结核病与糖尿病共病的治疗管理专家共识

doi:10.3969/j.issn.1000-6621.2021.01.004

摘要/Abstract

摘要：

结核病与糖尿病均是临床上的常见病和多发病,两者可合并存在,相互影响。活动性结核病作为感染因素可加重糖尿病病情,而糖尿病患者又是发生结核病的高危人群,结核病与糖尿病双重负担将成为重大的全球公共卫生问题。因此,需重视结核病与糖尿病共病的治疗管理。本共识重点介绍了结核病与糖尿病共病的危害、发病机制、双向筛查、临床特点、诊断、治疗和管理等内容。

关键词: 结核, 糖尿病, 共病现象, 综合疗法, 疾病管理, 总结性报告(主题)

Abstract:

Tuberculosis (TB) and diabetes mellitus (DM) are both frequently-occurring clinical diseases and global pandemics. The two can coexist and influence each other. DM increases the risk of active TB, and TB may provoke hyperglycemia. The double burden of TB and DM has become a major public health problem. Therefore, it is necessary to manage the two diseases jointly. This consensus focuses on the pandemics, two-way screening, pathogenesis, clinical features, diagnosis, treatment and management of comorbidity of TB-DM, providing guidance to health care workers.

Key words: Tuberculosis, Diabetes mellitus, Comorbidity, Combined modality therapy, Disease management, Consensus development conferences as topic

国家感染性疾病临床医学研究中心, 深圳市第三人民医院, 国家代谢性疾病临床医学研究中心, 中南大学湘雅二医院, 中国防痨协会, 《中国防痨杂志》编辑委员会. 结核病与糖尿病共病的治疗管理专家共识[J]. 中国防痨杂志, 2021, 43(1): 12-22. doi: 10.3969/j.issn.1000-6621.2021.01.004

National Clinical Research Center for Infectious Disease/, The Third People’s Hospital of Shenzhen, National Clinical Research Center for Metabolic Disease, The Second Xiangya Hospital of Central South University, Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis. Expert consensus on treatment and management of tuberculosis-diabetes mellitus[J]. Chinese Journal of Antituberculosis, 2021, 43(1): 12-22. doi: 10.3969/j.issn.1000-6621.2021.01.004

图/表 4

表1

图1

表2

利福平与常用降糖药物之间的相互作用

药物名称	药理作用	同RFP的相互作用	建议的应对措施
二甲双胍	抑制肝脏血糖的产生、抑制肠道葡萄糖吸收、增加胰岛素敏感度	增加有机阳离子转运蛋白(OCT1)的表达和肝脏对二甲双胍的吸收;同时给予二甲双胍和利福平可增加二甲双胍的血药浓度,增强二甲双胍的降糖作用	当利福平加入二甲双胍治疗时,应密切监测血糖水平,观察同时服用二甲双胍和利福平患者的低血糖症状和体征
磺脲类	促进胰岛素分泌	磺脲类药物是CYP2C9的底物,与CYP2C9诱导物利福平同时使用可能会降低其血药浓度,增加高血糖的风险	增加血糖监测的频率、考虑调整药品剂量或选择其他降糖药物
格列奈类	促进胰岛素分泌	利福平诱导CYP3A4酶,降低了格列奈类药品的血药浓度	增加血糖监测的频率,考虑调整药品剂量或选择其他降糖药物
噻唑烷二酮类	增加胰岛素的敏感性,降低肝脏葡萄糖生成	利福平作为CYP2C8的诱导剂,能降低吡格列酮和罗格列酮的血药浓度	增加血糖监测的频率,考虑调整药品剂量或选择其他降糖药物
糖苷酶抑制剂类	延缓肠道葡萄糖的吸收	尚无报道	无特殊措施
DPP-IV抑制剂	促进胰岛素分泌	利福平通过诱导CYP3A4和三磷酸腺苷结合盒转运体(ATP-binding cassette transporters, ABC转运体)(P糖蛋白),可降低利格列汀、沙格列汀的血药浓度	增加血糖监测的频率,考虑调整药品剂量或选择其他降糖药物(推荐将利格列汀换为同类别的其他药品)
SGLT-2抑制剂	促进尿糖排泄	利福平诱导UGT1A9, UGT2B4使得卡格列净暴露降低而降低疗效	密切监测,并结合eGFR水平调整药品剂量。当eGFR<60ml·min^-1·(1.73m²)^-1时,应该考虑换药
GLP-1受体激动剂	结合GLP-1受体,刺激胰岛素分泌	GLP-1RA和利福平合用时,由于前者可延迟胃排空而可能减缓利福平的吸收	密切监测,如果需要同时使用,可以在GLP-1RA注射前1 h给予口服利福平,以达到有效的血药浓度

表2

表3

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典型糖尿病症状	静脉血浆葡萄糖水平
多尿、多饮、多食、	加上: 随机血糖≥11.1mmol/L
体质量减轻	或加上:空腹血糖≥7.0mmol/L
	或加上:葡萄糖负荷后2h血糖≥11.1mmol/L
	或加上:糖化血红蛋白≥6.5%

临床类别	血糖控制目标
结核病治疗期间^[6,55]
一般情况下	HbA1c<7.0%,空腹4.4~7.0mmol/L,非空腹<10.0mmol/L
并发心脑血管疾病、心脑血管疾病高风险、高龄、结核病病情严重	HbA1c<8.0%,空腹7.8~10.0mmol/L,非空腹7.8~13.9mmol/L
非结核病治疗期间^[36,55]
年龄较小、病程较短、预期寿命较长、无并发症、未并发心血管疾病	HbA1c<6.5%,空腹4.4~6.1mmol/L,非空腹6.1~7.8mmol/L
大多数非妊娠成年患者	HbA1c<7.0%,空腹4.4~7.0mmol/L,非空腹<10.0mmol/L
高龄、低血糖发生风险较高且无法耐受低血糖、存在多器官功能不全、预期生存期低于5年、需重症监护	HbA1c<8.0%,空腹7.8~10.0mmol/L,非空腹7.8~13.9mmol/L