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*Only for medical professionals to read for reference.
Starting from the characteristics of elderly diabetic patients, explore the blood sugar management plan
.
With the intensification of aging in our country, the prevalence of diabetes in the elderly has increased significantly
.
IDF Global Diabetes Map predicts that by 2045, the number of elderly (65-99 years old) diabetic patients in China will reach 78.
1 million [1].
The management of elderly diabetes is in urgent need of standardization, and medication guidance urgently needs to be refined
.
Based on this, the "medical community" specially invited Professor Ma Li, the director of the Endocrinology Department of the Xinjiang Uygur Autonomous Region Traditional Chinese Medicine Hospital, to further interpret the characteristics of elderly type 2 diabetes (T2DM) patients, diabetes management and medication principles for the majority of medical workers
.
Q Medical circles: The prevalence of T2DM in the elderly in my country is high, and the number of patients is predicted to continue to increase.
This has gradually become an urgent problem in the field of diabetes treatment.
What do you think are the characteristics of elderly patients? ▎Professor Ma Li: China is a big country with diabetes, and the number of patients has exceeded 141 million
.
A nationwide cross-sectional study showed that the prevalence of T2DM among people aged 60-69 in China was 28.
8%, and the prevalence rate of people over 70 years old was 31.
8% [2]
.
Therefore, blood glucose management and program optimization of elderly T2DM patients in China is an important task of endocrinologists
.
Elderly patients have the following characteristics: Large differences in health status and heterogeneity: Due to differences in personal factors, genetic factors, environmental factors, life>
.
Clinical symptoms are not typical: Most elderly diabetic patients do not have obvious symptoms of "three more and one less" (ie polydipsia, polydipsia, polyuria, polyphagia, unexplained weight loss)
.
There are more complications and/or accompanying diseases: some elderly diabetic patients even start with complications or accompanying diseases as the first manifestation
.
Medication needs to pay attention to the complications of elderly patients, especially cardiovascular disease, followed by factors such as retinopathy, neuropathy, cerebrovascular disease, peripheral vascular disease and diabetic nephropathy.
It is necessary to coordinate the overall plan and comprehensively consider the treatment plan
.
The risk of hypoglycemia is high: elderly diabetic patients have weakened neurological reactivity, and their response threshold to hypoglycemia is lowered, and they are very prone to severe hypoglycemia; the ability to perceive hypoglycemia is reduced, leading to the risk of asymptomatic hypoglycemia in elderly diabetic patients than non-diabetics Patients are taller and more likely to suffer from severe hypoglycemia and even death [3]
.
Multiple medications: Elderly patients are often accompanied by multiple comorbidities.
The phenomenon of multiple medications is more common.
There are often unclear interactions between drugs, which can easily cause drug-induced diseases [4]
.
Cognitive impairment: Some elderly patients have memory loss and slow response, making it difficult to perform complex self-management tasks [5], such as monitoring blood sugar and adjusting insulin doses
.
Q Medical Circle: "Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)"[6] pointed out that life>How to do it ▎Professor Ma Li: Life>
.
Individualized life>
.
On the one hand, nutritional therapy is the basis of diabetes treatment, and should run through the entire course of diabetes treatment, by controlling total calorie intake, meal distribution, and dietary structure adjustment to help blood sugar reach the target
.
First of all, the nutritional status of elderly patients with T2DM should be evaluated, including blood routine, biochemical, creatinine clearance, etc.
, and appropriate adjustments should be made based on inherent eating habits.
When formulating nutritional treatment programs, attention should be paid to appropriately increasing protein and energy intake
.
Elderly diabetic patients have low muscle content, and adequate energy intake can avoid muscle protein breakdown.
Protein intake should be increased appropriately, with high-quality protein intake rich in leucine and other branched-chain amino acids
.
Carbohydrates are the main source of energy for elderly diabetic patients in China.
During meals, attention should be paid to the order of carbohydrates, protein and vegetables consumed by elderly patients.
Eating carbohydrates later can reduce the patient's postprandial blood sugar increase
.
For elderly diabetic patients with unbalanced food intake for a long time, it is also necessary to pay attention to supplementing vitamins and minerals [6]
.
