2024年美国糖尿病学会《糖尿病诊疗标准》解读——糖尿病诊断和分型

摘要/Abstract

摘要：

糖尿病是一种常见的慢性疾病，在全球范围内造成了重大的卫生经济负担。糖尿病具有高度异质性，准确诊断和分型是实现糖尿病标准化精准治疗、改善患者临床结局的前提。近期，美国糖尿病协会（American Diabetes Association, ADA）发布了2024年《糖尿病诊疗标准》。糖尿病诊断和分型章节结合当前的最新进展，对非典型糖尿病的鉴别诊断、不同类型糖尿病的筛查、诊断和随访等流程均提出了推荐意见。本文对该指南这一部分内容进行了解读，以期为我国内分泌领域医务人员进行糖尿病诊断、分型和个体化诊疗实践提供参考。

关键词:糖尿病,诊断,分型,美国糖尿病学会

Abstract:

Diabetes is a common chronic disease, which has caused a significant health and economic burden worldwide. Diabetes is highly heterogeneous. Accurate diagnosis and classification are the premises to achieve standardized and accurate treatment of diabetes and improve the clinical outcomes of patients. Recently, the American Diabetes Association (ADA) issued the 2024 Standards of Medical Care in Diabetes. In the chapter on diabetes diagnosis and classification, the latest developments have been taken into account, with recommended approaches for the differential diagnosis of atypical diabetes, screening, diagnosis, and follow-up processes of different types of diabetes. This article interprets this section of the guidelines to provide a reference for healthcare professionals in the endocrine field in China for the accurate diagnosis, classification, and individualized treatment of diabetes.

Key words:Diabetes,Diagnosis,Classification,American Diabetes Association

中图分类号:

R587.1
R446

李延兵. 2024年美国糖尿病学会《糖尿病诊疗标准》解读——糖尿病诊断和分型[J]. 诊断学理论与实践, 2024, 23(05): 467-473.

LI Yanbing. Interpretation of 2024 American Diabetes Association’s Standards of Care in Diabetes — diabetes diagnosis and classification[J]. Journal of Diagnostics Concepts & Practice, 2024, 23(05): 467-473.

图/表6

标准
（1）HbA1c≥ 6.5%(48 mmol/mol)* 实验室要求：经NGSP认证且DCCT法标准化
（2）FPG≥7.0 mmol/L(126 mg/dL)* 空腹指的是至少8小时没有热量摄入
（3）OGTT 2-h PG≥11.1 mmol/L(200 mg/dL)* 试验应按照WHO标准进行试验，葡萄糖负荷使用含有相当于75 g无水葡萄糖溶于水
（4）高血糖或高血糖危象的典型症状的患者，随机（一天中任意时间）血糖≥11.1 mmol/L(200 mg/dL)

表1

图1

新诊断成人疑似1型糖尿病筛查流程图 1：没有单一临床特征可独立诊断1型糖尿病。2：谷氨酸脱羧酶是测定的主要抗体，如果其结果为阴性，后续应检测胰岛酪氨酸磷酸酶2和（或）锌转运体8。对于未接受过胰岛素治疗的个体，检测抗胰岛素抗体或许可能有用；对于年龄<35岁且无2型糖尿病或单基因糖尿病临床特征的患者，阴性结果不会改变1型糖尿病的诊断，因为5%~10%的1型糖尿病患者没有抗体。3：单基因糖尿病特征是指存在下列一种或多种特征，包括诊断时HbA1c<58 mmol/mol (<7.5%)；父母一方患有糖尿病；具有特定单基因疾病的特征（如肾囊肿、部分脂肪营养不良、母系遗传性耳聋以及无肥胖的情况下重度胰岛素抵抗）；以及单基因糖尿病预测模型评估患病风险>5%。4：C肽检测仅适用于接受胰岛素治疗的人。进食后5 h内的随机C肽伴血糖检测可代替标准C肽刺激试验。如果结果≥600 pmol/L (≥1.8 ng/mL)，结果可靠；如果结果<600 pmol/L (<1.8 ng/mL）且血糖<4 mmol/L (<70 mg/dL)，考虑禁食原因，可重复检测；对于水平极低的结果[<80 pmol/L（如<0.24 ng/mL）]，无需重复检测。如果患者接受胰岛素治疗，则必须在胰岛素停用前检测C肽，以排除严重的胰岛素缺乏症。勿在高血糖急症发生后2周内检测C肽。5：2型糖尿病的特征包括BMI增加（≥25 kg/m2)、无体重减轻、无酮症酸中毒和高血糖症状不明显。鉴别价值稍低的特征包括非白种人、家族史、就诊前症状轻微且病程长、代谢综合征的特征、无自身免疫家族史。6：如果基因检测未证实为单基因糖尿病，即使分类不明确，也应作出治疗的临床决策。7：老年人应强烈考虑2型糖尿病。在某些情况下，可能需要检查胰腺或考虑其他类型的糖尿病。8：可能患有1型糖尿病但未接受胰岛素治疗的患者，需要仔细监测和教育，以便在血糖恶化的情况下可以迅速开始使用胰岛素。9：C肽介于200~600 pmol/L(0.6~1.8 ng/mL）多见于1型糖尿病或MODY，也可见于接受胰岛素治疗的2型糖尿病患者，尤其是正常/低BMI或病程较长的患者。

