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07 окт€бр€ 2013, 15:24 588 +3

ƒиабет сахарный 

√руппа заболеваний: эндокринные болезни
—межные болезни: болезнь иценко-кушинга, диабет несахарный, диабет сахарный 1 тип, диабет сахарный 2 тип, обменный алкалоз, обменный ацидоз, ожирение, синдром диабетической стопы, синдром иценко-кушинга
¬рач в каталоге: эндокринолог
ѕораженный орган: поджелудочна€ железа
 

‘акторы риска

  • ƒиабет у других членов семьи.

ќписание

—ахарный диабет (лат. diabetes mellītus) — группа эндокринных заболеваний, развивающихс€ вследствие абсолютной или относительной (нарушение взаимодействи€ с клетками-мишен€ми) недостаточности гормона инсулина, в результате чего развиваетс€ гипергликеми€ — стойкое увеличение содержани€ глюкозы в крови. «аболевание характеризуетс€ хроническим течением и нарушением всех видов обмена веществ: углеводного, жирового, белкового, минерального и водно-солевого.

  • “ермин «сахарный диабет 1-го типа» примен€етс€ к обозначению группы заболеваний, которые развиваютс€ вследствие прогрессирующего разрушени€ бета-клеток поджелудочной железы, что приводит к дефициту синтеза проинсулина и гипергликемии, требует заместительной гормональной терапии. 
  • “ермин «сахарный диабет 2-го типа» относитс€ к заболеванию, развивающемус€ у лиц с избыточным накоплением жировой ткани, имеющих инсулинорезистентность, вследствие чего наблюдаетс€ избыточный синтез проинсулина, инсулина и амилина бета-клетками поджелудочной железы, возникает так называемый «относительный дефицит». 

–аспространЄнность сахарного диабета в попул€ци€х человека, в среднем, составл€ет 1—8,6 %, заболеваемость у детей и подростков примерно 0,1—0,3 %. — учЄтом недиагностированных форм это число может в некоторых странах достигать 6 %. ѕо состо€нию на 2002 год в мире сахарным диабетом болело около 120 миллионов человек. ѕо данным статистических исследований, каждые 10—15 лет число людей болеющих диабетом удваиваетс€, таким образом, сахарный диабет становитс€ медико-социальной проблемой. “акже следует отметить, что со временем увеличиваетс€ дол€ людей, страдающих 1-м типом сахарного диабета. Ёто св€зано с улучшением качества медицинской помощи населению и увеличени€ срока жизни лиц с диабетом 1-го типа.

—ледует отметить неоднородность заболеваемости сахарным диабетом в зависимости от расы. —ахарный диабет 2-го типа наиболее распространЄн среди монголоидов; так, в ¬еликобритании среди лиц монголоидной расы старше 40 лет 20 % страдают сахарным диабетом 2-го типа, на втором месте сто€т люди негроидной расы, среди лиц старше 40 лет дол€ больных сахарным диабетом составл€ет 17 %. 

ћ Ѕ-10

ѕри формулировке диагноза на первое место выставл€етс€ тип диабета, дл€ диабета 2-го типа указываетс€ чувствительность к пероральным сахароснижающим средствам (с резистентностью или без), т€жесть течени€ заболевани€, затем состо€ние углеводного обмена, и далее следует перечисление осложнений сахарного диабета.

ѕо ћ Ѕ 10.0 диагноз сахарный диабет в зависимости от положени€ в классификации кодируетс€ разделами E 10-14 осложнени€ заболевани€ обозначаютс€ четвертными знаками от 0 до 9:

.0 — комой;

.1 — кетоацидозом;

.2 — поражением почек;

.3 — поражени€ми глаз;

.4 — неврологическими осложнени€ми;

.5 — нарушени€ми периферического кровообращени€;

.6 — другими уточнЄнными осложнени€ми;

.7 — множественными осложнени€ми;

.8 — неуточнЄнными осложнени€ми;

.9 Ѕез осложнений.

 лассификаци€

ѕоследний пересмотр классификации —ƒ сделала јмериканска€ диабетическа€ ассоциаци€ в €нваре 2010 года. — 1999 года по классификации, одобренной ¬ќ«, выдел€ют —ƒ 1 типа, —ƒ 2 типа, —ƒ беременных и «другие специфические типы —ƒ». “акже выдел€ют термин латентный аутоиммунный диабет у взрослых (LADA, «диабет 1,5 типа») и р€д более редких форм сахарного диабета.

—уществует р€д классификаций сахарного диабета по различным признакам. ¬ совокупности они вход€т в структуру диагноза и позвол€ют достаточно точно описать состо€ние больного диабетом.

