糖尿病患者静脉滴注甲基强的松龙后动态血糖特征及胰岛素方案调整

Characteristics of daily blood glucose profiles of diabetes mellitus receiving methylprednisolone and adjustment of insulin

目的 研究糖尿病患者短期甲基强的松龙（甲强龙）治疗后血糖升高的特点,及应用胰岛素控制血糖时剂量的调整方法.方法 应用动态血糖监测系统（CGMS）对慢性阻塞性肺病（COPD）伴糖尿病未接受甲强龙治疗（DM1组）及COPD伴（DM2组）或不伴糖尿病（NDM组）接受甲强龙治疗后进行动态血糖监测,比较血糖平均水平（MBG）、餐后血糖水平超过11.1 mmol/L的血糖曲线下面积（AUC）、血糖水平超过10 mmol/L的时间百分比（PT）、餐后血糖峰值（PGS）、餐后血糖波动幅度（PPGE）、平均血糖波动幅度（MAGE）等指标,并分析DM2组甲强龙治疗前后胰岛素剂量变化.结果 DM2组患者24 h MBG比DM1组高约42％,比NDM组高约38％ （P＜0.05）,餐后血糖AUC、PT及MAGE均明显高于DM1、NDM两组（P＜0.01）.DM2组早餐PGS及PPGE均高于NDM组（P＜0.01）,与DM1组相比差别无统计学意义（P＞0.05）.DM2组午餐、晚餐PGS及PPGE均明显高于DM1、NDM两组（P＜0.01）.NDM、DM2两组午餐、晚餐PGS及PPGE均明显高于早餐后（P＜0.05）.NDM组餐后血糖高峰出现在午餐后大约70 ～ 80 min,约为静滴甲强龙后（5.71±0.56）h,大约21：00血糖水平开始下降,夜间维持在较低水平.DM2组餐后血糖高峰出现在晚餐后大约1.5h左右.DM2组应用甲强龙治疗后胰岛素剂量明显增加,较未用激素前增加了74％（P＜0.01）.其中午餐、晚餐前胰岛素需要量最多,比早餐前高53％ ～ 67％ （P＜0.01）.结论 COPD不伴糖尿病的患者应用甲强龙治疗引起的血糖高峰主要在午餐后.而COPD伴糖尿病者应用甲强龙后血糖达峰时间延迟至晚餐后约1.5h.2型糖尿病患者开始应用糖皮质激素的同时胰岛素剂量即应增加约50％,主要应增加午餐、晚餐前剂量.使血糖水平控制良好至少应增加74％的胰岛素剂量.

Objective To study the characteristics of daily blood glucose profiles in diabetic patients receiving methylprednisolone and to provide an optimal adjustment of insulin for glucocorticoid-induced hyperglycemia.Methods Patients with chronic obstructive pulmonary disease（COPD） and diabetes not treated with methylprednisolone （group DM1）,COPD with diabetes （group DM2） or without diabetes （group NDM） treated with methylprednisolone were studied by means of continuous glucose monitoring system（CGMS） for3 days.Levels of mean blood glucose（MBG）,the area under the curve of postprandial glucose above 11.1 mmol/L（AUC）,percentage of time spent in hyperglycemia above 10 mmol/L （PT）,postprandial glucose spike （PGS）,postprandial glycemic excursion （PPGE）,and mean amplitude of glycemic excursions（MAGE） were calculated in each individual.Changes of insulin doses after using methylprednisolone in group DM2 were observed.Results The 24 h MBG in group DM2 was 42％ higher than that in group DM1 and 38％ higher than that in group NDM（P＜0.05）.AUC,PT,and MAGE were significantly higher in group DM2 than in group DM1 and NDM （P＜0.01）.PGS and PPGE after breakfast in group DM2 were significantly higher than those in group NDM （P＜0.01）,but there was no significant difference between group DM2 and DM1 （P＞0.05）.PGS and PPGE after lunch and dinner in group DM2 were both significantly higher than those of in group DM1 and group NDM （P＜0.01）,and both lunch and dinner yielded higher PGS and PPGE than those after breakfast in group NDM and group DM2 （P＜0.05）.The peak of plasma glucose in group NDM occurred at 70-80 min after lunch,ie.about （5.71 ± 0.56） h after methylprednisolone administration.However,the peak occurred at about 1.5 h after dinner in group DM2.Insulin doses were significantly increased by 74％ in patients with COPD and diabetes after treatment with methylprednisolone （P＜0.01）.The insulin doses before lunch and dinner were 53％-67％ higher than those before breakfast（P＜0.01）.Conclusions The daily blood glucose peak in COPD patients without diabetes mostly occurred after lunch during treatment with methylprednisolone.In eontrast,in COPD patients with diabetes,the peak glucose level occurred 1.5 h after dinner.I1 is suggested that insulin doses should be increased by 50％ when the glucocortieoid therapy is started and may need to be increased by 74％ or more to control blood glucose levels.The increased insulin doses should be distributed before lunch and dinner.