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    Home > Active Ingredient News > Endocrine System > The 2022 edition of "China's Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly" was released!

    The 2022 edition of "China's Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly" was released!

    • Last Update: 2022-01-26
    • Source: Internet
    • Author: User
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    Edited by Yimaitong, please do not reprint without authorization
    .

    According to the Seventh National Census Bulletin of the National Bureau of Statistics, in 2020, the population of the elderly aged 60 and above in China will reach 260.
    4 million, of which about 30% are diabetic patients (over 95% are type 2 diabetes).
    —2030) one of the key actions
    .

    Recently, the "Chinese Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly (2022 Edition)" was released in the "Chinese Journal of Internal Medicine".
    , The implementation of clinical measures for diagnosis and treatment, and continuously improve the overall management level of elderly diabetes
    .

    This article shares the contents of "Optimization of Treatment Strategies for Type 2 Diabetes in the Elderly" and "Drug Treatment of Hyperglycemia"
    .

    Optimizing strategies for the treatment of type 2 diabetes in the elderly - focusing on "comprehensive evaluation" and "four early principles" The "Guidelines" pointed out that with the intensification of aging in China, the elderly with diabetes has grown rapidly and has become the mainstream population of diabetes, and the prevalence rate is still high.
    In addition, the prevalence of prediabetes increased (30%, 2017) from 45% to 47%
    .

    Elderly diabetic patients have high mortality and morbidity rates due to diabetic complications and complications, but overall blood sugar control is not ideal
    .

    Regarding the "optimization of the treatment strategy for type 2 diabetes in the elderly", the "Guidelines" suggest the following points: ➤ For elderly patients with type 2 diabetes mellitus, blood glucose and pancreatic islet function levels, complications and comorbidities, organ function and personal living ability5 Comprehensive assessment of each aspect is the basis for making individualized treatment plans (A, I)
    .

    ➤Early prevention, early diagnosis, early treatment, and early compliance are the basic principles for optimizing treatment outcomes of type 2 diabetes in the elderly (B, I)
    .

    ➤Develop individualized glycemic control goals to maximize benefits and minimize risks in older adults with type 2 diabetes (A, I)
    .

    ➤ The blood glucose control target defined by HbA1c <7.
    0%, corresponding to fasting blood glucose 4.
    4-7.
    0 mmol/L and 2hPG <10.
    0 mmol/L, is suitable for most patients with long life expectancy, no risk of hypoglycemia, and no serious heart, brain and kidney disease.
    Elderly patients with type 2 diabetes (A, I)
    .

    ➤HbA1c≤8.
    5%, corresponding FPG≤8.
    5 mmol/L and 2hPG<13.
    9 mmol/L are acceptable blood sugar control standards for elderly diabetic patients
    .

    It is suitable for elderly diabetic patients with long course of disease, difficulty in blood sugar control, and high risk of hypoglycemia, and it is necessary to avoid the occurrence of acute complications of diabetes (B, I)
    .

     1.
    Comprehensive evaluation strategy Comprehensive evaluation of the patient's condition is the basic condition for formulating a personalized treatment plan for elderly diabetes mellitus.
    The "Guide" recommends that the following five aspects should be evaluated for the first-time diagnosis/first-time doctor, and the follow-up re-evaluation plan should be determined according to the overall level.

    .

      Table 1 Contents of comprehensive assessment 2.
    Principles of "Four Earlys" The "Guide" points out that the management of elderly diabetic patients should pay attention to the "four early" principles, namely "early prevention, early diagnosis, early treatment, and early compliance"
    .

     1.
    Early prevention: the change of concept is very important
    .

    Diabetes, hypertension, dyslipidemia, hyperuricemia, and central obesity (four highs + obesity) are genetic backgrounds, influenced by environmental factors, and have a high incidence of multiple combinations.
    Prevention should follow the concept of "preventing disease"
    .

    Actively carry out the study and education of diabetes prevention and control knowledge, promote a healthy life>
    .

    In particular, high-risk groups of diabetes (those with a family history, abdominal obesity, hypertension, hypertriglyceridemia, and hyperinsulinemia) should be listed as key prevention and treatment targets, and primary prevention of diabetes should be done well
    .

     2.
    Early diagnosis: The development of type 2 diabetes can go through the compensation period of hyperinsulinemia-normal blood sugar, prediabetes with mild abnormal blood sugar, early diabetes (mild to moderate increase in blood sugar) and the stage of complication damage
    .

    High-risk patients are encouraged to undergo regular diabetes screening, early detection of potential diabetes risk, and early protection of their ß-cell function
    .

    Combined FPG, random or 2hPG and HbA1c testing, or diabetes screening with OGTT can help reduce the rate of missed diagnoses
    .

    Do not relax the upfront management of people with abnormal glucose metabolism levels
    .

     3.
    Early treatment: including early initiation of therapeutic life>
    .

    The study found that FPG>6.
    1 mmol/L, 2hPG or random blood glucose>7.
    8 mmol/L or HbA1c>6.
    0% are the warning points to start diabetes prevention by TLC
    .

