第二型糖尿病發生低血糖原因，危險因素及處置

Causes, Risk Factors and Management of Hypoglycemia in Type 2 Diabetes

第二型糖尿病的發病比例在全球都在逐年上升中，在台灣，其盛行率大約占總人口的10%。糖尿 病一旦得到後，若控制不良，則會發生大血管病變（中風與心肌梗塞）與小血管病變（視網膜病變、腎病變 及糖尿病足）。但這些併發症都是在發病數十年後才會發生。但是在糖尿病治療的過程當中，會用到各種 的降血糖藥物。這些藥物，若使用不當，就會引發低血糖。病人常常會因為此緣故，造成了更多的共病 症，或甚至有了不同程度的慢性神經功能受損。因此，可以說是血糖控制太高，數十年後出問題。但低 血糖，可以在數小時後出問題。也因如此，往往使得醫師陷入醫療糾紛。低血糖的定義，看似簡單，實 際上並不單純。因為血糖與臨床症狀的排列組合，有許多不同的可能性。一旦發生，其症狀也是千變萬 化。但主要會有神經缺糖症狀及自主神經兩大類別。病人、家屬或醫師，必須提高警覺，才能識別低血 糖的出現與否。因為定義不同，一般糖尿病的患者中發生低血糖的比例各家報導也不盡相同。不同藥物 的使用，也會造成低血糖比例的統計分歧。大致上說來，老一代的藥物如磺胺類或是胰島素，造成低血 糖的比例较高，分別是8%及20%左右。而較新一代的藥物，例如DPP-- inhibitor 或是 SGLT-2 | inhibitor 其低血糖的比例就只有2%左右，相對性的安全許多。那些糖尿病患者容易得到低血糖是有跡 可循的。在這些病人當中，要特別的提高警覺並適時的給予衛教。尤其是年長者，因其反應的時間較慢， 所以更應予以特別的關注。預防及治療低血糖則須要有完善的制度及團隊，才能達到此目標。在緊急處 理病患時，給予糖分及食物是最基本的方法。若能夠用昇糖素注射則更好。但千萬不要低估了藥物的半 衰期，尤其是口服的長效磺胺類藥物，用時間有時候會達数日之久。

The prevalence of type 2 diabetes (T2D) has been increasing recently globally including Taiwan. It is estimated that approximately 10% of the general population have diabetes. If not controlled well, macro- (stroke and coronary heart disease) and micro-vascular diseases will eventually occur after decades. However, because of improper use of the anti-diabetic drugs during the treatment, these drugs could easily cause hypoglycemia. Patients will suffer many different comorbidities and even permanent damage of the neurological function. Therefore, it could be concluded that ‘hyperglycemia will cause complications years later, but hypoglycemia will cause complications hours later'. This is also one of the major reason of legal problem for endocrinologist. The definition of hypoglycemia is complicated. This is because that there are different combinations of blood glucose levels and clinical presentations. Once happens, the symptoms and signs are also variate tremendously. But in general, they can be classified as ‘neuroglycopenic' and ‘autonomic' groups. The patients, families and health providers must keep alert so that hypoglycemia could be identified. Because of different definitions, the percentages of having hypoglycemia are reported different in studies. In general, older anti-diabetic drugs, such as sulfonylurea and insulin, have higher chance for hypoglycemia (8% and 20%, respectively). The other newer medications such as DPP-4 inhibitor and SGLT-2 inhibitor have an incidence of 2% hypoglycemia which is obviously much lower. Subjects prone to have hypoglycemia have certain clinical characteristics. In these patients special attention and education could be provided. Particularly in the elderlies, due to the narrow responding time, they should be put on the highest priority for caring. It needs a comprehensive system and medical team to fulfill the goal of good management. When emergent, providing sufficient carbohydrates and foods is the first step. If glucagon could be given, the anti-hypoglycemic effect will be longer. It is important to keep in mind that the half life of sulfonylurea is long and hypoglycemia caused by this drug might last for days.