"Learning both internally and externally to talk about sugar control"-To improve the quality of life and prolong lifespan, how to optimize the insulin treatment plan for elderly patients with T2DM?

This article shares a case of basal insulin therapy in elderly type 2 diabetic patients with poorly controlled premixed insulin, and invited Chen Lei, director of the Department of Endocrinology, Suzhou Municipal Hospital, to comment on the case
.

Director Chen Lei, Suzhou Municipal Hospital: The case described in this issue is an elderly T2DM patient with poor blood glucose control with premixed insulin, combined with diabetic retinopathy, hypertension grade 2 (very high risk), coronary heart disease, atrial fibrillation, and blood glucose levels that are not up to standard In addition, there are large fluctuations, high fasting blood glucose and postprandial blood glucose, and poor compliance.
It is necessary to control blood glucose steadily, reduce the risk of hypoglycemia, and improve patient compliance
.

Case narrator Qi Luyue, a physician from the Endocrinology Department of the Second Affiliated Hospital of Soochow University, scrolls upwards to view the patient data.
Female, 81 years old.
Chief complaint: Blood glucose is found to be elevated for 18 years.
Current medical history: The patient went to the local hospital 18 years ago due to fatigue.
The fasting blood glucose was measured: 13.
6 mmol/L, diagnosis of "diabetes", no obvious dry mouth, polydipsia, polyuria, and successive oral administration of a variety of hypoglycemic drugs (Gliclazide sustained-release tablets, metformin hydrochloride tablets, etc.
), and irregular blood glucose monitoring
.

In July last year, due to poor blood sugar control and sore legs, he was admitted to our department.
After admission, he was given a subcutaneous injection of "protamine biosynthetic human insulin injection (premixed 30R)" and combined with acarbose to lower blood sugar
.

CTA of both lower extremity arteries during hospitalization showed that bilateral femoral and popliteal arteries showed limited stenosis, and bilateral posterior tibial arteries were interrupted
.

After adjusting the blood glucose stability in our department, he was transferred to the Department of Vascular Surgery in our hospital.
On July 29, he underwent the right femoral artery stenosis segment with ball expansion and internal stenting, and the right calf anterior tibial posterior tibial artery balloon dilatation
.

After discharge, the patient felt it was inconvenient to inject insulin, and the community clinic changed to oral hypoglycemic drugs.
The pre-hospital treatment plan was acarbose 50mg tid, glimepiride 1mg qd, and blood glucose was measured at 15.
2mmol/l on fasting a week ago, occasionally Fatigue and palpitation were relieved after eating, and no serious hypoglycemia event occurred
.

In order to further control blood sugar, the outpatient department plans to admit "type 2 diabetes" to the hospital with a history of drug allergy: no family history: one patient with a history of diabetes slides up to read the physical examination PBP 70 times/min 130/90 mmHg HWBMI_160 cm52 kg20.
3kg/ m2_Physical examination: auscultation of clear breath sounds in both lungs, arrhythmia, atrial fibrillation, low heart sounds, no special abdomen, no swelling of both lower limbs, dorsal artery pulsation, laboratory examination of venous fasting blood glucose: 8.
31mmol/L, Admission random fingertip blood glucose: 22.
2mmol/L glycosylated hemoglobin: 10.
7%; fasting C-peptide: 1.
31ng/ml 2 hours after meal C-peptide: 2.
97ng/ml Diabetes autoantibodies: GAD, ICA, IAA are all negative Other laboratory tests : Blood routine: Hb 121g/L Urine routine: glucose 3+, protein-stool routine and OB: (-) liver and kidney function, electrolytes: normal blood lipids: TC 5.
8 mmol/L, TG 1.
45 mmol/L, LDL-C 4.
12 mmol/L, HDL-C 1.
17mmol/L 24-hour urine microalbumin: 26 mg/24 hours auxiliary examination ECG: atrial fibrillation, ST-T changes Full chest radiograph: increased lung texture, aortic arch sclerosis, abdominal ultrasound: cholecystectomy Later change of vascular color Doppler ultrasound (neck + both lower extremities): neck and lower extremities atherosclerosis with multiple plaque formation Eye examination: DR phase II electromyography of both eyes: bilateral peroneal nerve conduction velocity slowed down Clinical diagnosis Slide up to read the main Diagnosis of Type 2 Diabetes Diabetic Retinopathy Hypertension Grade 2 Very High Risk Right Femoral Artery Stenosis After Coronary Heart Disease and Atrial Fibrillation Cases Features of Patients with Elderly Women, Blood Glucose Fluctuations: Monitor fasting peripheral blood glucose 8.
2-12.
6mmol/L after admission , The peripheral blood sugar of 8.
7-20.
4 mmol/l 2 hours after meal
.

