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1

2???????????
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2
????

??????
T2DM???????
? ????????????
? ???????
????

3
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4
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????(Evidence-Based Medicine,EBM,??????????)???,??
???20??90??????,??,???????????????????
????????????????????????
????????????????????????????

5
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(1909-1988, ??)

???? (1925-, ??)
??? (1934-, ??)
?? ??
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6
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????????????????????????,??????????????????,??????
?,?????????

7
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8
?????????????
1???? 2????
1?DPT-1?? 1?DPP??
2?DCCT-EDIC?? 2?????
3?Finnish DPS??
4?Stop-NNDIM??
5?UKPDS??
6?Kumamoto??
7?ADOPT??
8?Steno-2??
9?DIS??
10?DECODE??
11?DECODA??
12?ACCORD??
13?ADVANCE??
14?VADT??
9
2???????????????
UKPDS
ADVANCE
VADT
ACCORD
10
UKPDS(??????????)

20??????( 1977 1997)
1977-1991??5,102 ????T2DM????
?6??20?,???? 10?
????? 1998 EASD ??????
10??????? (1997 2007)
????
?5??????
?5????????
???????? 17.0?, ??? 16 ? 30 ?

11
UKPDS ???????? ???????????
???????
?????
HbA1c ???1
N4,585
N3642
????
??? ?????
?1000???????? ()
????
(ns)
-1
??? ???
?????
?? HbAIc ()
plt0.0001
Stratton IM et al. BMJ 200032140512
12
???????????????(UKPDS)
N Engl J Med 2008359.
13
UKPDS????????????2??????????
10??????????,???????????????,????????????????????
????????????
??????????????????????????????,?????????????????
?? UKPDS??????
Rury R Holman et al. 10-Year Follow-up of
Intensive Glucose Control in Type 2 Diabetes. N
Engl J Med20083591-13
14
ACCORD?ADVANCE?VADT???????

????
?????????????????????????????
????
?????????,ACCORD???VADT??????????????????????????,
ADVANCE???,????????????????????

15
VADT? ACCORD ?ADVANCE???????????????????????
VADT ACCORD ADVANCE
?????? ?????? ?????? ????? ?????????? ???? ?????? ?????? ????? ?????? ?????? ?????
?????????? (95?????) 0.87(0.730-1.04) 0.90(0.78-1.04) 0.94(0. 84-1.06)
?????? (95?????) 1.065(0.801-1.416) 1.22(1.01-1.46) 0.93(0.81-1.06)
P0.04
16
?????????? ?????????????
17
?????????
???? ????
???? ???? ???? ??????
?? ?? ??CV?? ??????
UKPDS 53 ?? ??????????????
ADVANCE 66 8? ?????32 ???????,?????????
VADT 60 11.5? ???72,????? 40 ????????
ACCORD 62 10? ????? 35 ????????
18
? ?
DCCT/EDIC
UKPDS
ADVANCE
ACCORD
VADT
??????????????,??????????,?????????
??
19
????

??????
T2DM???????
? ????????????
? ???????
????

20
????????T2DM????
??????
436???
26????????
410???
17?????,11???
MDI n124
CSII n137
OHA n121
??13?, 7???????
??4?
??6?
??18?
??10?
??14?
????124?
????113?
????94?
Jianping Weng, Yanbing Li,etal. Lancet 2008 371
175360
21
???T2DM??????????
??????
????
Jianping Weng, Yanbing Li,etal. Lancet 2008
371 175360
22
???T2DM??????????
???????
???
???
???
Jianping Weng, Yanbing Li,etal. Lancet 2008 371
175360
23
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????2?????????????????,
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??????????,???????
??????????

24
2007??2??????????
25
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T2DM???????
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26
2?????????????

2????????ß?????????
2???????,??50?ß??????
??????,?????????????

ß????()
27
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28
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(??,????)
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29
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30
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(2????)
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31
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32
Light ??

??
??????????????
????????????????2???????????????

Vergès B,et al. 2009 EASD Poster. Poster number
972
33
Light ??

??761???????????
????
???????????????????????????
????
????(HbA1c?FBG)
????
??????

Vergès B,et al. 2009 EASD Poster. Poster number
972
34
??
????2??????,???????,
??gt40?,???????? HbA1cgt7?
Vergès B,et al. 2009 EASD Poster. Poster number
972
35
?? __ HbA1c??
plt0.001
plt0.001
HbA1c??

