肥胖合并2型糖尿病的血脂紊乱治疗策略

The Management of Dyslipidemia in Obesity with Type 2 Diabetes

肥胖与2型糖尿病(type 2 diabetes mellitus,T2DM)、血脂异常关系密切。肥胖合并2型糖尿病的患者血脂达标率低,心血管风险增加。T2DM患者具有独特的血脂特点,表现为甘油三酯(triglyceride,TG)水平升高、高密度脂蛋白胆固醇(high density lipoprotein-cholesterol,HDL-C)水平下降,低密度脂蛋白胆固醇(low density lipoprotein-cholesterol,LDL-C)水平正常或轻度升高。血脂异常与胰岛素抵抗和代谢综合征密切相关,其不仅只是代谢紊乱的一种伴随疾病,而且是2型糖尿病的病因之一。而在肥胖合并2型糖尿病的患者中,肥胖可加重血脂紊乱。因此,在肥胖合并2型糖尿病的患者中血脂管理对改善胰岛素抵抗、胰岛β细胞分泌功能意义重大。糖尿病患者因被糖基化的胆固醇和小而密的LDL-C,其动脉粥样硬化进展更迅速、病变更复杂、部位更弥漫、管腔更狭窄。此类人群血脂管理的首要目标是降低LDL-C水平,从而降低心血管事件的发生风险。高TG是糖尿病发病的独立危险因素,降低TG水平并不能明显减少冠心病事件,但可减少胰腺炎的发生风险。治疗方面,以减重为目的的生活方式干预应当作肥胖合并2型糖尿病治疗的基础性措施并长期坚持。以降低LDL-C水平为目的的他汀类及以降低TG水平为目的的贝特类药物分别对于心血管事件减少,预防胰腺炎发生起重要作用。磺脲类、双胍类、α-糖苷酶抑制剂、噻唑烷二酮类、胰高血糖素样肽-1受体激动剂类(glucagon-like peptide-1 receptor agonists,GLP-1RA)对于肥胖合并2型糖尿病的患者均有不同程度地改善血脂的作用。降脂药物、降糖药物治疗在肥胖合并2型糖尿病的患者的血脂管理中均起到至关重要的作用。

Obesity closely relates to type 2 diabetes and dyslipidemia. Obesity patients with type 2 diabetes had a lower target control rate, which could increase the risk of cardiovascular disease. Type 2 diabetes has increased TG,decreased HDL-C and normal/slightly increased LDL-C. Dyslipidemia is closely related to insulin resistance and metabolic syndrome, it is not only a kind of metabolic disorders, but also one reason in the mechanism of diabetes. Obesity could increase blood lipid disorders, therefore, the management of dyslipidemia would have a great effect on improving insulin resistance and islet beta cells among obesity patients with type 2 diabetes. Type 2 diabetes patients with glycosylated cholesterol and small dense LDL-C,are inclined to accelerate the progress of atherosclerosis. The primary aim among these patients is to reduce LDL-C, which could decrease the risk of cardiovascular disease. High TG level is the risk factor for diabetes, however, decreased TG could reduce the risk of acute pancreatitis. The lifestyle intervention to weight control should be considered the basic treatment in type 2 diabetes therapy. The statins and fibrates could decrease the risk of cardiovascular events and acute pancreatitis respectively. The sulfonylureas, metformin, α-glycosidase inhibitors, thiazolidinedione and GLP-1RA could improve lipid profiles among obesity with type 2 diabetes. Lipid-lowering combined with hypoglycemic play important effects in the therapy among obesity patients with type 2 diabetes.