On the other hand, exercise therapy can improve insulin resistance in diabetic patients [7]
.
Before starting exercise therapy, elderly diabetic patients need to conduct exercise risk assessment based on medical history, family history, physical activity level, and related medical examination results, and pass cardiopulmonary endurance, body composition, muscle strength and muscle endurance, flexibility and balance ability, etc.
This test evaluates the exercise ability of elderly patients and provides a basis for the formulation of exercise treatment programs [6]
.
Endocrinologists can instruct patients to reasonably arrange the interval between medication time and exercise time, and evaluate the impact of exercise on drug metabolism
.
Encourage elderly patients to choose suitable exercise methods that can be adhered to for a long time (such as aerobic exercise, resistance training, etc.
).
Elderly patients should be prevented from falling during exercise and be alert to hypoglycemia during and after exercise [6]
.
QMedical community: The "Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)" includes nine types of hypoglycemic drugs, including oral drugs and injection drugs.
For elderly patients, what principles should be followed when choosing these drugs? How to choose hypoglycemic drugs to help patients safely reduce blood sugar? ▎Professor Ma Li: Based on the particularity of elderly diabetic patients, the choice of drugs needs to be more targeted
.
Most elderly patients have unsatisfactory β-cell function, and the incidence of hypoglycemia is relatively high
.
The results of the comprehensive assessment of the patient’s health status and the corresponding blood sugar control goals should be combined.
Elderly T2DM patients whose blood sugar still does not meet the standard after life>
.
The principles of drug treatment include [4]: Give preference to drugs with a lower risk of hypoglycemia
.
In order to avoid the risk of hypoglycemia in elderly diabetic patients, reasonable individualized blood glucose control goals should be established, and hypoglycemic drugs with low risk of hypoglycemia, such as metformin, α-glycosidase inhibitors, and dipeptidyl peptidase-4 inhibitors (DPP- 4i), Na + - glucose cotransporter-2 inhibitors (SGLT-2i) and the like
.
Choose simple and highly compliant drugs to reduce the risk of multiple drugs
.
Consider the application of oral drugs, drugs that are less frequently administered and simple to operate
.
When formulating a drug treatment plan, it is necessary to consider the drug use of elderly patients.
For patients with multiple drugs, try to choose hypoglycemic drugs with less drug interactions to avoid adverse drug-drug interactions
.
Weigh the benefit-risk ratio and avoid over-treatment
.
For elderly diabetic patients with poor health, the goal of blood sugar control can be appropriately relaxed, but it should be based on "avoid high blood sugar and obvious symptoms of diabetes", "avoid high blood sugar and high blood sugar crisis", and "avoid low blood sugar symptoms.
" "Principles such as choosing hypoglycemic drugs
.
Pay attention to factors such as liver and kidney function, heart function, complications and accompanying diseases
.
New hypoglycemic drugs with related benefits besides hypoglycemia can be used, such as glucagon-like peptide-1 receptor agonist (GLP-1RA), which can reduce the risk of adverse cardiovascular events in patients and reduce cardiovascular death or heart failure Hospitalization risk
.
QMedical community: Because elderly patients with T2DM have more comorbidities and their body functions are degraded, multiple medications are common and unavoidable in elderly diabetic patients.
Is there any risk in multi-drug combination therapy? What should be done clinically to avoid the side effects caused by multiple medications as much as possible? ▎Professor Ma Li: Elderly diabetic patients often have hypertension, coronary heart disease, stroke and chronic respiratory diseases.
Multiple medications are common and unavoidable in elderly diabetic patients
.
Multi-drug treatment refers to the simultaneous use of ≥5 drugs by the patient
.
Multiple medications will increase the risk of drug interactions, which may not only affect the blood glucose-lowering efficacy of elderly diabetic patients, but may also increase the risk of hypoglycemia [5]
.
For multiple medications, attention should be paid to individualized dosage
.
The individual differences in the medication response of the elderly are more prominent than those of the young.
The medication should start with a small dose and gradually reach the appropriate individual optimal dose [8]
.
Adopt the "strengthen first and simplify" treatment mode, first strengthen the treatment to improve β cell function and insulin sensitivity [9], closely monitor the blood glucose profile, and turn on the "less but refined" treatment mode after the blood sugar reaches the target
.