T0
T3
T0
T3
Glargine
Detemir
Vergès B,et al. 2009 EASD Poster. Poster number
972
36
?? __ FBG??
Detemir
Glargine
????????
mmo/L
Vergès B,et al. 2009 EASD Poster. Poster number
972
37
?? __ ?????
plt0.001
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plt0.05
T0
T3
T0
T3
Detemir
Glargine
Vergès B,et al. 2009 EASD Poster. Poster number
972
38
?? __ ????
Glargine
Detemir
???? Kg
???????????????0.5kg,???????????
Vergès B,et al. 2009 EASD Poster. Poster number
972
39
??

??????????????
??/????????????????????????????OADs??????
??????????????????????????,?????????
????????????????

Vergès B,et al. 2009 EASD Poster. Poster number
972
40
1707??-???????
????????2?????? ????2??3???? 30
????. Diabetes Care 31852856, 2008
41
1707??

???????????6??????????2?????????????2??3????
30???????
??????24??????????????????
????321?T2DM??

42
????
n160
??????HbA1c????? ???2h??
???? ??T2DM?? ??????? 6?? ??????? HbA1c 7.5
?????2?
???????????????????????
n161
?????3?
???
??FBG????????? ???? ????lt4.4 - 6.1 mmol/L
Yang wenying et al. Diabetes Care 31852856, 2008
43
???????
???30 ??2? ???30 ??3?
?? N () N ()
?? 72 (45.0) 82 (50.9)
?? 88 (55.0) 79 (49.1)

?? (SD) ?? (SD)
??(?) 54.4 (9.13) 55.3 (8.79)
????(kg/m2) 24.3 (3.20) 24.3 ( 3.10)
??(?) 7.7 (5.05) 8.0 ( 4.78)
??HbA1c () 9.5 ( 1.44) 9.6 ( 1.50)
Yang wenying et al. Diabetes Care 31 852-856
44
HbA1c?????
?2??3??????30??????HbA1c

Yang wenying et al. Diabetes Care 31 852-856
45
??HbA1c ???
BID TID
Yang wenying et al. Diabetes Care 31 852-856
46
??????????
??? 30??2? N ( ) ?? ??? 30 ??3? N ( ) ??
??????? 160 161
?? 1 ( 1) 1 3 ( 2) 5
?? 37 ( 23) 91 30 ( 19) 65
???????????????????
Yang wenying et al. Diabetes Care 31 852-856
47
???????????????(U/kg)
??? 30 ??2? ??? 30 ??2? ??? 30 ??3? ??? 30 ??3? ??? 30 ??3? ??? 30 ??3?
?? ?? ?? ?? ??
N 151 151 157 156 157
?? (SD) 0.40(0.15) 0.41(0.16) 0.29(0.14) 0.22(0.11) 0.36(0.14)
?? 50 50 33.3 25.3 41.4
??? 0.81U/Kg 0.81U/Kg 0.86U/Kg 0.86U/Kg 0.86U/Kg
??????? ??2???? ???1 1 ??3??????????11
2
Yang wenying et al. Diabetes Care 31 852-856
48
1707????

???30??2????????????2?????????????????????
?????????,???30??3?????????????????,?????????????
??????????

Yang wenying et al. Diabetes 200751(supp.1)2154-
PO
49
????

??????
T2DM???????
? ????????????
? ???????
????

???
??????????????????

51
??

????,55?,?????4?,??????????,????,?????????????,???
?gt10mmol/L,?????????,??????160mg BID,????500mg
TID?

52
????????

????,BMI 23.7Kg/m2,????,???????
??
FBG10.2mmol/L
PBG 19.3mmol/L
HbA1c9.4
F-CP1.5nmol/L

53
??

2????

54
????

??????????,?????tid ???????NPH??

?? ??? ??? ??? ??? ??? ??? ??
???(mmol/L) 10.2 19.3 19.3 12.8 16.8 12.5 14.9 11.2
???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1? ???1mg TID,???N 8U?? ??,??????1?
???1? 10.1 10.1 13.6 10.5 14.1 9.9 11.8 9.0
????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)?? ????????2mg TID,???N 12U(??????14U)??
???3? 7.2 7.2 10.2 8.4 10.3 7.9 9.2 7.1
??10? 6.8 6.8 9.8 8.3 10.5 7.6 8.2 7.6
HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,?????????? HbA1c 7.3,??4??????????????,????????????,?????????,??????????
55
? ?

???????????????
?????????????????,????????????????????????,?????
??????,???????????,???????????????????
????????????????????

???
??????????????????

57
??2-3??????????????????????

????, 67?
??2????12?
????????????????
???????,??????????
???
FBG11-17mmol/L
PBG13-15mmol/L
HbA1c 11.2(???)

58
???????

????BP 140/80mmHg BMI 23.4 kg/m2
ECG ??
24h????,?????????
????????B???
OGTT

??
??1h
??2h
331
C?pmol/l
769
605
11.1
??mmol/l
20.6
23.4
??C????265-1324 pmol/l
59
????

