病例研究I：2型糖尿病的胰岛素治疗

患者女性,65岁
因多饮、多尿13年，伴视物模糊1年，加重半月入院
患者13年前因多饮多尿诊断为2型糖尿病，应用多种口服药治疗，近一年来血糖控制欠佳，外院诊断为糖尿病肾病、视网膜病变、神经病变和高血压
目前主要症状：口干、多饮、多尿,视物模糊
既往及目前治疗情况：
* 糖适平：60mg Tid、二甲双胍：0.5 Tid、拜唐苹：50mg Tid、文迪雅：4mg Qd
* 半月来因血糖控制不佳(FPG12.8mmol/L)入院
其它相关疾病：
高血压10年，最高160/95mmHg，脂肪肝5年
无糖尿病家族史 其它：无特殊
体格检查
一般情况
血压：140/85mmHg
身高：161cm 体重：72kg
体重指数：27.8kg/m2
心肺检查：无明显异常
眼底检查：非增殖期中度
心电图检查：大致正常
本次就诊实验室检查
血糖
* 空腹血糖：12.5mmol/L
* 餐后2小时血糖：14.8mmol/L
* 糖化血红蛋白：9.2％
血脂：
* CHO：7.8 mmol/L
* TG：9.6mmol/L
* HDL-C:1.0 mmol/L
* LDL-C：4.6mmol/L
肝功能：
ALT：23U/L
肾功能：
* BUN：6.2mmol/L
* CREA：79umol/L
*尿微量白蛋白：451μg/min

问题讨论
1.最恰当的临床诊断是什么？
2.下一步治疗应为：
*增加磺脲类用量?
*增加其他口服降糖药?
*开始胰岛素治疗?
3.为什么要这样做？
4.何种治疗方案最好？为什么？

Case Study II:The Treatment of Type 2 Diabetes Mellitus with high A1C level

Chief Complaint:
The patient is a 48-year-old male with type 2 diabetes mellitus (DM) who presents with elevated levels of glycosylated hemoglobin (A1C).
History of Present Illness:
The patient was diagnosed with type 2 DM 8 years ago. He had presented initially 2 years prior for treatment. He was taking glimepiride 2 mg QD and metformin 500 mg BID. Over time, however, doses of both agents were increased to the maximum due to worsening glycemic control. Insulin glargine was added 1 year ago because of rising A1C levels. The patient is currently taking glimepiride 4 mg BID, metformin 1000 mg BID, and insulin glargine 30 units QHS. He also takes simvastatin 40 mg at night, enalapril 20 mg QD, and acetylsalicylic acid 81 mg daily. The patient was testing his glucose levels before breakfast and dinner, with records revealing fasting blood glucose (FBG) levels of 90 to 130 mg/dL and predinner readings in the 90 to 130 mg/dL range. Review of the memory of his glucose meter supports these results. He does not do blood glucose measurements at work or on weekends, and he stated he was too tired to check at bedtime. Diet history reveals meals high in carbohydrates (eg, bagels, rice and beans, pasta).
Medical History:
He was diagnosed 5 years prior with hypertension that is now controlled with enalapril. He also has hyperlipidemia, which is being treated with simvastatin. He has a history of intermittent nausea and gastroesophageal reflux disease; at the present time both are stable. He has no allergies but had experienced fluid retention 1 year prior when taking pioglitazone 15 mg. Both parents and an older brother have DM. His father was diagnosed with coronary artery disease at 64 years of age.
Social History:
The patient is married with 2 children. He works during the day as a paralegal. He does not smoke or drink alcohol, and he does minimal exercise.
Physical Exam:
His BMI was 25.2kg/m2.His blood pressure was 120/80 mm Hg.His heart rate was 72 beats/min; his respiration was 12 breaths/min. No retinopathy or thyromegaly was noted. Neck examination revealed 2+ carotids and no bruits. His lungs were clear. A cardiac examination showed a normal S1 and S2, a regular rate and rhythm, and no murmur, rubs, or gallops. His abdominal examination revealed a soft abdomen with normal bowel sounds and no organomegaly. His extremity examination showed 2+ peripheral pulses with no signs of clubbing, cyanosis, or edema. With the neurologic examination, the patient displayed intact sensation to a 5.07-mm monofilament and 2+ reflexes, except for 1+ ankle jerks.
Lab Results:
creatinine, 0.9 mg/dl; microalbumin/creatinine, 12 mg/g ; total cholesterol, 160 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; triglycerides, 250 mg/dL; and low-density lipoprotein cholesterol, 62 mg/dL. His A1C was 8.2%. A fingerstick in the office 2 hours after breakfast showed a reading of 232 mg/dL. The patient FBG was 102 mg/dL that morning.
Question for Discussion
1.What is the most likely explanation for the elevation in A1C?
a.Fasting glucose elevations. b.Postprandial glucose elevations. c.All of the above
2.What would be the best way to confire the diagnosis?
a:Two-hour postprandial testing on a consistent basis by the patient.
b:confirm the meter readings with the laboratory and control solutions
c:have the patient perform some weekend fingerstick tests
d.All of the above
3.What would be the most logical form of trentment?
a:Diet modification and initation of a rapid premeal insulin analogue
b:Diet modification and initation of a regular insulin analogue
c:Diet modification and initation of a basal insulin
4.If the treatment choice above does not lead to optimal glycemic control,what other options are available?


