-
Categories
-
Pharmaceutical Intermediates
-
Active Pharmaceutical Ingredients
-
Food Additives
- Industrial Coatings
- Agrochemicals
- Dyes and Pigments
- Surfactant
- Flavors and Fragrances
- Chemical Reagents
- Catalyst and Auxiliary
- Natural Products
- Inorganic Chemistry
-
Organic Chemistry
-
Biochemical Engineering
- Analytical Chemistry
- Cosmetic Ingredient
-
Pharmaceutical Intermediates
Promotion
ECHEMI Mall
Wholesale
Weekly Price
Exhibition
News
-
Trade Service
*Read only for medical professionals How is the reference treatment path released? How to recommend various hypoglycemic drugs? Just reading this is enough! With the intensification of aging in China, the prevalence of diabetes in the elderly has increased significantly, and there is an urgent need for standardized management of elderly patients with diabetes
.
Experts organized by the National Geriatrics Center, the Geriatrics Branch of the Chinese Medical Association, and the Diabetes Professional Committee of the China Geriatrics Health Care Association have written the "Guidelines for Diabetes in the Elderly in China (2021 Edition)" (hereinafter referred to as the "Guidelines")
.
The "Guide" emphasizes the high heterogeneity of elderly diabetic patients, which requires comprehensive evaluation and a stratified and individualized management strategy [1]
.
So under this premise, what are the highlights of the "Guidelines" for the management concept and drug treatment path of elderly diabetic patients? Professor Xiao Xinhua from the Department of Endocrinology, Peking Union Medical College Hospital, one of the corresponding authors of the guidelines specially invited by the "Medical Community", made further interpretations for the majority of medical workers
.
Medical community: Could you please talk about the ideas for the formulation of the treatment path of the Guidelines? Professor Xiao Xinhua: A major feature of the "Guidelines" is that the choice of treatment path is not entirely based on the patient's glycated hemoglobin (HbA1c) level, but refers to the comprehensive assessment results of their health status (divided into "good", "moderate", "poor").
"Level 3)
.
The treatment pathways of elderly diabetic patients with "good" and "moderate" evaluation results are divided into non-insulin treatment pathways and insulin treatment pathways [1]
.
For non-insulin treatment pathways, the Guidelines recommend the following for eight classes of hypoglycemic drugs (Figure 1) [1]: Primary recommendation: metformin, sodium-glucose co-transporter-2 (SGLT-2) inhibitor, two Peptidyl peptidase-4 (DPP-4) inhibitor; secondary recommendation: alpha-glucosidase inhibitor, glucagon-like peptide-1 receptor agonist (GLP-1RA), glinides; tertiary Recommended: sulfonylureas, thiazolidinediones
.
Figure 1.
Non-insulin therapy roadmap for elderly patients with type 2 diabetes.
If the patient's blood sugar control is not up to standard on the basis of life>
.
In addition, for HbA1c>10.
0%, or with symptoms of hyperglycemia (such as polydipsia, polyuria), or evidence of catabolism (such as weight loss), or severe hyperglycemia (fasting blood glucose>16.
7 mmol/L), according to The patient's health status and treatment goals can be treated with short-term insulin therapy [1]
.
The "Guidelines" mentioned that insulin treatment should follow a "de-intensive treatment strategy".
For elderly diabetic patients who have already used insulin, it should be assessed whether insulin treatment is necessary and whether the insulin treatment plan can be simplified.
In elderly diabetic patients with satisfactory control, the insulin regimen should also be simplified as much as possible [1]
.
When starting insulin therapy, basal insulin can be selected
.
If necessary, basal insulin combined with mealtime insulin or drugs to improve postprandial blood sugar can be used to further strengthen blood sugar control
.
When combining mealtime insulin, not all elderly diabetic patients need to use the 1+3 regimen of basal insulin combined with mealtime insulin, but to flexibly choose which meal to add mealtime insulin to based on postprandial blood sugar and eating conditions.
to minimize the risk of hypoglycemia
.
In addition, when basal insulin does not control blood sugar well, you can switch to double insulin (currently only soluble double insulin - degluaspart double insulin), which is also the first-level recommended regimen in the insulin treatment pathway in the "Guide" (Fig.
2)
.
Figure 2 Insulin treatment route of elderly patients with type 2 diabetes.
Two different components of bi-insulin exist alone, and do not need to be mixed during injection, which is convenient for patients to use
.
