健康生活:糖尿病治療新策略
Researchers are trying new approaches to treat Type 2 diabetes amid widespread uncertainty about the most effective therapies and concerns that current strategies might be doing some patients more harm than good.
在人們普遍對何種糖尿病療法最有效感到不確定、並且擔憂當前的治療策略對某些患者可能弊大於利的情況下，研究人員正在嘗試治療II型糖尿病的新方法。New guidelines for treating the disease, which many experts consider a public-health crisis among millions of mostly overweight individuals, suggest doctors vary treatments depending on a patient's age, general health and even personal preferences. The recently updated guidelines recommend that doctors back away from pushing patients to get their blood sugar down to a standard targeted level. Aiming for a very low blood-sugar level might be appropriate for a younger person, for example, while older patients might do better with a less aggressive approach, according to the guidelines, published in June in the journal Diabetes Care.
糖尿病被許多專家視爲是一個公共健康危機，患病人數達數以百萬計，其中大多數爲體重超重的人。6月份發表在《糖尿病護理》(Diabetes Care)雜誌上的糖尿病治療最新指引建議醫生要根據患者的年齡、總體健康狀況甚至是個人偏好來改變治療方案。該指引建議，醫生要避免強迫患者將血糖降至標準的目標水平。例如，該指引提出，制定一個非常低的血糖水平目標或許適用於年輕患者，但是採取更溫和的治療方法對年紀較大的患者效果或許會更好。'We need to be less dogmatic about what matters and be open to different approaches and give patients a voice' in treatment decisions, says Victor Montori, a diabetes specialist at Mayo Clinic, in Rochester, Minn., who wasn't involved with writing the guidelines but supports the new direction.
美國明尼蘇達州羅切斯特市梅奧診所(Mayo Clinic)的糖尿病專家維克多•蒙托裏(Victor Montori)說，“關於什麼是重要因素，我們應該要不那麼固守成規，要願意接受不同的方法，並讓患者（在決定治療方案上）擁有話語權。”蒙托裏並未參與撰寫這份新指引，但他對這個新方向持支持態度。
Another approach gaining wider acceptance for some patients is the use of bariatric surgery, which results in dramatic weight loss. Though it comes with risk of serious complications, the operation has been shown in recent studies to lead to a rapid lowering of blood sugar, often enabling patients to go off most or all of their diabetes medicines.
對於某些患者而言，另外一個獲得較廣泛認可的治療方法是施行可大幅降低體重的減肥手術。雖然嚴重併發症風險會隨之產生，但近期一些研究顯示該手術能使血糖水平迅速降低，常常可使患者停用大部分或全部在服的糖尿病藥物。Some experts also are questioning the benefits of gradually stepping up the intensity of drug therapy, a widely accepted approach that was reaffirmed in the latest guidelines. The aim is to maintain a patient's blood-sugar level while keeping up with the progressive nature of the disease. But researchers at UT Southwestern Medical Center in Dallas, for instance, argue in a recent small study that hitting the disease early and hard is better.
有些專家也對逐漸增強藥物療法強度的益處提出質疑，這一獲得廣泛認可的方法在最新的指引中也再次得到肯定。該療法的目的是要維持患者的血糖水平，同時也要跟上糖尿病會不斷加重的這種特性。其中，位於達拉斯的德克薩斯大學西南醫學中心(UT Southwestern Medical Center)的研究人員在最近一次小規模研究中提出，早早採用高強度療法治療糖尿病會更好。More than 24 million Americans have Type 2 diabetes, the version of the disease usually associated with being overweight and living a sedentary lifestyle. By some estimates the number could double by 2025.
美國目前有2400多萬II型糖尿病患者，該類型糖尿病通常與體重超重或是久坐不運動的生活方式存在關聯。據估計，II型糖尿病的患病人數到2025年可能會翻番。In diabetes, the body isn't able to effectively use insulin or to make enough of it to metabolize glucose in the food we eat, resulting in higher than normal levels of blood sugar. Heart attacks and strokes, kidney failure, nerve damage, blindness and vascular problems leading to amputation are among the long-term complications when the disease isn't well controlled. That makes diabetes a precursor to many of medicine's most debilitating conditions. Annual costs for treatment and loss of productivity associated with the disease are about $174 billion, according to the American Diabetes Association, an education and research association that devised the new treatment guidelines in collaboration with its counterpart the European Association for the Study of Diabetes.
