Follow up with the new concept of type 2 diabetes prevention and treatment in China, and interpret the updated points of the new CDS 2020 guide

*Only for medical professionals to read and understand the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)", knowing what is happening, but also knowing why! On April 19, 2021, "China Type 2 Diabetes Prevention and Control Guidelines (2020 Edition)" (hereinafter referred to as the 2020 Edition Guidelines) was released[1]! The previous article has listed the 10 main points of the guideline update (the full text of the "Chinese Type 2 Diabetes Prevention and Control Guide" has finally been released, and the 10 main update points are coming! A quick overview).
This article will introduce the background of the update points and their clinical implications.
significance.

 Figure: The development history of China's Type 2 Diabetes Prevention Guidelines.
The inclusion of glycosylated hemoglobin (HbA1c) into the diagnostic criteria for diabetes is closely related to the occurrence and development of diabetes complications.
Clinically, HbA1c has been widely used to assess long-term blood glucose control status and is also clinical An important basis for deciding whether to adjust the treatment [2].

In 2011, WHO recommended that HbA1c be used to diagnose diabetes in countries and regions where conditions are available, and the diagnostic cut-off point is HbA1c ≥ 6.
5% [2].

 In view of the fact that HbA1c detection is not universal in my country, the standardization of the detection method is not enough, the instrument and quality control for measuring HbA1c still cannot meet the requirements of diabetes diagnosis standards, so HbA1c diagnosis is not recommended in the 2017 edition of "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" Diabetes [2].

In recent years, my country’s HbA1c standardization work has accelerated rapidly.
With the continuous improvement of HbA1c awareness and measurement quality, my country has completed the standardization of HbA1c detection.
This update of the guideline uses HbA1c≥6.
5% as a supplementary diagnostic criterion [1 ].

 Table: Diagnosis criteria for diabetes Incorporate TIR into the goal of blood glucose control to promote multi-dimensional blood glucose management.
Although HbA1c is the "gold standard" for blood glucose monitoring, it cannot reflect hypoglycemia, blood glucose variability, or HbA1c in clinical applications.
Differences among other issues [3-9]. Time within the target range of glucose (TIR) ​​can perfectly analyze the blood glucose control status from the multi-dimensional perspective of hyperglycemia, hypoglycemia, and blood glucose variability, and effectively supplement HbA1c [10-11].

 The attention and understanding of TIR in the field of diabetes treatment is increasing.
A large number of studies have found that TIR is significantly related to microvascular complications, cardiovascular disease, pregnancy outcomes, etc.
Based on prospective studies in the Chinese population, it has been found that TIR is completely related to type 2 diabetes (T2DM).
Death due to cardiovascular disease is negatively correlated [12-13].

Figure: TIR is negatively correlated with T2DM all-cause deaths and cardiovascular deaths.
With the rapid development of continuous blood glucose monitoring (CGM) and self-glucose monitoring (SMBG), the monitoring of TIR, a new indicator of blood glucose management, is becoming more and more convenient [1] .

The consensus on TIR recommendations is gradually improved.
The TIR international consensus released in 2019 recommends that the TIR control target for patients with type 1 diabetes (T1DM) and T2DM is >70%, but it should be highly individualized, while paying attention to hypoglycemia and blood glucose fluctuations[14] .

 This update of the CDS guidelines mentioned: "TIR should be included in the blood sugar control goal (B)" [1].

 The new concept of diabetes prevention and treatment promotes the renewal of diabetes treatment pathways.
Atherosclerotic cardiovascular disease (ASCVD) and/or chronic kidney disease (CKD) are not only common complications of T2DM, but also the primary cause of disability and death in T2DM patients[15] .

A 7-year prospective study in China also showed that cardiovascular disease is the main cause of death in T2DM patients [16].

Therefore, the guidelines increasingly emphasize the concept of patient-centered and cardiovascular risk assessment first [17].

 Figure: In response to the mortality of Chinese diabetes patients, the 2020 version of the guidelines has also made certain adjustments in the treatment path.
For patients with ASCVD (or high-risk factors), heart failure, and CKD, after life>
 Figure: Diabetes treatment pathways of the 2020 version of the guidelines.
In addition, the 2020 version of the guidelines re-emphasizes the importance of combination therapy-one type of hypoglycemic drug treatment but blood sugar does not meet the target, the use of two or even three different mechanisms of drug combination therapy [1], insulin therapy can also be added (A).

For short-term intensive insulin therapy, the guidelines emphasize that it is not limited to newly diagnosed T2DM 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 , You can choose basic + meal insulin, premixed insulin or insulin pump [1].

 Innovation promotes the progress of hypoglycemic drugs In recent years, new types of hypoglycemic drugs such as SGLT-2i and GLP-1RA have sprung up.

The cardiovascular outcome study (CVOT) of new hypoglycemic drugs successively found that some hypoglycemic drugs not only do not increase the risk of cardiovascular disease, but also bring cardiovascular benefits [1].

 Insulin preparations are also constantly making breakthroughs and innovations.
New long-acting insulin analogues have longer and longer action times, sugar control is more and more stable, and efficacy and safety are getting better and better [1, 18].

Among them, insulin degludec has a half-life of up to 25 hours and an action time of up to 42 hours.
The action curve is more stable and the variability is smaller.

Achieves ultra-long and stable pharmacokinetic characteristics, which is more in line with physiological insulin secretion [1, 18].

 In addition, the innovative drug dual insulin analogue was included in the Chinese guidelines for the first time.
As the world’s first dual insulin preparation, deglubber is composed of 70% deglubber and 30% insulin aspart.
The two insulin components are in The preparation can exist independently in the body and in the body, without interfering with each other, and effectively control fasting blood glucose and postprandial blood glucose [3].

 The update of the guidelines pointed out that Degu aspart insulin generally starts from 0.
1 to 0.
2 U·kg-1·d-1 and is injected before the main meal, and the dosage is adjusted according to the fasting blood glucose level until it reaches the target.

Patients with obesity or HbA1c>8.
0% can choose to start with a higher dose. Degu aspart double insulin is treated once a day, and the dose reaches 0.
5U·kg-1·d-1 or 30~40U blood glucose is still poorly controlled after meals, or the patient has two main meals a day, consider changing to daily 2 injections [1].

In addition, the guidelines include the combination of GLP-1RA and basal insulin into the guidelines for the first time, such as insulin glargine and lisnatide compound preparations, and insulin deglubber and liraglutide injection [1].

In the case of the same or lower dosage of insulin, the hypoglycemic effect is better than that of basal insulin, and it can reduce the risk of hypoglycemia and avoid adverse effects such as weight gain caused by insulin therapy [1].

 Summary This guideline is based on new concepts and evidence-based evidence in the diagnosis, evaluation and drug treatment of diabetes, based on the latest results of clinical research on diabetes at home and abroad and based on my country's national conditions.
It has strong operability and fully embodies its authority and innovation.
The characteristics of science, advancement and practicality will definitely play a positive role in improving and standardizing the level of diagnosis and treatment of T2DM in my country. References: [1] Diabetes Branch of Chinese Medical Association.
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