Vyresnio amžiaus asmenų cukrinio diabeto gydymo ypatumai

Vyresnio amžiaus asmenų cukrinio diabeto gydymo ypatumai

Įvadas

Sergamumas cukriniu diabetu (CD) sparčiai plinta. Viena priežasčių – senstanti populiacija, nes ligotumas CD gerokai didesnis vyresnių pacientų grupėje. Lietuvos higienos instituto Sveikatos informacijos centro duomenimis, 2001–2015 metais ligotumas CD 18–44 metų amžiaus grupėje siekė 5,9 atvejo 1 tūkst. gyventojų, 45–64 metų grupėje – 45,5 atvejų 1 tūkst. gyventojų, o didžiausias buvo vyriausių pacientų, >65 metų, grupėje – 104,8 atvejų 1 tūkst. gyventojų [1]. Gydant CD, visais atvejais siekiama to paties – koreguoti glikemiją ir kardiovaskulinės rizikos veiksnius. Tačiau tikslinė glikemija įvairaus amžiaus grupėse skiriasi, o CD priežiūra turi tam tikrų nuo amžiaus priklausomų ypatumų. Šiame straipsnyje aptariami CD sergančių pagyvenusių pacientų gydymo ir priežiūros aspektai.

 

Vyresnio amžiaus pacientų CD gydymo ypatumai

Vyresni pacientai, sergantys CD, yra heterogeniška grupė, apimanti ir sveikus, stiprius, savarankiškus, ir ligotus, reikalaujančius nuolatinės artimųjų priežiūros, asmenis, todėl tikslinė glikemija šiose pacientų grupėse skiriasi. Lietuvoje galiojančiame CD ambulatorinio gydymo kompensuojamaisiais vaistais tvarkos apraše nurodytas tikslinis HbA1c yra <7 proc. visiems pacientams [2]. Tačiau tarptautinėse diabeto gydymo rekomendacijose akcentuojama individualizuoto gydymo svarba, kai medikamentinis gydymas ir gydymo tikslai skiriami atsižvelgiant į kiekvieno paciento charakteristiką [3]. Paciento amžius ir numatoma gyvenimo, taip pat ir CD trukmė, yra vienas kriterijų, į kurį svarbu atsižvelgti parenkant antidiabetinį gydymą ir numatant glikemijos kontrolės tikslus. Skiriant antidiabetinį gydymą vyresniam pacientui, ypač svarbu įvertinti hipoglikemijos, hipotenzijos ir vaistų sąveikos riziką. Su amžiumi ryškėjanti gretutinė patologija dažnai turi įtakos CD savikontrolės kokybei, todėl, siekiant kuo ilgiau išsaugoti paciento savarankiškumą, turi būti laiku diagnozuojama ir gydoma.

 

Siektini glikemijos kontrolės rodikliai

Tyrimų, pagrindžiančių glikemijos kontrolės tikslus vyresnių pacientų grupėje, yra nedaug [4, 5]. Gydymas turėtų būti individualizuotas, atsižvelgiant į bendrąją paciento sveikatą ir numatomą gyvenimo trukmę, nes CD komplikacijų rizika priklauso nuo jo trukmės.

Tarptautinės diabeto organizacijos vyresniems pacientams rekomenduoja siekti individualių glikemijos kontrolės rodiklių [6–11]:

  • sveikiems pagyvenusiems pacientams, kurių numatoma gyvenimo trukmė viršija 10 metų, rekomenduojamas 7,5 proc. ir mažesnis HbA1c, priklausomai nuo hipoglikemijos rizikos ir paciento gebėjimo laikytis nurodyto gydymosi režimo. Glikemija nevalgius ir po valgio, siekiant tokio HbA1c, turėtų svyruoti 7,8–8,3 mmoml/l ribose;
  • ligotiems pacientams, kuriems išreikšta gretutinė patologija ir kurių numatoma gyvenimo trukmė mažesnė nei 10 metų, siektini glikemijos kontrolės rodikliai aukštesni: HbA1c– ≤8 proc., glikemija nevalgius ir po valgio – 8,9–9,4 mmol/l;
  • pacientams, kurių numatoma gyvenimo trukmė labai trumpa, siekiant nepabloginti gyvenimo kokybės ir išvengti hipoglikemijos, glikemija gali būti dar aukštesnė: tikslinis HbA1C– <8,5 proc., glikemija nevalgius ir po valgio – apie 11,1 mmol/l;