Under the circumstance of ensuring the efficacy, minimize the number of drugs used when multiple drugs are used, and give priority to drugs with fewer interactions to reduce the risk of drug interactions
.
According to the principles of chronobiology and chronopharmacology of various drugs, the optimal dosage and time of each drug should be selected to extend the time interval of combination medication [8]
.
Expert Profile Ma Li Chief Physician, Professor, Doctoral Supervisor Director of the Endocrinology Department, Xinjiang Uygur Autonomous Region Hospital of Traditional Chinese Medicine, Member of the Primary Endocrinology and Metabolism Group of the Endocrinology Branch of the Chinese Medical Association Member of the Fourth Endocrinology Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine Member of the Chinese Microcirculation Society Member of Diabetes and Microcirculation Specialty Committee Deputy Chairman of the Endocrinology Specialty Committee of Xinjiang Integrative Medicine Association Member of the 5th Endocrinology and Diabetes Specialty Committee of Xinjiang Medical Association Reference: [1] Sinclair A, et al.
Diabetes Res Clin Pract.
2020 Apr;162:108078.
[2]Li Y, et al.
BMJ.
2020;369:m997.
[3]StahnA, et al.
Diabetes Care.
2014;37(2):516-520.
[4]Chinese Medicine Diabetes Association.
Chinese Journal of Diabetes.
2021;13(4):315-409.
[5]Tomlin A.
Psychol Res Behav Manag.
2016;9:7-20.
[6]National Center for Geriatrics, etc.
China Journal of Diabetes.
2021;13(1):14-46.
[7]Sampath Kumar A, et al.
Ann Phys Rehabil Med.
2019;62(2):98- 103.
[8] Chinese Society of Geriatric Healthcare for the Elderly Branch of Endocrinology and Metabolic Diseases, Professional Committee of Clinical Toxicology of Chinese Toxicology Society.
Chinese Journal of Diabetes.
2018;26(9):705-717.
[9] Chinese Insulin Secretion Research Group.
Chinese Journal of Diabetes.
2021;13(10) :949-959.
-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
Starting from the characteristics of elderly diabetic patients, explore the blood sugar management plan
.
With the intensification of aging in our country, the prevalence of diabetes in the elderly has increased significantly
.
IDF Global Diabetes Map predicts that by 2045, the number of elderly (65-99 years old) diabetic patients in China will reach 78.
1 million [1].
The management of elderly diabetes is in urgent need of standardization, and medication guidance urgently needs to be refined
.
Based on this, the "medical community" specially invited Professor Ma Li, the director of the Endocrinology Department of the Xinjiang Uygur Autonomous Region Traditional Chinese Medicine Hospital, to further interpret the characteristics of elderly type 2 diabetes (T2DM) patients, diabetes management and medication principles for the majority of medical workers
.
Q Medical circles: The prevalence of T2DM in the elderly in my country is high, and the number of patients is predicted to continue to increase.
This has gradually become an urgent problem in the field of diabetes treatment.
What do you think are the characteristics of elderly patients? ▎Professor Ma Li: China is a big country with diabetes, and the number of patients has exceeded 141 million
.
A nationwide cross-sectional study showed that the prevalence of T2DM among people aged 60-69 in China was 28.
8%, and the prevalence rate of people over 70 years old was 31.
8% [2]
.
Therefore, blood glucose management and program optimization of elderly T2DM patients in China is an important task of endocrinologists
.
Elderly patients have the following characteristics: Large differences in health status and heterogeneity: Due to differences in personal factors, genetic factors, environmental factors, life>
.
Clinical symptoms are not typical: Most elderly diabetic patients do not have obvious symptoms of "three more and one less" (ie polydipsia, polydipsia, polyuria, polyphagia, unexplained weight loss)
.
There are more complications and/or accompanying diseases: some elderly diabetic patients even start with complications or accompanying diseases as the first manifestation
.
Medication needs to pay attention to the complications of elderly patients, especially cardiovascular disease, followed by factors such as retinopathy, neuropathy, cerebrovascular disease, peripheral vascular disease and diabetic nephropathy.
It is necessary to coordinate the overall plan and comprehensively consider the treatment plan
.
