2023美國糖尿病協會更新四大重點：
- 減重計畫 weight loss plan (emphasis GLP 1)
- 降血糖藥物選擇(high light on SGLT2i)：考慮共病症 (CVD & CKD)
- 著重在CVD risk management (更嚴格的血壓&血脂目標)
- Kidney disease in diabetes (new drug: Finerenone)
☆最重要的概念更新：重要性去階層化。從2007年強調控糖(the lower the better)→到後來強調控糖後的CV risk(the lower the better, but without hypoglycemia and weight gain)→再到Holistic person-centred care(控糖、器官保護、糖胖、血壓等共病一樣重要)。
▲Decision cycle for person-centred glycaemic management in type 2 diabetes. (Diabetologia 65(8):1-42)
▲Importance of 24-hour physical behaviours for type 2 diabetes
減重 weight loss
- 更嚴格的減重計畫，預計目標達到最高15%的體重減少。包含減重藥物(Semaglutide & tirzepatide )的使用。
- 糖尿病病人的睡眠品質與physical activity建議更新
- 小幅度的減重(↓3-7%原體重)可改善血糖控制和降低中成度的心血管風險。
- 大幅度的減重(持續>1年的下降>10%原體重)可望達到disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality.
▲ Treatment options for overweight and obesity in type 2 diabetes
▲Benefits from percentage of weight loss
體重控制方法：
- Nutrition, Physical Activity, and Behavioral Therapy
- 介入營養、運動、行為改善以達到每日500-750kcal的熱量減少並目標5%的體重下降。
- 短期可以介入very-low-calorie meals (800–1,000 kcal/day)
- 已達到長期（一年以上的體重下降）者，建議維持每週200–300分鐘的運動。
Look AHEAD trial
嚴格的生活型態介入並無法降低第二型糖尿病合併有過重或肥胖者的心血管事件。但此嚴格介入證實可以維持病人的體重下降（八年平均4.7%的體重下降）。嚴格介入組可以減少血壓血脂血糖藥物的使用。次族群分析中顯示，嚴格介入組可以提升病人的生活品質，包含mobility, physical and sexual function, and health-related quality of life.
- Pharmacotherapy
- 選擇降血糖藥物給過重的糖尿病病人時，請考慮到降糖藥對體重的影響。
- 當處方藥物給BMI ≥27 kg/m2的糖病病病人時，務必合併nutrition, physical activity, and behavioral 的衛教。
▲Medications approved by the FDA for the treatment of overweight or obesity in adults
- 減重手術
- The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. (E)In adults with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible. (A)If insulin is used, combination therapy with a glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of treatment effect, and weight and hypoglycemia benefit. (A)
- For people with type 2 diabetes and established ASCVD or indicators of high ASCVD risk, HF, or CKD, an SGLT2 inhibitor and/or GLP-1 RA with demonstrated CVD benefit is recommended as part of the glucose-lowering regimen independent of A1C, independent of metformin use and in consideration of person-specific factors.
▲Use of glucose-lowering medications in the management of type 2 diabetes.
▲Medications for lowering glucose, summary of characteristics
- BP目標 130/80 mmHg
- 40-75歲合併有CVD risk建議使用高強度statin以期降低>50%的baseline LDL，並以LDL<70 mg/dL為目標。
- 75歲以上已使用或開始使用中強度的statin者，建議繼續使用並以LDL<70 mg/dL為目標。
- 若已經有CVD事件的糖尿病病人，建議給予高強度的statin以期降低>50%的baseline LDL，並以LDL<55 mg/dL為目標。
- The addition of ezetimibe or a PCSK9 inhibitor is recommended if goals are not achieved on maximum statin therapy.
- The expanded role of SGLT2 inhibitor use in preserved and reduced heart failure ejection fraction. (START if eGFR >=20 mL/min/1.73 m2 and urinary albumin of at least 200 mg/g creatinine)
- 2023更新：The role of finerenone (藥物介紹) in individuals with diabetes and chronic kidney disease with albuminuria.
Finerenone為非類固醇類礦物皮質素受體拮抗劑 (nonsteroidal mineralocorticoid receptor antagonist)，2020年FIDELIO-DKD (finerenone in reducing kidney failure and disease progression in diabetic kidney disease)試驗結果發現finerenone用於第二型糖尿病合併慢性腎臟病人可降低腎衰竭、eGFR (estimated glomerular filtration rate) 持續減少40%以上以及因腎臟原因致死之綜合事件。
UACR improvement was observed with finerenone in patients with CKD and T2D already receiving SGLT-2is at baseline, and benefits on kidney and cardiovascular outcomes appear consistent irrespective of use of SGLT-2i.
▲Finerenone in Predominantly Advanced CKD and Type 2 Diabetes With or Without Sodium-Glucose Cotransporter-2 Inhibitor Therapy (Article Link)
- CKD primary prevention方法: 血壓血脂血糖控制。
- CKD intervention：營養、藥物
- 營養：
低蛋白飲食，約蛋白質0.8 g/kg/day，不建議低於0.8。限鹽飲食 (<2,300 mg/day)
- 藥物：
RAAS inhibitorSGLT2 inhibitorFinerenone
- ADA 2023藥物指引摘錄：
- In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (urinary albumin-to-creatinine ratio ≥300 mg/g creatinine) and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. A
- An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of chronic kidney disease in people with diabetes who have normal blood pressure, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal estimated glomerular filtration rate. A
- Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion. A
- For people with type 2 diabetes and diabetic kidney disease, use of a SGLT2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ≥200 mg/g creatinine. A
- For people with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ranging from normal to 200 mg/g creatinine. B
- 腎功能eGFR切點：SGLT2 inhibitor(≥20)；GLP1 agonist(≥25) A
- The Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial assessed the safety and efficacy of finerenone in reducing cardiovascular events among people with type 2 diabetes and CKD with elevated UACR (30 to <300 mg/g creatinine) and eGFR 25–90 mL/min/1.73 m2 (N Engl J Med2021;385:2252–2263).
The primary composite outcome was cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure. The finerenone group showed a 13% reduction in the primary end point compared with the placebo group (12.4% vs. 14.2%; HR 0.87 [95% CI 0.76–0.98]; P = 0.03). This benefit was primarily driven by a reduction in heart failure hospitalizations: 3.2% vs. 4.4% in the placebo group (HR 0.71 [95% CI 0.56–0.90]).Of the secondary outcomes, the most noteworthy was a 36% reduction in end-stage kidney disease: 0.9% vs. 1.3% in the placebo group (HR 0.64 [95% CI 0.41–0.995]). There was a higher incidence of hyperkalemia in the finerenone group, 10.8% vs. 5.3%, although only 1.2% of the 3,686 individuals on finerenone stopped the study due to hyperkalemia (0.6% vs. 0.4% of the placebo group).
1st released: Feb.12.2023
2nd Update: June.19.2023
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