The current hypoglycemic program needs to adjust the patient’s advanced age, long history of diabetes, poor long-term blood sugar control, combined with C-peptide level, to assess poor pancreatic islet function and severe macrovascular disease; high risk of cardiovascular events; and life with microvascular complications Methods: Old age living alone, poor cognition, difficult to strictly control diet, exercise restriction, medication sometimes irregular.
Therapeutic strategies educate patients on the correct diet and exercise within their capacity, taking walking as the main strategy to reduce blood pressure, regulate fat, and treat blood sugar with anticoagulation : First, ensure that hypoglycemia does not occur, and then gradually control postprandial hyperglycemia, that is: first flatten the valley, then cut the peak.
The hospitalization treatment plan slides up to read the hypoglycemic treatment plan.
Premixed insulin injection, poor blood glucose control, adjust to insulin glargine U300 According to postprandial blood glucose level, it was decided to add acarbose (using insulin glargine U300 and adding acarbose 50mg tid after 3 days) life>
.

Dynamic blood glucose monitoring results: monitoring time: 72 hours total blood glucose: 889 times Average blood glucose: 9.
7 (3.
4-21.
1) mmol/L blood glucose ≥ 7.
8mmol/L time 43:40, accounting for 59% of blood glucose in 3.
9 ~ 7.
8 mmol/ L time 28:05, accounted for 38% blood glucose <3.
9mmol/L time 02:20, accounted for 3% CGMS overall evaluation: the patient's overall blood glucose fluctuates greatly, the highest blood sugar appears after breakfast on the first day, and the lowest blood sugar is on the first day The fasting blood glucose and postprandial blood glucose of the patients after dinner were both high, and the postprandial blood glucose was mainly elevated, mostly between 7.
8 and 12.
0mmol/L.
Hypoglycemia occurred less frequently, but both occurred at night and the risk was high
.

Dawn phenomenon is not significant 3.
Adjust to insulin glargine U300 discharge treatment plan and discharge follow-up scroll up to read the post-discharge treatment plan: 1.
Insulin glargine U300 18U qd, the patient can adjust the dosage according to the fasting blood glucose self-test.
2.
Aka Boose 50mg tid 3-month follow-up: During the outpatient follow-up, 1 month after discharge, self-test fasting blood glucose 7.
5mmol/L, the patient adjusted the dose of insulin glargine U300 to 19U qd, fasting blood glucose was controlled to 6-7mmol/L, blood glucose No hypoglycemia event occurred, the condition is stable, the blood glucose is about 10 mmol/L 2 hours after the meal, and the glycosylated hemoglobin is 7.
1% ■ Clinical thinking 1.
The insulin regimen should be patient-centered, evidence-based medical evidence-based, and individualized Target-oriented blood sugar control; scientifically and rationally determine feasible insulin varieties and medication plans on the premise of minimizing the risk of hypoglycemia and weight gain
.

2.
Basal insulin is the cornerstone of individualized treatment of diabetes, throughout the entire process
.

3.
Insulin glargine U300 is a more ideal choice for initial insulin therapy: it achieves stable glucose control while lowering the risk of hypoglycemia, can take into account the efficacy and safety, and the adjustment is more flexible and convenient, convenient to simplify medication, and patient experience High, can improve patient compliance
.