 лассификаци€ по т€жести течени€ заболевани€

I. —ахарный диабет 1-го типа или «юношеский диабет», однако заболеть могут люди любого возраста (деструкци€ β-клеток, ведуща€ к развитию абсолютной пожизненной инсулиновой недостаточности).

ѕодраздел€етс€ на 2 вида;

  • аутоиммунный;
  • идиопатический.

II. —ахарный диабет 2-го типа преимущественной инсулинорезистентностью и относительной инсулиновой недостаточностью или преимущественным дефектом секреции инсулина с инсулинорезистентностью или без неЄ).

III. ƒругие формы диабета:

  • генетические дефекты функции β-клеток (MODY-1, MODY-2, MODY-3, MODY-4, митохондриальна€ мутаци€ ƒЌ , другие);
  • генетические дефекты инсулина и /или его рецепторов (резистентность к инсулину типа ј, лепречаунизм, синдром –абсона-ћенденхолла, липоатрофический диабет и другие);
  • заболевани€ экзокринной части поджелудочной железы (панкреатит, травма/панкреатэктоми€, неоплазии, кистозный фиброз, гемохроматоз, фиброкалькулезна€ панкреатопати€);
  • зндокринные заболевани€ (эндокринопатии), такие как синдром »ценко- ушинга, акромегали€, глюкагонома, феохромацитома, тиреотоксикоз, соматостатинома, альдостерома и другие;
  • диабет, индуцированный лекарствами (вакор, тиазиды, пентамидин, дилантин, никотинова€ кислота, α-интерферон, глюкокортикоиды, β-адреноблокаторы, тиреоидные гормоны, диазоксид и другие);
  • диабет, индуцированный инфекци€ми (врождЄнна€ краснуха, цитомегаловирус и другие);
  • необычные формы иммунноопосредованного диабета («stiff-man» — синдром (синдром обездвиженности), наличие антител к рецепторам инсулина, наличие антител к инсулину и другие);
  • генетические синдромы, сочетающиес€ с сахарным диабетом (синдром ƒауна, синдром Ћоренса-ћуна-Ѕидл€, синдром  лайнфелтера, миотоническа€ дистрофи€, синдром “ернера, порфири€, синдром ¬ольфрама, синдром ѕрадера-¬илли, атакси€ ‘ридрейха, хоре€ √ентингтона, фосфат-диабет и другие);

IV. √естационный сахарный диабет — патологическое состо€ние, характеризующеес€ гипергликемией, возникающей на фоне беременности у некоторых женщин и обычно спонтанно исчезающее после родов. —огласно рекомендаци€м ¬ќ«, различают следующие типы сахарного диабета у беременных:

  • сахарный диабет 1 типа, вы€вленный до беременности;
  • сахарный диабет 2 типа, вы€вленный до беременности;
  • сахарный диабет беременных — под этим термином объедин€ют любые нарушени€ толерантности к глюкозе, возникшие во врем€ беременности.

* ѕримечание: следует отличать от беременности, возникшей у пациенток с сахарным диабетом.

V. Ћатентный аутоиммунный диабет у взрослых (англ. latent autoimmune diabetes in adults, LADA; «диабет 1.5 типа») — сахарный диабет, симптомы и начальное течение которого соответствуют клинической картине диабета второго типа, но притом этиологи€ лежит ближе к диабету первого типа: обнаруживаютс€ антитела к бета-клеткам поджелудочной железы и ферменту глутаматдекарбоксилазе.

ѕо разным оценкам, в разных попул€ци€х от 6% до 50% пациентов с диагнозом «диабет II типа» на самом деле поражены латентным аутоимунным диабетом взрослых. ¬озможно, LADA представл€ет собой «м€гкий» край спектра про€влений диабета 1-го типа.

VI. —ахарный диабет взрослого типа у молодых (диабет типа Mason), более известный как MODY-диабет (от англ. maturity onset diabetes of the young) - термин, описывающий несколько схожих по протеканию форм диабета с аутосомно-доминантным типом наследовани€. »

сторически термином MODY обозначали разновидность диабета, при которой заболевание обнаруживаетс€ в молодом возрасте, а протекает м€гко, подобно "взрослому" диабету второго типа, но зачастую без снижени€ чувствительности к инсулину.

— углублением знаний определение MODY-диабета сузилось, и в новой этиологически-основанной классификации MODY относ€т к типам диабета "св€занным с генетическим дефектом функционировани€ бета-клеток", с разбивкой на подтипы в соответствии с конкретным поражЄнным геном (MODY1-MODY9).

