Explore the new concept of insulin therapy from the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)"

*Only for medical professionals to read for reference.
On April 19, 2021, the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)" will be released [1]! The guidelines condense the wisdom and hard work of nearly a hundred domestic experts, based on the latest results of domestic and foreign diabetes clinical research and based on my country’s national conditions, are highly maneuverable, and fully embody authority, innovation, scientificity, advancement and Practical features will definitely play a positive role in improving and standardizing the level of diagnosis and treatment of T2DM in my country.

Insulin is an important means of controlling blood sugar, and its treatment and application are also newly defined in the guidelines.

The inclusion of HbA1c in the diagnostic criteria strengthens the importance of achieving HbA1c standards.
It is clear that the initial insulin treatment time of glycosylated hemoglobin (HbA1c) is one of the criteria for diabetes diagnosis and blood glucose control recommended by the World Health Organization (WHO).

In recent years, the standardization of HbA1c testing in my country has gradually increased.
In order to be in line with the world, the guidelines have officially included HbA1c≥6.
5% in the diagnostic criteria for diabetes.

Evidence-based medical evidence suggests that early strict control of blood glucose can reduce the risk of microvascular and macrovascular disease.
Hypoglycemic therapy should not ignore the benefits while avoiding risks.
The guidelines recommend that most non-pregnant adult T2DM patients have HbA1c<7%.

In addition, HbA1c control goals should follow the principle of individualization.
For newly diagnosed, young, and no serious complications or comorbidities in T2DM patients, it is recommended that blood glucose be strictly controlled as soon as possible (HbA1c<6.
5%, even close to normal) to reduce diabetes complications.
There is a risk.

The diabetes treatment pathway in the guideline uses HbA1c compliance as the main indicator of medication decision-making.

At present, insulin is still the drug with the strongest hypoglycemic effect.
In the insulin treatment pathway, patients with T2DM should start as soon as possible (3 months) if their blood sugar has not reached the control target based on the combination of life>
 Time within the glucose target range (TIR) ​​is included in the blood sugar control target.
Blood sugar control needs to take into account multiple dimensions, including improving HbA1c, reducing the risk of hypoglycemia, and reducing blood glucose variability.

Although HbA1c is the "gold standard" that reflects the status of blood sugar control, it still has certain limitations in clinical application and cannot reflect hypoglycemia, blood glucose variability and individualized differences in HbA1c.

With the rapid development of CGM, a new indicator of blood glucose management-time within target glucose range (TIR) ​​has been widely recognized.

TIR can perfectly analyze the blood sugar control status from the multi-dimensional perspectives of hyperglycemia, hypoglycemia, and blood sugar variability, and is significantly related to microvascular complications, cardiovascular disease, pregnancy outcome, etc.
, combined with other classic indicators such as HbA1c to provide more comprehensive blood sugar control information .

The new guidelines recommend that TIR should be included in blood glucose control indicators for patients with T2DM and gestational diabetes.

The TIR international consensus released in 2019 recommends that the TIR control target for patients with T1DM and T2DM is >70%, but it should be highly individualized.

Studies have confirmed that the new long-acting insulin analogue degludec has a unique mechanism of prolonging action, achieving 24-hour stable glucose control [2].

While effectively reducing blood sugar, insulin degludec has lower blood glucose variability and lower risk of hypoglycemia than insulin glargine, which can better help multi-dimensional optimization of blood glucose management [2,3].

Clinical studies have shown that the TIR of patients with T2DM treated with insulin deglubber can reach 77%, which is better than insulin glargine [4].

 Innovative insulin analogues are included in the guidelines to further optimize the insulin treatment experience of diabetic patients.
The new generation of insulin analogues has been further upgraded in terms of effectiveness, safety and convenience.
It has been confirmed by a large number of evidence-based medicine and has been recognized in clinical practice.
The concept of insulin treatment for diabetes was updated, and the insulin treatment plan for patients was further optimized. Innovative dual insulin analogues are included in the Chinese guidelines for the first time.
The only dual insulin analogues currently on the market in China are IDegAsp.
The dual insulin analogues can be initiated after 3 months of oral treatment with HbA1c≥7% , 1 treatment a day, injection before the main meal, the dose reaches 0.
5U/kg/d or 30~40U after the meal, blood glucose is still poorly controlled, or the patient has two main meals a day, consider changing to 2 injections a day .

In addition, the new guidelines elaborate on the characteristics and efficacy of long-acting insulin analogs.
Insulin deglubber and insulin glargine U300 (300U/ml) are two new long-acting insulin analogs.

The half-life of insulin degludec is 25h, and the action time is 42h.

The half-life of insulin glargine U300 is 19h, and the action time is 36h.

The innovative development of insulin has never stopped, and it has continued to explore in a more convenient, more effective, safer and more economical direction.

The combination of GLP-1RA and basal insulin has also been included in the new guidelines this time.

In the case of the same or lower insulin dosage, the compound preparation has a better hypoglycemic effect than basal insulin, and can reduce the risk of hypoglycemia and avoid adverse effects such as weight gain caused by insulin therapy.

 Short-term insulin intensification can be used in the presence of hyperglycemia symptoms and is not limited to newly diagnosed T2DM.
Intensive insulin therapy is one of the important methods to strengthen blood sugar control, and it plays an important role in different stages of T2DM.

The guidelines emphasize that short-term intensive insulin therapy is not limited to newly diagnosed type 2 diabetic patients, who have a certain course of disease and have significant hyperglycemia symptoms (HbA1c≥9%) at the time of drug treatment or diagnosis, and short-term (2 weeks to 3 months) intensive insulin therapy can be given directly , Can choose basic + meal insulin, premixed insulin or insulin pump.

Studies have shown that when T2DM patients are treated with basal + meal insulin (4 times/d) or 3 times a day premixed insulin analogues, the two effects of HbA1c reduction, hypoglycemia incidence, total insulin dose, and weight loss There is no significant difference in impact.

References: [1] Diabetes Branch of Chinese Medical Association.
Chinese Journal of Diabetes.
2021;13(4):317-411.
[2]Heise Tim,et al.
J Diabetes Sci Technol, 2018, 12(2):356 -363.
[3]Heise,et al.
Diabetes Obes Metab, 2017, 19:1032-1039.
[4]Yamabe M, et al.
J Diabetes Investig.
2019;10(2):352-357.