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*For reference only for medical professionals, middle-aged female patients with short-term type 2 diabetes (disease duration ≤ 1 year) but poor blood glucose control, after simplifying the insulin regimen and adding GLP-1RA treatment, the patient's blood glucose reached the ideal value and gained more Good blood sugar control effect
.
Case patient, female, 48 years old
.
Main complaint: It was found that blood sugar increased for 1 year
.
History of present illness: The patient found elevated blood sugar and abnormal liver function 1 year ago due to urinary calculi, diagnosed as "diabetes", and was given a subcutaneous injection of "mixed recombinant human insulin injection 16 in the morning and 18 in the evening, 0.
5 g of metformin twice a day (BID), Saxagliptin 5 mg once a day (QD) "controls blood sugar, but the control effect is not good
.
See a doctor for further treatment
.
Past history: 2 years of medical history of "urinary calculi", recent surgical treatment; 1 year of history of hyperlipidemia, current treatment with fenofibrate
.
Personal history: Nothing special
.
Family history: nothing special
.
▌ Physical examination: Note: Body Mass Index (BMI)
.
The blood pressure was 132/84 mmHg, and the pulse was 78 beats/min
.
There is nothing special about cardiopulmonary auscultation
.
The abdomen is soft, no tenderness and rebound pain
.
No buckle pain in the kidney area
.
▌ Auxiliary examination: Note: glycosylated hemoglobin (HbA1c), serum γ-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), high-density lipoprotein Cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), triglycerides (TG), urine albumin/creatinine ratio (UACR)
.
▌ Preliminary diagnosis: Type 1.
2 diabetes 2.
Hyperlipidemia 3.
Fatty liver 4.
Left fallopian tube stone with hydrops ▌ Treatment plan: The patient has type 2 diabetes, the course of the disease is short, and the previous blood sugar control level is not satisfactory.
This further treatment The main goal is to achieve blood glucose standards
.
In addition, patients with dyslipidemia, overweight, etc.
, need to take into account cardiovascular protection to maximize the benefits of patients
.
Then he was treated with 14 units of insulin dexamethasone once per night (QN), liraglutide 0.
6 mg QN (adjusted to 1.
2 mg QN after one week), metformin 1 g BID, and fenofibrate 160 mg QD
.
▌ Follow-up: After treatment for more than 1 month, the comparison of the situation before and after treatment is as follows: ★ Doctor interviewed the medical profession: In this case, considering the characteristics of the patient, what considerations did you choose to add liraglutide to? Professor Zhao Yiming: The patient had poor blood glucose control in the past, so in further treatment, blood glucose needs to be effectively controlled without increasing the risk of hypoglycemia
.
At the same time, in conjunction with the guidelines, it is necessary to take into account the benefits of heart and kidney
.
A meta-analysis included 7 studies, and the results showed that liraglutide 1.
8 mg/day can enable 40% of patients to reach the high-quality end point of "HbA1c<7% + no weight gain + no hypoglycemia", which is significantly better than Western Gliptin (p<0.
0001), sulfonylureas (p<0.
0001), Exenatide (p<0.
001) and other drugs [1]
.
In addition, GLP-1RA can also reduce body weight, improve blood lipids and lower blood pressure [2,3], bringing multiple metabolic benefits to patients and reducing cardiovascular disease risk factors
.
The LEADER study also shows that liraglutide can significantly reduce the risk of major adverse cardiovascular events in patients and bring clear benefits from cardiovascular events [4]
.
Combined with the characteristics of the patient in this case, the addition of GLP-1RA liraglutide is a better choice
.
Medical community: Based on this case and related clinical experience, would you please briefly share what factors should be considered when adjusting the treatment plan for patients with short-term type 2 diabetes with poor blood sugar control? Professor Zhao Yiming: According to the recommendations of domestic and foreign guidelines, the clinical development of a sugar control plan will first assess whether the patient has atherosclerotic cardiovascular disease (ASCVD, or high-risk factors*), even if some patients with type 2 diabetes have a short course, but In fact, there have been major and/or microvascular complications, so it is necessary to evaluate whether the patient has ASCVD (or high-risk factors*)
.
