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*For medical professionals to read and refer to diabetes + complications and comorbidities, only one injection a week after discharge can stabilize blood sugar
.
The patient, male, 44 years old, was admitted to the hospital because of "discovery of elevated blood sugar for 6 years and dry mouth for 2 months"
.
History of present illness: The patient's physical examination found elevated blood sugar 6 years ago, fasting blood glucose (FPG): 8.
6 mmol/L, and then was diagnosed with type 2 diabetes by oral glucose tolerance test (OGTT), and started to take oral hypoglycemic drugs 4 years ago.
blood sugar
.
The recent hypoglycemic regimen is metformin sustained-release tablets 1 g twice a day (BID), acarbose 100 mg three times a day (TID), blood sugar is not regularly monitored, and blood sugar control is unknown
.
Dry mouth, polydipsia, and numbness of limbs began to appear before 2 months.
The outpatient measurement of FPG was 13.
0mmol/L, and the glycosylated hemoglobin (HbA1c) was 11.
5%.
He was admitted to our department for further diagnosis and treatment
.
Past history: a history of hyperlipidemia, taking atorvastatin treatment; denying the history of coronary heart disease and hypertension
.
He denied any history of infectious diseases such as hepatitis and tuberculosis
.
Personal history and family history: the mother has a history of type 2 diabetes, the father has a history of hypertension, and has no history of other mental and genetic diseases
.
Physical examination: body temperature 36.
3°C, respiration 20/min, pulse 85/min, blood pressure 158/98mmHg
.
Cardiopulmonary abdominal sign (-), no edema in both lower extremities, and normal muscle tone in the limbs
.
The lower extremities were not swollen, and the pulse of the dorsal artery of the feet was weakened
.
Auxiliary tests: Laboratory tests: Note: Alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum total cholesterol (TC), serum triglyceride (TG), high density lipoprotein Cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), 2-hour postprandial blood glucose (2hPPG), prothrombin time (PT), international normalized ratio (INR), sodium (Na+), potassium ( K+), chlorine (Cl-)
.
Physical examination: Diagnosis of type 1 and type 2 diabetic peripheral neuropathy, diabetic peripheral vascular disease 2, hypertension grade II (very high risk) 3, hyperlipidemia 4, fatty liver (severe) Treatment plan ① The first stage: 2 In patients with type 2 diabetes mellitus with marked hyperglycemia, intensive insulin pump therapy can be used to improve glucotoxicity as soon as possible
.
On admission, insulin was continuously infused subcutaneously to control blood sugar
.
②The second stage: The insulin pump was discontinued 1 week after admission, and basal insulin + metformin sustained-release tablets and dapagliflozin were given
.
③The third stage: 5 days later (discharge): semaglutide 0.
25mg QW, metformin extended-release tablets, dapagliflozin, nateglinide 3 weeks after discharge: semaglutide 0.
5mg QW, metformin delayed Release tablets, dapagliflozin Blood glucose profile (mmol/L): 3-month follow-up after discharge: FPG, PPG, HbA1c, body weight, blood lipids, blood pressure, etc.
were all decreased compared with those before admission (see the table below for details)
.
★The doctor shared with the medical community: The diabetic patient has poor blood sugar control and is accompanied by a variety of comorbidities and diabetic complications.
How do you formulate an individualized hypoglycemic plan for the patient? What kind of hypoglycemic effect and other benefits does the use of semaglutide bring to patients? Professor Deng Tingting: The patient is a 44-year-old middle-aged man with a history of diabetes for 6 years.
His pancreatic islet function is acceptable.
He has a history of hyperlipidemia, an irregular diet, and an obese body.
Two oral hypoglycemic drugs are used to treat poor blood sugar control.
FPG and PPG are not up to the standard
.
New-onset hypertension, diabetic peripheral nerve and vascular disease on admission
.
Based on the characteristics of the patient, effective hypoglycemic control is required first, and at the same time, it is urgent to manage indicators such as blood lipids, blood pressure, and body weight
.
Due to the existing arterial plaque, timely treatment is needed to prevent atherosclerotic cardiovascular disease (ASCVD)
.
The "China Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)" pointed out that metformin is the first-line drug for hyperglycemia control and the basic drug in the combination of drugs for patients with type 2 diabetes.
