle changes (increased physical activity, stopping smoking), blood pressure control, and lowering cholesterol). The initial medical treatment should always be a combination treatment with metformin and a sodium-glucose transporter 2 (SGLT-2) inhibitor or a glucagon-like 1 peptide (GLP-1) receptor agonist. Metformin is given first and up-titrated, followed by SGLT-2 inhibitors or GLP-1 receptor agonists. In persons with type 2 diabetes, if the initial double combination is not sufficient, a triple combination (SGLT-2 inhibitor, GLP-1 receptor agonist, and metformin) is recommended. This triple combination has not been officially tested in cardiovascular outcome trials, but there is more and more real-world experience in Europe and in the USA that proves that the triple combination with metformin, SGLT-2 inhibitor, and GLP-1 receptor agonist is the best treatment to reduce 3-point MACE, total mortality, and heart failure as compared to other combinations. The treatment with sulfonylurea is no longer recommended because of its side effects and higher mortality compared to the modern treatment with SGLT-2 inhibitors and GLP-1 receptor agonists. If the triple combination is not sufficient to reduce the HbA1c to the desired target, insulin treatment is necessary. A quarter of all patients with type 2 diabetes (sometimes misdiagnosed) require insulin treatment. If insulin deficiency is the predominant factor at the outset of type 2 diabetes, the order of medications has to be reversed: insulin first and then cardio-renal protective medications (SGLT-2 inhibitors, GLP-1 receptor agonists).
作为第一步，作者强调生活方式的改变（增加体育活动、戒烟）、血压控制以及降低胆固醇。初始药物治疗应始终采用二甲双胍与钠-葡萄糖协同转运蛋白2（SGLT-2）抑制剂或胰高血糖素样肽1（GLP-1）受体激动剂的联合治疗。先给予二甲双胍并逐步滴定剂量，随后使用SGLT-2抑制剂或GLP-1受体激动剂。对于2型糖尿病患者，如果初始双联组合治疗效果不佳，建议采用三联组合治疗（SGLT-2抑制剂、GLP-1受体激动剂和二甲双胍）。这种三联组合尚未在心血管结局试验中得到官方验证，但在欧洲和美国，越来越多的实际经验证明，与其他组合相比，二甲双胍、SGLT-2抑制剂和GLP-1受体激动剂的三联组合是降低3点主要不良心血管事件（MACE）、全因死亡率和心力衰竭的最佳治疗方案。由于磺脲类药物存在副作用且与使用SGLT-2抑制剂和GLP-1受体激动剂的现代治疗相比死亡率更高，因此不再推荐使用。如果三联组合治疗不足以将糖化血红蛋白（HbA1c）降至目标水平，则需要进行胰岛素治疗。四分之一的2型糖尿病患者（有时会被误诊）需要胰岛素治疗。如果在2型糖尿病发病初期胰岛素缺乏是主要因素，则用药顺序必须颠倒：先使用胰岛素，然后使用心脏肾脏保护药物（SGLT-2抑制剂、GLP-1受体激动剂）。