Dėl mažesnio glomerulų filtracijos greičio ir prastesnės gliukozės reabsorbcijos inkstų kanalėliuose vyresni CD sergantys pacientai, palyginti su jaunesniais, paprastai geriau toleruoja hiperglikemiją, jiems vėliau išsivysto osmosinė diurezė. Pasiekus kritinę ribą, hiperglikemija dažniau sukelia dehidrataciją, regos ir kognityvinius sutrikimus, padidina infekcijos riziką [12]. Šie pokyčiai pablogina bendrą vyresnio paciento sveikatą ir padidina kritimų riziką. Nepageidaujamas vaistų poveikis, dažniausiai hipoglikemija, taip pat gali reikšmingai pabloginti vyresnio paciento sveikatą – apsunkinti gretutinių ligų eigą ir padidinti kritimų riziką. Vyresniems pacientams jautrumas hipoglikemijoms gerokai padidėja [13], jiems būdingesni neuroglikopeniniai hipoglikemijos simptomai (galvos svaigimas, silpnumas, kliedesiai, sumišimas), o adrenerginiai simptomai (tremoras, prakaitavimas) pasireiškia rečiau, todėl hipoglikemija dažnai atpažįstama pavėluotai arba minėti simptomai klaidingai palaikomi neurologinėmis ligomis (pvz., praeinančiuoju smegenų išemijos priepuoliu) [14]. Vyresniems pacientams hipoglikemija gali padidinti kardiovaskulinių įvykių dažnį ir kardialinės autonominės disfunkcijos riziką [15, 16]. ACCORD (angl. Action to Control Cardiovascular Risk in Diabetes) tyrimu nustatyta, kad intensyviai mažinant glikemiją CD sergantiems pacientams, vartojantiems daug vaistų ir turintiems aukštą kardiovaskulinę riziką, bendrasis ir kardiovaskulinis mirštamumas gali padidėti [17]. Taip pat nustatyta, kad sunki hipoglikemija, reikalaujanti hospitalizacijos, yra susijusi su demencijos išsivystymu [18, 19]. Didesnė demencijos rizika pasireiškia pacientams, patiriantiems pakartotinių sunkių hipoglikemijos epizodų. Ligotiems, senyviems pacientams net lengvos hipoglikemijos gali smarkiai pabloginti sveikatą. Pavyzdžiui, galvos svaigimas ir silpnumas padidina kritimų ir lūžių riziką, sumažina paciento mobilumą, savarankiškumą ir padidina mirštamumą.

Hipoglikemijos rizika visuomet turi būti įvertinta parenkant pacientui medikamentinį gydymą ir nustatant tikslinę glikemiją. Preparatai, kuriems būdinga hipoglikemija (sulfonilkarbamidai, meglitinidai, insulinas) ligotiems vyresniems pacientams skiriami ypač atsargiai, pamažu titruojant dozę.

Svarbu atminti, kad vyresni pacientai dažniau serga ligomis, kurių metu HbA1c rodiklis išmatuojamas netiksliai (pvz., anemija ir kitos ligos, darančios įtaką eritrocitų gyvavimo trukmei, lėtinės inkstų ir kepenų ligos, kraujo transfuzijos ir eritropoetino infuzijos, ūminės ligos ir hospitalizacijos).

 

Kardiovaskulinės rizikos sumažinimas

Vyresniems CD sergantiems pacientams pasireiškia tos pačios makrovaskulinės komplikacijos kaip ir jaunesniems ligoniams, tačiau pirmųjų kardiovaskulinė rizika yra gerokai didesnė. Taip pat vyresniems pacientams, sergantiems CD, būdingas gerokai didesnis sergamumas ir mirštamumas nei jų bendraamžiams, nesergantiems CD [20]. Diabetas ir amžius yra vieni svarbiausių koronarinės širdies ligos (KŠL) rizikos veiksnių, todėl KŠL yra pagrindinė CD sergančių vyresnių pacientų mirties priežastis. Tyrimų, kuriuose analizuojama kardiovaskulinių rizikos veiksnių korekcijos įtaka vyresnių pacientų sveikatai, trūksta, tačiau atskirai analizuojant vyresnių pacientų grupes bendruose CD tyrimuose, nustatyta, kad lipidų ir arterinio kraujo spaudimo (AKS) kontrolė pagyvenusiems pacientams sumažina kardiovaskulinį sergamumą ir mirštamumą, o griežta glikemijos kontrolė, atvirkščiai, gali padidinti bendrąjį ir kardiovaskulinį mirštamumą [6, 17].

