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    Home > Active Ingredient News > Endocrine System > Insulin application from clinical cases-how to treat elderly patients with long course of disease and complications?

    Insulin application from clinical cases-how to treat elderly patients with long course of disease and complications?

    • Last Update: 2021-10-02
    • Source: Internet
    • Author: User
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    *Only for medical professionals to read for reference.
    Clinical diabetic patients have a complicated condition, and choosing the right insulin can get twice the result with half the effort
    .

     Case characteristics ▎Patient characteristics: Elderly male, long course of illness, previous use of multiple oral hypoglycemic agents (OADs), poor β-cell function, poor blood sugar control recently, and chronic complications of diabetes
    .

    ▎History of present illness: 10 years ago, there was no obvious cause for conscious dry mouth and polydipsia, polyuria, but no significant polyphagia, accompanied by general fatigue, random blood glucose 17.
    5mmol/L in the outside hospital, type 2 diabetes-insufficient insulin secretion with resistance, He was given "metformin 1.
    5g/day, gliclazide 60mg/day or gliquidone 120mg/day, acarbose 150mg/day" hypoglycemic therapy, intermittent medication, no diet control
    .

    In the past month, the patient felt that his fatigue had worsened.
    Monitored fasting blood glucose (FPG) at 10-12 mmol/L and postprandial blood glucose (PPG) at 19-24 mmol/L.
    He is now admitted to the hospital for adjustment treatment
    .

    Since the onset of the disease, the patient can be old and sleep
    .

    Consciously lose about 10 kilograms of weight gradually in the past 4 years, but did not take the measurement, and the lower limbs have been numb and painful in the past 2 years
    .

     ▎Past history: deny the history of hypertension and coronary heart disease; deny the history of hepatitis and tuberculosis; deny the history of surgery and trauma; deny the history of drug allergy
    .

     ▎Personal history, family history: smoking history for 20 years, 10 cigarettes/day, denying history of drinking; younger sister suffers from "diabetes"
    .

     ▎Physical examination: blood pressure 135/80mmHg, weight 65kg, body mass index (BMI) 22.
    6 kg/m2, normal cardiopulmonary and abdominal examination, no edema in both lower limbs, spotted pigmentation on the front of the shin, dry skin on the feet, and toes The nails are thickened and the pulsation of the dorsal arteries of the feet is weakened
    .

     ▎Laboratory examination: A, routine laboratory test of glycosylated hemoglobin (HbA1c) 11.
    1%, pancreatic islet function: insufficient insulin secretion (type 2 diabetes); blood routine, normal liver and kidney function, blood lipid: low-density lipoprotein cholesterol (LDL-C) 3.
    61 mmol/L, the rest is normal
    .

    24h urine microalbumin: 96.
    2mg
    .

    B.
    Auxiliary examination of chest X-ray and ECG are normal
    .

    Color Doppler ultrasound of carotid and lower extremity arteries: atherosclerosis, mural plaque
    .

    Fundus examination: retinopathy (microangioma, spotting hemorrhage)
    .

    Electroneurophysiological examination: peripheral neuropathy
    .

     ▎Diagnosis: Type 1.
    2 Diabetes, Lower Extremity Vascular Disease, Peripheral Neuropathy, Retinopathy, Nephropathy Stage III 2.
    Formulation of Hyperlipidemia Blood Sugar Treatment Plan and Individualized Blood Sugar Management Target: According to the patient’s situation, the blood sugar control target is set as: HbA1c7% , FPG 7.
    0mmol/L, PPG 10.
    0mmol/L
    .

     Hypoglycemic treatment: Phase 1: Gliquidone 120mg/day, Metformin 1.
    5g/day, Acarbose 150mg/day
    .

    The time for patients to measure blood glucose is different every day.
    At this stage, the FPG is about 9-10mmol/L, and the 2h PPG is about 11-16mmol/L.
    The more representative data are selected as follows: Stage 2: Degu aspart double insulin early 14U night and 12U meal with subcutaneous injection + 0.
    5g of metformin three times a day (TID)
    .

    Adjustment considerations: poor pancreatic islet function, start insulin therapy
    .

    At this stage, the patient's FPG is about 8mmol/L, and the 2h PPG is about 9~10mmol/L
    .

    Phase 3: Degu aspart insulin subcutaneous injection + metformin 0.
    5g TID at 14U in the morning and 14U in the evening
    .

    Adjustment considerations: high fasting blood glucose is the main cause, increase the insulin dose (+2U)
    .

    At this stage, the FPG of patients is about 6~7mmol/L, and the PPG of 2h is about 9mmol/L
    .

    Dietary guidance: Eat a reasonable diet, and the calorie distribution ratio of the three meals is 1/5 in the morning, 2/5 in the middle, and 2/5 in the evening
    .

    Other treatment: appropriate exercise, 5 times a week, 30 minutes of aerobic exercise each time
    .

     Follow-up observation of HbA1c changes
    .

    About one month later, the patient’s physical examination revealed that HbA1c gradually decreased from 11.
    1% to 8.
    9%, and HbA1c decreased to 7.
    4% during the three-month follow-up, which was a significant improvement
    .