1~2 injections per day can achieve stable blood sugar control, the efficacy is equivalent to the 1+3 scheme, the number of injections is less, the convenience is better, and the risk of hypoglycemia is lower, and it has similar drugs in elderly diabetic patients as non-elderly patients.
Kinetics, efficacy and safety
.
Compared with the premixed insulin regimen, the study showed that when HbA1c was controlled at a similar level, the risk of confirmed hypoglycemic events was reduced by 54% in patients using double insulin degludec aspart; the risk of nocturnal hypoglycemia events was reduced by 75%.
[2]
.
In general, for the drug treatment of elderly patients with diabetes, the four principles proposed in the "Guidelines" should still be followed: (1) priority to choose drugs with lower risk of hypoglycemia; (2) choose simple and high compliance drugs, Reduce the risk of polypharmacy; (3) weigh the benefit-risk ratio and avoid overtreatment; (4) pay attention to factors such as liver and kidney function, cardiac function, complications and concomitant diseases
.
Medical community: Metformin has always been regarded as a "magic drug"-level hypoglycemic drug, and it is recommended as a first-line drug in major guidelines.
In the "Guidelines", metformin is not the only first-level recommended drug.
What kind of consideration? Among the different dosage forms such as ordinary tablets, controlled-release tablets, sustained-release tablets, and enteric-coated tablets, which one is more suitable for elderly patients? Professor Xiao Xinhua: Metformin is one of the first-line hypoglycemic drugs for elderly patients with type 2 diabetes recommended by domestic and foreign guidelines and/or consensuses
.
In this guideline, metformin is not the only Tier 1 recommended drug because of some limitations in the use of metformin [1]
.
First, when using metformin, care should be taken to estimate the glomerular filtration rate (eGFR) >45 ml•min-1•(1.
73 m2)-1
.
Second, gastrointestinal reactions limit the use of metformin in some elderly patients, who may consider DPP-4 inhibitors or SGLT-2 inhibitors
.
If you choose to use metformin, you need to pay attention to the following aspects: first, start the drug with a small dose to minimize gastrointestinal reactions; second, metformin will increase the risk of vitamin B12 deficiency in elderly patients with diabetes, and regular monitoring of vitamin B12 is required after treatment.
B12 level, supplement vitamin B12 if necessary; thirdly, patients with eGFR≥60 ml·min-1·(1.
73 m2)-1 should stop metformin on the same day when using iodine-containing contrast agent for examination, and at least 48 hours after the examination and If the patient's eGFR is 45-59 ml·min-1·(1.
73 m2)-1, the drug needs to be stopped 48 hours before receiving iodine-containing contrast agent and general anesthesia, and it is still necessary after that.
After stopping the drug for 48-72 hours, the drug can be continued after the renal function has not deteriorated after reexamination
.
Metformin is available in the form of ordinary tablets, enteric-coated tablets, sustained-release tablets, and controlled-release tablets, each with its own characteristics
.
Compared with ordinary tablets, enteric-coated tablets reduce the irritation to the stomach, while sustained-release tablets can delay drug release, avoid local high-concentration drug stimulation to the gastrointestinal tract, reduce gastrointestinal reactions, and are more suitable for elderly diabetic patients
.
Medical community: According to the "Guidelines", GLP-1RA, which has become popular in recent years, and α-glucosidase inhibitors commonly used in clinics are listed as secondary recommendations in the management of diabetes in the elderly.
What is the reason? Professor Xiao Xinhua: GLP-1RA has a high status in domestic and foreign guidelines, including the "China Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)"
.
In this guideline, GLP-1RA is listed as a secondary recommendation for non-insulin drugs [1]
.
GLP-1RA has the advantages of cardiovascular protection, weight reduction, blood pressure and blood lipid reduction, good hypoglycemic effect, and low risk of hypoglycemia.
, GLP-1RA needs to be administered by injection, and elderly patients have poor self-management ability and vision, and injection drugs should be avoided as much as possible; second, the main adverse reaction of GLP-1RA is gastrointestinal adverse reactions, and has the effect of reducing body weight However, many elderly diabetic patients have digestive tract problems, sarcopenia, fatigue, etc.
, and are not suitable for the application of GLP-1RA
.
For α-glucosidase inhibitors, from the perspective of safety, although the risk of hypoglycemia is low when used alone, the common adverse reactions are abdominal distension, diarrhea, increased gas, etc.
, all of which are gastrointestinal reactions
.
