IDF發表糖尿病處置的新指引
作者：Alison Palkhivala
出處：WebMD醫學新聞
October 26, 2009 (蒙特婁) — 國際糖尿病聯盟(International Diabetes Federation，IDF)在第20屆世界糖尿病研討會中發表有關糖尿病處置的諸多新指引，包括國際上首次提出懷孕期間的糖尿病處置指引，以及未使用胰島素治療之第2型糖尿病患者的自我血糖監測(self-monitoring of blood glucose，SMBG)指引。
【懷孕期間的糖尿病指引呼籲廣泛篩檢】
IDF之「懷孕與糖尿病綜合指引(Global Guideline on Pregnancy and Diabetes) 」作者群之一，南加州大學洛杉磯醫學中心臨床醫學教授、Sansum糖尿病研究中心科學主任暨執行長Lois Jovanovic醫師向Medscape Diabetes Endocrinology表示，我們根據實證醫學建立該指引，我們邀請一群國際專家提供意見。
Jovanovic醫師表示，妊娠糖尿病的診斷與處置並沒有國際標準，沒有共識、有許多令人混淆之處，因此沒有標準可供判斷孕婦是否需要治療她們的糖尿病、是否會影響她們的懷孕結果。這是首次獲得全球共識。
根據Jovanovic醫師指出，新指引的關鍵訊息之一，是廣泛篩檢的重要性。她表示，懷孕期間檢查高血糖和產前諮詢都必須普及。身為一線照護醫師，面對生育年齡的糖尿病患時，第一個問診問題應該是：您考慮再度懷孕嗎？
【未使用胰島素治療之第2型糖尿病患者的自我血糖監測】
IDF之「未使用胰島素治療之第2型糖尿病患者的自我血糖監測指引(Guideline on Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes) 」的發展過程和IDF孕婦糖尿病指引相似。重點如下：
* 診斷時即應考慮SMBG，但是只有在病患、照護者和/或健康照護提供者有相關知識和意願，可將檢測發現納入糖尿病處置計畫時才可實施。
* SMBG可以作為持續性糖尿病自我管理教育的一部份
* SMBG的規則應因人而異
* 病患與其健康照護提供者應對如何使用SMBG資料有共識
* 用來測量SMBG的工具應簡單使用且準確
【指引的特徵】
Jovanovic醫師表示，兩套指引各自有其特徵，使它們有別於其他糖尿病協會如美國糖尿病協會(ADA)的相關指引。
ADA希望近期內也有所改變，但是目前他們並未提出懷孕時進行廣泛篩檢的觀念，他們所提的是選擇性篩檢。我們的指引不只討論廣泛篩檢，而且假定每個糖尿病婦女藉由檢測以再度確定她有沒有此疾病。因此，這是不同的模式。第二個主要差異是，IDF建議進行一步驟的口服葡萄糖耐受測試，而非ADA目前建議的兩步驟測試。ADA的妊娠糖尿病診斷準則規定太高，以致確認的婦女數太少。IDF版的指引，策略為實際增加確認的婦女數，因而提供全球單一照護標準的治療。
根據SMBG指引的一名共同作者、英國Cardiff大學糖尿病研究小組的David Owens醫師，IDF的SMBG指引有一個特徵，就是釐清SMBG在未接受胰島素治療之病患的角色。對於未接受胰島素治療的病患，其他指引認為整合SMBG是個好主意，但是沒有真正提出該怎樣做。因此我們試圖提出就病患而言可以如何進行。有其他指引認為，未接受胰島素治療的病患並不需要監控血中葡萄糖值，他們認為應檢討現有的資料，以瞭解其限制。而這些論述有許多在研究設計時並非針對此一問題。
Jovanovic醫師宣告沒有相關財務關係。Owens醫師報告接受Roche Diagnostics、Sanofi-Aventis、Novo Nordisk、Merck Sharpe Dohme、LifeScan和Pfizer等的演講費；也擔任Roche Diagnostics、Sanofi-Aventis、Novo Nordisk、Merck Sharpe & Dohme、LifeScan和Pfizer等的諮詢委員；也接受Sanofi-Aventis和Novo Nordisk的研究資金。
國際糖尿病聯盟(IDF)在第20屆世界糖尿病研討會：摘要0498和0499。發表於2009年10月22日。
IDF Releases New Guidelines on Diabetes Management
By Alison Palkhivala
Medscape Medical News
October 26, 2009 (Montreal, Quebec) — The International Diabetes Federation (IDF) announced the release of several new guidelines related to diabetes management here at the IDF 20th World Diabetes Congress. These include the first-ever international guidelines on the management of diabetes in pregnancy and guidelines on the use of self-monitoring of blood glucose (SMBG) among type?2 diabetic patients not being treated with insulin.