Based on this, according to the patient's individualized situation, such as the patient's pancreatic islet function, medication contraindications, baseline medication status, etc.
, further integrate the patient's life expectancy, glucose control goals and other factors to formulate a plan
.
The most ideal situation is of course to achieve the high-quality composite endpoint of "HbA1c<7% + no weight gain + no hypoglycemia event" [5,6] to reflect the comprehensive benefits of the drug
.
At the same time, choose hypoglycemic drugs with heart and kidney benefits as appropriate, which is also a treatment that meets the recommendations of the guidelines
.
★ The director commented on the medical community: What do you think of the hypoglycemic effect of drugs like GLP-1RA? Professor Ren Yuezhong: First of all, blood sugar control is the cornerstone and key to diabetes management
.
The LEAD series of studies is a global phase 3 clinical study of liraglutide.
The results of this series show that [5,7-9], GLP-1RA liraglutide 1.
8 mg/day can significantly reduce HbA1c levels by up to 1.
6%, and low The incidence of blood sugar is extremely low
.
Therefore, GLP-1RA is a very good hypoglycemic choice
.
Only when blood sugar is up to the standard can it be more helpful to control the occurrence and development of other complications and bring more benefits to patients
.
Secondly, it is equally important to ensure that patients' blood sugar meets safety standards
.
GLP-1RA not only has a good hypoglycemic effect, it is also a feature of safety compliance
.
A meta-analysis included 7 studies, and the results showed that GLP-1RA liraglutide 1.
8 mg/day can enable 40% of patients to reach the high-quality end point of "HbA1c<7% + no weight gain + no hypoglycemia" [8 ]
.
In addition, GLP-1RA can also reduce weight, improve blood lipid profile and lower blood pressure[2,3], improve multiple cardiovascular risk factors, reduce the risk of patients with major cardiovascular adverse events (MACE), and bring all-round benefits to patients
.
LEADER, SUSTAIN 6 and other studies have confirmed that GLP-1RA such as liraglutide and smeglutide can bring clear cardiovascular benefits to patients and delay the progression of ASCVD[4,10]
.
Medical community: For diabetes patients with a short course of disease, when do you think GLP-1RA should be used in clinical practice? Should it be as early as possible? Professor Ren Yuezhong: The clinical development of a hypoglycemic plan should be considered from the actual situation of the patient
.
When patients with type 2 diabetes have ASCVD/high-risk factors, renal insufficiency, etc.
, they should use drugs with cardiorenal benefits, such as GLP-1RA, as soon as possible
.
In addition, GLP-1RA is also a better choice of medication when it is necessary to take into account conditions such as not gaining weight and the risk of hypoglycemia
.
The 2020 edition of "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China"[2] pointed out that patients with diabetes with ASCVD or high cardiovascular risk factors, regardless of whether HbA1c meets the standard, can be considered as a priority based on standard treatments such as metformin with clear evidence of cardiovascular benefits Anti-diabetic medications (such as liraglutide)
.
*High-risk factors refer to age ≥55 years with at least one of the following: coronary artery or carotid artery or lower extremity artery stenosis ≥50%, left ventricular hypertrophy
.
References: [1] Zinman, et al.
Diabetes, Obesity and Metabolism 2012;14:77-82.
[2] Diabetes Branch of Chinese Medical Association.
Chinese Journal of Diabetes.
2021; 13(4): 315-409.
[ 3]W Yang,et al.
Diabetes Obes Metab.
2011;13(1):81-8.
[4] Ji Linong, et al.
Chinese Journal of Diabetes 2018.
26(5):353-361[5]Zinman,et al.
Diabetes Care.
2009;32:1224-1230.
[6]ADA.
Diabetes Care.
2021;44(Suppl 1):S1-S232.
[7]Garber,et al.
Lancet.
2009;373:473–481.
[8 ]Marre M,et al.
Diabet Med.
2009;26:268-278.
[9]Nauck,et al.
Diabetes Care.
2009;32;84-90.
[10]Marso SP,et al.
N Engl J Med .