图1

	1期	2期	3期
特征	自身免疫正常血糖症状前	自身免疫血糖升高症状前	自身免疫显性高血糖症状性
诊断标准	多种胰岛自身抗体阳性；无IGT或IFG	胰岛自身抗体阳性（通常为多种）血糖异常：IFG和（或）IGT FPG 5.6~6.9 mmol/L 2 h PG 7.8~11.0 mmol/L HbA1c 5.7%~6.4%或HbA1c 增加≥10%	自身抗体可能缺失达到糖尿病诊断标准

表2

筛查标准
对于有以下一种或多种风险因素的超重或肥胖成人（BMI≥25 kg/m²或亚裔美国人≥23 kg/m²)，应考虑进行检测： · 糖尿病一级亲属 · 高危种族/族裔（例如，非洲裔美国人、拉丁美洲人、美洲原住民、亚裔美国人、太平洋岛民） · 心血管疾病史 · 高血压（≥130/80 mmHg或正在接受高血压治疗） · HDL胆固醇水平< 35 mg/dL (0.90 mmol/L）和/或甘油三酯水平> 250 mg/dL (2.82 mmol/L) · 多囊卵巢综合征女性 · 缺乏运动 · 与胰岛素抵抗相关的其他临床病症（例如严重肥胖、黑棘皮病）
糖尿病前期（A1_C≥5.7%、IGT或IFG）的患者应每年检测一次
确诊为GDM的女性应至少每3年进行一次直至终生
对于所有其他患者，检测应在35岁时开始
如果结果正常，应至少每隔3年重复检测一次，并根据初始结果和风险状态考虑缩短间隔
· 艾滋病毒携带者、接触高危药物、胰腺炎病史

表3

诊断条件	FPG	1 h PG	2 h PG	3 h PG
一步法：	≥5.1 mmol/L	≥10.0 mmol/L	≥8.5 mmol/L
75 g OGTT
两步法：
50 g GLT（非禁食）		≥7.2/7.5/7.8 mmol/L*
100 g OGTT（禁食）	≥5.3 mmol/L	≥10.0 mmol/L	≥8.6 mmol/L	≥7.8 mmol/L

表4

项目	ADA	WHO/CDS
IFG（FPG）	5.6~6.9 mmol/L (100~125 mg/dL)	6.1~6.9 mmol/L(110~125 mg/dL)且2 h PG<7.8 mmol/L(140 mg/dL)
IGT（OGTT 2 h PG）	7.8~11.0 mmol/L(140~199 mg/dL)	7.8~11.0 mmol/L(140~199 mg/dL)
HbA1c	5.7%~6.4%(39~46 mmol/mol)

表5

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	1期	2期	3期
特征	自身免疫正常血糖症状前	自身免疫血糖升高症状前	自身免疫显性高血糖症状性
诊断标准	多种胰岛自身抗体阳性；无IGT或IFG	胰岛自身抗体阳性（通常为多种）血糖异常：IFG和（或）IGT FPG 5.6~6.9 mmol/L 2 h PG 7.8~11.0 mmol/L HbA1c 5.7%~6.4%或HbA1c 增加≥10%	自身抗体可能缺失达到糖尿病诊断标准