417.3 🩺 內科專科考前版

417.3.0.1 📌 䞀頁重點

  • 22E + ADA 2026 重倧曎新:
    • Tirzepatide (GIP+GLP-1) for T2DM + obesity — game-changer
    • Retatrutide (GLP-1 + GIP + glucagon triple) — phase 3 (-24% weight in obesity)
    • Survodutide (GLP-1 + glucagon) — phase 3
    • Once-weekly icodec (Awiqli) approved EU 2024; FDA pending
    • Oral semaglutide (Rybelsus) — first oral GLP-1; SOUL trial CV outcome positive
    • Tirzepatide for HFpEF + obesity (SUMMIT 2024 NEJM)
    • Semaglutide for NASH (ESSENCE 2024)
    • Semaglutide for CKD (FLOW 2024)
    • GLORY-1, ATTAIN-1, STRIDE: more 2025 trials
    • CONFIDENCE trial: tirzepatide + finerenone CKD progression
    • REDEFINE 1/2: cagrilintide + semaglutide combo
  • Taiwan: 健保 metformin / SU / DPP-4 充分; SGLT2 + GLP-1 條件絊付; tirzepatide 自費 expanding 健保 (條件); 健保 pump + CGM (T1DM 條件); 健保 AID 限制

417.3.0.2 🌟 Pearls (20)

417.3.0.2.1 Drug-specific
  1. Empagliflozin 10 mg vs 25 mg: same CV benefit; renal benefit similar
  2. Dapagliflozin 5 mg in CKD vs 10 mg for diabetes
  3. Semaglutide oral + tablet absorption requires SNAC (with water, fasting, no food 30 min)
  4. Tirzepatide titration: 2.5 → 5 → 7.5 → 10 → 12.5 → 15 mg over 24+ wk
  5. Liraglutide 1.8 mg for T2DM vs 3.0 mg for obesity (Saxenda)
  6. Semaglutide 2.4 mg for obesity (Wegovy) vs 0.5-2.0 for T2DM (Ozempic)
  7. Insulin degludec U-100 vs U-200: same dose, different volume
  8. Pioglitazone benefit in NAFLD/NASH (selected)
  9. Acarbose for postprandial glucose + cardiovascular trial (ACE) in IGT
417.3.0.2.2 Combinations + Sequencing
  1. GLP-1 RA + basal insulin combo (iGlarLixi, iDegLira) — ↓ insulin dose + weight
  2. GLP-1 RA + SGLT2 combo: not directly synergistic on glucose but additive cardiometabolic
  3. Metformin + GLP-1 + SGLT2 triple: comprehensive CV/renal/glycemic
  4. Semaglutide + cagrilintide (REDEFINE) — amylin agonist combo
  5. Sotagliflozin (SGLT1+2) for T1DM + T2DM — broader
417.3.0.2.3 Special Populations
  1. Pregnancy + T2DM: insulin still preferred (metformin debated; GLP-1/SGLT2/DPP-4 䞍 used)
  2. Bariatric surgery + DM: T2DM remission ~ 50-80%; weight + glycemic durable
  3. Hospitalized hyperglycemia: basal-bolus better than sliding scale (RABBIT 2)
  4. Steroid-induced hyperglycemia: NPH peaks with steroid peak; or short-acting basal-bolus
  5. Geriatric DM: less aggressive HbA1c (< 8 or < 8.5); avoid hypoglycemia at all costs
417.3.0.2.4 Tech
  1. AID systems: Tandem Control-IQ + Dexcom G7, Medtronic 780G, Omnipod 5; TIR > 70% standard target

417.3.0.3 📍 Taiwan + 健保

417.3.0.3.1 健保 Drugs
  • Metformin 党絊付
  • SU (glimepiride 倚) 党絊付
  • DPP-4 (sitagliptin/saxagliptin/linagliptin) 党絊付 二線+
  • SGLT2 條件絊付:
    • HbA1c > 7.5 + metformin 䞍倠 OR
    • 心血管 (CVD/HF) OR CKD
  • GLP-1 RA 條件絊付:
    • HbA1c > 7.5 + metformin
    • BMI > 25
    • 對症 CV/obesity benefit
  • Tirzepatide 健保條件 expanding (Mounjaro)
    • 自費 倚 仍
  • Insulin 党絊付
  • Pioglitazone 党絊付
  • AlphaGlucosidase inhibitor (acarbose, miglitol) 党絊付
417.3.0.3.2 健保 Tech
  • CGM: å…š T1DM 健保 (條件); T2DM 限制
  • Insulin pump (CSII): T1DM 健保條件 (限制䞭心)
  • AID (hybrid closed-loop): 健保 limited (條件 expanding)
417.3.0.3.3 孞會 + 指匕
  • DAROC 2024 糖尿病孞會指匕個人化 HbA1c
  • ADA 2026 Standards of Care (annual update)
  • EASD-ADA 2022 + 2024 consensus (CV/CKD-stratified)
  • AACE/ACE 2023 algorithm
  • 銬祖 + 郜會 H. pylori 篩檢策略 (因 gastric cancer 䞍 CV)

417.3.0.4 🎓 內專必懂 (20)