, heart failure or chronic kidney disease (CKD), it is recommended to first combine glucagon-like peptide-1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter- 2 inhibitor (SGLT-2i) [1]
.
The GLP-1RA weekly preparation, semaglutide, which was just launched in 2021, has a significant hypoglycemic effect, and can improve blood lipids, blood pressure, body weight and other indicators [2].
It also has indications for reducing cardiovascular risk in patients with type 2 diabetes.
Combined with the patient's desire to reduce the number of injections and simplify the treatment plan, we chose this drug for the patient, together with dapagliflozin, hoping to help patients with strong blood sugar lowering while achieving comprehensive management and multiple benefits
.
After treatment, the hypoglycemic effect was obvious.
After 3 months, HbA1c decreased from 11.
5% to 7.
8%, FPG decreased from 13.
21mmol/L to 6.
1mmol/L, and 2hPPG decreased from 18.
9mmol/L to 7.
9mmol/L.
, blood pressure, blood lipids and other cardiovascular and metabolic indicators have also been significantly improved, and the overall effect is satisfactory
.
Medical community: This patient has severe fatty liver.
What is your opinion on the treatment of such patients? Professor Deng Tingting: Fatty liver increases the risk of death in patients.
Studies have shown that even mild fatty liver increases the risk of death, and the risk of death increases with the severity of the disease [3]
.
Therefore, timely management is very important
.
In this case, the patient's fatty liver improved after treatment
.
Previously, many studies have shown the potential of GLP-1RA drugs in the treatment of non-alcoholic fatty liver disease, which needs to be further explored in the future [4]
.
★The director commented on the medical community: Please talk about what kind of diabetic patients are suitable for the application of semaglutide for hypoglycemic therapy based on the situation of your hospital department? Director Qin Yingfen: When a patient is diagnosed with type 2 diabetes, we will first conduct complication screening to assess whether the patient has comorbidities such as ASCVD.
beneficial drug regimen
.
The "Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)"[1] recommends that T2DM patients with ASCVD or high risk factors for ASCVD, regardless of whether their HbA1c is up to standard, should use metformin on the basis of evidence of ASCVD benefit as long as there is no contraindication GLP-1RA or SGLT-2i
.
According to the "Criteria for Diabetes Care (2022 Edition)" issued by the American Diabetes Association (ADA) [5], for patients with type 2 diabetes with ASCVD or high-risk factors, heart failure and/or chronic kidney disease, use as needed has clear benefits GLP-1RA, SGLT-2i, with or without metformin, may be suitable first-line initial treatment regimens
.
Choosing such a drug can not only potently lower blood sugar, but also protect the cardiovascular system
.
In addition, for patients with type 2 diabetes who do not have ASCVD or high risk factors for ASCVD, injectable drugs, such as GLP-1RA and insulin, can be used in combination with metformin treatment to further control blood sugar[1,5]
.
GLP-1RA is recommended as the preferred injection preparation in the Diabetes Treatment Standards (2022 Edition), which can effectively control glucose while reducing the risk of hypoglycemia without increasing the risk of weight gain [5]
.
As a newly marketed weekly preparation of GLP-1RA, semaglutide has a half-life of up to 7 days.
It can effectively lower blood sugar by subcutaneous injection once a week.
It is simple and easy to use and helps improve patient compliance.
It can be said that for For patients with type 2 diabetes, semaglutide is indeed a recommended medication option
.
Medical community: Talk about the current clinical use of semaglutide, liraglutide and other hypoglycemic drugs with cardiovascular indications in China, and your views on their future use
.
Director Qin Yingfen: With the deepening of the understanding of diabetes, the goal of diabetes treatment has gradually changed from "simple hypoglycemic and intensive hypoglycemic" in the early stage to "target organ protection", "prevention of chronic complications, improvement of patients' quality of life and improvement of diabetes".
life expectancy”, and the “Guidelines for the Prevention and Treatment of Type 2 Diabetes in China” are constantly being updated[1,6,7], which is also due to the birth of new drugs such as GLP-1RA that can effectively lower blood sugar and have cardiovascular benefits , provides a powerful weapon for clinicians
.
