多管齐下降低血糖,临床疗效卓尔不凡。 2型糖尿病(T2DM)发病率逐年攀升,其引起心血管并发症所造成的危害与负担日益严峻。而作为全球糖尿病防控的核心药物,二甲双胍的临床应用也随之愈发普遍。因此,对心血管专科医生而言,了解并掌握二甲双胍的作用机制及临床疗效,可以更好地管理合并心血管并发症的糖尿病患者。 上一期,我们已经了解了《二甲双胍临床应用专家共识(2018版)》中“二甲双胍的临床地位与使用时机”(二甲双胍的临床地位与使用时机,一文教你get!丨专家共识解读第一篇),今天就一起来学习“二甲双胍的作用机制及临床疗效”吧! 1多种武器齐上阵,360°降糖不留死角 二甲双胍作用途径丰富,以多路并进的方式全方位、协同降低血糖,逐个击破高血糖防线。
2单打独斗还是众人抬柴?花式应用,卓群依旧 不论是单药治疗还是与其他口服降糖药、胰岛素联合治疗,二甲双胍确切的降糖疗效都已通过各类大型药物研究的考验,获得共识推荐(表1)。下面对二甲双胍单用/联用以及部分特殊用法的具体疗效逐一介绍。 表1:二甲双胍的临床疗效 二甲双胍单药应用即效果卓群,29周可降低空腹血糖(FPG)3.2 mmol/L、餐后血糖(PPG)4.0 mmol/L、糖化血红蛋白(HbA1c)1.8%(Ⅰ级) [9]。研究显示基线HbA1c接近9%的新诊断患者,使用二甲双胍单药2000 mg可使近70%的患者达标。 3老将联手,无往不利 除出类拔萃的单药降糖疗效,二甲双胍可改善胰岛素抵抗,减少肝糖输出,增强肝脏和肌肉组织的胰岛素敏感性,因此二甲双胍可以与其他经典口服降糖药物和胰岛素联合,可因作用机制互补或协同,产生1+1>2的效应。 中国的MERIT研究显示,与胰岛素单药治疗相比,二甲双胍联合胰岛素可进一步降低HbA1c,减少胰岛素用量、体重增加和低血糖风险;二者联合与心血管疾病和肿瘤风险下降相关[10-15](Ⅰ级)。 4新老搭档,一拍即合 二甲双胍不仅能与降糖老将联手,与近年涌现的降糖新秀也配合默契:加用钠-葡萄糖协同转运蛋白2 (SGLT-2)抑制剂可在二甲双胍疗效的基础上进一步改善血糖控制,显著减轻体重及改善血压 [16-18]。 除单用或与其他降糖药物联用于T2DM治疗外,共识还针对二甲双胍的3种特殊应用场景予以阐释,即:接替短期胰岛素强化治疗、在1型糖尿病(T1DM)中的应用以及减重作用。
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