"Talking about sugar control internally and externally"-If blood sugar is continuously poorly controlled, how can patients with T2DM control their sugar steadily?

This article shares a case of insulin therapy for patients with type 2 diabetes, and invited Professor Wang Junfen from the Second Hospital of Shijiazhuang City to comment on the case
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Professor Wang Junfen from the Second Hospital of Shijiazhuang City Case: Elderly women, fasting blood sugar and postprandial blood sugar are both high, recurring nocturnal hypoglycemia, due to blood sugar fluctuations prone to diabetic microvascular complications, including diabetic peripheral neuropathy, diabetic fundus disease, diabetic nephropathy Diseases, it is necessary to control sugar steadily to improve patient satisfaction
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Case narrator: Chief Physician Yang Zhixia, Department of Endocrinology, Langfang People's Hospital.
Patient data scroll up to read.
Female, 67 years old.
Chief complaint: Found that blood sugar has been elevated for 15 years and poor blood sugar control for 6 months.
Current medical history: The patient had no obvious cause 15 years ago.
Dry mouth, polyuria, polydipsia, and weight loss occurred
.
At that time, the weight loss was about 3kg .

At that time, the fasting venous blood glucose was 9.
0mmol/L, and he was diagnosed as "type 2 diabetes"
.

He took "Metformin 0.
25 3 times a day, 5mg Glipizide Controlled Release Tablets 1 time / before breakfast" to control blood sugar
.

Normal life is very self-disciplined-strictly control diet, exercise properly, take medication regularly and monitor blood sugar regularly
.

Good blood glucose control, fasting blood glucose 5-7mmol/L, postprandial blood glucose 8-10mmol/L
.

The treatment lasted 3 years
.

In case of a family accident, blood glucose increased after half a year; self-test fasting 8-9.
0mmol/l, 2 hours postprandial blood glucose 11-13.
0mmol/l, weight loss was obvious, go to the doctor again, glycosylated hemoglobin 8.
2%, adjust the basis of treatment plan Insulin glargine U100 combined with oral glimepiride 2mg once a day, the "one injection and one tablet" regimen, blood sugar control is acceptable.
After 3 years of treatment, there is no inducement for blood glucose to rise again.
The treatment adjustment plan is Insulin aspart 30 18u before breakfast, 16u before dinner, subcutaneous injection, combined with metformin and acarbose, blood sugar control is acceptable, but not very satisfactory
.

The blood sugar fluctuated significantly in the past year
.

Fasting blood sugar has been too high and not up to the standard.
To manage fasting blood sugar, increase the amount of insulin before dinner, and there will be repeated low blood sugar at night
.

The program was repeatedly adjusted to measure night blood glucose combined with oral medication and additional meals, but blood glucose still did not meet the standard
.

The patient came to the clinic again and was given the "3+1" or "insulin pump" regimen.
The patient did not accept it and did not receive hospitalization
.

Outpatient adjustment of treatment plan: adjust to insulin glargine U300 combined with GLP-1RA (Lisnatide)
.

The specific adjustment results were satisfactory.
Past history: no hypertension and coronary heart disease, no dyslipidemia, no history of surgical trauma and history of blood transfusion.
Personal history: no history of birth of a huge baby, and one child is healthy
.

Regular life, no history of smoking, family history of drinking habits: the mother has diabetes
.

There is no family history of hypertension, coronary heart disease and cerebrovascular disease in the family, and patients with no family history of tumors slide up to read the physical examination TPRBP36.
4 ℃ 72 times/minute 18 times/minute 130/80 mmHgHWBMIWC159 cm50 kg19.
77Kg/m280 cm There was no abnormality in the heart, lungs and abdomen, no edema in both lower limbs, good pulsation of both dorsal foot arteries, and no abnormality in sensory threshold measurement.
Laboratory examination Fasting blood glucose: 9.
5 mmol/L HbA1c: 8.
1% Fasting C peptide: 1.
23ng/ml (0.
81- 3.
85) Fasting insulin: 18IU/ml (5-22) Urine routine: glucose 3+, ketone body -, protein: +- other laboratory tests and auxiliary examinations, blood routine: Hb 121g/L and no abnormal liver function: ALT 35.
0u/L AST 31.
0u/L Blood lipid: TG 2.
3 mmol/L TC 5.
21mmol/L LDL-C 2.
4mmol/L Normal electrolyte Renal function: Creatinine 69.
2umol/L Urea nitrogen 5.
7mmol/L Uric acid 326umol/L UACR 30mg /L No abnormal thyroid function in all biochemical items, thyroid-related antibody-negative diabetic macrovascular/microvascular complications Screening for macrovascular complications Cardiovascular disease: normal electrocardiogram, no abnormal heart ultrasound Cerebrovascular disease: cervical vascular color Doppler ultrasound See plaque and stenosis.
Peripheral artery disease: color Doppler ultrasound of lower limb blood vessels, visible intima, no plaque formation, microvascular complications, diabetic retinopathy: no exudation and hemorrhage, diabetic nephropathy: UACR 30mg/L diabetic neuropathy: measurement of sensory threshold-- Normal pain and temperature sensation, normal 10g nylon wire measurement, normal tuning fork vibration sensation, normal tendon reflex and ankle reflex Clinical diagnosis slide up to view the main diagnosis of type 2 diabetes diabetic nephropathy Lower limb vascular sclerosis characteristics of elderly women, fasting blood glucose and postprandial blood glucose It is very high, and nighttime hypoglycemia occurs repeatedly, and diabetic microvascular complications are prone to occur due to blood sugar fluctuations, including diabetic peripheral neuropathy, diabetic fundus disease, and diabetic nephropathy
.

