The full text of "Chinese Insulin Pump Treatment Guidelines (2021 Edition)" is released!

Recently, the "Chinese Insulin Pump Treatment Guidelines (2021 Edition)" was published in the "Chinese Journal of Endocrinology and Metabolism".
This article shares with you the guidelines and recommendations on "blood glucose control goals, insulin dose setting and adjustment"
.

(The full version of the guide download link is attached at the end of the article) 1.
Blood glucose control goals Blood glucose control goals should be individualized based on the patient’s age, course of disease, health status, risk of hypoglycemia, risk of adverse drug reactions, and other factors, and be timely in light of changes in the condition Adjust blood glucose control goals to maintain the best balance of risks and benefits
.

➤Glucose control goals for patients with type 1 diabetes (T1DM) are shown in Table 1
.

The recommended HbA1c target for children and adolescents with T1DM is <7.
0%
.

➤Glucose control goals for patients with type 2 diabetes (T2DM) are shown in Table 2
.

➤See Table 3 for the general blood glucose control goals of patients with gestational diabetes
.

➤For non-emergency and critically ill hospitalized patients with short-term insulin intensive treatment, the blood glucose stratification management goals are shown in Table 4
.

➤See Table 5 for the blood glucose control goals of patients during the perioperative period
.

2.
The time recommended target within the glucose target range of different diabetic people.
The combination of CGM technology and insulin pump can help patients achieve refined management of blood sugar
.

In the CGM chart, the time within the target range of glucose (TIR), the time above the target (TAR) and the time below the target (TBR) can provide blood glucose management information other than HbA1C.
The recommended targets for the above indicators in the TIR international consensus are shown in Table 6.

.

The TIR goal also emphasizes individualization, while paying attention to hypoglycemia and blood sugar fluctuations
.

Second, the choice of insulin CSII treatment can choose fast-acting insulin analogues or short-acting insulin with indications for insulin pump use (Table 7), the conventional concentration is U-100 (100 U/ML); in special cases, the concentration can be U- 40 (40U/ML) low-concentration insulin, but pay attention to conversion and verify whether the insulin pump has functions related to low-concentration insulin.
The application of conventional short-acting insulin in the pump may slightly increase the risk of pipeline blockage.
It is recommended to use with caution
.

Medium-acting, long-acting, premixed insulin cannot be used for insulin pump therapy
.

3.
The initial dose setting of the insulin pump (according to the two principles of body weight and the existing insulin dose) The total amount of insulin for the patient treated by the insulin pump should be set first, and then the basic rate and the distribution of large doses before meals should be carried out
.

Patients who have received insulin therapy before insulin pump treatment can refer to the previous plan for setting; if there is no previous plan for reference, the daily insulin dose calculation should be determined according to the patient's diabetes type, weight and clinical reality
.

 1.
The setting of total daily insulin dosage (TDD) (1) The calculation of the initial insulin dose for patients who have not received insulin treatment.
According to different types of diabetes, the preliminary dose setting is carried out: ➤T1DM: TDD (U) = weight ( KG) × (0.
4 ~ 0.
5) ➤ T2DM: TDD (U) = weight (KG) × (0.
5 ~ 0.
8) The clinician should set the dose calculation coefficient according to the assessment results of the specific situation
.

If the patient’s baseline blood glucose level is high and insulin resistance is prominent (such as abdominal obesity, hyperlipidemia, hyperinsulinemia, pregnancy, etc.
), a higher calculation coefficient should be set; on the contrary, if the patient’s insulin sensitivity is high or The risk of hypoglycemia is high, and the calculation coefficient should be set more conservatively
.

In addition, short-term insulin intensive therapy for newly diagnosed T2DM patients can also be estimated by referring to the following formula: TDD (U) = 80% × [0.
35 × body weight (KG) + 2.
05 × fasting blood glucose (mmoL/L) + 4.
24 × triacylglycerol (mmoL/L) + 0.
55 × waist circumference (CM)-49.
1]
.

 (2) Patients who have been treated with insulin before insulin pump treatment For patients who have received multiple insulin injections (≥2 times) daily before insulin pump treatment, TDD can be estimated based on the previous insulin regimen
.

Because the insulin dosage during insulin pump treatment is lower than that of multiple insulin injections a day, TDD can be appropriately lowered according to the actual situation of the patient
.
See Table 8 for details .

In addition, if the patient has only used basal insulin therapy in the past, the original basal insulin dosage can be set as the basal insulin infusion amount
.

(3) Drug wash-out period The superimposition of the effects of hypoglycemic drugs can increase the risk of hypoglycemia
.

If intermediate-acting, long-acting insulin or oral hypoglycemic drugs are not discontinued before starting insulin pump therapy, a temporary basal infusion rate can be set.
In the first 12 to 24 hours, the infusion is equivalent to 50% to 75% of the calculated dose of basal insulin
.

 2.
Dosage distribution of daily insulin infusion amount (1) Setting of basic infusion amount and basic infusion rate The speed of basal insulin, expressed in U/H
.