The gastrointestinal function of elderly diabetic patients is decreased, and the absorption capacity of the gastrointestinal tract is poor, and the gastrointestinal reaction of taking α-glucosidase inhibitors will further affect the patient's gastrointestinal function, which may reduce appetite and aggravate malnutrition
.
In addition, α-glucosidase inhibitors are frequently taken three times a day, which is inconvenient
.
However, alpha-glucosidase inhibitors may be considered for patients who eat more carbohydrates
.
Expert Profile Professor Xiao Xinhua, Chief Physician, Doctor of Medicine, Department of Endocrinology, Peking Union Medical College Hospital, Professor, Doctoral Student and Postdoctoral Supervisor, Chairman of the Diabetes Professional Committee of the Chinese Research Hospital Association, Member of the Standing Committee and Deputy Secretary General of the Diabetes Branch of the Chinese Medical Association, and Diabetes Nutrition Group He is the chairman-designate of the Diabetes Branch of the Beijing Medical Association, the vice-chairman of the China Metabolic Disease Prevention and Innovation Alliance, the vice-chairman of the Endocrinology Professional Committee of the Chinese Society of Integrative Medicine, and the vice-chairman of the Beijing Diabetes Prevention and Control Association
.
Won the first "People's Good Doctor-Science and Technology Innovation Model Award" in 2020.
Participated in the compilation of several academic monographs, editor-in-chief of "Practical Diabetes Therapeutics", and published more than 300 papers and reviews as the first or corresponding author, among which were published in PNAS, Diabetes More than 120 Sci articles including Care and Metabolism, etc.
, and presided over the application of many national scientific research projects
.
He has won the provincial and ministerial level scientific and technological achievement awards 5 times.
He is currently the deputy editor-in-chief of the Chinese Journal of Diabetes, the deputy editor-in-chief of the Chinese version of Diabetes Research and Clinical Practice, the editorial board member of Diabetes Metabolism Research and reviewer, the English version of Chinese Medical Journal, and the editor-in-chief of the Chinese Journal of Multiple Organs in the Elderly.
Journal of Diseases, Journal of Internal Medicine Emergency and Critical Care, and International Diabetes
.
At the same time, he is an evaluation expert of the National Science and Technology Award, an evaluation expert of the National Natural Science Foundation of China, and an evaluation expert of the Beijing Science and Technology Award.
The main research directions are the pathogenesis and early prevention and treatment of diabetes, and the molecular genetics of abnormal glucose metabolism.
References: [1] National Geriatrics Center, etc.
.
Chinese Journal of Diabetes.
2021;13(1):14-46.
[2]Franek E,et al.
Diabet Med.
2016 Apr;33(4):497-505.
-End-"This article is only for Medical and health professionals provide scientific information and do not represent the platform's position.
" For submission/reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
.
Experts organized by the National Geriatrics Center, the Geriatrics Branch of the Chinese Medical Association, and the Diabetes Professional Committee of the China Geriatrics Health Care Association have written the "Guidelines for Diabetes in the Elderly in China (2021 Edition)" (hereinafter referred to as the "Guidelines")
.
The "Guide" emphasizes the high heterogeneity of elderly diabetic patients, which requires comprehensive evaluation and a stratified and individualized management strategy [1]
.
So under this premise, what are the highlights of the "Guidelines" for the management concept and drug treatment path of elderly diabetic patients? Professor Xiao Xinhua from the Department of Endocrinology, Peking Union Medical College Hospital, one of the corresponding authors of the guidelines specially invited by the "Medical Community", made further interpretations for the majority of medical workers
.
Medical community: Could you please talk about the ideas for the formulation of the treatment path of the Guidelines? Professor Xiao Xinhua: A major feature of the "Guidelines" is that the choice of treatment path is not entirely based on the patient's glycated hemoglobin (HbA1c) level, but refers to the comprehensive assessment results of their health status (divided into "good", "moderate", "poor").
"Level 3)
.
The treatment pathways of elderly diabetic patients with "good" and "moderate" evaluation results are divided into non-insulin treatment pathways and insulin treatment pathways [1]
.
For non-insulin treatment pathways, the Guidelines recommend the following for eight classes of hypoglycemic drugs (Figure 1) [1]: Primary recommendation: metformin, sodium-glucose co-transporter-2 (SGLT-2) inhibitor, two Peptidyl peptidase-4 (DPP-4) inhibitor; secondary recommendation: alpha-glucosidase inhibitor, glucagon-like peptide-1 receptor agonist (GLP-1RA), glinides; tertiary Recommended: sulfonylureas, thiazolidinediones
.