Kardiovaskulinės rizikos veiksnių mažinimo priemonės CD sergantiems pacientams vienodos visoms amžiaus grupėms:

  • nustoti rūkyti – rūkymas yra nepriklausomas rizikos veiksnys, didinantis bendrąjį ir kardiovaskulinį mirštamumą CD sergantiems pacientams. Todėl svarbu kaskart paraginti rūkantį pacientą atsisakyti žalingo įpročio;
  • arterinės hipertenzijos gydymas – arterinės hipertenzijos gydymas neabejotinai naudingas visiems pacientams, įskaitant vyresnius nei 80 metų;
  • gydyti dislipidemiją – nesant kontraindikacijų, visiems vyresniems pacientams, sergantiems CD, rekomenduojama dislipidemiją gydyti statinais. ACCORD tyrime papildoma fenofibrato skyrimo nauda CD sergantiems, didelės kardiovaskulinės rizikos pacientams nenustatyta [21]. Dislipidemijos gydymo statinais nauda didesnė vyresniems pacientams, palyginti su jaunesniais [22, 23]. Siektini lipidų rodikliai, gydant dislipidemiją (kaip ir hiperglikemiją), priklauso nuo pagyvenusio paciento numatomos gyvenimo trukmės, gretutinės patologijos, kognityvinės būklės ir asmeninio pasirinkimo. Kardiovaskulinių įvykių reikšmingas sumažėjimas vartojant statinus atsiranda gana greitai (per keletą savaičių ar mėnesių), todėl net ir gerokai vyresniems pacientams toks gydymas yra kliniškai svarbus ir reikšmingas;
  • aspirinas – gydymo aspirinu nauda pacientams su nustatyta makrovaskuline liga (antrinė prevencija) yra įrodyta. Didelės apimties antrinės prevencijos tyrimų metaanalizėje nustatyta, kad aspirino nauda buvo didžiausia gydant vyresnius nei 65 metai pacientus, sergančius CD ar arterine hipertenzija [24]. Aspirino nauda pirminei kardiovaskulinės rizikos prevencijai neįrodyta;
  • mankšta – fiziniai pratimai sergantiesiems CD padeda palaikyti fizinį aktyvumą, sumažinti kardiovaskulinę riziką ir pagerinti audinių jautrumą insulinui. Vyresniems pacientams fizinis krūvis taip pat padidina raumenų jėgą ir pagerina pusiausvyrą, sumažina kritimų ir depresijos riziką, pagerina gyvenimo kokybę ir padidina išgyvenamumą [25–28]. Tyrimai, atlikti su silpnais pagyvenusiais asmenimis, įrodo jėgos pratimų naudą, kai jie skiriami su aerobine mankšta [29].

 

Svarbiausi vyresnių pacientų CD gydymo principai

Svarbiausi vyresnių pacientų CD gydymo principai yra tokie patys kaip ir jaunesnių asmenų – gyvenimo būdo korekcija, medikamentinis gydymas ir komplikacijų prevencija.

Gyvenimo būdo korekcija. Nustačius CD, visiems pacientams turėtų būti pateikiama informacija apie gyvenimo būdo korekciją (mankšta, dieta ir svorio sumažinimas). DPP (angl. Diabetes Prevention Program) tyrime ryškiausias glikemijos pagerėjimas, susijęs su nuosekliu elgesio rekomendacijų laikymusi (dieta ir 150 min./sav. mankšta), stebėtas vyriausiųjų pacientų grupėje [30, 31]. Šie duomenys patvirtina, kad vyresnių CD sergančių pacientų elgesio korekcija gali būti efektyvi siekiant pagerinti glikemiją.

Mankšta. Fizinis aktyvumas sumažina visų amžiaus grupių pacientų sergamumą ir prailgina gyvenimo trukmę. Vyresniems pacientams rekomenduojama būti aktyviems tiek, kiek leidžia jų fizinė būklė. Fiziškai nepriklausomiems pacientams rekomenduojama 30 min. vidutinio intensyvumo aerobinė mankšta (pvz., greitasis ėjimas) bent 5 k./sav. Jei pacientas neišsako su kardiovaskuline sistema susijusių skundų ir neturi didelės kardiovaskulinės rizikos anamnezės, elektrokardiogramos ar veloergometrijos prieš pradedant nurodyto intensyvumo mankštą atlikti nebūtina. Vyresni pacientai, kuriems nustatyta didelė kritimų rizika, turėtų būti nukreipti konsultuotis su  kineziterapeutu.