     The medical profession interviews the medical profession: Through this patient, please share with regard to the elderly type 2 diabetes patients with a long course of disease and poor pancreatic islet function, what is the dosage of Degu aspartic acid twice a day (BID) treatment? set up? And how to choose the oral medicine used in combination? Dr.
    Wu Yanli: The starting dose of insulin recommended by the general guidelines is all within a range
    .

    According to experience, we generally start degludec di-insulin at 0.
    3~0.
    5U/kg/d.
    If the patient has a larger body weight and more severe insulin resistance, you can choose a higher starting dose, and vice versa, choose a lower dose
    .

     This patient is an elderly type 2 diabetic patient with a long course of disease and poor pancreatic islet function.
    He has high blood sugar on an empty stomach and after meals.
    An insulin-based treatment plan should be used to control fasting and postprandial blood glucose.

    .

    When using Degu aspart insulin, the starting dose is 26 U per day, which is about 0.
    4 U/kg/d
    .

    This patient is an inpatient with a high blood sugar level, so we chose the BID plan
    .

     How to choose the oral medicine combined with Degu aspart and insulin should be combined with the characteristics of the patient and the recommendations of the guidelines, and a comprehensive judgment should be made
    .

    In this case, the patient has used a variety of oral hypoglycemic drugs in the past, but the patient expressed hope that the treatment plan will be simpler
    .

    We considered that metformin was used as a first-line treatment in authoritative guidelines at home and abroad [1, 2], combined with the patient’s islet function, gastrointestinal adverse reactions caused by some drugs and other factors, and finally only retained metformin as an oral drug.
    , Combined with Degu aspart insulin an injection preparation, while effectively controlling sugar, it simplifies the treatment plan as much as possible, also reduces the occurrence of hypoglycemia, and improves patient compliance
    .

    Medical circles: What are the advantages of Degu aspartic acid in this patient's individualized blood glucose management program? Dr.
    Wu Yanli: The 2020 edition of "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" points out that insulin therapy can be initiated when the blood glucose level (HbA1c≥7.
    0%) is still not up to standard (HbA1c≥7.
    0%) by life>
    .

    In this case, the patient has a long course of disease and poor pancreatic islet function.
    After treatment with oral hypoglycemic agents, he has high blood sugar on an empty stomach and after meals, and he is not heavy.
    He belongs to a positive body type.
    Insulin treatment is urgently needed to relieve high glucose.
    Toxicity
    .

     Degu aspartic double insulin can take into account both fasting and postprandial blood glucose control.
    It is an effective treatment for such patients and can help patients achieve full blood glucose standards
    .

    Among them, the fast-acting insulin aspart component can quickly control the patient’s postprandial blood glucose, while the degludec component has an action time of up to 42 hours, which can help patients to control blood glucose steadily throughout the day, which also helps increase the flexibility of dual insulin injections Sex, can be used daily with the main meal [3]
    .

    In addition, the risk of hypoglycemia of insulin degludec is lower than that of traditional long-acting insulins such as insulin glargine [4], which also makes the risk of hypoglycemia of deglubber double insulin lower
    .

    Therefore, considering the patient's blood sugar status and the fear of hypoglycemia, Degu aspart is an ideal therapeutic drug
    .

     In clinical application of Degu aspart dual insulin BID regimen, it is generally used with breakfast and dinner, of course, it can also be used with lunch and dinner
    .

    The director commented on the medical community: Could you please talk about how to choose the QD and BID regimens of Degu aspartic acid for patients with poor blood sugar control in the treatment of oral medications? Director Gao Feng: Degu Aspartic Double Insulin can be treated in an individualized regimen according to the patient's own situation
    .

    It can be used with the patient's main meal, that is, the most carbohydrate-rich meal (multiple), and 1-2 injections a day can help patients control fasting and postprandial blood sugar
    .

    The 2020 edition of the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" pointed out that for patients whose blood glucose has not yet reached the control target (3 months) based on the combined treatment of life>
    .

    The "Multinational Consensus on Clinical Application of Degu aspart" pointed out that for patients with high glucose toxicity or symptomatic hyperglycemia, and a large increase in postprandial blood glucose, the initial Degu aspart insulin therapy is better than the initial treatment.
    Basic insulin therapy [3]
    .

     General patients can start with the QD program.
    If the patient uses a large dose of Degu aspart insulin, such as a dose of 0.
    5U/kg/d or 30~40U, the BID program can be considered [3]
    .

     In this case, considering the patient’s condition, the course of the disease is relatively long, the islet function is relatively poor, and there is a problem of increased blood sugar after multiple meals.
    beneficial
    .

    References: [1] Diabetes Branch of Chinese Medical Association.
    Chinese Journal of Diabetes.
    2021;13(4):315-409.
    [2]American Diabetes Association.
    Diabetes Care.
    2020;44(Suppl.
    1).
    [3] Mehta R, et al.
    Diabetes Obes Metab.
    2020;22(11):1961-1975.
    [4]Rodbard, et al.
    Diabet Med.
    2013;30:1298–304.
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