     ➤ TLC alone can reduce the incidence of diabetes by 40% to 58%.
    Although metformin, acarbose, and pioglitazone drug intervention studies reduced the incidence of diabetes by 77%, 88%, and 54%, respectively, these drugs are used in elderly people with diabetes.
    The long-term efficacy and safety of diabetes prevention are yet to be further verified
    .

    ➤In terms of diabetes management and treatment strategies, it is necessary to avoid the delay in starting life>
    .

    ➤In elderly diabetic patients with HbA1c>7.
    0% on the basis of diet and exercise therapy, single drug or combined oral hypoglycemic drug treatment other than sulfonylurea or glinide should be considered.
    According to the patient's insulin level, obesity degree and blood sugar fluctuation It is beneficial to reduce the complications of diabetes by controlling HbA1c to less than 7.
    0%
    .

    ➤ If HbA1c is still >7.
    5% after combined with 2-3 kinds of oral hypoglycemic drugs, injection of hypoglycemic drugs can be started.
    If insulin treatment is required, basal insulin is the first choice
    .

    However, for patients with poor dietary control, obesity, and low levels of insulin secretion, it is not advisable to apply insulin prematurely.
    Strict life>
    .

     4.
    Early achievement of targets: Individualized control targets for elderly diabetic patients include blood sugar and other metabolic-related indicators other than blood sugar
    .

    Previous studies have shown that for elderly diabetic patients with multiple cardiovascular risk factors, early comprehensive control of multiple cardiovascular risk factors can lead to early benefits
    .

     Assess the patient's physical condition and formulate "individualized" control goals - blood sugar and other metabolic-related indicators The "Guide" points out that the goals of elderly diabetic patients should follow the principle of individualization, and strive to maximize the benefits and minimize the risks for patients' survival
    .

     1.
    Glycemic control goals of elderly diabetic patients The clinical manifestations of elderly patients with diabetes are more heterogeneous.
    On the basis of comprehensive evaluation, the formulation of diagnosis and treatment strategies needs to "focus on the starting point and balance the target"
    .

    Based on the concept of striving for optimal treatment and management for each patient, avoiding excessive medical treatment and avoiding treatment risks, and simplifying stratification, the following standards for blood sugar control in elderly patients can be referred to: (1) HbA1c≤7.
    0%: corresponding FPG 4.
    4 ~7.
    0 mmol/L and 2hPG < 10.
    0 mmol/L, with the goal of good glycemic control for long-term benefit
    .

    It is suitable for patients with new diagnosis, short course of disease, strong self-management ability, and better medical conditions, or elderly patients who use insulin secretagogues or insulin therapy and can avoid the risk of hypoglycemia
    .

    Elderly diabetic patients with early detection of abnormal blood sugar and early self-management and treatment can control their blood sugar to normal levels and reduce the risk of diabetic complications
    .

    (2) HbA1c7.
    0%~<8.
    0%: the corresponding FPG<7.
    5 mmol/L and 2hPG<11.
    1 mmol/L, as the intermediate adjustment stage of optimal control and acceptable control standards, suitable for poor self-management ability or Elderly diabetic patients at high risk of hypoglycemia
    .

    (3) HbA1c 8.
    0%~8.
    5%: corresponding FPG≤8.
    5 mmol/L and 2hPG<13.
    9 mmol/L, suitable for diabetic patients with difficulty in blood sugar control and limited benefit from strict blood sugar control, focusing on avoiding severe hyperglycemia (FPG>16.
    7 mmol/L) caused acute complications of diabetes and refractory infections
    .

    2.
    Other metabolic-related indicators other than blood sugar The Guidelines recommend that the control targets of hypertension, LDL-C, TG, serum uric acid and BMI in elderly patients with type 2 diabetes should follow the principle of individualization, as shown in the table below
    .

    "New Treatment Path" and "Clinical Medication Thinking" "Guide" pointed out that before starting hypoglycemic drug treatment, it is necessary to pay attention to the overall evaluation of elderly patients with type 2 diabetes to understand whether there is organ dysfunction that affects the choice of hypoglycemic drugs.
    Whether there is a need for concomitant medication, and whether there are factors that affect medication compliance (funding, self-management ability, etc.
    )
    .

    The following points are highlighted: ➤ Pancreatic islet function should be assessed before treatment, and a treatment plan should be formulated based on the patient's blood glucose level during treatment and with HbA1c detection as a reference (B, I)
    .

    ➤The choice of hypoglycemic drugs should pay attention to cardiovascular and cerebrovascular diseases, renal function, hypoglycemia risk, impact on body weight, cost, risk of side effects, and the patient's medical insurance affordability, and formulate more beneficial individualized hypoglycemic treatment plans (A, I )
    .

    ➤Selecting a simplified, easy-to-operate, and low-risk medication mode can improve compliance (B, I)
    .

    ➤Metformin is the drug of choice (no age limit) and can be used for a long time (except for severe renal insufficiency) (A, I)
    .