4.
Pre-mixed insulin blood glucose control is not good.
T2DM patients have large fluctuations in fasting blood glucose and postprandial blood glucose.
Lowering blood sugar needs to choose a more stable blood glucose control plan to avoid the sudden rise and fall of blood sugar and improve patient compliance
.

Experts comment on the case described by Director Chen Lei of Suzhou Municipal Hospital in this issue is an elderly T2DM patient with poor blood glucose control with premixed insulin, combined with diabetic retinopathy, hypertension grade 2 (very high risk), coronary heart disease, atrial fibrillation, and blood sugar substandard In addition, there are large fluctuations, high fasting blood glucose and postprandial blood glucose, and poor compliance.
It is necessary to control blood glucose steadily, reduce the risk of hypoglycemia, and improve patient compliance
.

In the 2021 Geriatric Diabetes Guidelines, basal insulin ranks among the first-level recommendations, which is better than premixed insulin [1]
.

The new generation of basal insulin analogue insulin glargine U300 uses subcutaneous reservoir microprecipitation technology to achieve a stable and sustained release, while steadily controlling sugar without increasing the risk of hypoglycemia, and better balancing efficacy and safety [2-5]
.

Previous studies have shown that [6] premixed insulin combined with OAD treatment is converted to glargine combined with OAD treatment, which can effectively control FBG and reduce the amount of insulin
.

Real-world research suggests: start insulin glargine U300 treatment, actively achieve FPG ≤6.
1 mmol/L, improve blood sugar in an all-round way, and do not increase the risk of hypoglycemia [7]
.

BRIGHT subgroup analysis: In elderly patients, insulin glargine U300 has a better hypoglycemic effect than insulin degluargine, and insulin glargine U300 and insulin deglucker have similar risks of hypoglycemia [8]
.

The patient in this case uses premixed insulin, which has poor compliance and needs to improve patient compliance
.

Insulin glargine U300 SoloSTAR® injection pen has accurate dosage, low injection pressure and good patient experience [9]
.

Insulin glargine U300 allows more free injection time (±3h) to cope with changes in daily life situations [10]
.

The method of adjusting one unit of insulin glargine U300 a day is effective and safe
.

For elderly T2DM patients with poorly controlled premixed insulin, the safety and effectiveness of the hypoglycemic regimen need to be considered.
Insulin glargine U300 can stably control glucose, reduce the risk of hypoglycemia, and also has a good patient experience and allows more freedom The advantages of injection time and other advantages make it a more ideal choice for insulin therapy
.

References: [1] National Center for Geriatrics, Chinese Medical Association Branch of Geriatrics, Diabetes Professional Committee of Chinese Geriatric Healthcare Association.
Chinese Diagnosis and Treatment Guidelines for Diabetes in the Elderly (2021 Edition).
Chinese Journal of Diabetes 2021,13(1):14-46.
[2]Hedrington MS et al.
Diabetes Technol Ther.
2011;13 Suppl 1:S33-42.
[3]Becker RH et al.
Diabetes Care.
2015;38:637-43.
[4]Jax T et al.
Poster presented at EASD 2013; Abstract 1029.
Available at http:// May 2014.
[5]Steinstraesser A et al.
Diabetes Obes Metab.
2014;16:873-6.
[6]Yang W,et al.
Curr Med Res Opin.
2012 Apr;28(4):533-41.
[7]Pfohl M, et al.
Diabetes Obes Metab 2020,22(5):759-766.
[8]Bernard Charbonnel , et al.
Presented at: American Diabetes Association Scientific Sessions 2019,131-LB.
[9]Klonoff D, et al.
J Diabetes Sci Technol 2015,10(1):125-130.
[10]Riddle MC, et al .
Diabetes Technol Ther 2016,18(4):252-257.
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