Dieta. Svarbi CD gydymo dalis, kai individualios mitybos rekomendacijos pacientui paruošiamos remiantis medicininiais, gyvenimo būdo ir asmeniniais aspektais. Atsitiktinių imčių tyrime vyresnių nei 65 metai pacientų dietinio gydymo grupėje stebėta reikšmingai geresnė alkio glikemija ir HbA1c, palyginti su kontroline grupe (atitinkamai –1,05 vs. –0,08 mmol/l ir –0,5 proc. vs. jokio pokyčio) [32]. Todėl kiekvienam vyresniam pacientui turėtų būti paaiškinti CD mitybos principai ligos pradžioje ir nuolat aptariami gydymo eigoje iškilę klausimai. Aptariant mitybos planą su pagyvenusiu pacientu, svarbu atsižvelgti į galimus amžinius sveikatos pokyčius (pasikeitusį skonio jutimą, gretutinių ligų sukeltus mitybos apribojimus (pvz., podagra), dantų būklę, virškinimo trakto ligas, galimybę nusipirkti rekomenduojamus maisto produktus ir pasiruošti maisto, atminties sutrikimus, galinčius paskatinti nereguliariai maitintis). Mitybos planai, sudaromi pagyvenusiems pacientams, turi būti nesudėtingi ir lengvai suprantami, o sudaryto plano tikslas – derinant dietą su fiziniu krūviu, padėti pacientui kūno svorį sumažinti vidutiniškai 5 proc. [6, 33]

Medikamentinis gydymas. Svorio kontrolė laikantis dietos ir mankštinantis yra labai svarbi CD gydymo sudėtinė dalis, tačiau daugumai vyresnių pacientų prireikia antidiabetinių preparatų. Nesant kontraindikacijų (pvz., inkstų nepakankamumo, ūminio širdies nepakankamumo, insulto, kvėpavimo nepakankamumo), naujai diagnozuotam CD gydyti metforminas yra pirmo pasirinkimo vaistas visiems, taip pat ir pagyvenusiems, pacientams, derinant medikamentinį gydymą su mitybos ir fizinio krūvio korekcija. Pagrindinis principas pradedant gydyti CD, naujai diagnozuotą pagyvenusiam pacientui, yra pradėti nuo nedidelių dozių ir vaistą titruoti pamažu. Sveikiems pagyvenusiems pacientams, kaip ir jaunesniems, naujai diagnozavus CD, rekomenduojama metforminą skirti net tada, kai yra normalus HbA1c – ankstyvas gydymas metforminu užkerta kelią hiperglikemijai progresuoti ir komplikacijoms vystytis [34]. Tačiau jei HbA1c yra normalus ir pacientas atsisako medikamentinio gydymo arba dėl išreikštos gretutinės patologijos vartojama daug vaistų, 3–6 mėnesius galima leisti pacientui koreguoti gyvenseną, neskiriant metformino. Svarbu informuoti pagyvenusį pacientą, kad sunkiai sutrikus sveikatai ir prieš diagnostinę ar gydomąją procedūrą, kuriai naudojamas jodo kontrastas, metformino vartojimą būtina nutraukti.

Jei po pirmojo preparato paskyrimo tikslinės glikemijos nepasiekiama, ypač svarbu išsiaiškinti, ar pagyvenęs pacientas nepamiršta išgerti vaistų, laikosi mitybos rekomendacijų ar nepasireiškė nepageidaujamas vaisto poveikis. Sutrikus atminčiai, į pagalbą reikėtų pasitelkti artimuosius. Vaistų vartojimą taip pat palengvina specialios tablečių dėžutės savaitei.