In the past, 50% of TDD was allocated as the basal infusion based on the characteristics of normal people's pancreatic basal state and insulin secretion during meals
.

However, many studies on Chinese and East Asian populations suggest that the total base rate is mostly around 40% of TDD, which is different from foreign studies and guidelines recommendations
.

It may be related to the characteristics of China's high carbohydrate intake and the obvious increase in blood sugar after meals
.

In East Asian children and adolescents with T1DM, the basic rate is as low as about 30%.
Based on the existing evidence, this guide recommends setting the basic infusion volume to the total dose ratio in accordance with the following principles: ➤Adults: TDD×(40%~ 50%) ➤ Teens: TDD × (30% ~ 40%) ➤ Children: TDD × (20% ~ 40%) The time period of the basic infusion rate should be set according to the patient's islet function status, blood glucose fluctuations and living conditions
.

In general, T2DM patients with stable disease or T1DM patients with residual pancreatic islet function can use a simple 1-2 segment method to distribute the basic rate evenly in 24H, and reduce it by 10% from 22:00 to 2:00~ 20%.
Follow-up adjustments will be made according to the patient's blood glucose monitoring.
In T1DM and T2DM patients with poor islet function and large blood glucose fluctuations, it can be set to 3 to 6 time periods.
Early morning and evening often require a higher basic rate to cope with "dawn".
Phenomenon” and high blood sugar before going to bed (also known as “dusk phenomenon”), while the night and early morning basal rate is lower, and T1DM often requires more segments
.

The method of setting the basal rate on the insulin pump is as follows: ➤One-stage method: The amount of insulin infusion in each period of the day is the same, that is, the amount of infusion per hour = the total amount of insulin in the whole day ÷ 24
.

➤Two-stage method: When using short-acting insulin, increase the basal rate from 1:00 to 3:00 in the morning until 9:00 to 11:00 in the morning, and return to the original basal rate after 11:00; if fast-acting insulin is used, then The basic rate should be increased from 2:00 to 4:00 in the morning until 10:00 to 12:00 in the morning, and the original basic rate should be restored after 12:00 to resist the dawn phenomenon
.

In addition, for some patients who are prone to night hypoglycemia, the basic rate from 2 hours before bedtime to 3 to 4 hours after falling asleep can be reduced, and the normal basic rate can be restored at other times
.

➤Three-stage method: For patients who have both early morning high blood sugar and night low blood sugar, combining the two methods in (2) can avoid large fluctuations in blood sugar
.

➤Six steps method: the total amount of insulin throughout the day ÷ 24 to get the constant β, then the basic rate from 0:00 to 3:00 is 0.
6β, the basic rate from 3:00 to 9:00 is 1.
2β, and from 9:00 to 12:00 The basic rate is β, the basic rate is β±0.
1 from 12:00 to 16:00, the basic rate from 16:00 to 20:00 is 1.
1β, and the basic rate from 20:00 to 24:00 is 0.
8β
.

➤24-step method: Under the physiological state of the human body, basal insulin is not secreted at a constant rate, but there are 2 peaks and 2 valleys in a day.
The first peak is between 4:00 and 6:00 in the morning.
The second peak is from 15:00 to 18:00 in the afternoon, and the two troughs of basal secretion in the day are 23:00 to 2:00 and 8:00 to 14:00, respectively
.

 (2) Setting of high-dose before meals The high-dose before meals refers to the amount of insulin that is rapidly infused at one time before the three meals
.

The total amount of TDD after deducting basal insulin is the total amount of pre-meal infusion, which can be allocated according to 1/3, 1/3, and 1/3 of the three meals
.

Then gradually adjust to the optimal ratio, that is, according to the specific dietary components of each meal, especially the carbohydrate content, exercise volume, and blood sugar situation to personalize the ratio of three meals
.

 An insulin pump with a large-dose guide function can also set the carbohydrate coefficient, insulin sensitivity coefficient, target blood glucose range and active insulin metabolism time, etc.
according to needs, and then automatically perform automatic based on the current blood glucose level and intake of carbohydrates before each meal Calculate to obtain the precise required large dose
.

 Fourth, the application of short-term intensive treatment of insulin pump in hospitalization 1.
The adjustment of insulin dose (1) The adjustment of the basic infusion rate The basic infusion rate is divided into the night basic rate and the day basic rate
.

 ➤Night basal rate: refers to the basal rate before going to bed to the next day before eating.
It is generally divided into the first half of the night and the second half of the night.
The basal rate of insulin in the first half of the night is relatively small.
Take care to avoid hypoglycemia, especially in the morning 2: 00~3: 00 low blood sugar
.

In the middle of the night, you should pay attention to the high blood sugar caused by the secretion of glucose hormones in the morning, which is the "dawn phenomenon"
.

Therefore, the adjustment of the night basal rate should be combined with the day and night blood glucose baseline fluctuations
.