Although it has been recommended by authoritative guidelines at home and abroad [1, 5], the current status of the use of such hypoglycemic drugs in China is not optimistic, and there is still a lot of room for improvement from the guideline recommendation to clinical application
.
The CAPTURE China subgroup study shows [8]: 33.
9% of Chinese patients with type 2 diabetes suffer from cardiovascular disease (CVD), and about 95% of them have ASCVD, suggesting the necessity of clinical application of drugs with cardiovascular benefits.
However, ASCVD Only 1.
5% of patients were prescribed GLP-1RA with clear cardiovascular benefit
.
Awareness and compliance with the use of such drugs still needs to be improved
.
With the launch of semaglutide, we have a one-week injection that can take into account the efficacy and safety of hypoglycemics, as well as the treatment options for reducing cardiovascular risk in patients with type 2 diabetes, bringing great benefits to patients.
It is convenient and helps to improve patient compliance.
It is expected that such drugs can be applied to more suitable diabetic patients in the future to benefit more patients
.
In addition, drug prices are also an important factor hindering patients from using injectable drugs.
Recently, with the entry of semaglutide into the medical insurance catalog, the price has been greatly reduced, which also brings good news to patients
.
Reference: [1] Diabetes Branch of Chinese Medical Association.
International Journal of Endocrinology and Metabolism.
2021;41(05):482-548.
[2]Marso SP et al.
N Engl J Med.
2016;375:1834–44.
[3]Simon TG, et al.
Gut.
2020 Oct 9:gutjnl-2020-322786.
[4]Mantovani A, et al.
Metabolites.
2021 Jan 27;11(2):73.
[5]Diabetes Care.
2022 Jan;45(Suppl 1):S1-S264.
[6] Chinese Medical Association Diabetes Society.
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China: 2010 Edition[M].
Peking University Medical Press.
2011.
[7] Jia Weiping, et al.
Chinese Journal of Diabetes.
2018;10(1):4-67.
[8]Guillermo Dieuzeide.
2021 ADA presentation.
-End-"This article is only for providing scientific information to healthcare professionals and does not represent the platform's position" Contribution/ For reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
.
The patient, male, 44 years old, was admitted to the hospital because of "discovery of elevated blood sugar for 6 years and dry mouth for 2 months"
.
History of present illness: The patient's physical examination found elevated blood sugar 6 years ago, fasting blood glucose (FPG): 8.
6 mmol/L, and then was diagnosed with type 2 diabetes by oral glucose tolerance test (OGTT), and started to take oral hypoglycemic drugs 4 years ago.
blood sugar
.
The recent hypoglycemic regimen is metformin sustained-release tablets 1 g twice a day (BID), acarbose 100 mg three times a day (TID), blood sugar is not regularly monitored, and blood sugar control is unknown
.
Dry mouth, polydipsia, and numbness of limbs began to appear before 2 months.
The outpatient measurement of FPG was 13.
0mmol/L, and the glycosylated hemoglobin (HbA1c) was 11.
5%.
He was admitted to our department for further diagnosis and treatment
.
Past history: a history of hyperlipidemia, taking atorvastatin treatment; denying the history of coronary heart disease and hypertension
.
He denied any history of infectious diseases such as hepatitis and tuberculosis
.
Personal history and family history: the mother has a history of type 2 diabetes, the father has a history of hypertension, and has no history of other mental and genetic diseases
.
Physical examination: body temperature 36.
3°C, respiration 20/min, pulse 85/min, blood pressure 158/98mmHg
.
Cardiopulmonary abdominal sign (-), no edema in both lower extremities, and normal muscle tone in the limbs
.
The lower extremities were not swollen, and the pulse of the dorsal artery of the feet was weakened
.
Auxiliary tests: Laboratory tests: Note: Alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum total cholesterol (TC), serum triglyceride (TG), high density lipoprotein Cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), 2-hour postprandial blood glucose (2hPPG), prothrombin time (PT), international normalized ratio (INR), sodium (Na+), potassium ( K+), chlorine (Cl-)
.
