"Talking about sugar control internally and externally"-OAD is not well controlled, how do elderly patients with T2DM choose the initial insulin treatment plan?

This article shares a case of an elderly patient with T2DM who had poor blood glucose control with oral hypoglycemic agents (OAD) using initial insulin therapy, and invited Dr.
Han Liping, chief physician of the Department of Geriatrics, Zhu Xianyi Memorial Hospital, Tianjin Medical University to comment on the case
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Professor Han Liping, Zhu Xianyi Memorial Hospital of Tianjin Medical University Case: Elderly woman with type 2 diabetes (T2DM) for 2 years, poor blood glucose control in OAD treatment, combined with hypertension, hyperlipidemia and other diseases, type 2 diabetes with painful peripheral neuropathy, lower extremity arteries Sclerosing obliterans, effective and stable control of blood glucose through initial insulin therapy, and improvement of islet function.
Case narrator, Dr.
Chen Bixiao, Department of Endocrinology, Zhu Xianyi Memorial Hospital, Tianjin Medical University.
2 years, dizziness in January, current medical history: 2 years of type 2 diabetes, voglibose and metformin oral medication were used for hypoglycemic treatment before admission, dizziness symptoms occurred a month ago, and no attention was paid
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Self-tested fasting blood glucose 16mmol/L and postprandial blood glucose 19mmol/L one week ago.
Visited our hospital one day ago
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Past history: Living in Tianjin for a long time .Smoking for nearly 50 years, family history of non-drinking: Parents with a history of high blood pressure, the eldest son with diabetes, swipe up to read the physical examination TPRBP36.
5℃ 80 times/minute 16 times/minute 150/90 mmHgHWBMI_155 cm61 kg25.
4Kg/m2 _The heart, lungs and abdomen have no positive signs, and the bilateral dorsal foot arteries are pulsating.
Laboratory examination HbA1c: 9.
8% Fasting blood glucose (FPG): 10.
1mmol/L, 2 hours postprandial blood glucose 14.
5mmol/L Insulin 10.
62mIU/LC peptide: 2.
33ng /mL Urine routine: normal, other laboratory tests and auxiliary examinations, blood routine, liver function, kidney function, etc.
have no abnormalities.
Diabetes macrovascular/microvascular complications Screening for macrovascular complications: no microvascular complications: no clinical diagnosis sliding upward View the main diagnosis of type 2 diabetes with painful peripheral neuropathy, lower extremity arteriosclerosis obliterans, vertigo, hypertension, grade 2 (very high risk) hyperlipidemia, fatty liver, and lacunar infarction.
Features 1.
Elderly female, history of type 2 diabetes 2 years, poor control of 2 kinds of oral drugs, poor blood sugar control in the past 3 months 2.
Family history of diabetes, bad habits such as smoking 3.
Combined with hypertension, hyperlipidemia and other diseases, type 2 diabetes and pain have appeared Peripheral neuropathy, lower extremity arteriosclerosis obliterans treatment goals Strict control of blood sugar, symptomatic treatment of complications, and delay the progression of complications.
Hospitalized treatment plan.
Slide upward to read the hypoglycemic treatment plan.
Insulin glargine U300, metformin sustained-release tablets, and voglibose plan basis The patients are older, oral hypoglycemic drugs, poor blood sugar control, high fasting and postprandial blood sugar, and combined with macrovascular complications, need to strengthen blood sugar management to reduce the occurrence of hypoglycemia
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Insulin glargine U300 has a definite hypoglycemic effect, with a low incidence of hypoglycemia [1], flexible dose adjustment, blood glucose monitoring value and treatment plan scroll up to read ■ Clinical thinking 1.
The choice of insulin treatment plan should be patient-centered, with full consideration of many aspects Situation: Under the premise of minimizing the risk of hypoglycemia, scientifically and reasonably determine feasible insulin varieties and medication plans
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2.
Basal insulin is the cornerstone of individualized treatment of diabetes, throughout the entire process
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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, and the patient experience is high
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Experts comment on Professor Han Liping, Zhu Xianyi Memorial Hospital of Tianjin Medical University.