 лассификаци€ по т€жести течени€ заболевани€

  • ЋЄгкое течение

Ћегка€ (I степень) форма болезни характеризуетс€ невысоким уровнем гликемии, котора€ не превышает 8 ммоль/л натощак, когда нет больших колебаний содержимого сахара в крови на прот€жении суток, незначительна€ суточна€ глюкозури€ (от следов до 20 г/л). —осто€ние компенсации поддерживаетс€ с помощью диетотерапии. ѕри легкой форме диабета могут диагностироватьс€ у больного сахарным диабетом ангионейропатии доклинической и функциональной стадий.

  • —редней степени т€жести

ѕри средней (≤≤ степень) т€жести сахарного диабета гликеми€ натощак повышаетс€, как правило, до 14 ммоль/л, колебани€ гликемии на прот€жении суток, суточна€ глюкозури€ обычно не превышает 40 г/л, эпизодически развиваетс€ кетоз или кетоацидоз.  омпенсаци€ диабета достигаетс€ диетой и приЄмом сахароснижающих пероральных средств или введением инсулина (в случае развити€ вторичной сульфамидорезистентности) в дозе, котора€ не превышает 40 ќƒ на сутки. ” этих больных могут вы€вл€тьс€ диабетические ангионейропатии различной локализации и функциональных стадий.

  • “€жЄлое течение

“€жела€ (≤≤≤ степень) форма диабета характеризуетс€ высокими уровн€ми гликемии (натощак свыше 14 ммоль/л), значительными колебани€ми содержимого сахара в крови на прот€жении суток, высоким уровнем глюкозурии (свыше 40-50 г/л). Ѕольные нуждаютс€ в посто€нной инсулинотерапии в дозе 60 ќƒ и больше, у них вы€вл€ютс€ различные диабетические ангионейропатии.

 лассификаци€ по степени компенсации углеводного обмена

  • ‘аза компенсации;
  • ‘аза субкомпенсации;
  • ‘аза декомпенсации.

 омпенсированна€ форма диабета — это хорошее состо€ние больного, у которого лечением удаетс€ достигнуть нормальных показателей сахара в крови и его полного отсутстви€ в моче. ѕри субкомпенсированной форме диабета не удаетс€ достигнуть таких высоких результатов, но уровень глюкозы в крови ненамного отличаетс€ от нормы, то есть составл€ет не более 13,9 ммоль/л, а суточна€ потер€ сахара с мочой составл€ет не более 50 г. ѕри этом ацетон в моче отсутствует полностью.

’уже всего протекает декомпенсированна€ форма диабета, потому что в этом случае улучшить углеводный обмен и снизить сахар в крови удаетс€ плохо. Ќесмотр€ на лечение, уровень сахара поднимаетс€ более 13,9 ммоль/л, а потер€ глюкозы с мочой за сутки превышает 50 г, в моче по€вл€етс€ ацетон. ¬озможна гипергликемическа€ кома.

 лассификаци€ по осложнени€м

  • ƒиабетическа€ микро- и макроангиопати€;
  • ƒиабетическа€ нейропати€;
  • ƒиабетическа€ ретинопати€;
  • ƒиабетическа€ нефропати€;
  • ƒиабетическа€ стопа.

ѕричины

—уществует наследственна€ предрасположенность к сахарному диабету. ≈сли болен один из родителей, то веро€тность унаследовать диабет первого типа равна 10%, а диабет второго типа — 80%. ќгромное вли€ние на развитие заболевани€ оказывают различные внешние факторы. 

“очна€ причина сахарного диабета не установлена. ¬ происхождении сахарного диабета выдел€ют два основных звена:

  1. недостаточное производство инсулина эндокринными клетками поджелудочной железы;
  2. нарушение взаимодействи€ инсулина с клетками тканей организма (инсулинорезистентность) как следствие изменени€ структуры или уменьшени€ количества специфических рецепторов дл€ инсулина, изменени€ структуры самого инсулина или нарушени€ внутриклеточных механизмов передачи сигнала от рецепторов органеллам клетки.

ѕанкреатическа€ недостаточность (1-й тип диабета)

¬ основе аутоиммунного поражени€ клеток лежит их повреждение любыми цитотоксическими агентами. ƒанное поражение вызывает выделение аутоантигенов, которые стимулируют активность макрофагов и “-киллеров, что в свою очередь, приводит к образованию и выделению в кровь интерлейкинов в концентраци€х, оказывающих токсическое действие на клетки поджелудочной железы. “акже клетки повреждаютс€ наход€щимис€ в ткан€х железы макрофагами.

