"Talking about sugar control with internal and external training" Poor blood sugar control in type 2 diabetes, accompanied by many complications——Discussion on the treatment plan for sugar control

This article shares a case of a patient with type 2 diabetes mellitus (T2DM) with poor blood sugar control and many complications.
Director Chen Liqin from the Department of Endocrinology of Dagang Hospital is invited to comment on the case
.

Case of Director Chen Liqin of Dagang Hospital: The case mentioned in this issue is a middle-aged male who was admitted to the hospital for treatment mainly because of "blood sugar rise for more than 10 years and poor blood sugar control for one month".
He was diagnosed as type 2 diabetes with diabetic nephropathy, diabetic peripheral neuropathy, high Lipemia and carotid atherosclerosis, due to substandard blood sugar and poor compliance, after insulin glargine U300 combined with OAD hypoglycemic program, blood sugar reached the standard smoothly
.

Case Narrator Wang Xuemei, Physician, Department of Endocrinology, Ninghe District Hospital, Tianjin Swipe up to read the patient information.
Male, 56 years old.
Chief complaint: It was found that the blood sugar has been elevated for more than 10 years, and the blood sugar control is not good.
He was diagnosed as "diabetes mellitus" due to elevated blood sugar, and started drug treatment.
Currently, "metformin, repaglinide, and linagliptin" are used to lower blood sugar
.

In the past 1 month, the self-tested blood sugar was not well controlled, and the fasting blood sugar was about 10mmol/L, accompanied by numbness of the extremities, foamy urine, no obvious blurred vision, no nausea, anorexia, no chest tightness, shortness of breath, and went to our hospital for further treatment.
, The outpatient was admitted to the hospital with "diabetes, diabetic peripheral neuropathy".
Past history: there was a history of epilepsy for 6 years, and he usually took carbamazepine for treatment
.

He denied the history of hypertension, coronary heart disease, cerebral infarction, cerebral hemorrhage, hepatitis, tuberculosis, major trauma, surgery, blood transfusion
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Denial of food and drug allergies Personal history: born and raised in the country of origin, no history of long-term living abroad, regular life, smoking for more than 10 years, about 20 cigarettes per day, occasional alcohol consumption, no history of exposure to toxic substances Family history: no family history of diabetes, no other Physical examination of patients with family history of hereditary diseases Swipe up to read physical examination TPRBP36.
2 ℃98 times/min 18 times/min 128/74mmHgHWBMI Waist circumference 175 cm76 kg28.
41 kg/m274 cm Physical examination: clear consciousness, good spirit, bilateral pupils Equal large and equal round, thick breath sounds in both lungs, no dry or wet rales
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The heart sounds were normal, the rhythm was uniform, the heart rate was 98 beats/min, and no murmur was heard in the auscultation area of ​​each valve
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The abdomen was flat, soft without resistance, without tenderness and rebound tenderness, and no palpable enlargement of the liver and spleen
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Both lower extremities are not swollen
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The muscle strength of the limbs was grade V, the muscle tension was normal, the pulse of the dorsal artery of the foot was acceptable, and the tuning fork response was slightly sluggish
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Auxiliary examination for normal pain and temperature sense—blood sugar and islet function Islet function: fasting C-peptide: 1.
0ng/ml fasting insulin: 4.
72mIu/ml 2 hours postprandial C-peptide: 1.
9ng/ml 2 hours postprandial insulin: 8.
9mIU/ml Clinical diagnosis Swipe up to view the main diagnosis of type 2 diabetes with Poor blood sugar control Type 2 diabetes with multiple complications Type 2 diabetic nephropathy Type 2 diabetic peripheral neuropathy Hyperlipidemia Fatty liver Carotid arteriosclerosis Thyroid nodules If blood sugar is not well controlled with oral drugs, blood sugar control target fasting blood sugar: 6.
1mmol/L; 2h postprandial blood sugar: 9-11mmol/L; HbA1c: 7%-7.
5% Glycerine and insulin glargine to strengthen hypoglycemia; after blood sugar improves, adjust to insulin glargine, metformin, empagliflozin hypoglycemic life>
.

Program Basis Objective: Good hypoglycemic effect, low incidence of hypoglycemia Initial hypoglycemic treatment After swiping up to read Discharge Follow-up Swipe up to read 1 month follow-up: Fasting blood glucose: 6.
2mmol/L Blood glucose 2 hours after meals: 9.
3mmol/L No occurrence of hypoglycemia.
Swipe up for the treatment experience of this case ■Clinical considerations 1.
FPG≤6.
1 is the ideal blood sugar control target for Chinese patients with type 2 diabetes
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2.
A new long-acting basal insulin analog, insulin glargine U300, has a more stable PK/PD curve, less hypoglycemia, and more flexible dose adjustment.
It is a new choice for basal insulin therapy
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3.
Compared with insulin degludec, insulin glargine U300 has a lower risk of hypoglycemia during the initial dose adjustment period.
The insulin dose can be adjusted every day to make blood sugar reach the target quickly
.

4.
Compared with insulin degludec, insulin glargine U300 has better hypoglycemic effect and lower hypoglycemia in patients with renal insufficiency
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Experts commented on the case of Chen Liqin, director of Dagang Hospital.
The case mentioned in this issue is type 2 diabetes with a course of more than 10 years, combined with diabetic nephropathy and diabetic peripheral neuropathy.
Before admission, oral hypoglycemic drugs were used for poor blood sugar control.
Poor patients with renal insufficiency (chronic kidney disease stage 3b), according to the 2020 edition of the CDS guidelines for the diagnosis and treatment of type 2 diabetes, use basal insulin to control blood sugar
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After using insulin glargine U300 combined with OAD hypoglycemic program, blood glucose reached the standard stably
.