Physical examination: Diagnosis of type 1 and type 2 diabetic peripheral neuropathy, diabetic peripheral vascular disease 2, hypertension grade II (very high risk) 3, hyperlipidemia 4, fatty liver (severe) Treatment plan ① The first stage: 2 In patients with type 2 diabetes mellitus with marked hyperglycemia, intensive insulin pump therapy can be used to improve glucotoxicity as soon as possible
.
On admission, insulin was continuously infused subcutaneously to control blood sugar
.
②The second stage: The insulin pump was discontinued 1 week after admission, and basal insulin + metformin sustained-release tablets and dapagliflozin were given
.
③The third stage: 5 days later (discharge): semaglutide 0.
25mg QW, metformin extended-release tablets, dapagliflozin, nateglinide 3 weeks after discharge: semaglutide 0.
5mg QW, metformin delayed Release tablets, dapagliflozin Blood glucose profile (mmol/L): 3-month follow-up after discharge: FPG, PPG, HbA1c, body weight, blood lipids, blood pressure, etc.
were all decreased compared with those before admission (see the table below for details)
.
★The doctor shared with the medical community: The diabetic patient has poor blood sugar control and is accompanied by a variety of comorbidities and diabetic complications.
How do you formulate an individualized hypoglycemic plan for the patient? What kind of hypoglycemic effect and other benefits does the use of semaglutide bring to patients? Professor Deng Tingting: The patient is a 44-year-old middle-aged man with a history of diabetes for 6 years.
His pancreatic islet function is acceptable.
He has a history of hyperlipidemia, an irregular diet, and an obese body.
Two oral hypoglycemic drugs are used to treat poor blood sugar control.
FPG and PPG are not up to the standard
.
New-onset hypertension, diabetic peripheral nerve and vascular disease on admission
.
Based on the characteristics of the patient, effective hypoglycemic control is required first, and at the same time, it is urgent to manage indicators such as blood lipids, blood pressure, and body weight
.
Due to the existing arterial plaque, timely treatment is needed to prevent atherosclerotic cardiovascular disease (ASCVD)
.
The "China Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)" pointed out that metformin is the first-line drug for hyperglycemia control and the basic drug in the combination of drugs for patients with type 2 diabetes.
, heart failure or chronic kidney disease (CKD), it is recommended to first combine glucagon-like peptide-1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter- 2 inhibitor (SGLT-2i) [1]
.
The GLP-1RA weekly preparation, semaglutide, which was just launched in 2021, has a significant hypoglycemic effect, and can improve blood lipids, blood pressure, body weight and other indicators [2].
It also has indications for reducing cardiovascular risk in patients with type 2 diabetes.
Combined with the patient's desire to reduce the number of injections and simplify the treatment plan, we chose this drug for the patient, together with dapagliflozin, hoping to help patients with strong blood sugar lowering while achieving comprehensive management and multiple benefits
.
After treatment, the hypoglycemic effect was obvious.
After 3 months, HbA1c decreased from 11.
5% to 7.
8%, FPG decreased from 13.
21mmol/L to 6.
1mmol/L, and 2hPPG decreased from 18.
9mmol/L to 7.
9mmol/L.
, blood pressure, blood lipids and other cardiovascular and metabolic indicators have also been significantly improved, and the overall effect is satisfactory
.
Medical community: This patient has severe fatty liver.
What is your opinion on the treatment of such patients? Professor Deng Tingting: Fatty liver increases the risk of death in patients.
Studies have shown that even mild fatty liver increases the risk of death, and the risk of death increases with the severity of the disease [3]
.
Therefore, timely management is very important
.
In this case, the patient's fatty liver improved after treatment
.
Previously, many studies have shown the potential of GLP-1RA drugs in the treatment of non-alcoholic fatty liver disease, which needs to be further explored in the future [4]
.
★The director commented on the medical community: Please talk about what kind of diabetic patients are suitable for the application of semaglutide for hypoglycemic therapy based on the situation of your hospital department? Director Qin Yingfen: When a patient is diagnosed with type 2 diabetes, we will first conduct complication screening to assess whether the patient has comorbidities such as ASCVD.
beneficial drug regimen
.
The "Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)"[1] recommends that T2DM patients with ASCVD or high risk factors for ASCVD, regardless of whether their HbA1c is up to standard, should use metformin on the basis of evidence of ASCVD benefit as long as there is no contraindication GLP-1RA or SGLT-2i
.
