嘉義市糖尿病共同照護網 實習個案報告 嘉基家庭醫學科 盧敬文 2021.7.12 @嘉基糖尿病中心

1. 嘉義市糖尿病共同照護網
實習個案報告
嘉基家庭醫學科
盧敬文
2021.7.12 @嘉基糖尿病中心

2. Case
43-year-old female
Chief complaint:
• previous DM but lost 2-3 months f/u after child birth, felt thirsty
and frequent urinary voiding in recent 1 month
• Diagnosed and followed at Tainan Municipal Hospital for 5 years
Past history:
• Hypertension diagnosed since 2018
• Insomnia taken Stilnox for 3-4 years and stopped in 2017
• HBV carrier
• Allergic rhinitis
OP History:
left dorsal foot full thickness skin necrosis s/p fasciotomy and wound
closure s/p fasciotomy and wound closure on 2020/9/10

3. Occupation: housekeeping, accounting and shoes sewing
Alcohol:(-) Betel nuts chewing :(-) Smoking :(-)
Diet:
• breakfast: skip often due to getting up late
• lunch: self cooking
• Dinner: self cooking, eat out in night market
• Like sweet foods, fried foods, drink tea or coffee without sugar
• 會幫小孩吃吃不完的食物
Exercise: seldom, walking
**no home SMBG, due to broken 血糖機
No home SMBP

4. Family history
DM, poor control
HTN
dyslipidemia
8 m/o

5. Physical examination
BH: 157cm, BW:86kg, BMI: 34.9
BP: 159/116 mmHg, HR: 88 bpm
Abdomen: ovoid, no OP scar
Others: no specific finding

6. 2018/
8/27
11/5 2019/
2/19
5/20 6/27 11/5 12/13 2020/
2/24
3/25 5/29 10/12 12/3 2021/
1/28
3/3 5/7
BW(kg) 86 87.2 88 86.5 90 89 87.9 86.5 88.2
BP 159/116 148/96 135/101 143/100 130/86 144/100 144/96 134/95 136/95 134/94
ALT 33 26 31 28 29 40 33 26
T-Chol 156 187 164 185 173 161 168 181
HDL-C 40 45 42 44 44 40 43 44 40
LDL-C 100 126 122 101 120 112 112 102 96 125
TG 89 78 142 104 84 65 84 81 96
Cr. 0.39 0.37 0.46 0.4 0.41 0.51 0.35 0.32
eGFR 190.6 202.6 156.8 184.3 178.3 138.6 214 236.3
AC 163 152 163 195 174 157 169 121 152 180 247
PC 219 189 359
HbA1c 11.7 9.1 9.8 10 8.3 8 8.3 9 9.2 9.5 10.1 9.5
UACR 7.8 12.11 23.57 16.01 17.56
Rx
Metformin 500
1# BID
Metformin 500 1# TID
(sometimes only QD)
Jardiance Duo 12.5/850 1# BID
ForXiga 10
1# QD
Jardiance 10 1# QD (2018/11/12) (due to GTI) Toujeo
14U
NovoMix(30)
12/8 U
14/10 U
(2021/02)
18/18 U
AmarylM 2/500 1# QD DiamicronMR 30 1# QD Acarbose 50 1# TIDM Oseni
25/30 1#
QD
Crestor 10 1# QD
Cozaar 50 1# QD

7. Impression
1.Type 2 diabetes mellitus, poor control, w/o proteinuria,
HbA1c: 9.5% (2021/5)
2. Dyslipidemia with fatty liver, stable
3. Hypertension, unstable
4. HBV carrier
5. L-spine HIVD
6. adjustment insomnia, improved
7. r/o stress incontinence, improved

8. Discussion
• Poor drug compliance
• lifestyle modification difficulty (esp. diet control)，個案表示女兒九月上
幼稚園，希望比較有時間運動
• 不固定回診時間(與小孩打疫苗或復健同時)，無法長時間候診，醫師變動
（前後五位醫師）
• 打胰島素後，覺得胃口變好
1. When should checking C-peptide ?
2. How to titrate OADs under current medications regimen ?
• Ryzodeg ?
3. What is the adequate time point shifting to GLP-1RAs ?
• Soliqua(IGlarLixi) ?
4. 糖胖症（diabesity/diobesity）的處理？

10. A 6-month, randomized, pragmatic, parallel-group,
active-control, open-label, single-center trial
July 2019, in Italy
age >35 years, HbA1c >7.5%
current use of a full BBI regimen (four injections daily)
with or without metformin
for at least 6 months.

11. Exclusion criteria:
type 1 diabetes or latent autoimmune diabetes in adults
history of diabetes secondary to pancreatitis or pancreatectomy
Use of GLP-1RA, SGLT2i, or DPP4 inhibitor within the last 3 months
history of diabetic ketoacidosis or pancreatitis
impaired kidney function, liver insufficiency
pregnancy or planned pregnancy
history of cancer within 5 years prior to baseline
Participants were randomized (1:1:1) to
1) intensification of the BBI regimen (n=101)
2) fixed ratio of basal insulin plus GLP-1RA (fixed-combo group; n=102)
3) combination of basal insulin plus SGLT2i (gliflo-combo group; n=102)
The primary efficacy outcome：
change from baseline in HbA1c at 6 months

12. 60歲左右
糖尿病病史17年左右
BMI: 31左右
HbA1c 8.5%左右
一半左右使用
metformin

13. 相似降A1c效果
使用的總胰島素劑量較少

14. 體重減少

15. 糖胖症
BMI介於23-25的女性，未來罹患第二型糖尿病的比例是BMI<20
的四倍；若是BMI>35者則增加93倍
糖胖症在一般人口中的整體盛行率約略在5%到7%左右
基因學研究顯示，第一對染色體的q31到q42和第十一對染色體的
q14到q24，在第二型糖尿病病人身上，與其肥胖有密切的關係
基層醫學；21(6): 132-138

16. 糖胖症的治療對策
生活型態
然而要達到長期穩定的血糖控制，卻需要更大幅度的減重
運動且合併熱量限制，被認為是能夠減去較多的脂肪，而維持較多的瘦肉
組織
減重手術(Bariatric surgery)
血糖控制
優先考慮改善胰島素敏感性的藥物(如Metformin)及延遲腸道內醣類吸收
的藥物(如α-glucosidase inhibitors)
ACEI可以增加胰島素的敏感度，又可降低肥胖且高血壓的病人變
成第二型糖尿病的機會
基層醫學；21(6): 132-138

17. 社團法人中華民國糖尿病學會
第2型糖尿病的藥物治療(2020
修訂版)

18. Back
to our
case…
社團法人中華民國糖尿病學會
第2型糖尿病的藥物治療(2020
修訂版)

19. 社團法人中華民國糖尿病學會
第2型糖尿病的藥物治療(2020
修訂版)

20. 社團法人中華民國糖尿病學會
第2型糖尿病的藥物治療(2020
修訂版)

21. 社團法人中華民國糖尿病學會
第2型糖尿病的藥物治療(2020
修訂版)

23. 1. When should checking C-peptide ?
2. How to titrate OADs under current medications regimen ?
• Ryzodeg ?
3. What is the adequate time point shifting to GLP-1RAs ?
• Soliqua(IGlarLixi) ?
4. 糖胖症（diabesity/diobesity）的處理？

24. Thanks for your attention !