We need to consider 2 important issues before adjusting the insulin regimen in this case: (1) Setting of blood glucose control goals: HbA1c and FPG
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(2) Patients with renal insufficiency cannot increase the risk of hypoglycemia
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The 2020 CDS guidelines recommend a reasonable HbA1c control target of <7% for most non-pregnant adult T2DM patients[1]
.

Chinese population studies have shown that prioritizing fasting blood glucose control is the key to achieving HbA1c target[2]
.

HbA1c has set clear control targets in the guidelines, but FPG target values ​​have not been unified [1, 3-4]
.

The BEYOND III study explored the ideal FPG target for Chinese patients with type 2 diabetes, and the study confirmed that: FPG≤6.
1, the proportion of safe compliance is higher [5]
.

The FPG GOAL study confirmed that the HbA1c corresponding to FPG reaching 6.
1 was 7.
0%, and there was a significant linear relationship [6]
.

The Chinese consensus on clinical application of basal insulin recommends FPG≤6.
1mmol/L as the ideal control target for T2DM patients, which can further improve the HbA1c compliance rate without increasing the risk of hypoglycemia[7]
.

Diabetic nephropathy is a common complication of type 2 diabetes: the prevalence of diabetic nephropathy in Chinese community type 2 diabetic patients is 10% to 40% [8]
.

The prevalence of CKD in hospitalized diabetic patients was 52.
3% [9]
.

The detection rate of albuminuria in Asian patients with type 2 diabetes was 56%, which was higher than that in Caucasians 41% [8]
.

The annual decline rate of eGFR in patients with type 2 diabetes was 1.
39mL/min/1.
73m2/year
.

Type 2 diabetes mellitus patients with renal impairment can lead to shortened life expectancy, we should pay attention to the impact of diabetes on the kidney as soon as possible [10-11]
.

In patients with T2DM and CKD, blood sugar control goals: patients with CKD stages 1-3, if they have a longer life expectancy and no serious vascular complications, the blood sugar control goals can be the same as the normal population (HbA1c <7%); patients with CKD stages 4-5, If life expectancy is short, the HbA1c target can be appropriately relaxed to 8.
5%
.

Insulin selection: For patients with CKD stages 1-3a, try to choose drugs with less renal excretion, preferably drugs with renal function protection; patients with CKD stages 3b-5 should be treated with insulin, and it is recommended to choose low risk of hypoglycemia and is conducive to self-management of patients Insulin, such as basal insulin analogs, should be started with small doses of insulin, and the dose should be adjusted in small increments to avoid hypoglycemia [12]
.

With the continuous development and innovation of basal insulin, insulin glargine U300, which can better simulate the physiological insulin secretion pattern, achieve more stable blood sugar control, and reduce the risk of hypoglycemia, came into being
.

Pharmacokinetic and pharmacodynamic studies have confirmed that insulin glargine U300 has the advantage of a more stable pharmacokinetic/pharmacodynamic curve than other basal insulins[13]
.

The BRIGHT study showed that insulin glargine U300 has an exact hypoglycemic effect, and the risk of hypoglycemia in the initial dose adjustment period was significantly reduced [14]
.

BRIGHT subgroup analysis showed that in elderly/renal insufficiency patients, insulin glargine U300 had better hypoglycemic effect, and the risk of hypoglycemia was similar to that of the control group[15]
.


References: [1] Diabetes Branch of Chinese Medical Association.
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition).
Chinese Journal of Diabetes 2021,4(13):315-409[2]2018 IDF abstract: The Relative and Absolute Contributions of Postprandial and Basal Glucose to Overall Hyperglycemia and HbA1c in Type 2 Diabetes[3]ADA.
Diabetes Care 2021,44(Supplement 1):S111-S124[4]IDF Diabetes atlas: 9th edition 2019[5]Yang W, Diabetes Obes Metab .
2019 Aug;21(8):1973-1977[6]Ma, J.
et al.
Adv Ther 2020, 37 (9), 3816-3826[7] Chinese expert guidance on clinical application of basal insulin in adults with type 2 diabetes ( 2020 edition).
Chinese Journal of Diabetes.
2020; 28(10): 52-59\[8] Endocrinology Branch of Chinese Medical Association.
Chinese Journal of Endocrinology and Metabolism.
2015, 31(5): 375-389.
[9] Chinese Physician Chinese Society of Endocrinology and Metabolism.
Chinese Journal of Endocrinology and Metabolism.
2019.
35(6):447-454.
[10]Szczech LA, et al.
PLoS One.
2014 Nov 26;9(11):e110535.
[11]Wen CP, et al.
Kidney Int.
2017;92(2):388-396[12] Chinese expert guidance on clinical application of basal insulin in adults with type 2 diabetes (2020 edition)[13]Bailey TS, et al.
Diabetes Metab 2018,44( 1):15-21.
[14]Bolli GB, et al.
Diabetes Obes Metab.
2021 Jul;23(7):1588-1593.
[15]Haluzík M, et al.
Diabetes Obes Metab.
2020 Aug;22(8):1369-1377.
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