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[ADA2012]解读吡格列酮的心血管获益
——李光伟教授专访
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作者:李光伟 2012/6/11 14:05:00    加入收藏
内容概要:李光伟教授:我所在的医院非常关注心血管疾病患者的血糖控制,因为超过半数以上的心血管疾病患者有高血糖。现在,我们建立了糖尿病门诊,接诊北京及周边地区的患者。此外,还为患者选择合适的药物提供指导,帮助他们实现血糖达标。在我们医院,对于新诊断为T2DM的心血管疾病患者,在短期内给予胰岛素强化治疗,以获得长期的血糖控制

  李光伟教授  中国医学科学院阜外心血管病医院内分泌与心血管病诊治中心首席专家、主任,中华医学会内分泌学会副主任委员、中华内分泌代谢杂志副主编

  <International Diabetes>:Earlier this year in an interview, you told us the steps to the prevention and treatment of cardiovascular disease at your hospital will be moving forward. How does that apply in the context of the management of diabetes?
  Prof. Li: In our hospital, we were very concerned about glucose control in patients with cardiovascular disease because more than half of the patients with cardiovascular disease had hyperglycemia. Before we set up a diabetes center in this hospital, it was very hard to ask experienced diabetologists to help patients improving their glucose control. in the largest cardiovascular disease hospital in China. Now in the outpatient clinic,  we deal with the patients from Beijing and other provinces. For the newly diagnosed type 2 diabetes cases with cardiovascular disease, we like to use intensive insulin therapy for a very short period of time to induce long-term remission. In the remission period patients can maintain good glucose control without any medication. We have a lot of experience with this issue , about 50% of the newly diagnosed type 2 diabetes patients have this honeymoon period. We help the admitted patients to select appropriate medications to treat their blood glucose to target. We believe this has improved the quality of care in this cardiovascular disease hospital. Since our limited medical resources can not cover so many patient throughout the country,  clinician should not only pay attention to the treatment of diabetes, but should also involve in the prevention of diabetes.
  《国际糖尿病》:今年早些时候的一次访谈中,您告诉了我们您所在医院正在推进预防和治疗心血管疾病的步伐。糖尿病管理方面有哪些举措?
  李光伟教授:我所在的医院非常关注心血管疾病患者的血糖控制,因为超过半数以上的心血管疾病患者有高血糖。现在,我们建立了糖尿病门诊,接诊北京及周边地区的患者。此外,还为患者选择合适的药物提供指导,帮助他们实现血糖达标。在我们医院,对于新诊断为T2DM的心血管疾病患者,在短期内给予胰岛素强化治疗,以获得长期的血糖控制,这样患者就能够在不应用其他药物的情况下维持良好的血糖控制。在这方面我们有很丰富的经验,大约半数新诊断T2DM患者都有蜜月期。我认为这改善了心血管病医院的疾病管理质量。临床医生不仅要关注糖尿病的治疗,还应当参与到糖尿病的预防中去。

  <International Diabetes>:At the clinical level, how does the clinician apply those principles?
  Prof. Li:  The clinician should not only pay attention to the treatment of diabetes, but should be involved in the prevention of diabetes. In our hospital, if we have newly diagnosed type 2 diabetes cases with cardiovascular disease, we like to use intensive insulin therapy for a very short period of time to induce long-term remission and so the patient can maintain good glucose control without any medication.

  《国际糖尿病》:在临床上医生如何应用这些原则?
  李光伟教授:临床医生不仅要关注糖尿病的治疗,还应当参与到糖尿病的预防中去。在我们医院,对于新诊断为T2DM的心血管疾病患者,我们会在短期内给予胰岛素强化治疗,以获得长期的血糖控制,这样患者就能够在不应用其他药物的情况下维持良好的血糖控制。 

  <International Diabetes>:Are you finding that the application of these management principles is working?
  Prof. Li: Yes. We have a lot of experience with this issue and about 50% of the newly diagnosed type 2 diabetes patients have this honeymoon period.

  《国际糖尿病》:您觉得应用这些管理原则是否有效?
  李光伟教授:在这方面我们有很丰富的经验,大约半数新诊断T2DM患者都有蜜月期。

  <International Diabetes>: In 2010, the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes and the newest position statements of the ADA and the EASD for 2012, still list TZDs as the recommended second-line drug. Regarding those guidelines, what is your opinion about the use of TZDs in the management of type 2 diabetes?
  Prof. Li:  I think the TZDs are a very important medication for glucose control.. About 70%-80% of Chinese type 2 diabetics are insulin resistant. Clinically if we only use sulfonylureas or insulin,  very large doses were needed ,which may lead to hyperinsulinemia  then promote the development of cardiovascular disease. So the  insulin sensitizer are very helpful when it combined with sulfonylureas or in some special circumstances with insulin. This way allow us to reduce the insulin dose and avoid hyperinsulinemia. The Pioglitazone not only to activate PPAR-gamma receptor, but also actvate PPAR-alpha receptor,whic makes it unique to Avandia.
  《国际糖尿病》:在2010年《中国2型糖尿病防治指南》和2012年ADA/EASD关于高血糖管理的最新声明中,噻唑烷二酮类药物(TZD)仍然被推荐作为二线治疗。参考上述指南,您对T2DM中应用TZD类药物有什么看法?
  李光伟教授:我认为TZD类药物是非常重要的一类降糖药物。大约70%~80%的中国T2DM患者存在胰岛素抵抗,因此临床上单独应用磺脲或胰岛素时通常需要非常大的剂量,这将引起高胰岛素血症进而增加患者的心血管风险。从这个意义上说,TZD与磺脲联用或在某些情况下与胰岛素联用将有助于避免高胰岛素血症的发生。

  <International Diabetes>:The PROactive Study published in 2005 and subsequent meta-analysis published in 2007, studied the cardiovascular benefits of pioglitazone. In 2012, there are three more studies being published at this ADA meeting alone with newer evidence regarding the cardiovascular benefits of pioglitazone. Based on the available evidence, what is your view of the cardiovascular benefits of pioglitazone?
  Prof. Li: Because hyperinsulinemia will cause dyslipidemia and hypertension, the improvement of insulin sensitivity by pioglitazone will be good for the reduction of blood pressure and normalization of lipid levels. This is very important as diabetes patient always has dyslipidemia and hypertension.
  I have just completed an animal study and the results were surprising. I found that pioglitazone can increase sodium excretion in the urine which is very useful in avoiding water retention. For some patients, if they have hyperinsulinemia and hypertension, the action of pioglitazone on the kidneys may be beneficial for blood pressure control. We have finished the paper however we have not published the data. Insulin can increase absorption of salt and cause water retention. If we can reduce the insulin therapy levels by improving insulin sensitivity then we can show benefits in blood pressure reduction. That contradicts the current guidelines. The guidelines do not recommend that TZDs be combined with insulin, however in some patients, if we cannot reduce the insulin dose, the TZD- insulin combination may be harmful. However, if the insulin sensitizer can improve the insulin sensitivity and reduce the dosage, I think the net effect should be better.
  《国际糖尿病》:2005年发表的PROactive研究和随后2007年发表的荟萃分析观察了吡格列酮的心血管益处。2012年的ADA年会上又有3项新的研究发表,为吡格列酮的心血管获益提供了新的证据。基于现有证据,您如何看待吡格列酮的心血管益处?
  李光伟教授:鉴于高胰岛素血症会导致高脂血症与高血压,因此吡格列酮改善胰岛素敏感性的效应有助于降低血压并使血脂水平恢复正常。这一点很有意义,因为糖尿病患者往往合并高脂血症和高血压。
  我刚刚完成了一项动物实验,其结果尚未发表。该实验发现,吡格列酮能够增加肾脏的尿钠排泄,这对避免水潴留非常有益。对于合并高血压的糖尿病患者而言,吡格列酮的这一效应可能有助于血压控制。另外,由于胰岛素会增

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网站用户: fisfer@126.com 时间:2012/12/30 20:14:58
吡格列酮不是有水肿的风险吗

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