患糖尿病後，人體會無法有效地利用胰島素或是無法分泌足量的胰島素來使我們從食物中攝取的葡萄糖發生代謝，從而導致血糖水平高於正常水平。糖尿病若沒有控制好會引發一些慢性併發症，包括心臟病、中風、腎衰竭、神經損傷、失明和會導致截肢的血管問題等。這使糖尿病成爲藥物所引發的最易使體質變差的諸多症狀的前兆。美國糖尿病協會(American Diabetes Association，簡稱“ADA”)的數據顯示，美國用於治療糖尿病的費用以及與該疾病相關的生產力的損失每年達到1740億美元左右。ADA爲一家教學和研究機構，其與歐洲糖尿病研究協會(European Association for the Study of Diabetes)合作制訂了這份糖尿病治療新指引。There have been conflicting findings over the benefits for patients of keeping blood sugar strictly controlled, helping to fuel uncertainty about how best to treat the disease. Some popular diabetes drugs come with side effects─including weight gain, bone loss and even a small risk of certain cancers. And some data have shown that aggressive efforts to achieve tight glucose control, until recently considered a desirable goal, can lead to troubling episodes of low blood sugar called hypoglycemia or to increased risk for serious heart-related problems.
關於嚴格控制血糖水平的益處一直存在一些相互牴觸的研究結果，這也加大了何種糖尿病療法最有效這一問題的不確定性。一些常見的糖尿病藥物具有副作用，例如體重增加、骨質疏鬆，甚至還有引發某些癌症的小風險。此外，一些數據也顯示，採取激進療法來嚴格控制住葡萄糖含量（直到最近還被認爲是一個理想的目標）可能會造成患者有些時候血糖低的麻煩問題（即低血糖症），也可能會加大出現嚴重心臟問題的風險。Although available drugs all improve blood-sugar levels, there is a lack of data to show whether they actually prevent or delay development of diabetes' long-term consequences.
儘管現有的藥物都能改善血糖水平，但仍然缺乏有關它們是否真能阻止或延遲糖尿病的慢性併發症進一步加重的數據。'The goal for treatment and the choice of individual drug must be personalized depending on the patient,' says Vivian Fonseca, the ADA's president for science and medicine and chief of endocrinology at Tulane University Health Sciences Center, in New Orleans.
ADA科學與醫學事務主席、新奧爾良杜蘭大學醫學中心(Tulan University Health Sciences Center)內分泌學主任薇薇安•馮塞卡(Vivian Fonseca)認爲，必須根據病人的情況制定專門的治療目標和選擇藥物。For most patients newly diagnosed with Type 2 diabetes, the first line of therapy is to improve diet and exercise habits to reduce blood-sugar levels. Usually metformin, a basic diabetes medication, is also prescribed. But patients with only mildly elevated blood-sugar levels may try to improve their health habits for up to six months to see if they can control the disease before beginning medication.
對於大多數新近被診斷患有II型糖尿病的患者，首先展開的系列療法就是改善飲食和鍛鍊習慣以降低血糖水平，同時醫生常常還會給他們開一種名爲二甲雙胍的治療糖尿病的基本藥物。不過，如果患者的血糖水平只是溫和上升，他們可能要先試着改善自己的生活習慣六個月時間，以看看是否能在用藥之前控制住糖尿病。Blood sugar is typically defined as being under control for diabetic patients when it is below 7%, using a measure known as hemoglobin A1c, or HbA1c, according to the ADA. Under the new guidelines, that level is still desirable. But younger, newly diagnosed and well-motivated patients with a long life expectancy may want to aim for even lower levels, closer to 6%, according to the recommendations. Such aggressive therapy is expected to better keep the disease from progressing.
ADA稱，糖化血紅蛋白(HbA1c)水平低於7%的糖尿病患者通常會被認定血糖受到控制。新發布的指引也認爲這一水平比較理想。但是，指引中還提到，年紀較輕、新近被診斷患病、強烈希望自身長壽的患者可能要把血糖控制在接近6%的更低水平。這一比較激進的治療方案可能會更好地防止糖尿病加重。For older patients vulnerable to severe hypoglycemia or who may already have advanced cardiovascular disease, less stringent targets of up to 8% or even a little higher would be sufficient, the guidelines say. This also could reduce the burden of side effects from medications.
新指引稱，對於易患嚴重低血糖症的老年患者或是可能已經患有心血管疾病的患者，目標可以放鬆一些，8%甚至是略高一些的血糖水平就足夠了。這可能會減輕藥物副作用帶來的負擔。