    ➤On the basis of life>
    .

    ➤ When combined with atherosclerotic cardiovascular disease (ASCVD) or high risk factors, renal disease or heart failure, SGLT-2i or GLP-1RA is preferred according to individual patient conditions (A, I)
    .

    ➤ On the basis of life>
    .

    ➤ It is recommended to use multiple insulin injections (intensive therapy) or continuous subcutaneous insulin in special circumstances such as concomitant hyperglycemia (HbA1c>9.
    5%, FPG>12 mmol/L), co-infection or acute complications, surgery or stress state Infusion (CSII) method (A, I)
    .

    1.
    The development of diabetes can be roughly divided into 4 stages, and the selection of hypoglycemic drugs is different.
    The "Guide" points out that the development of type 2 diabetes includes "early normal blood sugar-compensatory hypersecretion of insulin", "pre-diabetes (mild increase in blood sugar)".
    There are four representative stages in the selection of hypoglycemic drugs: high), insufficient insulin secretion, and insufficient insulin secretion
    .

     ➤Pre- and early-stage type 2 diabetes: The pathological features are insulin resistance + relative secretion insufficiency.
    In the pre-diabetes stage, life>
    .

    ➤In the early stage of diabetes: treatment should be mainly to reduce insulin resistance, supplemented by non-insulin secretagogue hypoglycemic drugs
    .

    ➤In the stage of markedly insufficient insulin secretion: use insulin secretagogues and combine basal insulin if necessary
    .

    ➤Insulin deficiency mainly: Insulin treatment is the main treatment, supplemented by oral hypoglycemic drugs
    .

     2.
    If there is a need for weight loss, in addition to lowering blood sugar, metformin, GLP-1RA or SGLT-2i drugs can be preferred if there is a need for weight loss, improvement of ASCVD, CKD occurrence and development risk, or heart failure needs
    .

     3.
    According to the HbA1c level at the time of consultation, determine the initial single drug or combination therapy.
    The "Guide" recommends that the initial single drug or combination therapy can be determined according to the patient's blood glucose level at the time of the doctor's visit (with the HbA1c detection value as the reference).
    In the past, the step-by-step glycemic control model, stratified according to the HbA1c level, and the earlier combined treatment model had better effect on the overall glycemic control
    .

    Recommendations: ➤ If HbA1c < 7.
    5%: choose monotherapy; ➤ If HbA1c ≥ 7.
    5%: choose dual/triple combination therapy; ➤ If HbA1c ≥ 9.
    5%: consider combined insulin therapy
    .

     4.
    Special circumstances that may be encountered: Newly diagnosed or uncontrolled elderly diabetic patients with hyperglycemia (HbA1c>9.
    5%, FPG>12 mmol/L), co-infection or acute complications, undergoing surgery or emergency treatment.
    In special circumstances, such as the use of drugs that antagonize insulin action (such as glucocorticoids), due to the obvious insulin resistance, high glucose toxicity, high lipid toxicity and other factors that aggravate islet β-cell damage, it is necessary to actively use it for more than one day.
    Sub-insulin intensive treatment mode, relieve β-cell glucotoxicity, and correct hyperglycemia as soon as possible
    .

    After the condition is stabilized, re-evaluate, adjust or return to the conventional treatment mode; it is not recommended to use the difficult-to-operate multiple insulin treatment mode in the conventional hypoglycemic treatment of elderly patients
    .

     At present, the mechanism of action of all hypoglycemic drugs is relatively limited.
    When the blood sugar target cannot be reached by single drug treatment, the combination of drugs with complementary mechanisms has greater advantages
    .

    In addition to the closed-loop insulin therapy system that can adjust insulin dosage on demand, other insulin preparations often cannot take into account the needs of patients with blood sugar changes at three meals.
    Combining oral hypoglycemic drugs to make up for the deficiency is a very practical and effective treatment mode
    .

     The proportion of patients with diabetes before old age complicated with macrovascular and microvascular disease is much higher than that of patients with diabetes after old age.
    These patients have poor islet β-cell function and usually have large fluctuations in blood sugar.
    If they are not well managed and treated for a long time, they will There are different degrees of organ function damage, and the possible impact on the application of hypoglycemic drugs should be fully considered in the choice of treatment, especially to prevent the occurrence of severe hypoglycemia
    .

    For elderly patients with severe hypoglycemia, the dosage form or dosage of insulin/insulin secretagogues needs to be adjusted
    .

    If the cause cannot be completely blocked, the goal of blood sugar control should be relaxed, with the goal of no hypoglycemia and no severe hyperglycemia
    .

    Original text of the guideline: http://rs.
    yiigle.
    com/CN112138202201/1347049.
    htm Edited by Yimaitong: China Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly Chinese Society of Geriatric Endocrinology and Metabolism, et al.
    Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly in China (2022 Edition) [J].
    Chinese Journal of Internal Medicine, 2022, 61(1): 12-50.
    DOI: 10.
    3760/cma.
    j.
    cn112138- 20211027-00751.
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