Figure 1.
Non-insulin therapy roadmap for elderly patients with type 2 diabetes.
If the patient's blood sugar control is not up to standard on the basis of life>
.
In addition, for HbA1c>10.
0%, or with symptoms of hyperglycemia (such as polydipsia, polyuria), or evidence of catabolism (such as weight loss), or severe hyperglycemia (fasting blood glucose>16.
7 mmol/L), according to The patient's health status and treatment goals can be treated with short-term insulin therapy [1]
.
The "Guidelines" mentioned that insulin treatment should follow a "de-intensive treatment strategy".
For elderly diabetic patients who have already used insulin, it should be assessed whether insulin treatment is necessary and whether the insulin treatment plan can be simplified.
In elderly diabetic patients with satisfactory control, the insulin regimen should also be simplified as much as possible [1]
.
When starting insulin therapy, basal insulin can be selected
.
If necessary, basal insulin combined with mealtime insulin or drugs to improve postprandial blood sugar can be used to further strengthen blood sugar control
.
When combining mealtime insulin, not all elderly diabetic patients need to use the 1+3 regimen of basal insulin combined with mealtime insulin, but to flexibly choose which meal to add mealtime insulin to based on postprandial blood sugar and eating conditions.
to minimize the risk of hypoglycemia
.
In addition, when basal insulin does not control blood sugar well, you can switch to double insulin (currently only soluble double insulin - degluaspart double insulin), which is also the first-level recommended regimen in the insulin treatment pathway in the "Guide" (Fig.
2)
.
Figure 2 Insulin treatment route of elderly patients with type 2 diabetes.
Two different components of bi-insulin exist alone, and do not need to be mixed during injection, which is convenient for patients to use
.
1~2 injections per day can achieve stable blood sugar control, the efficacy is equivalent to the 1+3 scheme, the number of injections is less, the convenience is better, and the risk of hypoglycemia is lower, and it has similar drugs in elderly diabetic patients as non-elderly patients.
Kinetics, efficacy and safety
.
Compared with the premixed insulin regimen, the study showed that when HbA1c was controlled at a similar level, the risk of confirmed hypoglycemic events was reduced by 54% in patients using double insulin degludec aspart; the risk of nocturnal hypoglycemia events was reduced by 75%.
[2]
.
In general, for the drug treatment of elderly patients with diabetes, the four principles proposed in the "Guidelines" should still be followed: (1) priority to choose drugs with lower risk of hypoglycemia; (2) choose simple and high compliance drugs, Reduce the risk of polypharmacy; (3) weigh the benefit-risk ratio and avoid overtreatment; (4) pay attention to factors such as liver and kidney function, cardiac function, complications and concomitant diseases
.
Medical community: Metformin has always been regarded as a "magic drug"-level hypoglycemic drug, and it is recommended as a first-line drug in major guidelines.
In the "Guidelines", metformin is not the only first-level recommended drug.
What kind of consideration? Among the different dosage forms such as ordinary tablets, controlled-release tablets, sustained-release tablets, and enteric-coated tablets, which one is more suitable for elderly patients? Professor Xiao Xinhua: Metformin is one of the first-line hypoglycemic drugs for elderly patients with type 2 diabetes recommended by domestic and foreign guidelines and/or consensuses
.
In this guideline, metformin is not the only Tier 1 recommended drug because of some limitations in the use of metformin [1]
.
First, when using metformin, care should be taken to estimate the glomerular filtration rate (eGFR) >45 ml•min-1•(1.
73 m2)-1
.
Second, gastrointestinal reactions limit the use of metformin in some elderly patients, who may consider DPP-4 inhibitors or SGLT-2 inhibitors
.
If you choose to use metformin, you need to pay attention to the following aspects: first, start the drug with a small dose to minimize gastrointestinal reactions; second, metformin will increase the risk of vitamin B12 deficiency in elderly patients with diabetes, and regular monitoring of vitamin B12 is required after treatment.
B12 level, supplement vitamin B12 if necessary; thirdly, patients with eGFR≥60 ml·min-1·(1.
73 m2)-1 should stop metformin on the same day when using iodine-containing contrast agent for examination, and at least 48 hours after the examination and If the patient's eGFR is 45-59 ml·min-1·(1.
73 m2)-1, the drug needs to be stopped 48 hours before receiving iodine-containing contrast agent and general anesthesia, and it is still necessary after that.
After stopping the drug for 48-72 hours, the drug can be continued after the renal function has not deteriorated after reexamination
.