According to the "Criteria for Diabetes Care (2022 Edition)" issued by the American Diabetes Association (ADA) [5], for patients with type 2 diabetes with ASCVD or high-risk factors, heart failure and/or chronic kidney disease, use as needed has clear benefits GLP-1RA, SGLT-2i, with or without metformin, may be suitable first-line initial treatment regimens
.
Choosing such a drug can not only potently lower blood sugar, but also protect the cardiovascular system
.
In addition, for patients with type 2 diabetes who do not have ASCVD or high risk factors for ASCVD, injectable drugs, such as GLP-1RA and insulin, can be used in combination with metformin treatment to further control blood sugar[1,5]
.
GLP-1RA is recommended as the preferred injection preparation in the Diabetes Treatment Standards (2022 Edition), which can effectively control glucose while reducing the risk of hypoglycemia without increasing the risk of weight gain [5]
.
As a newly marketed weekly preparation of GLP-1RA, semaglutide has a half-life of up to 7 days.
It can effectively lower blood sugar by subcutaneous injection once a week.
It is simple and easy to use and helps improve patient compliance.
It can be said that for For patients with type 2 diabetes, semaglutide is indeed a recommended medication option
.
Medical community: Talk about the current clinical use of semaglutide, liraglutide and other hypoglycemic drugs with cardiovascular indications in China, and your views on their future use
.
Director Qin Yingfen: With the deepening of the understanding of diabetes, the goal of diabetes treatment has gradually changed from "simple hypoglycemic and intensive hypoglycemic" in the early stage to "target organ protection", "prevention of chronic complications, improvement of patients' quality of life and improvement of diabetes".
life expectancy”, and the “Guidelines for the Prevention and Treatment of Type 2 Diabetes in China” are constantly being updated[1,6,7], which is also due to the birth of new drugs such as GLP-1RA that can effectively lower blood sugar and have cardiovascular benefits , provides a powerful weapon for clinicians
.
Although it has been recommended by authoritative guidelines at home and abroad [1, 5], the current status of the use of such hypoglycemic drugs in China is not optimistic, and there is still a lot of room for improvement from the guideline recommendation to clinical application
.
The CAPTURE China subgroup study shows [8]: 33.
9% of Chinese patients with type 2 diabetes suffer from cardiovascular disease (CVD), and about 95% of them have ASCVD, suggesting the necessity of clinical application of drugs with cardiovascular benefits.
However, ASCVD Only 1.
5% of patients were prescribed GLP-1RA with clear cardiovascular benefit
.
Awareness and compliance with the use of such drugs still needs to be improved
.
With the launch of semaglutide, we have a one-week injection that can take into account the efficacy and safety of hypoglycemics, as well as the treatment options for reducing cardiovascular risk in patients with type 2 diabetes, bringing great benefits to patients.
It is convenient and helps to improve patient compliance.
It is expected that such drugs can be applied to more suitable diabetic patients in the future to benefit more patients
.
In addition, drug prices are also an important factor hindering patients from using injectable drugs.
Recently, with the entry of semaglutide into the medical insurance catalog, the price has been greatly reduced, which also brings good news to patients
.
Reference: [1] Diabetes Branch of Chinese Medical Association.
International Journal of Endocrinology and Metabolism.
2021;41(05):482-548.
[2]Marso SP et al.
N Engl J Med.
2016;375:1834–44.
[3]Simon TG, et al.
Gut.
2020 Oct 9:gutjnl-2020-322786.
[4]Mantovani A, et al.
Metabolites.
2021 Jan 27;11(2):73.
[5]Diabetes Care.
2022 Jan;45(Suppl 1):S1-S264.
[6] Chinese Medical Association Diabetes Society.
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China: 2010 Edition[M].
Peking University Medical Press.
2011.
[7] Jia Weiping, et al.
Chinese Journal of Diabetes.
2018;10(1):4-67.
[8]Guillermo Dieuzeide.
2021 ADA presentation.
-End-"This article is only for providing scientific information to healthcare professionals and does not represent the platform's position" Contribution/ For reprint/business cooperation, please contact: pengsanmei@yxj.
org.
cn