Palyginamųjų tyrimų, vertinančių vieno vaisto pranašumą prieš kitą derinyje su metforminu, vertinant tolimąsias išeitis (pvz., diabeto komplikacijų vystymasis), trūksta, todėl teoriškai tolesniam gydymui derinyje su metforminu galima skirti bet kurį antidiabetinį preparatą, atsižvelgiant į vaisto efektyvumą, hipoglikemijos riziką, galimus svorio pokyčius gydymo fone, gretutinę patologiją ir paciento norą bei sugebėjimą vartoti konkretų vaistą. Lietuvoje antros ir trečios eilės medikamentų skyrimą apibrėžia CD ambulatorinio gydymo kompensuojamaisiais vaistais tvarkos aprašas, pagal kurį, toleruojant metforminą, antros eilės gydymui gali būti skiriami sulfonilkarbamidų preparatai [2]. Sulfonilkarbamidai – efektyvūs, gerai toleruojami, plačiai vartojami, pigūs antidiabetiniai preparatai. Tačiau dažniausias nepageidaujamas poveikis, hipoglikemija, ir svorio didėjimas dažnai riboja šių vaistų skyrimą, ypač pagyvenusiems pacientams. Nustatyta, kad vyresni pacientai, sergantys CD (>75 metai) dėl hipoglikemijos dažniau hospitalizuojami nei jaunesni ligoniai (65–74 metų) [35]. 10 proc. hospitalizacijų dėl nepageidaujamo vaisto veikimo sudaro hipoglikemijos dėl antidiabetinio gydymo geriamaisiais vaistais [36]. Hipoglikemijos dažnesnės skiriant ilgo veikimo sulfonilkarbamidų preparatus (pvz., glimepiridą), todėl vyresniems pacientams rekomenduojama skirti trumpo veikimo preparatus (pvz., glipizidą, gliklazidą). Hipoglikemijos rizika vartojant sulfonilkarbamidų preparatus didesnė esant šioms aplinkybėms: po fizinio krūvio, praleidus valgį, menkai maitinantis, piktnaudžiaujant alkoholiu, inkstų, širdies nepakankamumo atveju, sergant virškinimo trakto ligomis, vartojant salicilatus, sulfonilamidus, varfariną, pasikeitus bendrai sveikatos būklei. Hipoglikemijos rizika ir galimi simptomai turėtų būti įvertinti kiekvieno vizito metu, apklausiant pagyvenusį pacientą.

DPP-4 inhibitoriai pagal šiuo metu Lietuvoje galiojantį CD ambulatorinio gydymo kompensuojamaisiais vaistais tvarkos aprašą gali būti skiriami kaip trečios eilės vaistas diabetui gydyti arba kaip antros eilės vaistas, kai netolejuomas metforminas. Ši vaistų grupė patraukli, ypač skiriant vyresniems pacientams, dėl minimalios hipoglikemijos rizikos. Priešingai nei sulfonilkarbamidų preparatai, DPP-4 inhibitoriai nedidina svorio. Kadangi DPP-4 inhibitoriai vidutiniškai HbA1c sumažina 0,6 proc., juos geriau skirti kai HbA1c nedaug viršija tikslinį. Prieš skiriant DPP-4 inhibitorius (išskyrus linagliptiną), svarbu įvertinti paciento inkstų funkciją.

GLP-1 agonistai skiriami derinyje su geriamaisiais antidiabetiniais preparatais, kai siekiama sumažinti paciento svorį ir išvengti hipoglikemijų. Vaistai rekomenduojami, kai ankstesnio gydymo fone HbA1c ≤8,5 proc.

Insulinas pradiniam 2 tipo CD gydymui skiriamas, jei nustatoma didelė glikemija (HbA1c – >9 proc., alkio glikemija – >13,9 mmol/l, atsitiktinė glikemija – >16,7 mmol/l), nustatoma ketonurija arba sunku atskirti pirmo ar antro tipo CD. Prieš paskiriant insuliną, svarbu įvertinti, ar paciento fizinė ir kognityvinė būklė pakankama, kad jis galėtų pats parinkti reikiamą insulino dozę, naudotis insulino švirkštikliu, pasimatuoti glikemiją kraujyje, atpažinti ir žinoti, kaip elgtis ištikus hipoglikemijai. Dėl didelės hipoglikemijos rizikos insulinas vyresniam pacientui turėtų būti titruojamas ypač atsargiai. Paprastai gydymo pradžioje skiriama 10 vv arba 0,2 vv/kg bazinio insulino vakare, palaipsniui didinant dozę, pavyzdžiui, kas savaitę, pagal rytinę glikemiją. Paskyrus insuliną papildomai tolesnei diabeto kontrolei prie jau esančio medikamentinio antidiabetinio gydymo, sulfonilkarbamidų preparatai iš karto arba palaipsniui, progresuojant diabetui, nutraukiami (sprendžiama pagal klinikinę situaciją), toliau paliekant vartoti metforminą. Dėl paciento baimės ar klinikinės inercijos gydymas insulinu dažnai skiriamas pavėluotai, o lėtinės hiperglikemijos sukeltą nuovargį pacientai palaiko senatvės požymiu. Paskyrus gydymą insulinu ir parinkus tinkamą dozę, ne tik išvengiama diabeto komplikacijų, bet ir pagerėja paciento savijauta bei gyvenimo kokybė. Svarbu atminti, kad insulino metabolizmas pasikeičia progresuojant inkstų funkcijos nepakankamumui – sumažėjus glomerulų filtracijos greičiui <50 mL/min., insulino dozę paprastai tenka mažinti.

