Patients with ASCVD and multiple complications, control sugar and ease work

*For medical professionals to read for reference, what kind of hypoglycemic plan is needed for middle-aged T2DM office workers with ASCVD? Case patient, female, 44 years old
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Main complaint: It was found that blood sugar had risen for 10 years
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History of present illness: The patient's routine physical examination during pregnancy 20 years ago (20 weeks of gestation) found that blood glucose was elevated, and fasting blood glucose was measured to be 8 mmol/L.
After examination in the local hospital, gestational diabetes was considered, and insulin hypoglycemic treatment was given
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After the lactation period, the local hospital adjusted to 30 mg gliquidone twice a day (BID) orally, self-tested fasting blood glucose of 6 mmol/L, and postprandial blood glucose of 9 mmol/L
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Two years ago, I went to the local hospital for a follow-up visit.
The adjusted plan was metformin 0.
5 g three times a day (TID) + acarbose 50 mg TID orally.
The blood glucose was not monitored regularly, and the diagnosis and treatment were not performed regularly
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A week ago, I went to the outpatient department of our hospital for reexamination, and checked the glycosylated hemoglobin (HbA1c) 11.
8%.
Considering the poor blood sugar control of type 2 diabetes, he was admitted to the hospital for further diagnosis and treatment
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The patient's recent appetite and sleep are good, and his weight remains unchanged
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Personal history: Denies the history of hypertension, coronary heart disease, chronic kidney disease and other diseases, and denies the history of smoking and drinking
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Family history: Mother, grandmother, and grandmother all suffered from type 2 diabetes
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▌ Physical examination: Note: Body Mass Index (BMI)
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Body temperature is 37°C, pulse rate is 75 beats/min, and breathing is 18 beats/min
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Hairless too dense, non-moon face, buffalo hump, and the like purple lines
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There was no obvious abnormality in the physical examination of the heart, lungs and abdomen
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Both dorsal foot arteries were pulsating, there was no edema in both lower limbs, and no ulcers were seen in both lower limbs
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Bilateral ankle reflex (++), bilateral Pap sign (-)
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▌ Auxiliary examination: Note: total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (γ-GT) , Creatinine (Scr)
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▌ Preliminary diagnosis: type 1.
2 diabetes mellitus diabetic ketosis diabetic nephropathy diabetic peripheral neuropathy diabetic retinopathy (non-proliferative phase) 2.
atherosclerosis 3.
hyperlipidemia 4.
fatty liver 5.
solid lung nodules 6.
Cataract ▌ Treatment plan: the first stage (1~4 days after admission): massive rehydration + continuous intravenous infusion of insulin to correct ketone therapy, and continuous monitoring of blood glucose levels
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After the ketosis is relieved, switch to insulin subcutaneous injection treatment: insulin aspart TID + insulin detemir once a night (QN) subcutaneous injection
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Oral medication was added from the 4th day: metformin 1.
0 g BID + acarbose 100 mg TID
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The second stage of blood glucose monitoring (mmol/L): plan to change to a comprehensive treatment plan before discharge, insulin aspart before stopping meals, and use the glucagon-like peptide-1 receptor agonist (GLP-1RA) liraglutide[ The initial dose is 0.
6 mg once daily (QD), increased to 1.
2 mg QD after 2 days, and 1.
8 mg QD after 1 week], combined with 24 U of insulin detemir subcutaneous injection + metformin 1.
0 g BID + acarbose 100 before bedtime mg TID
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At the same time, life>
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Blood glucose monitoring (mmol/L) After 2 weeks of treatment, blood sugar was well controlled, and insulin detemir was gradually reduced; after 3 months of treatment, her weight was reduced by 6 kg
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The comparison of relevant auxiliary examination results after 3 months of treatment is as follows: Doctor interviews the medical profession: In this case, based on the characteristics of the patient, why did you choose to stop the 3+1 insulin injection plan and switch to basal insulin combined with GLP-1RA? Do you think the final effect is satisfactory? Dr.
Lin Yi: The advantage of GLP-1RA lies in its pathophysiological mechanism for the onset of type 2 diabetes
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In recent years, our goal of hypoglycemic therapy has progressed from pure hypoglycemic treatment to improving the pathophysiological defects of diabetes
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Impaired secretin effect is one of the important mechanisms of type 2 diabetes.
GLP-1RA supplements this problem
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In addition, the following three points are also the main reasons for our application of GLP-1RA: ①GLP-1RA stimulates insulin secretion and inhibits glucagon secretion in a glucose concentration-dependent manner, effectively manages blood glucose throughout the day and reduces postprandial blood glucose; long-acting basic insulin One injection can improve the control of the whole stomach and pre-meal blood sugar
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Such a combination plan can cover the whole day's blood glucose spectrum, which can not only control fasting and postprandial blood glucose at the same time, but also help reduce blood glucose fluctuations
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②In the process of long-term clinical application, GLP-1RA has shown high therapeutic safety.
It "intelligently" reduces blood sugar in a glucose concentration-dependent manner, with low risk of hypoglycemia and high safety factor
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③The reduction in the number of injections will help patients to improve their confidence in disease management
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The 4-needle plan will undoubtedly have a great impact on the life of patients, and it is necessary to simplify the treatment plan
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This strategy of formulating a treatment plan based on the individual characteristics of the patient is also a prerequisite for ensuring the benefit of the patient
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Medical profession: This patient has diseases such as atherosclerosis and belongs to a high-risk group of cardiovascular disease.
