"Talking about Diabetes Control with Internal and External Practice" - How to choose the initial insulin treatment plan for newly diagnosed T2DM patients?

This article shares a case of a newly diagnosed type 2 diabetes mellitus (T2DM) patient who initiated insulin therapy, and invited Professor Gao Fang from Nanfang Hospital to comment on the case
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The case of Professor Zou Mengchen, Nanfang Hospital of Southern Medical University: A middle-aged woman, newly diagnosed with T2DM, with fasting blood glucose as high as 21.
12mmol/L, combined with type 2 diabetic neurological complications, type 2 diabetic nephropathy (G1A2), and grade 1 hypertension (very high risk).
), aortic sclerosis
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After short-term intensive treatment with an insulin pump, he was switched to insulin glargine U300 treatment, and his blood sugar reached the standard
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Case Narrator Professor Zou Mengchen, Department of Endocrinology, Nanfang Hospital, Southern Medical University, swipe up patient information to read Female, 46-year-old Chief complaint: dry mouth, polydipsia, polyuria, polyphagia, weight loss Dry mouth, polydipsia, and polyphagia.
The daily water intake is about 2000-3000ml.
The weight has lost 11 kg in the past four months.
There is no discomfort such as palpitations, sweating, abdominal pain, diarrhea, blurred vision, and urine sugar is found in the 3-week physical examination.
3+, urine 2+, blood glucose 23mmol/L, no diagnosis and treatment
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On July 19, 2021, he was seen in our hospital, and his HbA1c was 14.
4%, his fasting blood glucose was 21.
12 mmol/L, his urine glucose was 4+, and his urine ketone was 2+
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Since the onset of the disease, the patient's mental state is normal, physical strength is normal, appetite and appetite are good, sleep conditions are normal, weight is as described above, stool is normal, urine volume has increased, and the past history of foamy urine is denied: 2020-03 Due to ankle sprain, our hospital diagnosis " Common peroneal nerve palsy", he complained that his blood pressure was high in recent years, about 140/100mmHg
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No history of infectious diseases such as dysentery, malaria, viral hepatitis and tuberculosis
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Vaccination history unknown
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No history of surgery
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No history of blood transfusion, no history of drug allergy Personal history: born in Guangzhou City, Guangdong Province, living in the area for a long time, no history of exposure to epidemic areas, epidemics, and epidemic water, moderate nutrition, positive development, more than 20 years of smoking history, about 15 per Days, no history of drinking Family history: living parents, living brothers, denying familial genetic history, denying familial tumor history Patient physical examination slide up to read physical examination TPRBP36.
1 ℃ 112 times/min 20 times/min 134/106 mmHg HWBMIWC174 cm69.
2 kg22.
9kg/m282 cm Physical examination: general health status, normal development, good nutrition, normal face, free expression, automatic posture, clear consciousness, good mental state, physical examination cooperation
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Right heel walking is slightly worse, mild atrophy of the right tibialis anterior muscle Laboratory examination Fasting blood glucose (FPG): 21.
12mmol/LHbA1c: 14.
4% C-peptide: 0.
60nmol/l Insulin: -Urine routine: urine sugar 4+, Urine ketone 2+ other laboratory tests: blood routine: no obvious abnormal liver function: no obvious abnormal renal function: no obvious abnormal thyroid function: normal GAD: negative ICA: negative IAA: negative auxiliary examination: ECG: sinus rhythm; T wave Changed chest X-ray: aortic sclerosis; thoracolumbar degenerative changes Others: electrolytes were K3.
65mmol after potassium supplementation, hypokalemia; right upper eyelid pain and discomfort after admission, ophthalmology consultation considered right eye upper eyelid pancreatitis diabetes mellitus Complications screening Macrovascular complications without microvascular complications Diabetic retinopathy: no abnormal diabetic nephropathy in the initial screening: 24h urine protein quantitative UTP 0.
18g/24h, urine albumin ALBU 16.
4mg/L, total urine microalbumin UALB 36mg /24h diabetic neuropathy: damage to the common peroneal nerve of both lower extremities.
Diabetic foot: no clinical diagnosis.
Hypokalemia Hypertension Grade 1 (very high risk) Eyelid hordeolum (right upper eyelid) Aortic sclerosis Thoracolumbar degeneration Factor treatment goals Strengthen blood sugar control, avoid blood sugar fluctuations, prevent hypoglycemia, and delay the progression of complications Liejing 10mg/qd glargine U300 insulin + insulin aspart + metformin regimen is based on the patient's poor blood sugar control, high fasting blood sugar, and needs to be intensively controlled.