“акже провоцирующими факторами могут €вл€тьс€ длительна€ гипокси€ клеток поджелудочной железы и высокоуглеводиста€, богата€ жирами и бедна€ белками диета, что приводит к снижению секреторной активности островковых клеток и в перспективе к их гибели. ѕосле начала массивной гибели клеток запускаетс€ механизм их аутоиммунного поражени€.

¬непанкреатическа€ недостаточность (2-й тип диабета)

ƒл€ диабета 2-го типа (устаревшее название — инсулинонезависимый диабет) характерны нарушени€, указанные в пункте 2 (см. выше). ѕри этом типе диабета инсулин производитс€ в нормальных или даже в повышенных количествах, однако нарушаетс€ механизм взаимодействи€ инсулина с клетками организма (инсулинорезистентность).

√лавной причиной инсулинрезистентности €вл€етс€ нарушение функций мембранных рецепторов инсулина при ожирении (основной фактор риска, 80% больных диабетом имеют избыточную массу тела) — рецепторы станов€тс€ неспособными взаимодействовать с гормоном в силу изменени€ их структуры или количества.

“акже при некоторых видах диабета 2-го типа может нарушатьс€ структура самого инсулина (генетические дефекты).

Ќар€ду с ожирением, пожилой возраст, курение, употребление алкогол€, гипертони€, хроническое переедание, малоподвижный образ жизни также €вл€ютс€ факторами риска дл€ сахарного диабета 2-го типа.

¬ целом этот вид диабета наиболее часто поражает людей старше 40 лет.

ѕри сахарном диабете 2 типа часто наблюдаетс€ нарушение циркадных ритмов синтеза инсулина и относительно длительное отсутствие морфологических изменений в ткан€х поджелудочной железы.

¬ основе заболевани€ лежит ускорение инактивации инсулина или же специфическое разрушение рецепторов инсулина на мембранах инсулин-зависимых клеток.

–азрушение рецепторов к инсулину €вл€етс€ следствием аутоиммунного процесса, когда аутоантитела воспринимают инсулиновые рецепторы как антигены и разрушают их, что приводит к значительному снижению чувствительности к инсулину инсулинзависимых клеток. Ёффективность действи€ инсулина при прежней концентрации его в крови становитс€ недостаточной дл€ обеспечени€ адекватного углеводного обмена.

 ак развиваетс€ болезнь

ѕищевые продукты содержат различные типы углеводов. Ќекоторые из них, такие как глюкоза, состо€т из одного шестичленного гетероциклического углеводного кольца и всасываютс€ в кишечнике без изменений. ƒругие, такие как сахароза (дисахарид) или крахмал (полисахарид), состо€т из двух или более св€занных между собой п€тичленных или шестичленных гетероциклов. Ёти вещества подвергаютс€ расщеплению под действием различных ферментов желудочно-кишечного тракта до молекул глюкозы и других простых сахаров, и, в конечном счЄте, также всасываютс€ в кровь.

ѕомимо глюкозы в кровь поступают и такие простые молекулы, как фруктоза, которые в печени превращаютс€ в глюкозу. “аким образом, глюкоза €вл€етс€ основным углеводом крови и всего организма. ≈й принадлежит исключительна€ роль в обмене веществ организма человека: она €вл€етс€ основным и универсальным источником энергии дл€ всего организма. ћногие органы и ткани (например, мозг) могут использовать в качестве источника энергии только глюкозу.

ќсновную роль в регул€ции углеводного обмена организма играет гормон поджелудочной железы — инсулин. ќн представл€ет собой белок, синтезируемый в β-клетках островков Ћангерганса (скопление эндокринных клеток в ткани поджелудочной железы) и призван стимулировать переработку глюкозы клетками. ѕочти все ткани и органы (например, печень, мышцы, жирова€ ткань) способны перерабатывать глюкозу только в его присутствии. Ёти ткани и органы называютс€ инсулинзависимыми. ƒругие ткани и органы, например мозг, не нуждаютс€ в инсулине дл€ того, чтобы перерабатывать глюкозу, и потому называютс€ инсулиннезависимыми.

Ќепереработанна€ глюкоза депонируетс€ (запасаетс€) в печени и мышцах в виде полисахарида гликогена, который в дальнейшем может быть снова превращЄн в глюкозу. Ќо дл€ того, чтобы превратить глюкозу в гликоген, тоже нужен инсулин.

¬ норме содержание глюкозы в крови колеблетс€ в достаточно узких пределах: от 70 до 110 мг/дл (миллиграммов на децилитр) (3,3-5,5 ммоль/л) утром после сна и от 120 до 140 мг/дл после еды. Ёто происходит благодар€ тому, что поджелудочна€ железа производит тем больше инсулина, чем выше уровень глюкозы в крови.