The risk of hypoglycemia is high: elderly diabetic patients have weakened neurological reactivity, and their response threshold to hypoglycemia is lowered, and they are very prone to severe hypoglycemia; the ability to perceive hypoglycemia is reduced, leading to the risk of asymptomatic hypoglycemia in elderly diabetic patients than non-diabetics Patients are taller and more likely to suffer from severe hypoglycemia and even death [3]
.
Multiple medications: Elderly patients are often accompanied by multiple comorbidities.
The phenomenon of multiple medications is more common.
There are often unclear interactions between drugs, which can easily cause drug-induced diseases [4]
.
Cognitive impairment: Some elderly patients have memory loss and slow response, making it difficult to perform complex self-management tasks [5], such as monitoring blood sugar and adjusting insulin doses
.
Q Medical Circle: "Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)"[6] pointed out that life>How to do it ▎Professor Ma Li: Life>
.
Individualized life>
.
On the one hand, nutritional therapy is the basis of diabetes treatment, and should run through the entire course of diabetes treatment, by controlling total calorie intake, meal distribution, and dietary structure adjustment to help blood sugar reach the target
.
First of all, the nutritional status of elderly patients with T2DM should be evaluated, including blood routine, biochemical, creatinine clearance, etc.
, and appropriate adjustments should be made based on inherent eating habits.
When formulating nutritional treatment programs, attention should be paid to appropriately increasing protein and energy intake
.
Elderly diabetic patients have low muscle content, and adequate energy intake can avoid muscle protein breakdown.
Protein intake should be increased appropriately, with high-quality protein intake rich in leucine and other branched-chain amino acids
.
Carbohydrates are the main source of energy for elderly diabetic patients in China.
During meals, attention should be paid to the order of carbohydrates, protein and vegetables consumed by elderly patients.
Eating carbohydrates later can reduce the patient's postprandial blood sugar increase
.
For elderly diabetic patients with unbalanced food intake for a long time, it is also necessary to pay attention to supplementing vitamins and minerals [6]
.
On the other hand, exercise therapy can improve insulin resistance in diabetic patients [7]
.
Before starting exercise therapy, elderly diabetic patients need to conduct exercise risk assessment based on medical history, family history, physical activity level, and related medical examination results, and pass cardiopulmonary endurance, body composition, muscle strength and muscle endurance, flexibility and balance ability, etc.
This test evaluates the exercise ability of elderly patients and provides a basis for the formulation of exercise treatment programs [6]
.
Endocrinologists can instruct patients to reasonably arrange the interval between medication time and exercise time, and evaluate the impact of exercise on drug metabolism
.
Encourage elderly patients to choose suitable exercise methods that can be adhered to for a long time (such as aerobic exercise, resistance training, etc.
).
Elderly patients should be prevented from falling during exercise and be alert to hypoglycemia during and after exercise [6]
.
QMedical community: The "Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)" includes nine types of hypoglycemic drugs, including oral drugs and injection drugs.
For elderly patients, what principles should be followed when choosing these drugs? How to choose hypoglycemic drugs to help patients safely reduce blood sugar? ▎Professor Ma Li: Based on the particularity of elderly diabetic patients, the choice of drugs needs to be more targeted
.
Most elderly patients have unsatisfactory β-cell function, and the incidence of hypoglycemia is relatively high
.
The results of the comprehensive assessment of the patient’s health status and the corresponding blood sugar control goals should be combined.
Elderly T2DM patients whose blood sugar still does not meet the standard after life>
.
The principles of drug treatment include [4]: Give preference to drugs with a lower risk of hypoglycemia
.
In order to avoid the risk of hypoglycemia in elderly diabetic patients, reasonable individualized blood glucose control goals should be established, and hypoglycemic drugs with low risk of hypoglycemia, such as metformin, α-glycosidase inhibitors, and dipeptidyl peptidase-4 inhibitors (DPP- 4i), Na + - glucose cotransporter-2 inhibitors (SGLT-2i) and the like
.
Choose simple and highly compliant drugs to reduce the risk of multiple drugs
.
Consider the application of oral drugs, drugs that are less frequently administered and simple to operate
.