In addition to reducing blood sugar, it is necessary to pay attention to how to control cardiovascular risk factors and improve cardiovascular outcomes
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Except for reducing blood sugar to reach the standard, does liraglutide bring other benefits to this patient? Dr.
Lin Yi: This patient is only 44 years old and has had a course of diabetes for 20 years
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The earlier a patient’s age is, the more he faces the risk of atherosclerotic cardiovascular disease (ASCVD)
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At present, under the protection of estrogen, this risk may not be obvious, but once the patient is in the perimenopausal period, the patient may be affected by cardiovascular and cerebrovascular complications
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The color Doppler ultrasound results indicate that the patient already has atherosclerotic plaque, and timely intervention to prevent the progression of ASCVD is very important
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In addition to lowering blood sugar, GLP-1RA brings other benefits to patients, which is also the main reason why we use this type of drug.
From the case point of view, patients also have the following benefits: ① Weight loss and constriction
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Chinese registration studies [1] suggest that different doses of liraglutide can reduce body weight by 1.
8~2.
44kg
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At the same time, liraglutide can reduce waist circumference and visceral fat, thereby reducing the risk of future cardiovascular and cerebrovascular diseases in patients
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②Improve blood lipid profile
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LEAD series of studies [2] suggest that liraglutide can reduce the levels of total cholesterol, triglycerides and low-density lipoprotein cholesterol [2]
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③ Cardiovascular benefits
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LEADER study [3] confirmed that liraglutide significantly reduces the risk of major cardiovascular adverse events (MACE) by 13%, bringing long-term benefits to patients
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According to the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)" [4] For diabetic patients with ASCVD or high cardiovascular risk factors, after life>
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The patient met the characteristics of the population recommended by the guidelines, so GLP-1RA liraglutide, which has cardiovascular benefits, was added
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All in all, through treatment, we hope to reduce the risk of cardiovascular disease in patients and extend the life of patients, not just lowering blood sugar.
This is our original intention to treat patients
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Medical community: In this case, does liraglutide benefit and improve the patient's microvascular disease? Dr.
Lin Yi: Unlike diabetic diabetic macrovascular complications that are affected by many factors such as blood pressure, blood lipids, and blood sugar, diabetic microvascular complications such as retinal and kidney disease are mainly affected by long-term high blood sugar
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In this case, the patient has retinopathy and proteinuria, which proves that the patient has diabetic microangiopathy.
Therefore, in order to improve this situation, we need to control blood sugar as the basis
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Liraglutide significantly reduces blood sugar (11.
8% to 7.
1%), and at the same time blood lipid profile, blood pressure are also improved, and proteinuria is significantly improved, suggesting that liraglutide can reduce the risk of microvascular disease in patients
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The LEADER study further confirmed that liraglutide significantly reduces the risk of microvascular events by 16%
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Therefore, liraglutide can be used safely in such patients
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In clinical practice, we should also pay attention to the screening and follow-up of patients with related lesions.
For patients with multiple complications, it is more suitable to use drugs with multiple benefits such as liraglutide
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Experts comment on the medical community: Which patients do you think should start liraglutide therapy in time? Professor Peng Yongde: There have been many new drugs in the field of diabetes treatment.
GLP-1RA is one of them.
Liraglutide has been clinically used in China for 10 years and has also been widely recognized.
It is currently believed that the following patients can consider starting the drug Laglutide treatment: Patients with type 2 diabetes whose blood sugar is still poorly controlled after the maximum tolerable dose of metformin or sulfonylureas are used in combination with metformin or sulfonylureas
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It is especially suitable for patients with BMI ≥ 25 kg/m2
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Diabetes patients with ASCVD or high cardiovascular risk factors may consider starting GLP-1RA therapy (such as liraglutide) [4]
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Type 2 diabetes patients with chronic kidney disease (CKD), regardless of whether HbA1c is up to standard, as long as there is no contraindication, sodium-glucose cotransporter (SGLT2) inhibitors should be added to metformin [2], if the patient cannot use SGLT2 Inhibitors (such as heavy eGFR not allowed), consider using GLP-1RA (such as liraglutide) [4]
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Medical profession: What are your personal opinions on the dosage adjustment of liraglutide? Please share with us
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Professor Peng Yongde: The most common adverse reaction of GLP-1RA treatment is gastrointestinal reaction.
In the early stage of injection, patients may experience adverse reactions such as loss of appetite, anorexia, nausea, vomiting, and diarrhea.
Some patients may also experience constipation
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Generally these adverse reactions are transient
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Moreover, in order to further reduce adverse reactions, we can start with a small dose when applying
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0.
6 mg was applied daily.
After 1 week, the dose was increased to 1.
2 mg after the patient tolerated it.
If the patient tolerated it for 1 week, the dose could be increased to 1.
8 mg
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According to our clinical experience, for patients with very poor tolerance, the dose can be increased according to clinical experience and patient conditions
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It needs to be emphasized that if patients with strong indications of laglutide have adverse reactions, they should not stop the drug as much as possible to ensure that the patients get the greatest long-term benefit
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Strategies such as explanation, drug reduction, and application of drugs to improve gastrointestinal motility can be adopted to allow patients to adhere to the application as much as possible to ensure the maximum benefit for patients
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References: [1]Yang W,et al.
Diabetes Obes Metab.
2011;13(1):81-8.
[2]Buse JB,et al.
Lancet.
2009;374(9683):39-47.
[ 3]Marso SP,et al.
N Engl J Med.
2016 Jul 28;375(4):311-22.
[4] Diabetes Branch of Chinese Medical Association.
Chinese Journal of Diabetes.
2021;13(4):315-409 .
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