➤Daytime basal rate (non-fasting principle) is the basal insulin rate that controls the pre-meal blood sugar between meals.
It refers to the comparison and adjustment based on the blood glucose values ​​of vS before lunch before breakfast, vS before lunch before dinner, and before dinner vS before going to bed.
It is normal.
Under the circumstances, the blood glucose of 2H after meal is higher than that before meal by 1.
7~3.
3mmoL/L
.

➤Basic rate adjustment principle: Under normal circumstances, the blood glucose before each meal does not change more than 1.
7mmoL/L compared with the 2H blood glucose after the previous meal
.

If the change is greater than 1.
7mmoL/L, adjust the base rate by 10%~20% 1~2H before the change.
If the blood sugar drops below 3.
9mmoL/L, you need to eat, and reduce the 1~2H before the hypoglycemia period the next day 10% to 30% of the basic rate, and those with greater fluctuations in basic blood glucose can appropriately increase the proportion of dose adjustment
.

 (2) Adjustment of insulin during meals.
If the 2H blood glucose after meals increases by 3.
3mmoL/L compared with the blood glucose before meals, consider increasing the insulin dose during meals by 10% to 20% (usually 1 to 4 U), or reducing the carbohydrate coefficient by 10% ~20%
.

If the postprandial 2H blood glucose rise is less than 1.
7mmoL/L or even lower than the pre-meal blood glucose, consider reducing the meal insulin dose by 10%-20% and increasing the carbohydrate coefficient by 10%-20%
.

 For T1DM and some T2DM patients with large blood glucose fluctuations, due to the complicated diet, exercise, illness, stress and other conditions of the patients, it is necessary to supplement and correct the calculation of large doses
.

 (3) Supplementing large doses Supplementing large doses refers to an additional large-dose insulin infusion before a temporary meal in addition to a regular meal, which is mainly calculated based on the carbohydrate content and carbohydrate coefficient in the food
.

Supplement large dose (U) = total carbohydrate of food / carbohydrate coefficient (see appendix 2 for the calculation method of supplement large dose)
.

 (4) Correcting large dose The correcting large dose is used to correct the amount of insulin that needs to be supplemented when the current blood sugar is higher than the target value
.

The corrected high dose is calculated by the difference between the measured and target blood glucose and the insulin sensitivity coefficient: corrected high dose = (measured blood glucose-target blood glucose)/insulin sensitivity coefficient: the insulin sensitivity coefficient is the blood glucose that the patient can reduce per 1 unit of insulin (MMoL/L ) Value (see appendix 3 for the calculation method of the corrected large dose)
.

 In order to facilitate patients to achieve individualized and precise blood glucose management in some special situations, some insulin pumps have, in addition to the above basic functions, also have temporary basic rate, square wave and double wave large doses, and large dose guide functions (Appendix 4 )
.

 2.
The adjustment principle of the sensor-enhanced insulin pump SAP integrates CGM and insulin pump to improve the efficiency of blood glucose management.
When interpreting real-time glucose monitoring data, it needs to be combined with the current patient's treatment plan
.

Combined with the CGM results, short-term and long-term insulin dose adjustments can be made
.

The purpose of short-term adjustment is to correct high and low blood sugar in a short time and control blood sugar to the target range
.

Changes in real-time blood glucose monitoring data within 2 to 3 hours before or after a meal can be used to guide short-term insulin dose adjustments
.

The data of rapid blood glucose fluctuations in a short period of time needs to be analyzed for specific reasons, and the amount of insulin cannot be adjusted blindly
.

Long-term insulin dosage adjustment needs to be adjusted based on life>
.

 3.
Conversion of out-of-hospital insulin treatment plan After short-term application of insulin pump treatment in the hospital, before discharge, the individualized out-of-hospital treatment plan can be replaced by combining the patient's blood sugar control goals, β-cell function, and treatment willingness
.

Under the prerequisite of avoiding hypoglycemia, the principles of the change are as follows: ➤Strict goals for blood glucose control during hospitalization (fasting blood glucose <6.
1mmoL/L, postprandial 2H blood glucose <7.
8mmoL/L), removal of high glucose incentives, and For patients with clinical remission, consider reducing TDD by 10% during insulin pump treatment before discharge as the post-discharge insulin treatment dose, and gradually adjust the treatment plan based on the results of blood glucose monitoring.
Some patients with better β-cell function can only be given life>
.

➤For taking oral hypoglycemic drugs before admission or having received insulin treatment but the original regimen cannot maintain the hypoglycemic effect, the goal of blood glucose control during hospitalization is average (fasting blood glucose <7.
8mmoL/L, postprandial 2H blood glucose <10.
0mmoL/L), insulin Most patients with partial recovery of sensitivity need to continue insulin therapy and adjust the insulin dose based on the results of blood glucose monitoring
.

 (1) Convert to 3 meals insulin plus 1 basal insulin regimen.
Consider increasing the TDD during insulin pump treatment by 10%, and you can directly use the pre-meal large dose (increased by 10%) as the changed pre-meal subcutaneous For the injection dose, change the basal insulin infusion volume of the insulin pump (increase by 10%) to the long-acting insulin dose
.

 (2) Convert to regular insulin plus 1 intermediate-acting insulin before going to bed ