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

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1、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(JACC)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-1 (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

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SGLT2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。Monitor rpo*iB Iq thrpy (5e Section 5.4 nd TbJ 7) and consider iurthr thrapi for CV risk reduction, as nd

3、katd-*图1. SGLT2抑制剂使用流程图。表LSGLT2抑制剂使用剂量、适应证、注意事项及不良反应CanagliflozinDapagliflozinEmpagliflozinRecommended doses for CV benefit100 mg PO daily10 mg PO daily10 mg PO dailyIndicationsImprove glycemic control in adults with T2D as an adjunct to diet and exerciseReduce risk of Mlt stroke, or CV death in adu

4、lts with T2D and CV diseaseReduce the risk of end-stage kidney disease, doubling of serum creatinine, CV death, and hospitalization for HF in patients with T2D and diabetic nephropathy with albuminuria Improve glycemic control in adults with T2D as an adjunct to diet and exercise Reduce the risk of

5、hospitalization for HF in adults with T2D and established CV disease or multiple CV risk factorsReduce the risk of CV death and hospitalization for HF in adults with HFrEFImprove glycemic control in adults with T2D as an adjunct to diet and exercise Reduce risk of CV death in adults with T2D and est

6、ablished CV diseaseDose modifications eGFR 30 to 59 ml/min/1.73 m2： max dose 100 mg daily eGFR 30 ml/min/1.73 m2： use is not recommended for glycemic controleGFR 45 ml/min/1.73 m2： use is not recommended for glycemic control eGFR 30 mL/min/1.73 m2： use is contraindicated.eGFR 45 mL/min/1.73 m2： use

7、is not recommended.Contraindications History of serious hypersensitivity reaction to drug Pregnancy or breastfeeding On dialysis eGFR 30 mL/min/1.73 m2 (dapagliflozin) ESRD (dapagliflozin and empagliflozin) Severe renal impairment (empagliflozin)Cautions Discontinue at least 3 days before a planned

8、surgery to prevent postoperative ketoacidosis. If HbAIc well-controlled at baseline, or known history of frequent hypoglycemic events, wean or stop sulfonylurea or glinide and consider reducing total daily insulin dose by 20% when starting therapy. May contribute to intravascular volume contraction；

9、 consider stopping or reducing diuretic dose if applicable. Use with caution in patients with prior amputation, severe peripheral neuropathy, severe peripheral vascular disease, or active diabetic ft ulcers or soft tissue infections. Possible increased risk of bone fractures (Canagliflozin)Adverse e

10、ffectsGenital fungal infectionsto monitorUrinary tract infectionsEuglycemic diabetic ketoacidosisLower limb ulcerations and soft tissue infectionsGLP-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、炎症和甘油三酯等心血 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Recom

11、mended doses for CV benefit Initiate 0.75 mg SC2 mg SC per weekInitiate 0.6 mg SC daily.Titrate slowly to 1.8 mg or maximally tolerated dose based on prescribing information.10 mcg SC daily Titrate as tolerated to 20 mcg daily based on prescribing information.Initiate 0.25 mg SC per week. Titrate sl

12、owly to 1 mg once weekly or maximally tolerated dose based on prescribing information.Initiate 3 mg PO per day for the first 30 days.Titrate slowly to 14 mg daily or maximally tolerated dose based on prescribing information.per week Titrate slowly to 1.5 mg or maximally tolerated dose based on presc

13、ribing information.IndicationsImprove glycemic conImprove glycemicImprove glycemicImprove glycemicImprove glycemicImprove glycemictrol in adults with T2D.control in adultscontrol in adultscontrol in adultscontrol in adultscontrol in adultsReduce MACE for peowith T2D.with T2D.with T2D.with T2D.with T

14、2D.ple with T2D with andReduce risk of Ml.Reduce risk of MI1without established CVCVA. or CV deathCVA1 or CV deathdisease.in adults with T2Din adults with T2Dand CV disease.and CV disease.DoseUp-titrate slowly toDiscontinue ifUp-titrate slowlyUp-titrate slowlyUp-titrate slowlyUp-titrate slowlymodificationsreduce nausea andpancreatitis isto reduce nauseato reduce nauseato reduce nauseato reduce nauseavomiting.suspected and doand vomiting.and vomiting.and vomiting.and vomiting.Discontinue if pancreanot restart ifDiscontinue ifDiscontinue ifD