2016;375:1834-44.
-End-"This article is only used to provide scientific information to medical and health professionals, and does not represent the position of the platform.
" For submission/reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
.
Case patient, female, 48 years old
.
Main complaint: It was found that blood sugar increased for 1 year
.
History of present illness: The patient found elevated blood sugar and abnormal liver function 1 year ago due to urinary calculi, diagnosed as "diabetes", and was given a subcutaneous injection of "mixed recombinant human insulin injection 16 in the morning and 18 in the evening, 0.
5 g of metformin twice a day (BID), Saxagliptin 5 mg once a day (QD) "controls blood sugar, but the control effect is not good
.
See a doctor for further treatment
.
Past history: 2 years of medical history of "urinary calculi", recent surgical treatment; 1 year of history of hyperlipidemia, current treatment with fenofibrate
.
Personal history: Nothing special
.
Family history: nothing special
.
▌ Physical examination: Note: Body Mass Index (BMI)
.
The blood pressure was 132/84 mmHg, and the pulse was 78 beats/min
.
There is nothing special about cardiopulmonary auscultation
.
The abdomen is soft, no tenderness and rebound pain
.
No buckle pain in the kidney area
.
▌ Auxiliary examination: Note: glycosylated hemoglobin (HbA1c), serum γ-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), high-density lipoprotein Cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), triglycerides (TG), urine albumin/creatinine ratio (UACR)
.
▌ Preliminary diagnosis: Type 1.
2 diabetes 2.
Hyperlipidemia 3.
Fatty liver 4.
Left fallopian tube stone with hydrops ▌ Treatment plan: The patient has type 2 diabetes, the course of the disease is short, and the previous blood sugar control level is not satisfactory.
This further treatment The main goal is to achieve blood glucose standards
.
In addition, patients with dyslipidemia, overweight, etc.
, need to take into account cardiovascular protection to maximize the benefits of patients
.
Then he was treated with 14 units of insulin dexamethasone once per night (QN), liraglutide 0.
6 mg QN (adjusted to 1.
2 mg QN after one week), metformin 1 g BID, and fenofibrate 160 mg QD
.
▌ Follow-up: After treatment for more than 1 month, the comparison of the situation before and after treatment is as follows: ★ Doctor interviewed the medical profession: In this case, considering the characteristics of the patient, what considerations did you choose to add liraglutide to? Professor Zhao Yiming: The patient had poor blood glucose control in the past, so in further treatment, blood glucose needs to be effectively controlled without increasing the risk of hypoglycemia
.
At the same time, in conjunction with the guidelines, it is necessary to take into account the benefits of heart and kidney
.
A meta-analysis included 7 studies, and the results showed that liraglutide 1.
8 mg/day can enable 40% of patients to reach the high-quality end point of "HbA1c<7% + no weight gain + no hypoglycemia", which is significantly better than Western Gliptin (p<0.
0001), sulfonylureas (p<0.
0001), Exenatide (p<0.
001) and other drugs [1]
.
In addition, GLP-1RA can also reduce body weight, improve blood lipids and lower blood pressure [2,3], bringing multiple metabolic benefits to patients and reducing cardiovascular disease risk factors
.
The LEADER study also shows that liraglutide can significantly reduce the risk of major adverse cardiovascular events in patients and bring clear benefits from cardiovascular events [4]
.
Combined with the characteristics of the patient in this case, the addition of GLP-1RA liraglutide is a better choice
.
Medical community: Based on this case and related clinical experience, would you please briefly share what factors should be considered when adjusting the treatment plan for patients with short-term type 2 diabetes with poor blood sugar control? Professor Zhao Yiming: According to the recommendations of domestic and foreign guidelines, the clinical development of a sugar control plan will first assess whether the patient has atherosclerotic cardiovascular disease (ASCVD, or high-risk factors*), even if some patients with type 2 diabetes have a short course, but In fact, there have been major and/or microvascular complications, so it is necessary to evaluate whether the patient has ASCVD (or high-risk factors*)
.
Based on this, according to the patient's individualized situation, such as the patient's pancreatic islet function, medication contraindications, baseline medication status, etc.