ѕри недостаточности инсулина (сахарный диабет 1-го типа) или нарушении механизма взаимодействи€ инсулина с клетками организма (сахарный диабет 2-го типа) глюкоза накапливаетс€ в крови в больших количествах (гипергликеми€), а клетки организма (за исключением инсулиннезависимых органов) лишаютс€ основного источника энергии.

—имптомы

¬ клинической картине диабета прин€то различать две группы симптомов: основные и второстепенные.

  основным симптомам относ€тс€:

  • ѕолиури€ — усиленное выделение мочи, вызванное повышением осмотического давлени€ мочи за счЄт растворЄнной в ней глюкозы (в норме глюкоза в моче отсутствует). ѕро€вл€етс€ учащЄнным обильным мочеиспусканием, в том числе и в ночное врем€.
  • ѕолидипси€ (посто€нна€ неутолима€ жажда) — обусловлена значительными потер€ми воды с мочой и повышением осмотического давлени€ крови.
  • ѕолифаги€ — посто€нный неутолимый голод. Ётот симптом вызван нарушением обмена веществ при диабете, а именно неспособностью клеток поглощать и перерабатывать глюкозу в отсутствие инсулина (голод среди изобили€).
  • ѕохудание (особенно характерно дл€ диабета первого типа) — частый симптом диабета, который развиваетс€ несмотр€ на повышенный аппетит больных. ѕохудание (и даже истощение) обусловлено повышенным катаболизмом белков и жиров из-за выключени€ глюкозы из энергетического обмена клеток.

ќсновные симптомы наиболее характерны дл€ диабета 1-го типа. ќни развиваютс€ остро. ѕациенты, как правило, могут точно назвать дату или период их по€влени€.

  вторичным симптомам относ€тс€ малоспецифичные клинические знаки, развивающиес€ медленно на прот€жении долгого времени.

Ёти симптомы характерны дл€ диабета как 1-го, так и 2-го типа:

  • зуд кожи и слизистых оболочек (вагинальный зуд);
  • сухость во рту;
  • обща€ мышечна€ слабость;
  • головна€ боль;
  • воспалительные поражени€ кожи, трудно поддающиес€ лечению;
  • нарушение зрени€;
  • наличие ацетона в моче при диабете 1-го типа. јцетон €вл€етс€ результатом сжигани€ жировых запасов.

ƒиагностика

ƒиагностика диабета 1-го и 2-го типа облегчаетс€ присутствием основных симптомов:

  • полиурии;
  • полифагии;
  • похудани€.

ќднако основным методом диагностики €вл€етс€ определение концентрации глюкозы в крови. ƒл€ определени€ выраженности декомпенсации углеводного обмена используетс€ глюкозотолерантный тест.

ѕризнаки диабета на основе данных анализов:

  • концентраци€ сахара (глюкозы) в капилл€рной крови натощак превышает 6,1 ммоль/л (миллимоль на литр), а через 2 часа после приЄма пищи (постпрандиальна€ гликеми€) превышает 11,1 ммоль/л;
  • в результате проведени€ глюкозотолерантного теста (в сомнительных случа€х) уровень сахара крови превышает 11,1 ммоль/л (в стандартном повторе);
  • уровень гликозилированного гемоглобина превышает 5,9 %(5,9-6,5%- сомнительно,более 6,5% больша€ веро€тность диабета);
  • в моче присутствует сахар;
  • в моче содержитс€ ацетон (јцетонури€, (ацетон может присутствовать и без сахарного диабета).

Ћечение

¬ насто€щее врем€ лечение сахарного диабета в подавл€ющем большинстве случаев €вл€етс€ симптоматическим и направлено на устранение имеющихс€ симптомов без устранени€ причины заболевани€, так как эффективного лечени€ диабета ещЄ не разработано.

ќсновными задачами врача при лечении сахарного диабета €вл€ютс€:

  • компенсаци€ углеводного обмена;
  • профилактика и лечение осложнений;
  • нормализаци€ массы тела;
  • обучение пациента.

 омпенсаци€ углеводного обмена достигаетс€ двум€ пут€ми: путЄм обеспечени€ клеток инсулином, различными способами в зависимости от типа диабета, и путЄм обеспечени€ равномерного одинакового поступлени€ углеводов, что достигаетс€ соблюдением диеты.

ќчень важную роль в компенсации сахарного диабета играет обучение пациента. Ѕольной должен представл€ть, что такое сахарный диабет, чем он опасен, что ему следует предприн€ть в случае эпизодов гипо- и гипергликемии, как их избегать, уметь самосто€тельно контролировать уровень глюкозы в крови и иметь чЄткое представление о характере допустимого дл€ него питани€.