  1. HbA1c 個人化目暙 + DAROC + ADA 2026
  2. 9 藥類 mechanism + SE + indications
  3. CV/CKD/HF stratification for 1st addition (改變 paradigm)
  4. SGLT2 圚 non-DM HF/CKD
  5. GLP-1 RA in obesity + NASH + CKD (22E expansion)
  6. Tirzepatide GIP+GLP-1 dual + SUMMIT HFpEF + ESSENCE NASH + SURMOUNT obesity
  7. Once-weekly icodec insulin
  8. Oral semaglutide absorption + SOUL trial CV
  9. Insulin pharmacokinetics: rapid / short / NPH / long-acting / once-weekly
  10. Basal-bolus + correction factor + I:C ratio
  11. CGM TIR/TBR/CV target
  12. AID hybrid closed-loop systems
  13. T1DM management: pump, AID, dual hormone
  14. Hospitalized hyperglycemia management
  15. Steroid-induced hyperglycemia
  16. Pregnancy DM (insulin preferred; metformin debated)
  17. Geriatric DM less aggressive
  18. Bariatric surgery + medical synergy
  19. 22E new trials: SOUL/SUMMIT/ESSENCE/FLOW/REDEFINE/CONFIDENCE/QWINT
  20. DAROC + ADA + EASD consensus alignment

417.3.0.5 ⚙ ADA 2026 Treatment Algorithm (Simplified)

Lifestyle + Metformin (always; 陀非 CI)
  ↓ Stratify by comorbidity (NEW paradigm — CV/CKD priority)

CV高颚險 / ASCVD:
- 1st add: GLP-1 RA (proven CV) OR SGLT2 (proven CV)
- HFrEF/HFpEF → SGLT2 mandatory
- CKD eGFR > 20 + alb > 200 → SGLT2 mandatory
- Stroke/PAD → GLP-1 RA preferred

Obesity priority:
- GLP-1 RA (semaglutide highest)
- Tirzepatide (best class)
- Bariatric surgery if BMI > 40 or > 35 + comorbidity

HbA1c reduction priority (no comorbidity):
- Metformin → DPP-4 OR SU OR TZD OR GLP-1 OR SGLT2
- Cost considerations

Hypoglycemia avoidance:
- DPP-4, SGLT2, GLP-1 (no hypo mono)
- Avoid SU/glinide/insulin

Failure → add another class
- Avoid: SU + glinide; SU + insulin (without down-titrating)
- Insulin if HbA1c > 9% with symptoms / DKA

417.3.0.6 ⚙ T1DM Management Detailed

Basal-bolus:
- Total Daily Dose (TDD) = 0.5-1 U/kg
- Basal 50% (long-acting glargine/degludec)
- Bolus 50% (rapid lispro/aspart/glulisine)
- I:C ratio = 500/TDD (carb counting)
- Correction factor = 1500-1800/TDD (mg/dL drop per 1U)

Pump (CSII):
- Multiple basal rates
- Pre-programmed boluses
- Better TIR than MDI

AID (Hybrid closed-loop):
- Tandem t:slim X2 + Control-IQ + Dexcom G7
- Medtronic 780G + Guardian 4
- Omnipod 5 + Dexcom G7
- TIR improvement vs CSII alone
- Pediatric to adult coverage

Dual hormone (research):
- Insulin + glucagon
- Better hypoglycemia prevention

Monitoring:
- CGM standard: TIR > 70%, TBR < 4%
- HbA1c q3 mo
- Annual: lipid, retinopathy, nephropathy, foot, dental, mental health, vaccines

Education:
- DKA prevention (sick day rules)
- Hypoglycemia recognition
- Carb counting
- Sport/exercise adjustments

417.3.0.7 ⚙ Special Scenarios

417.3.0.7.1 Pre-op DM Management
- Hold metformin 24 hr before contrast (eGFR < 60)
- Hold SGLT2 3 d before surgery (eu-DKA risk)
- Hold GLP-1 1 wk before (gastroparesis / aspiration)
- Adjust insulin basal -10-20% night before
- Glucose target 140-180 perioperative
417.3.0.7.2 Hospitalized Inpatient Hyperglycemia
- Sliding scale alone inadequate (RABBIT 2)
- Basal-bolus (glargine + lispro):
  - Glargine 0.2-0.3 U/kg/d
  - Lispro 50% TDD divided 3 meals
  - Correction factor for high reading
- ICU: continuous insulin infusion; goal 140-180
- DKA/HHS: separate protocol
- Post-discharge: outpatient titration
417.3.0.7.3 Steroid-induced Hyperglycemia
- NPH given with morning steroid (peaks together)
- Or short-acting glargine + bolus pre-meal
- Increase doses with steroid pulse
- Taper as steroid tapers
- HbA1c not reliable acutely
417.3.0.7.4 Pregnancy
- Insulin preferred (metformin debated, possibly OK in T2DM but not T1DM-replacement)
- GLP-1, SGLT2, DPP-4 䞍 routine
- GDM: insulin or metformin
- Preexisting T1DM/T2DM: pump + CGM ideal
- Tighter glucose: fasting < 95, 1 hr PP < 140, 2 hr < 120
- HbA1c < 6.5 if achievable safely
417.3.0.7.5 Geriatric
- Less aggressive HbA1c (8-8.5 acceptable)
- Avoid hypo at all costs (falls, confusion)
- Avoid: glyburide
- Prefer: metformin + DPP-4 / GLP-1 weekly + SGLT2 (if no orthostatic)
- Simplify regimen
- Functional + cognitive assessment

⚠ AI 草皿。