, further integrate the patient's life expectancy, glucose control goals and other factors to formulate a plan
.
The most ideal situation is of course to achieve the high-quality composite endpoint of "HbA1c<7% + no weight gain + no hypoglycemia event" [5,6] to reflect the comprehensive benefits of the drug
.
At the same time, choose hypoglycemic drugs with heart and kidney benefits as appropriate, which is also a treatment that meets the recommendations of the guidelines
.
★ The director commented on the medical community: What do you think of the hypoglycemic effect of drugs like GLP-1RA? Professor Ren Yuezhong: First of all, blood sugar control is the cornerstone and key to diabetes management
.
The LEAD series of studies is a global phase 3 clinical study of liraglutide.
The results of this series show that [5,7-9], GLP-1RA liraglutide 1.
8 mg/day can significantly reduce HbA1c levels by up to 1.
6%, and low The incidence of blood sugar is extremely low
.
Therefore, GLP-1RA is a very good hypoglycemic choice
.
Only when blood sugar is up to the standard can it be more helpful to control the occurrence and development of other complications and bring more benefits to patients
.
Secondly, it is equally important to ensure that patients' blood sugar meets safety standards
.
GLP-1RA not only has a good hypoglycemic effect, it is also a feature of safety compliance
.
A meta-analysis included 7 studies, and the results showed that GLP-1RA liraglutide 1.
8 mg/day can enable 40% of patients to reach the high-quality end point of "HbA1c<7% + no weight gain + no hypoglycemia" [8 ]
.
In addition, GLP-1RA can also reduce weight, improve blood lipid profile and lower blood pressure[2,3], improve multiple cardiovascular risk factors, reduce the risk of patients with major cardiovascular adverse events (MACE), and bring all-round benefits to patients
.
LEADER, SUSTAIN 6 and other studies have confirmed that GLP-1RA such as liraglutide and smeglutide can bring clear cardiovascular benefits to patients and delay the progression of ASCVD[4,10]
.
Medical community: For diabetes patients with a short course of disease, when do you think GLP-1RA should be used in clinical practice? Should it be as early as possible? Professor Ren Yuezhong: The clinical development of a hypoglycemic plan should be considered from the actual situation of the patient
.
When patients with type 2 diabetes have ASCVD/high-risk factors, renal insufficiency, etc.
, they should use drugs with cardiorenal benefits, such as GLP-1RA, as soon as possible
.
In addition, GLP-1RA is also a better choice of medication when it is necessary to take into account conditions such as not gaining weight and the risk of hypoglycemia
.
The 2020 edition of "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China"[2] pointed out that patients with diabetes with ASCVD or high cardiovascular risk factors, regardless of whether HbA1c meets the standard, can be considered as a priority based on standard treatments such as metformin with clear evidence of cardiovascular benefits Anti-diabetic medications (such as liraglutide)
.
*High-risk factors refer to age ≥55 years with at least one of the following: coronary artery or carotid artery or lower extremity artery stenosis ≥50%, left ventricular hypertrophy
.
References: [1] Zinman, et al.
Diabetes, Obesity and Metabolism 2012;14:77-82.
[2] Diabetes Branch of Chinese Medical Association.
Chinese Journal of Diabetes.
2021; 13(4): 315-409.
[ 3]W Yang,et al.
Diabetes Obes Metab.
2011;13(1):81-8.
[4] Ji Linong, et al.
Chinese Journal of Diabetes 2018.
26(5):353-361[5]Zinman,et al.
Diabetes Care.
2009;32:1224-1230.
[6]ADA.
Diabetes Care.
2021;44(Suppl 1):S1-S232.
[7]Garber,et al.
Lancet.
2009;373:473–481.
[8 ]Marre M,et al.
Diabet Med.
2009;26:268-278.
[9]Nauck,et al.
Diabetes Care.
2009;32;84-90.
[10]Marso SP,et al.
N Engl J Med .
2016;375:1834-44.
-End-"This article is only used to provide scientific information to medical and health professionals, and does not represent the position of the platform.
" For submission/reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