The case described in this issue is a 71-year-old woman with poor blood glucose control in OAD treatment.
The fasting and postprandial blood sugars are both high, and with major vascular complications, blood sugar management needs to be strengthened to reduce low blood sugar.
A blood sugar event occurred
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During the treatment period, insulin therapy was initiated on the basis of OAD, and the dosage was adjusted daily to make the patient's blood sugar reach the target stably
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The choice of insulin treatment plan should be patient-centered, with full consideration of many aspects
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The first head-to-head randomized controlled study of insulin glargine U300 and insulin degluargine, BRIGHT[2] proved that insulin glargine U300 has the same anti-diabetic effect as insulin degluargine, but the risk of hypoglycemia during the initial dose adjustment period is significantly reduced
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"Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)"[3] pointed out that diabetes in the elderly has the characteristics of high prevalence, poor cognitive function, large individual differences, and high risk of hypoglycemia
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For elderly patients, it is necessary to comprehensively evaluate the four dimensions of medicine, psychology, self-cognition and social fields to determine the treatment goals and methods of elderly diabetes
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In the elderly intensive hypoglycemic treatment, the basic + meal treatment mode is generally recommended
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Basal insulin should be the first choice for drugs that have a long half-life, small fluctuations, and can mimic the physiological insulin secretion pattern as much as possible
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As a new long-acting basic insulin, insulin glargine U300 uses subcutaneous reservoir micro-precipitation technology to achieve stable and sustained release.
CGM studies have confirmed that insulin glargine U300 has lower blood glucose variability and lower risk of hypoglycemia, and can make blood glucose stable and reach the standard
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BRIGHT subgroup analysis [4]: ​​In elderly patients, insulin glargine U300 has better hypoglycemic effect than insulin degludec
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 DELIVER-2 study [5]: A total of 6,033 patients with T2DM who had at least one BI prescription record during the baseline period were included.
The clinical data after 6 months of conversion to Laiyoushi or other basic insulin treatments were included.
The analysis was conducted to compare the hypoglycemic efficacy, safety and treatment cost of Laiyoushi or other first-generation basal insulins
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Compared with other basal insulin treatments, the Laiyoushi conversion program can achieve similar blood glucose control and significantly reduce the rate and incidence of hypoglycemia
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The dosage adjustment of insulin glargine U300 is more flexible and convenient[6-13].
Insulin glargine U300 can adopt a variety of dosage adjustment schemes, including daily, every 3 days and weekly adjustment, while insulin degluargine mostly adopts a weekly dose Adjustment
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In addition, insulin glargine U300 has the advantages of allowing more free injection time, and has now been included in the national medical insurance list
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Therefore, for OAD treatment of T2DM patients with poor blood glucose control, insulin glargine U300 is an ideal choice for insulin initiation therapy
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   References: [1]Rosenstock J, et al.
Diabetes Care 2018, 41(10):2147-2154.
[2]Rosenstock J, et al.
Diabetes Care 2018, 41(10):2147-2154.
[3] Guidelines for Diagnosis and Treatment of Diabetes in the Elderly in China (2021 Edition)[J].
Chinese Journal of Diabetes,2021,13(01):14-46.
[4]Bernard Charbonnel, et al.
Presented at: American Diabetes Association Scientific Sessions 2019,131-LB [5]Zhou FL et al.
Diabetes Obes Metab.
2018 May;20(5):1293-7.
[6]Riddle MC, et al.
Diabetes Care 2014, 37(10):2755-62.
[7]Yki -Jarvinen H, et al.
Diabetes Care 2014, 37(2):3235-43.
[8]Bolli GB, et al.
Diabetes Obes Metab 2015, 17(4):386-94.
[9]M Davies et al .
J Diabetes Sci Technol.
2019, 13(5):881-9.
[10]Gerstein HC, et al.
Diabet Med 2006, 23(7):736-42.
[11]Philis-Tsimikas A, et al.
Adv Ther 2013, 30(6):607-22.
[12]D Russell-Jone et al.
Diabetes Obes Metab 2019, 21:1615–24.
[13]Rosenstock J, et al.
Diabetes Care 2018, 41(10 ): 2147-54.
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