糖尿病患者使用SGLT2抑制剂和GLP 1受体激动剂使用进展与背景.docx

心血管疾病仍是2型糖尿病患者死亡的主要原因，因此，改善2型糖尿病患者的心血管结局具有重要意义。美国心脏病学会杂志(JAeC)发表的一份ACC专家共识决策路径，对降低2型糖尿病患者心血管病风险的新型治疗策略进行了阐述。共识推荐使用SGLT2抑制剂和GLP-I受体激动剂降低2型糖尿病患者的心血管风险。钠-葡萄糖共转运蛋白-2(SGLT2)抑制剂和胰高血糖素样肽-I(GLP-I)受体激动剂是新型降糖药。最新研究证实，SGLT2抑制剂和GLP-I受体激动剂可以直接改善2型糖尿病患者的心血管结局。对于患有或具有较高的动脉粥样硬化性心血管疾病(ASCVD)、心衰和/或糖尿病性肾病风险的2型糖尿病患者，在临床随访时，应与患者充分沟通使用SGLT2抑制剂和/或GLP-I受体激动剂治疗的心血管获益。合并心衰的2型糖尿病患者，尤其是合并射血分数降低的心衰患者，或者可能进展为心衰、糖尿病性肾病、ASCVD的患者，推荐使用具有明确心血管获益的SGEr2抑制剂进行治疗。已有研究证实，SGLT2抑制剂可改善患者的心血管和肾脏硬终点，其对患者血糖的影响远不及对心血管和肾脏的获益。图1.SGLT2抑制剂使用流程图。表1.SGLT2抑制剂使用剂量、适应证、注意事项及不良反应CdfUigIifIozinDapagIHlMinEmpjgIHIainRecommendedlmgPOdilyIOmgPOdiiIvK)BPOdXydosesforCVbenefit,IndkJtionsImproveglycemiccontrolinadultswithT2DasanimproveglycemiccontrolinMltSwithImprovegtycemkcontrolinadjuncttodietandexerciseVDasanadjuncttodietandexerciseadultswithT2DManX，UnCtReduceriskofMl.stroke,orCVdeathmadultswithT2DReducethenskofhospitalizationforHFIntodietandexerciseandCVdiseaseadultswithT20andestablishedCVdisew<ReduceriskofCVdeathinRductheri¼kofend*tagkidneydia.doublingoformultiplCVriskfactorsadultswithT2DandUbserumcreatinme.CVdeath.JMh<npUUzat>nforHFinReducetXrisko<CVdeathandhospital-UshedCVdiseasePJtientswithT20anddi>betkCePhroathywith2ati0nforHFinXUltSwithHFrCF.IbuminurUDoseeGFR30to59mlfnlrV1.73m,:maxdose100mgdaily«GFR45mVmirV1.73m?：useisnotrec-eGFR<45mUm4n173m2:modMkatiomeGFR<30ml/min/1.73m2：useisnotrecommendedforommendedfortycemiccontroluseisnotrecommended.glycemkcontrolGFR<30fnl/rmn/1.73m2;useKContraindiCdted.COntraindiCMi(XUHistoryofIerioushyperItmitivityretiontodrugPregnancyOfbeMStfeedingOndalysiseGFR30mLmitV1.73m2(d3p*gbfl02m>ESRD(BPHmOZEandempagliftozm)SevererenalimpairmentCmpagliAozin)CjutiomDiscontinueJtleMt3dysbeforeaplannedSUrgerytopreventPOuoPtrJtiektoidosi.IfHbAIcwU-controUdtg"Ux.Orknownhistoryoffrequenthypoglycemicrvts,weanorstopsulfonylureaorgliradeandconsiderreducingtotJldailyiHuUndoseby-20¼whenstartifgterpy.M3ycontributtointravM<uljrvolumeCOmrKtion；considerstoppingorreducingdiureticdoseifJPPdCJbIaUswithC3utkxinpatientswithporamputation,svfpriphralnurof>athy.vrepripfilvasculardiMaw.oractivedJbticfootulcersorsofttissueinfections.Posib(eincreasedriskolbonefractures(CJnagliRozin)Adversetf(tfGeniUlfungalinfectionstomonitorUrifUfyKrxtEfectiomu9lycmicduibHicketoacidosislowerlimbutcratiomandsofttissueinfectionsGLP-I受体激动剂适用于ASCVD风险极高或已确诊ASCVD的2型糖尿病患者。GLP-I受体激动剂可降低血糖，并对血压、体重、炎症和廿油三酯等心血管危险因素产生有益的作用。图2.应用GLP-I受体激动剂管理ASCVD风险的流程。表2.GLP-I受体激动剂使用剂量、适应证、注意事项及不良反应RecommendeddosesforCVbenefitImtiate0.75mgSC2mgSCperWWkperweekMtlte0.6mgSCdly.IonKgSCdailyTtrateastoleratedto20gd>lyt>MedonPCeSCribin9information.Initwte0.25mgInitiate3mgPOperdayforthefirst30days.Titrateslowlyto14mgdailyormaximallytolerateddosebasedonprescribingInformdtlcxi.SCpecweekTitrateslowlyto111>gonceweeklyormaxi11Mllytolerateddobasedonprescribinginformation.TitrateSiOWtyto1.Smgormaximallytolerateddosebasedonprescribinginformation.TiUiteslowlyto1.8mgoruxi-rMllytolerateddosebasedonpceribinginformation.IndkMionsImproveglycemiccon-ImProgglycemicimproveglycemicImprowglycemicImproveglycemicImproveglycemictrolinJdUltSwithT20.controlinadultscontrolinadultscontrolinadultscontrolinOdUUScontrolinadultsReduceMACEfoepcowithT20.withT2D.withT20.withT2D.withT2D.piewithT20withandReduceriskofmi.ReduceriskofMl.withoutestablishedCVCVA.orCVdeMhCVA.(XCVdeathdisease.inadultsWi曲T2DinadultswithT2DandCVdisease.andCVdisease.DoscUp-titrateslowlytoDiKontinueifUp-titrateslowlyUp-titrateUowtyUp-titrateslowlyUp-titrateslowlymodAcatiomreducenauseaandpancreatitisistoreducenauseatoreducenauseatoreducenauseatoreducenauseavomiting.suspectedanddoMdvomiting.Jndvomiting.andvomiting.andvomiting.DiscontinueifPanCreanotrestartifDiscontinueIfDiscontinueJfDiscontinueifOscontlnuetftitisissuspectedandpancreatitisispancreatitisisPMaeatitgispancreatitisispancreatitisissus-donotrestartIfconftrmed.SUWedMddo5uected.Mlddowpe<tedJnddoPeCtedanddonotpancreatitisiseGFR<45mLnotresurtifno<restartiffx>trestartifresurtifpanaea-confirmed.min/1.73m2：pancreatitisispancreatitisi$pancreatitisi$titit$confirmed.Nodose>stmentUs«notconrmed.confirmedconfirmed.Nodoseadjust-necessarywithrejiorrecommended.Nodoseadjust"eGFR二30ml/Nodoveadjust-men!Bneceswryhepaticimpairment；me11t«5necessarymtn/1.73m2：meatisnecessary