Pregnancy and Diabetes Guidelines Call for Universal Screening
Lois Jovanovi?, MD, CEO and chief scientific officer of Sansum Diabetes Research Institute in Santa Barbara, California, and clinical professor of medicine at the University of Southern California-Los Angeles Medical Center, is one of the authors of the IDF Global Guideline on Pregnancy and Diabetes. "The guidelines were created with evidence-based medicine. Then we asked an international group [of experts] to give us their opinion," she told Medscape Diabetes Endocrinology.
"There was no international standard [for the diagnosis and management of gestational diabetes], said Dr. Jovanovi?. "There was no consensus, there was a lot of confusion, women were suffering, and their pregnancy outcome was affected by having no standard by which to judge whether their diabetes was worth treating or not. This is the first time there is a worldwide consensus."
A key message of the new guidelines, according to Dr. Jovanovi?, is the importance of universal screening. "Look for hyperglycemia in pregnancy," she said. "Preconceptional counseling [also] has to be universal.?.?.?. For a [primary care] physician who has a [patient] in child-bearing years, the first question should be: Are you interested in getting pregnant again?"
Self-Monitoring of Blood Glucose in Noninsulin-Treated Type?2 Diabetes
The IDF Guideline on Self-Monitoring of Blood Glucose in Non-Insulin Treated Type?2 Diabetes was developed in a manner similar to the IDF pregnancy guidelines. Their highlights include the following:
SMBG should be considered at the time of diagnosis but should only be used when patients, their caregivers, and/or their healthcare providers have the knowledge and willingness to incorporate findings into the diabetes management plan.
SMBG should be considered a part of ongoing diabetes self-management education.
SMBG protocols should be individualized.
Patients and their healthcare providers should agree on how to use SMBG data.
Tools used to measure SMBG must be easy to use and accurate.
Unique Features of Guidelines
Both sets of guidelines have key features that differentiate them from guidelines on the same topics put out by other diabetes associations, such as the American Diabetes Association (ADA), said Dr. Jovanovi?.
"The ADA hopefully will change soon, but right now they don't subscribe to the philosophy of universal screening [in pregnancy]. They talk about selective screening. Our guidelines not only talk about universal screening but almost assume that every woman has diabetes [and] doing the testing is to reassure her that she doesn't. So, it's a paradigm shift. The second major difference is the [IDF] recommendation that it be a 1-step [oral glucose tolerance] test, not a 2-step test [as currently recommended by the ADA]. The ADA also have the criteria for diagnosis [of gestational diabetes] very high to minimize the number of women identified. The strategies in the [IDF] guidelines actually increase the number of women that would be identified and therefore offer treatment worldwide with 1 standard of care."
According to a coauthor of the SMBG guidelines, David Owens, MD, from the Cardiff University Diabetes Research Unit in the United Kingdom, a unique feature of the IDF SMBG guidelines is that they clarify the role of SMBG in diabetic patients who are not receiving insulin therapy. "For the noninsulin-treated individuals, [other guidelines] say that it's a good idea to incorporate SMBG,?.?.?. but there is no real clarity as to what to do about it. That's where we've tried to extend the story more toward what the patient can do about it in their circumstances.?.?.?. There are [other] guidelines that suggest that maybe there's no reason to monitor blood glucose in the noninsulin-treated, and they say that?.?.?. you need to look at the current evidence and see its limitations. Many of those publications are really not designed to ask [that] question."
Dr. Jovanovi? has disclosed no relevant financial relationships. Dr. Owens reports being paid for lecturing by Roche Diagnostics, Sanofi-Aventis, Novo Nordisk, Merck Sharpe Dohme, LifeScan, and Pfizer; being on advisory boards for Roche Diagnostics, Sanofi-Aventis, Novo Nordisk, Merck Sharpe & Dohme, LifeScan, and Pfizer; and receiving research funding from Sanofi-Aventis and Novo Nordisk.
International Diabetes Federation (IDF) 20th World Diabetes Congress: Abstracts 0498 and 0499. Presented October 22, 2009.