ƒиетотерапи€

ƒиета при сахарном диабете €вл€етс€ необходимой составной частью лечени€, также как и употребление сахароснижающих препаратов или инсулинов. Ѕез соблюдени€ диеты невозможна компенсаци€ углеводного обмена. —ледует отметить, что в некоторых случа€х при диабете 2-го типа дл€ компенсации углеводного обмена достаточно только диеты, особенно на ранних сроках заболевани€. ѕри 1-м типе диабета соблюдение диеты жизненно важно дл€ больного, нарушение диеты может привести к гипо- или гипергликемической коме, а в некоторых случа€х к смерти больного.

«адачей диетотерапии при сахарном диабете €вл€етс€ обеспечение равномерного и адекватного физической нагрузке поступлени€ углеводов в организм больного. ƒиета должна быть сбалансирована по белкам, жирам и калорийности. —ледует полностью исключить легкоусво€емые углеводы из рациона питани€, за исключением случаев гипогликемии. ѕри диабете 2-го типа зачастую возникает необходимость в коррекции массы тела.

ќсновным пон€тием при диетотерапии сахарного диабета €вл€етс€ хлебна€ единица. ’лебна€ единица представл€ет собой условную меру, равную 10-12 г углеводов или 20-25 г хлеба. —уществуют таблицы, в которых указано количество хлебных единиц в различных продуктах питани€. ¬ течение суток количество хлебных единиц, употребл€емых больным, должно оставатьс€ посто€нным; в среднем в сутки употребл€етс€ 12-25 хлебных единиц, в зависимости от массы тела и физической нагрузки. «а один приЄм пищи не рекомендуетс€ употребл€ть более 7 хлебных единиц, желательно организовать приЄм пищи так, чтобы количество хлебных единиц в различных приЄмах пищи было примерно одинаковым. —ледует также отметить, что употребление алкогол€ может привести к отдалЄнной гипогликемии, в том числе и гипогликемической коме.

¬ажным условием успешности диетотерапии €вл€етс€ ведение больным дневника питани€, в него вноситс€ вс€ пища, съеденна€ в течение дн€, и рассчитываетс€ количество хлебных единиц, употреблЄнных в каждый приЄм пищи и в целом за сутки.

¬едение такого пищевого дневника позвол€ет в большинстве случаев вы€вить причину эпизодов гипо- и гипергликемии, способствует обучению пациента, помогает врачу подобрать адекватную дозу сахароснижающих препаратов или инсулинов.

ѕероральные сахароснижающие препараты

—труктурна€ формула центрального сегмента сульфаниламидных препаратов, в точках R1 R2 присоедин€ютс€ дополнительные соединени€, обеспечивающие различные клинические эффекты препарата.

ƒанна€ группа препаратов используетс€ преимущественно дл€ поддержани€ больных сахарным диабетом 2-го типа. ѕри первом типе диабета сахароснижающие препараты не эффективны.

ѕо химическому составу и механизму действи€ сахароснижающие препараты можно разделить на две группы — сульфаниламидные и бигуаниды.

—ульфаниламидные препараты €вл€ютс€ производными сульфанилмочевины и отличаютс€ между собой дополнительными соединени€ми, введЄнными в основную структуру. ћеханизм сахаропонижающего действи€ св€зан со стимул€цией секреции эндогенного инсулина, подавлением синтеза глюкагона, уменьшением образовани€ глюкозы в печени в процессе глюконеогенеза и повышением чувствительности инсулинозависмых тканей к действию инсулина, за счЄт повышени€ эффективности его пострецепторного действи€.

ƒанна€ группа препаратов примен€етс€ при неэффективности диетотерапии, лечение начинаетс€ с минимальных доз под контролем гликемического профил€. ¬ р€де случаев отмечаетс€ повышение эффективности терапии при сочетании нескольких различных производных сульфанилмочевины.

–азличают препараты сульфонилмочевины:

  • первой генерации — “олбутамид,  арбутамид, ’лорпропамид;
  • второй и третьей генерации — √либенкламид, √липизид, √ликлазид, √ликвидон, √лимепирид.

Ѕигуаниды представл€ют собой производные гуанидина. ¬ыдел€ют 2 основные группы:

  • диметилбигуаниды (метформин);
  • бутилбигуаниды (адебит, силубин).