When formulating a drug treatment plan, it is necessary to consider the drug use of elderly patients.
For patients with multiple drugs, try to choose hypoglycemic drugs with less drug interactions to avoid adverse drug-drug interactions
.
Weigh the benefit-risk ratio and avoid over-treatment
.
For elderly diabetic patients with poor health, the goal of blood sugar control can be appropriately relaxed, but it should be based on "avoid high blood sugar and obvious symptoms of diabetes", "avoid high blood sugar and high blood sugar crisis", and "avoid low blood sugar symptoms.
" "Principles such as choosing hypoglycemic drugs
.
Pay attention to factors such as liver and kidney function, heart function, complications and accompanying diseases
.
New hypoglycemic drugs with related benefits besides hypoglycemia can be used, such as glucagon-like peptide-1 receptor agonist (GLP-1RA), which can reduce the risk of adverse cardiovascular events in patients and reduce cardiovascular death or heart failure Hospitalization risk
.
QMedical community: Because elderly patients with T2DM have more comorbidities and their body functions are degraded, multiple medications are common and unavoidable in elderly diabetic patients.
Is there any risk in multi-drug combination therapy? What should be done clinically to avoid the side effects caused by multiple medications as much as possible? ▎Professor Ma Li: Elderly diabetic patients often have hypertension, coronary heart disease, stroke and chronic respiratory diseases.
Multiple medications are common and unavoidable in elderly diabetic patients
.
Multi-drug treatment refers to the simultaneous use of ≥5 drugs by the patient
.
Multiple medications will increase the risk of drug interactions, which may not only affect the blood glucose-lowering efficacy of elderly diabetic patients, but may also increase the risk of hypoglycemia [5]
.
For multiple medications, attention should be paid to individualized dosage
.
The individual differences in the medication response of the elderly are more prominent than those of the young.
The medication should start with a small dose and gradually reach the appropriate individual optimal dose [8]
.
Adopt the "strengthen first and simplify" treatment mode, first strengthen the treatment to improve β cell function and insulin sensitivity [9], closely monitor the blood glucose profile, and turn on the "less but refined" treatment mode after the blood sugar reaches the target
.
Under the circumstance of ensuring the efficacy, minimize the number of drugs used when multiple drugs are used, and give priority to drugs with fewer interactions to reduce the risk of drug interactions
.
According to the principles of chronobiology and chronopharmacology of various drugs, the optimal dosage and time of each drug should be selected to extend the time interval of combination medication [8]
.
Expert Profile Ma Li Chief Physician, Professor, Doctoral Supervisor Director of the Endocrinology Department, Xinjiang Uygur Autonomous Region Hospital of Traditional Chinese Medicine, Member of the Primary Endocrinology and Metabolism Group of the Endocrinology Branch of the Chinese Medical Association Member of the Fourth Endocrinology Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine Member of the Chinese Microcirculation Society Member of Diabetes and Microcirculation Specialty Committee Deputy Chairman of the Endocrinology Specialty Committee of Xinjiang Integrative Medicine Association Member of the 5th Endocrinology and Diabetes Specialty Committee of Xinjiang Medical Association Reference: [1] Sinclair A, et al.
Diabetes Res Clin Pract.
2020 Apr;162:108078.
[2]Li Y, et al.
BMJ.
2020;369:m997.
[3]StahnA, et al.
Diabetes Care.
2014;37(2):516-520.
[4]Chinese Medicine Diabetes Association.
Chinese Journal of Diabetes.
2021;13(4):315-409.
[5]Tomlin A.
Psychol Res Behav Manag.
2016;9:7-20.
[6]National Center for Geriatrics, etc.
China Journal of Diabetes.
2021;13(1):14-46.
[7]Sampath Kumar A, et al.
Ann Phys Rehabil Med.
2019;62(2):98- 103.
[8] Chinese Society of Geriatric Healthcare for the Elderly Branch of Endocrinology and Metabolic Diseases, Professional Committee of Clinical Toxicology of Chinese Toxicology Society.
Chinese Journal of Diabetes.
2018;26(9):705-717.
[9] Chinese Insulin Secretion Research Group.
Chinese Journal of Diabetes.
2021;13(10) :949-959.
-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