???
?????????????????
??????????????
OGTT?B??????

??????????
60
??????HbA1c??????????????????
250
200
??2??????
??2??????
150
????? mg/dL
100
50
???
0
0600
1200
1800
2400
0600
????
?????(FPG)
?????(PPG)
Source Riddle MC. Diabetes Care 199013676-686
61
????????????????????
300
??? A1C 9
200
????? (mg/dL)
??????? A1C 7
??PPG A1C 6
100
??A1C 5
0800
1200
1800
0800
Time of Day
Data from Monnier L et al. Diabetes Care.
200326881-885.
62
????? 30R????? ?1?-?7?
?? ?? ?? ?? ?? ?? ?? ?? ?? ??? ???30R?? ???30R??
?? ?? ??? ??? ??? ??? ??? ??? ?? ??? ???
1 17.3 24.2 12.3 8u
2 9 10.8 24.1 17.4 17.8 16u 12u
3 9.1 19.2 12.4 14.8 20u 14u
4 8.6 16.9 14.4 9.2 12.1 9.1 24u 14u
5 8.5 14.1 8.9 13.8 24u 16u
6 6.4 7.2 12.2 6.2 8.7 26u 16u
7 6.1 10.3 7.2 10.1 7.1 8.5 26u 16u
63
????? 30R??????8?-?15?
?? ?? ?? ?? ?? ?? ?? ?? ?? ??? ???30R?? ???30R??
?? ?? ??? ??? ??? ??? ??? ??? ?? ??? ???
8 7.3 8.3 5.3 8.9 6.6 7.8 6.4 28u 16u
9 6.2 8.5 7.7 8.9 5.8 6.3 5.1 28u 16u
10 5.6 7.4 6.2 8.0 6.2 7.8 6.7 28u 15u
11 6.2 8.2 7.2 8.4 6.7 7.8 5.9 28u 15u
12 6.1 8.7 8.1 6.4 8.9 7.1 28u 15u
13 5.8 8.4 7.8 8.6 6.2 8.7 6.4 28u 15u
14 6.7 8.2 8.8 6.6 7.9 6.9 28u 15u
15 5.8 5.4 6.8 6.2 8.0 6.2 28u 15u
64
6?????

HbA1c 7
?????????

65
?????

??????????HbA1c????,??????????
HbA1c??,?????-C???????,??B??????
?????????????-???????
???30R??????,???????????,?????????,?????????,????
?????????????????????????????

???
??-??????????????????????

67
????

???,??,49?,
??T2DM 5?,????????80mg Bid,????0.5 Tid,???50mg
Tid?
????
FPG9.5mmol/L
2hPPG19.4mmol/L
HbA1c10.6
??168cm??65kgBMI23.0

68
????

T2DM,??5?
?????????????????
????????
????????????

69
????????????????,???????????
Stratton IM et al. BMJ 2000 321 405412.
70
???HbA1c??????????

????(PPG)????????????????,???PPG?HbA1c???????
??HbA1c??????(gt10.2),PPG??????????25
??HbA1c??,PPG?????????(?HbA1c ??lt7.3???????70),?
?PPG?????????????????????

Monnier L et al, 2003
71
????????

????
???????
?????????????(???R???N)
?????????????????

72
????? R??? N?????
?? ?? ?? ?? ?? ?? ?? ?? ?? ???N ???R?? ???R?? ???R??
?? ?? ??? ??? ??? ??? ??? ??? ?? ?? ??? ??? ???
1 17.3 19.2 12.3 8u 8u 8u 8u
2 9 9.8 18.1 10.1 17.6 13.4 17.8 9.4 10u 12u 10u 10u
3 8.6 14.3 8.1 15.6 10.2 14.8 7.9 14u 14u 12uu 12u
4 6.9 10.1 7.1 9.8 6.8 12.1 7 14u 14u 12u 14u
5 6.8 9.1 6.6 8.7 6.2 9.3 6.3 15u 14u 12u 14u
6 5.6 6.0 8.3 5.7 7.9 5.2 8.5 6.5
73
?????????

?????????-???????????????
????????
??????????,?????????

74
?????30R??????
?? ?? ?? ?? ?? ?? ?? ?? ?? ???30R?? ???30R?? ???30R??
?? ?? ??? ??? ??? ??? ??? ??? ?? ??? ???
1 28u 27u
2 4.0 5.1 8.1 6.1 9 6.5 8.6 7 27u 26u
3 4.2 5.4 7.8 5.4 8.9 6.4 8.2 6 26u 22u
4 5 6.1 8.3 4.9 9.1 6.5 8.7 6.9 25u 22u

75
7?????