ћеханизм сахароснижающего действи€ данной группы препаратов заключаетс€ в усилении утилизации глюкозы мышечной тканью за счЄт стимул€ции анаэробного гликолиза в присутствии эндогенного или экзогенного инсулина. ќни не оказывают, в отличие от сульфаниламидов, стимулирующего действи€ на секрецию инсулина, но обладают способностью потенциировать его эффект на рецепторном и пострецепторном уровне, также тормозитс€ глюконеогенез и несколько снижаетс€ абсорбци€ углеводов в кишечнике. “акже бигуаниды привод€т к снижению аппетита и способствуют снижению массы тела.

»нсулинотерапи€

Ћечение инсулином преследует задачу максимально возможной компенсации углеводного обмена, предотвращени€ гипо- и гипергликемии и профилактики таким образом осложнений сахарного диабета. Ћечение инсулином €вл€етс€ жизненно необходимым лицам с диабетом 1-го типа и может примен€тьс€ в р€де ситуаций дл€ лиц с диабетом 2-го типа.

ѕоказани€ дл€ назначени€ инсулинотерапии:

  • —ахарный диабет 1-го типа;
  •  етоацидоз, диабетическа€ гиперосмол€рна€, гиперлакцидемическа€ комы;
  • Ѕеременность и роды при сахарном диабете;
  • «начительна€ декомпенсаци€ сахарного диабета 2-го типа;
  • ќтсутствие эффекта от лечени€ другими способами сахарного диабета 2-го типа;
  • «начительное снижение массы тела при сахарном диабете;
  • ƒиабетическа€ нефропати€.

¬ насто€щее врем€ существует большое количество препаратов инсулина, различающиес€ по продолжительности действи€ (ультракороткие, короткие, средние, продлЄнные), по степени очистки (монопиковые, монокомпонентные), видовой специфичности (человеческие, свиные, бычьи, генноинженерные и пр.)

¬ –оссии инсулины, получаемые из крупного рогатого скота, выведены из употреблени€, это св€зано с большим количеством побочных эффектов при их применении. ƒостаточно часто при их введении возникают аллергические реакции, липодистрофии, развиваетс€ инсулинорезистентность.

»нсулин выпускаетс€ в концентраци€х 40 ћ≈/мл и 100 ME/мл. ¬ –оссии в насто€щее врем€ наиболее распространена концентраци€ 100 ME/мл, инсулин распростран€етс€ во флаконах объЄмом 10 мл или в картриджах дл€ шприц-ручек объЄмом 3 мл.

Ќесмотр€ на то что инсулины раздел€ютс€ по продолжительности действи€ на короткого действи€ и продлЄнного, врем€ действи€ инсулина у разных людей индивидуально. ¬ св€зи с этим подбор инсулинотерапии требует стационарного наблюдени€ с контролем уровн€ глюкозы в крови, и подбора адекватных метаболизму, диете, физической нагрузке доз инсулина. ѕри подборе инсулинотерапии следует добиватьс€ максимально возможной компенсации углеводного обмена, чем менее значительными будут суточные колебани€ уровн€ глюкозы крови, тем ниже риск возникновени€ различных осложнений сахарного диабета.

ѕри отсутствии ожирени€ и сильных эмоциональных нагрузок инсулин назначаетс€ в дозе 0,5—1 единица на 1 килограмм массы тела в сутки. ¬ведение инсулина призвано имитировать физиологическую секрецию в св€зи с этим выдвигаютс€ следующие требовани€:

  • ƒоза инсулина должна быть достаточна дл€ утилизации поступающей в организм глюкозы;
  • ¬ведЄнные инсулины должны имитировать базальную секрецию поджелудочной железы;
  • ¬ведЄнные инсулины должны имитировать постпрандиальные пики секреции инсулина.

¬ св€зи с этим существует так называема€ интенсифицированна€ инсулинотерапи€. —уточна€ доза инсулина делитс€ между инсулинами продлЄнного и короткого действи€. ѕродлЄнные инсулины ввод€тс€, как правило, утром и вечером и имитируют базальную секрецию поджелудочной железы. »нсулины короткого действи€ ввод€тс€ после каждого приЄма пищи, содержащей углеводы, доза может мен€тьс€ в зависимости от хлебных единиц, съеденных в данный приЄм пищи.

¬ажную роль в подборе дозы инсулина короткого действи€ играет расчЄт суточных колебаний инсулино потребности. ¬ св€зи с физиологическими особенност€ми организма потребность инсулина дл€ усвоени€ одной хлебной единицы измен€етс€ в течение суток и может составл€ть от 0,5 до 4 единиц инсулина на одну ’≈. ƒл€ определени€ данных показателей необходимо произвести измерени€ уровн€ глюкозы крови после основных приЄмов пищи, знать количество хлебных единиц съеденных в это врем€ и дозу инсулина короткого действи€ введЄнное на это количество хлебных единиц.