Metformin is available in the form of ordinary tablets, enteric-coated tablets, sustained-release tablets, and controlled-release tablets, each with its own characteristics
.
Compared with ordinary tablets, enteric-coated tablets reduce the irritation to the stomach, while sustained-release tablets can delay drug release, avoid local high-concentration drug stimulation to the gastrointestinal tract, reduce gastrointestinal reactions, and are more suitable for elderly diabetic patients
.
Medical community: According to the "Guidelines", GLP-1RA, which has become popular in recent years, and α-glucosidase inhibitors commonly used in clinics are listed as secondary recommendations in the management of diabetes in the elderly.
What is the reason? Professor Xiao Xinhua: GLP-1RA has a high status in domestic and foreign guidelines, including the "China Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)"
.
In this guideline, GLP-1RA is listed as a secondary recommendation for non-insulin drugs [1]
.
GLP-1RA has the advantages of cardiovascular protection, weight reduction, blood pressure and blood lipid reduction, good hypoglycemic effect, and low risk of hypoglycemia.
, GLP-1RA needs to be administered by injection, and elderly patients have poor self-management ability and vision, and injection drugs should be avoided as much as possible; second, the main adverse reaction of GLP-1RA is gastrointestinal adverse reactions, and has the effect of reducing body weight However, many elderly diabetic patients have digestive tract problems, sarcopenia, fatigue, etc.
, and are not suitable for the application of GLP-1RA
.
For α-glucosidase inhibitors, from the perspective of safety, although the risk of hypoglycemia is low when used alone, the common adverse reactions are abdominal distension, diarrhea, increased gas, etc.
, all of which are gastrointestinal reactions
.
The gastrointestinal function of elderly diabetic patients is decreased, and the absorption capacity of the gastrointestinal tract is poor, and the gastrointestinal reaction of taking α-glucosidase inhibitors will further affect the patient's gastrointestinal function, which may reduce appetite and aggravate malnutrition
.
In addition, α-glucosidase inhibitors are frequently taken three times a day, which is inconvenient
.
However, alpha-glucosidase inhibitors may be considered for patients who eat more carbohydrates
.
Expert Profile Professor Xiao Xinhua, Chief Physician, Doctor of Medicine, Department of Endocrinology, Peking Union Medical College Hospital, Professor, Doctoral Student and Postdoctoral Supervisor, Chairman of the Diabetes Professional Committee of the Chinese Research Hospital Association, Member of the Standing Committee and Deputy Secretary General of the Diabetes Branch of the Chinese Medical Association, and Diabetes Nutrition Group He is the chairman-designate of the Diabetes Branch of the Beijing Medical Association, the vice-chairman of the China Metabolic Disease Prevention and Innovation Alliance, the vice-chairman of the Endocrinology Professional Committee of the Chinese Society of Integrative Medicine, and the vice-chairman of the Beijing Diabetes Prevention and Control Association
.
Won the first "People's Good Doctor-Science and Technology Innovation Model Award" in 2020.
Participated in the compilation of several academic monographs, editor-in-chief of "Practical Diabetes Therapeutics", and published more than 300 papers and reviews as the first or corresponding author, among which were published in PNAS, Diabetes More than 120 Sci articles including Care and Metabolism, etc.
, and presided over the application of many national scientific research projects
.
He has won the provincial and ministerial level scientific and technological achievement awards 5 times.
He is currently the deputy editor-in-chief of the Chinese Journal of Diabetes, the deputy editor-in-chief of the Chinese version of Diabetes Research and Clinical Practice, the editorial board member of Diabetes Metabolism Research and reviewer, the English version of Chinese Medical Journal, and the editor-in-chief of the Chinese Journal of Multiple Organs in the Elderly.
Journal of Diseases, Journal of Internal Medicine Emergency and Critical Care, and International Diabetes
.
At the same time, he is an evaluation expert of the National Science and Technology Award, an evaluation expert of the National Natural Science Foundation of China, and an evaluation expert of the Beijing Science and Technology Award.
The main research directions are the pathogenesis and early prevention and treatment of diabetes, and the molecular genetics of abnormal glucose metabolism.
References: [1] National Geriatrics Center, etc.
.
Chinese Journal of Diabetes.
2021;13(1):14-46.
[2]Franek E,et al.
Diabet Med.
2016 Apr;33(4):497-505.
-End-"This article is only for Medical and health professionals provide scientific information and do not represent the platform's position.
" For submission/reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