Savikontrolė. Vyresniam pacientui, kuris laikosi CD dietos arba vartoja hipoglikemijos nesukeliančius vaistus, glikemijos matavimas įprastomis sąlygomis namuose, jei kyla sunkumų, nebūtinas. Savikontrolė rekomenduojama, jei pacientas vartoja hipoglikemiją galinčius sukelti vaistus arba jei glikemijos matavimas motyvuoja pacientą keisti mitybos įpročius, mankštintis.

Komplikacijų stebėjimas ir prevencija. Vyresniems CD sergantiems pacientams vystosi tos pačios mikrovaskulinės komplikacijos kaip ir jaunesniems pacientams:

 

Kiti veiksniai, į kuriuos reikėtų atsižvelgti skiriant gydymą

Gydant vyresnius pacientus, sergančius CD, svarbu atsižvelgti į senatvines ligas (pvz., kognityviniai sutrikimai, depresija, kritimai, šlapimo nelaikymas, skausminis sindromas), galinčias turėti įtakos gydymo eigai.

Kognityvinis sutrikimas. Diabetas, susijęs su didesne demencijos rizika. Pacientai, sergantys CD ir demencija, gali patirti sunkumų matuojant glikemiją, jiems sunku laikytis sudėtingesnių gydymosi rekomendacijų. Daugeliui vyresnių pacientų demencija lieka nediagnozuota, ypač ankstyvoje stadijoje. Demenciją reikėtų įtarti, jeigu pacientas nereguliariai vartoja vaistus, dažnai patiria hipoglikemijas, stebimas glikemijos pablogėjimas be aiškios priežasties.

Depresija dažniau pasireiškia vyresniems pacientams, sergantiems CD, nei jų bendraamžiams [40, 41]. Dažnai depresija lieka nediagnozuota ir negydoma [42]. Sergantiesiems CD depresija yra susijusi su prastesne glikemijos kontrole ir didesne KŠL rizika [43]. Ankstyva depresijos diagnostika dažnai nesudėtinga (pvz., naudojant geriatrinę depresijos skalę), o laiku paskirtas gydymas gali pagerinti glikemijos kontrolę [44].

Kritimai. Sergantiems CD vyresniems pacientams kritimų rizika padidėja dėl šių priežasčių: periferinės ir / ar autonominės neuropatijos, sutrikusios inkstų funkcijos, raumenų silpnumo, regos pablogėjimo, gretutinių ligų (pvz., osteoartrito). Tokiems pacientams net lengva hipoglikemija gali išprovokuoti kritimus.

Šlapimo nelaikymas. CD yra susijęs su šlapimo nelaikymo išsivystymu moterims. Rizikos veiksniai yra šlapimo takų arba makšties infekcijos, autonominė neuropatija (susijusi su neurogenine šlapimo pūsle arba vidurių užkietėjimas) ir hiperglikemijos sukelta poliurija.

 

Apibendrinimas

Ilgėjant gyvenimo trukmei, vis daugiau sergančiųjų CD sudaro vyresnio amžiaus pacientai, neretai sergantys ir kitomis ligomis. Šiame straipsnyje pateiktos rekomendacijos turėtų padėti gydytojams parinkti tinkamą gydymą vyresnio amžiaus pacientams, sumažinti tiek paties CD, tiek su jo gydymu susijusių komplikacijų riziką.

 

Gyd. Laura Šiaulienė

Vilniaus universiteto ligoninė Santariškių klinikos

Literatūra:

 

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393 mintys apie “Vyresnio amžiaus asmenų cukrinio diabeto gydymo ypatumai

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