病例研究II：2型糖尿病糖化血红蛋白升高的治疗

患者男性，48岁
主诉：发现血糖升高8年，加重1年。
现病史：患者8年前诊断2型糖尿病，坚持饮食运动治疗，2年前开始药物治疗，最初服用格列美脲2mg QD和二甲双胍500mg BID。由于血糖控制差，两种药物都增至最大用量。1年前由于A1C明显升高加用甘精胰岛素。目前，患者应用格列美脲4mg BID，二甲双胍1000mg BID和甘精胰岛素30单位 QHS控制血糖。其他用药包括辛伐他汀40mg QN，依那普利20mg QD，阿司匹林81mg QD。患者早餐和晚餐前测血糖，自我记录显示空腹血糖（FBG）90～130mg/dl，晚餐前血糖90～130mg/dl。其血糖仪记录与患者记录吻合。患者工作或周末不检测血糖，自诉由于过度疲劳而无法检测睡前血糖。饮食史显示碳水化合物含量高（如百吉饼、米饭、豆类、意大利面）。
既往史：高血压史5年，目前服用依那普利控制。高脂血症5年，服用辛伐他汀治疗。患者有过间断恶心和胃食管反流病，目前病情稳定。1年前服用15mg吡格列酮时出现体液潴留。
家族史：父母和一个哥哥患有糖尿病，父亲在64岁时诊断冠心病。
个人史：已婚，育有2个孩子。工作为律师助理。无烟酒等不良嗜好，平素很少运动。
体格检查：BMI 25.2kg/m2，血压120/80mmHg，心率72次/分，呼吸12次/分。甲状腺未见异常，双侧颈动脉搏动正常，无杂音。双肺呼吸音清。心脏检查S1和S2正常，心率和心律正常，无杂音、摩擦音或奔马律。腹软，肠鸣音正常，无金属性音调。四肢检查显示，外周动脉搏动减弱，未见杵状指、苍白或水肿。
神经系统检查：10克单尼龙丝检查正常，除踝反射减弱外，其他反射均正常。
实验室检查：肌酐0.9mg/dl，尿微量白蛋白肌酐比值为12mg/g，TC 160mg/dl，HDL-C 48mg/dl，TG 250mg/dl，LDL-C 62mg/dl。A1C 8.2％。早餐后2小时指血血糖232 mg/dl，当天FBG102 mg/dl。

问题讨论
1.此患者A1C升高最可能的解释是什么？
a:空腹血糖升高 b:餐后血糖升高 c:以上都有
2.明确以上判断最好的方法是什么？
a:由患者持续检测餐后2小时血糖 b:用实验室检测和控制液确定血糖仪读数
c:让患者周末测指血血糖 d:以上全有
3.最合理的治疗形式是什么？
a:饮食调整和应用速效胰岛素类似物 b:饮食调整和应用普通胰岛素 c:饮食调整和应用基础胰岛素
4.如果上述治疗选择不能使血糖得到理想控制，可以采用何种方法？