Hypoglycemia occurred during the insulin treatment before admission, and I was not satisfied with the previous treatment.
The treatment goal was to control blood sugar smoothly and reduce the risk of hypoglycemia.
The hospitalization treatment plan scroll up to read the hypoglycemic treatment plan.
The treatment plan: basal insulin + linatide Therapeutic drug 1: Insulin glargine U30018 IU Therapeutic drug 2: Risenatide 10 ug subcutaneous injection 1 hour before breakfast, start treatment, 2 weeks later, adjust to 20ug subcutaneous injection 1 hour before breakfast Life>
.

The patient does not receive multiple injections and insulin pump treatment, and hopes that the outpatient clinic will adjust the treatment plan.
At the same time, there may be diabetic nephropathy or macrovascular complications
.

Control blood sugar steadily, reduce the risk of hypoglycemia, and improve patient compliance for hospitalization.
Swipe up to read the discharge treatment plan and follow-up follow-up.
, Oriented by the goal of individualized blood sugar control; scientifically and rationally determine feasible insulin varieties and medication programs on the premise of reducing the risk of hypoglycemia and weight gain as much as possible
.

2.
Basal insulin is the cornerstone of individualized treatment of diabetes, throughout the entire process
.

The dosage of Ganjing U300 can be adjusted daily, which can guide patients to adjust by one unit per day until reaching the standard, which is flexible and convenient, and improves patient compliance
.

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, which is convenient to simplify the medication, and the patient experience High, can improve patient compliance
.

4.
Compared with the use of premixed insulin therapy, choose basal insulin-longer action time and smaller intra-day GIR variability
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5.
New preparations are the future direction of treatment: basal insulin + risnatide compound preparations will become a new trend in diabetes treatment in the future
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Experts commented that the case described by Professor Wang Junfen from Shijiazhuang Second Hospital is an elderly woman with high fasting blood sugar and postprandial blood sugar, recurring nocturnal hypoglycemia, and diabetic microvascular complications, including diabetic peripheral neuropathy, due to blood sugar fluctuations.
Diabetic fundus disease, diabetic nephropathy
.

Hypoglycemia occurred during the application of insulin therapy before admission.
This treatment is not satisfactory.
It is necessary to control glucose steadily, reduce the risk of hypoglycemia, and improve patient satisfaction
.

The new generation of basal insulin analogue insulin glargine U300 uses subcutaneous reservoir microprecipitation technology to achieve stable and sustained release, which can stably control glucose without increasing the risk of hypoglycemia, and better balance efficacy and safety [1-4]
.

The BRIGHT study [5] confirmed that, in terms of efficacy, insulin glargine U300 treatment for 24 weeks of HbA1c reduction is similar to insulin degludec
.

In terms of safety, the initial dose adjustment period (the first 12 weeks) of insulin glargine U300 treatment is lower in overall and nocturnal hypoglycemia
.

Studies [6] compared the steady-state PK/PD of insulin glargine U300 and insulin degluargine U100, and the results showed that insulin glargine U300 maintained a stable insulin level within 16 hours after administration, and then slowly decreased
.

Insulin degludec increased from the start of injection to the maximum value of 10 hours after administration, and then slowly decreased
.

The intra-day variability of insulin glargine U300 GIR was significantly lower than that of insulin deglu by 20%
.

In addition, insulin glargine U300 SoloSTAR® injection pen has accurate dosage, low injection pressure and good patient experience [7-8]
.

The patient reported that the injection device of insulin glargine U300 is the most satisfactory one of all injection devices at present
.

In addition, compared with other long-acting basal insulins, insulin glargine U300 can adjust the dose every day and has a 6-hour injection time window.
The injection time is more flexible and convenient, and the patient experience is good
.

In summary, insulin glargine U300 can control sugar steadily, has low risk of hypoglycemia, and has a good patient experience, making it a more ideal choice for insulin therapy
.

References: [1]Hedrington MS et al.
Diabetes Technol Ther.
2011;13 Suppl 1:S33-42.
[2]Becker RH et al.
Diabetes Care.
2015;38:637-43.
[3]Jax T et al.
al.
Poster presented at EASD 2013; Abstract 1029.
Available at http:// May 2014.
[4]Steinstraesser A et al.
Diabetes Obes Metab.
2014;16:873-6.
[ 5] Yang W,et al.
Curr Med Res Opin.
2012 Apr;28(4):533-41.
[6] Zhang X, et al.
Diabetes Obes Metab.
2020 Aug:22(8):1436-1442.
[7]Klonoff D, et al.
J Diabetes Sci Technol 2015,10(1):125-130.
[8]Pohlmeier H, et al.
J Diabetes Sci Technol 2017,11(2):263-269.
[9 ]Riddle MC, et al.
Diabetes Technol Ther 2016,18(4):252-257.
[10]Rosenstock J, et al.
Diabetes Care 2018, 41(10):2147-2154.
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