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metformin與第二種藥物未能將血糖控制下來,則應開 後,葡萄糖毒性的現象可望改善,β細胞功能可能恢
始使用胰島素或加強胰島素治療。若HbA1c不是太高 復;在血糖控制良好之後,可改回口服藥物。糖尿病
(<8.0%)可考慮加上第三種口服降血糖藥物,但這種治 患者合併有急性疾病(例如心肌梗塞、感染、手術前
療效果較差、花費較高。若使用三種口服藥物或基礎 後)時也要使用胰島素。
胰島素仍無法將HbA1c控制於7%以下,則應使用加強
胰島素治療 – 除給與基礎胰島素外,再加上控制飯後
結 語
血糖的短效或速效胰島素,以解決飯後血糖過高的問 治療糖尿病的主要目標在避免急性或長期的併發
題。注射胰島素患者仍可持續使用口服降血糖藥物, 症,要達到此目標最重要的做法為將血糖控制到接近
胰島素與metformin或胰島素與TZD合併使用可促進其 正常。要降低血糖最基本的仍是飲食、運動等生活形
降血糖的效果,可減少所需的胰島素劑量 (18)。若開始 態的改變,但多數患者仍需降血糖藥物治療。近年有
飯前注射短效或速效胰島素,應停用或逐漸減少刺激 很多新的口服降血糖藥物上市,雖然它們有些個別好
胰島素分泌的藥物(sulfonylurea或glinide),這些藥物與 處,但降血糖的效果不見的比傳統藥物更好。目前
胰島素合併使用不會產生協同作用。 的觀點認為若單一藥物未能達成血糖目標值(HbA1c
使用胰島素可有幾種不同的方式(19): <7%),應盡快加上其他藥物或換新的治療;若口服
(1)每天於睡前注射一次的基礎胰島素(NPH或glargine 藥物未能達到目標,應盡早使用胰島素。與傳統的
、detemir胰島素,開始時每天給10 U 或0.2 U/kg), regular與NPH胰島素比起來,新發明的胰島素類似物
之後視空腹血糖值每隔3天增加2U,調整劑量至達 的好處為血糖控制更好、發生血糖過低機率減少。圖1
成目標(空腹血糖<110 mg/dL)為止,若其間發生空 之標準化治療流程可應用於大多數的病患,但有時仍
腹血糖<60 mg/dL,則將胰島素減2U。這種胰島素 應依個別狀況而改變處置方式。
的用法的好處為簡單、有效、病人接受性良好,且
體重增加不會太多。
(2)在每天最大一餐時(通常是晚餐)注射預混型胰島
素。開始時於晚餐前打10U,每隔 2天增加2U,至
達成空腹血糖<110 mg/dL為止。
參考文獻
(3)早餐與晚餐前注射預混型胰島素。若上述每日注射 1.Nathan DM, Buse JB, Davidson MB, et al.: Management of
一次預混型胰島素未能控制血糖,則加上第二劑預 hyperglycemia in type 2 diabetes mellitus: a consensus algorithm
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>300 mg/dL、HbA1C>10%或有酮尿症)或有多尿、多
喝、體重下降等典型糖尿病症狀者,應使用胰島素治 7.Riddle MC, Rosenstock J, Gerich J: On behalf of the Insulin Glargine
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