"Talking about sugar control both internally and externally"-How can T2DM patients control their sugar steadily at the beginning of the year?

This article shares a case of insulin initiation therapy for a newly diagnosed type 2 diabetes patient, and invited Professor Xu Ji from the Endocrinology Department of the First Affiliated Hospital of Nanchang University to comment on the case
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Professor Xu Ji from the First Affiliated Hospital of Nanchang University Case: Elderly female, newly diagnosed T2DM patient, with obvious blood glucose fluctuations, accompanied by type 2 diabetic nephropathy, hypoproteinemia, iron deficiency anemia, coronary atherosclerotic heart disease , Hypertension level 2, high-risk syndrome, should quickly and steadily lower blood sugar, avoid blood sugar fluctuations, and avoid the risk of hypoglycemia
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Case narrator: Dr.
Zhang Yan from the Endocrinology Department of the First Affiliated Hospital of Nanchang University.
The patient profile is scrolled upwards.
Female, 64 years old.
Chief complaint: dry mouth, polydipsia, weight loss for half a year, and weakness of the lower limbs for 20 days.
History of the present disease: the patient had no obvious cause six months ago Symptoms of polydipsia, dry mouth, weight loss, etc.
, fasting blood glucose 6.
7mmol/L measured in a nearby clinic, did not pay attention to no treatment
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20 days ago, the patient developed upper abdominal discomfort, nausea, anorexia, dizziness, coughing, fatigue of both lower limbs, poor sleep, and history of admission to the hospital: history of “hypertension”, history of “iron deficiency anemia”, “coronary atherosclerosis” "Heart disease" personal history: born and raised in the country of origin, without long history of living in another place
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Living conditions are good, denying history of residence in the affected area, no history of tainted water, history of contact with the epidemic source, no history of smoking or drinking, and no history of travel
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No history of radiation and toxicant exposure: Family history of patients who deny family genetic medical history, slide up to read physical examination TPRBP36.
8℃ 88 beats/minute 22 beats/minute 130/80 mmHgHWBMI_158 cm50 kg19.
5Kg/m2_ skin and mucous membranes are not yellow Dyed, facial edema, weight loss and clarity, normal light reflex, clear breath sounds in both lungs, no dry and wet rales, normal heart dullness, regular heart rhythm, flat and soft abdomen, physiological curvature of the spine, extremity sensation Low sensitivity, normal muscle strength of the limbs, no edema of the lower limbs.
Laboratory examination of fasting blood glucose: 14.
0 mmol/L↑ 2h blood glucose after meal: 15.
6 mmol/L↑HbA1c: 8.
09% ↑Urine routine: glucose 3+, urine protein 3+ others Laboratory examination and auxiliary examination blood routine: red blood cell 2.
63 x 1012 /L hemoglobin 90g/L stool routine: normal biochemical examination: total protein: 56.
9g/L ↓, albumin: 29.
0g/L ↓, creatinine: 171.
9ummol/L ↑, uric acid: 507ummol/L ↑Auxiliary examination: ECG: sinus arrhythmia, poor R wave progression (V2), left ventricular high voltage, T wave changes Abdominal ultrasound: liver particles thickened, no other abnormal cardiac ultrasound : The clinical diagnosis of left ventricular diastolic dysfunction.
Slide up to view the main diagnosis of type 2 diabetes, type 2 diabetic nephropathy, hypoalbuminemia, iron deficiency anemia, coronary atherosclerotic heart disease, hypertension level 2, high-risk cases are characterized by elderly, combined with multiple complications, have been targeted organ damage, diabetes, kidney disease, hypoalbuminemia
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FPG, PPG and HbA1c are all poorly controlled.
Treatment goals Improve blood sugar control, avoid hypoglycemia, reduce the number of injections, and improve patient compliance.
Inpatient treatment plan scroll up to read hypoglycemic treatment plan.