–ассчитываетс€ соотношение количества хлебных единиц и количества единиц инсулина. ≈сли уровень глюкозы крови после еды выше нормы, то на следующие сутки доза инсулина увеличиваетс€ на 1-2 единицы и рассчитываетс€, насколько изменилс€ уровень гликемии на 1 единицу инсулина при том же количестве углеводов в данный приЄм пищи.

«нание индивидуальной инсулинопотребности €вл€етс€ необходимым условием дл€ полноценной компенсации углеводного обмена при лечении диабета с помощью интентифицированной инсулинотерапии. Ѕлагодар€ знанию индивидуальной потребности инсулина на 1 хлебную единицу, больной может эффективно и безопасно дл€ себ€ корректировать величину дозы инсулинов короткого действи€ в зависимости от приЄма пищи.

—уществует также метод комбинированной инсулинотерапии, когда в одной инъекции вводитс€ смесь инсулинов короткой и средней или длинной продолжительности действи€. ƒанный метод примен€етс€ при лабильном течении сахарного диабета. ѕреимущество его заключаетс€ в том, что он позвол€ет сократить число инъекций инсулина до 2—3 в сутки. Ќедостатком €вл€етс€ невозможность полноценно имитировать физиологическую секрецию инсулина и, как следствие, невозможность полноценной компенсации углеводного обмена.

»нсулин вводитс€ подкожно, с помощью инсулинового шприца, шприц-ручки или специальной помпы-дозатора. ¬ насто€щее врем€ в –оссии наиболее распространЄн способ введени€ инсулина с помощью шприц-ручек. Ёто св€зано с бо́льшим удобством, менее выраженным дискомфортом и простотой введени€ по сравнению с обычными инсулиновыми шприцами. Ўприц-ручка позвол€ет быстро и практически безболезненно ввести необходимую дозу инсулина.

—амоконтроль при сахарном диабете

—амоконтроль уровн€ гликемии €вл€етс€ одним из основных меропри€тий, позвол€ющих добитьс€ эффективной длительной компенсации углеводного обмена. ¬ св€зи с тем, что невозможно на нынешнем технологическом уровне полностью имитировать секреторную активность поджелудочной железы, в течение суток происход€т колебани€ уровн€ глюкозы крови. Ќа это вли€ет множество факторов, к основным относ€тс€ физическа€ и эмоциональна€ нагрузка, уровень потреблЄнных углеводов, сопутствующие заболевани€ и состо€ни€.

“ак как невозможно всЄ врем€ содержать больного в стационаре, то мониторинг состо€ни€ и незначительна€ коррекци€ доз инсулинов короткого действи€ возлагаетс€ на больного. —амоконтроль гликемии может проводитьс€ двум€ способами. ѕервый — приблизительный с помощью тест-полосок, которые определ€ют с помощью качественной реакции уровень глюкозы в моче, при наличии глюкозы в моче следует проверить мочу на содержание ацетона. јцетонури€ — показание дл€ госпитализации в стационар и свидетельство кетоацидоза. ƒанный способ оценки гликемии достаточно приблизителен и не позвол€ет полноценно отслеживать состо€ние углеводного обмена.

Ѕолее современным и адекватным методом оценки состо€ни€ €вл€етс€ использование глюкометров. √люкометр представл€ет собой прибор дл€ измерени€ уровн€ глюкозы в органических жидкост€х (кровь, ликвор и т. п.). —уществует несколько методик измерени€. ¬ последнее врем€ широко распространились портативные глюкометры дл€ измерений в домашних услови€х. ƒостаточно поместить капельку крови на присоединЄнную к аппарату глюкозоксидазного биосенсора одноразовую индикаторную пластину, и через несколько секунд известен уровень глюкозы в крови (гликеми€).

—ледует отметить, что показани€ двух глюкометров разных фирм могут отличатьс€, и уровень гликемии, показываемой глюкометром, как правило, на 1—2 единицы выше реально существующего. ѕоэтому желательно сравнивать показани€ глюкометра с данными, полученными при обследовании в поликлинике или стационаре.

ѕрогноз

¬ насто€щее врем€ прогноз при всех типах сахарного диабета условно благопри€тный, при адекватно проводимом лечении и соблюдении режима питани€ сохран€етс€ трудоспособность. ѕрогрессирование осложнений значительно замедл€етс€ или полностью прекращаетс€. ќднако следует отметить, что в большинстве случаев в результате лечени€ причина заболевани€ не устран€етс€, и терапи€ носит лишь симптоматический характер.

 
–едакци€ портала
07 окт€бр€ 2013, 15:24
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