: Metformin 1g/bid + Dapagliflozin 10mg/qd Clinical Considerations 1.
The formulation of insulin regimens should be patient-centered, evidence-based, and guided by individualized blood sugar control goals; Under the premise of the risk of weight gain, scientifically and rationally determine feasible insulin varieties and medication regimens
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2.
Basal insulin is the cornerstone of individualized treatment of diabetes, throughout the whole process
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Basal insulin therapy should be initiated as soon as possible in patients with T2DM who are poorly controlled by oral medication
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3.
Insulin glargine U300 is a more ideal choice for initial insulin therapy: Insulin glargine U300 has a more stable and longer-acting pharmacokinetics, while providing excellent hypoglycemic efficacy, less risk of hypoglycemia, In addition, the dose adjustment is more flexible, the blood sugar can be quickly achieved, and the patient experience is high, which can improve patient compliance
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Expert Comments Professor Gao Fang from Nanfang Hospital of Southern Medical University The case mentioned in this issue is a newly diagnosed T2DM patient with fasting blood sugar as high as 21.
12mmol/L, combined with type 2 diabetic neurological complications, type 2 diabetic nephropathy (G1A2), and grade 1 hypertension.
(very high risk), aortic sclerosis
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Patients with high fasting blood sugar and diabetes complications require strict and stable blood sugar control and symptomatic treatment of complications to reduce the risk of hypoglycemia
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The 2020 CDS guidelines point out that for newly diagnosed T2DM patients with HbA1c ≥ 9.
0% or fasting blood glucose ≥ 11.
1 mmol/L and obvious symptoms of hyperglycemia, short-term intensive insulin therapy can be implemented [1]
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The 2022ADA guidelines recommend [2]: basal insulin therapy alone is the easiest insulin initiation regimen for T2DM patients, which can be added to metformin and other oral drugs
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Insulin glargine U300, a new generation of basal insulin analogs, uses subcutaneous reservoir micro-precipitation technology to achieve stable and sustained release, which can control glucose smoothly without increasing the risk of hypoglycemia, and better balance both efficacy and safety [3-6]
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Therefore, after short-term intensive treatment with insulin pump, the patient was switched to insulin glargine U300 treatment, so that the patient's blood sugar could reach the standard as soon as possible
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The intraday variability of insulin glargine U300 GIR was significantly lower than that of insulin degludec by 20%, and insulin glargine U300 had a more durable and stable PKPD[7]
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The BRIGHT study confirmed that compared with insulin degludec, insulin glargine U300 had comparable hypoglycemic efficacy, but significantly reduced the risk of hypoglycemia during the initial dose adjustment period [8]
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This patient had type 2 diabetic nephropathy
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BRIGHT subgroup analysis: In patients with renal insufficiency, insulin glargine U300 has better hypoglycemic effect than insulin degludec [9]
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In addition, the patient is middle-aged, considering his life, insulin glargine U300 can allow more free injection time (± 3h) to cope with changes in daily life situations, with high patient satisfaction and better compliance
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Insulin glargine U300 for newly diagnosed T2DM patients can safely and effectively control glucose
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Therefore, insulin glargine U300 is a more ideal choice for insulin therapy for newly diagnosed T2DM patients
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References: [1] Diabetes Branch of Chinese Medical Association.
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition) [J].
Chinese Journal of Diabetes, 2021, 13(04): 315-409.
[2] American Diabetes Association.
Diabetes Care 2022 Jan; 45(Supplement 1): S139-140.
[3]Hedrington MS et al.
Diabetes Technol Ther.
2011;13 Suppl 1:S33-42.
[4]Becker RH et al.
Diabetes Care.
2015;38 :637-43.
[5]Jax T et al.
Poster presented at EASD 2013; Abstract 1029.
Available at http:// May 2014.
[6]Steinstraesser A et al.
Diabetes Obes Metab.
2014;16:873-6.
[7] Bailey TS, et al.
Diabetes Metab 2018,44(1):15-21.
[8] Rosenstock J, et al.
Diabetes Care 2018, 41(10): 2147-2154.
[9] Haluzík M, et al.
Diabetes Obes Metab 2020, 22(8):1369-1377.
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