Initial treatment plan: follow-up treatment plan to use insulin glargine U300 Treatment: Inject insulin glargine U300 10u at 8 o'clock every evening; repaglinide 2mg tid; dapagliflozin 10mg qd regimen according to elderly women, new-onset diabetes, high blood sugar, should quickly and steadily lower blood sugar, avoid hypoglycemia, and improve patients Compliance, at the same time, patients with renal insufficiency, add dapagliflozin, reduce blood sugar and reduce urinary protein.
Hospitalized treatment after sliding up to read the blood glucose monitoring value and treatment plan.
Discharge treatment plan and discharge follow-up.
Slide up to read ■ Clinical thinking 1.
Insulin plan The formulation should be patient-centered, evidence-based medicine evidence-based, and individualized blood glucose control goal-oriented; scientifically and rationally determine feasible insulin varieties and medication regimens under the premise of minimizing the risk of hypoglycemia and weight gain
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2.
Basal insulin is the cornerstone of individualized treatment of diabetes, throughout the entire process
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The basal insulin control glucose standard does not come at the expense of increasing the risk of hypoglycemia
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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 and simplified medication, and patient experience High, can improve patient compliance
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Experts comment on Professor Xu Ji from the First Affiliated Hospital of Nanchang University.
The case described in this issue is a newly diagnosed elderly T2DM patient with fasting blood glucose as high as 14.
0 mmol/L, blood glucose fluctuations, and type 2 diabetic nephropathy, hypoproteinemia, and iron deficiency.
Anemia, coronary atherosclerotic heart disease, hypertension grade 2, high-risk syndrome, blood sugar should be lowered quickly and steadily, blood sugar fluctuations should be avoided, and the risk of hypoglycemia should be avoided
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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 with obvious symptoms of hyperglycemia, short-term insulin intensive therapy can be implemented, and the treatment time is appropriate for 2 weeks to 3 months [1]
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2021 ADA guidelines recommend [2]: Basic insulin therapy alone is the easiest insulin initiation plan for patients with T2DM, and it can be used in addition to metformin and other oral drugs
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The patient was initially treated with insulin glargine U100 combined with OAD, and then switched to insulin glargine U300 combined with OAD treatment, achieving stable blood sugar
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Insulin Glargine U300 is a more ideal choice for initial insulin therapy.
The new generation of basal insulin analogue Insulin Glargine U300 uses subcutaneous reservoir micro-precipitation technology to achieve a stable and sustained release, while steadily controlling glucose without increasing the risk of hypoglycemia.
Better balance between efficacy and safety [3-6]
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Compared with insulin glargine U100, insulin glargine U300 has a longer lasting and more stable PKPD [7]
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 This patient is an elderly patient with type 2 diabetic nephropathy.
BRIGHT subgroup analysis: In patients with renal insufficiency, insulin glargine U300 has a better hypoglycemic effect than insulin degludec [8]
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The long-acting mechanism of insulin degludec relies on the binding of insulin to albumin in the blood, while insulin glargine U300 uses subcutaneous reservoir microprecipitation technology to achieve a stable and sustained release, and does not depend on the binding of albumin in the blood, thereby improving It is suitable for patients with renal insufficiency and hypoproteinemia
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For new-onset T2DM patients, basal insulin should be preferred when initial insulin treatment.
Insulin glargine U300 unique subcutaneous reservoir microprecipitation technology, natural and stable release, PK/PD longer and more stable, excellent hypoglycemic effect, lower risk of hypoglycemia , Dosage adjustment is more flexible, insulin glargine U300 is an ideal choice for insulin initiation therapy
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References: [1] Diabetes Branch of Chinese Medical Association.
Chinese Type 2 Diabetes Prevention and Treatment Guidelines (2020 Edition)[J].
Chinese Journal of Diabetes,2021,13(04):315-409.
[2]American Diabetes Association.
Diabetes Care 2021 Jan; 44(Supplement 1): S111-S124.
[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.
[6]Steinstraesser A et al.
Diabetes Obes Metab.
2014;16:873-6.
[7]Adapted from Becker RH et al.
Diabetes Care.
2015;38:637-43.
[8]Haluzík M, et al.
Diabetes Obes Metab 2020,22(8):1369-1377.
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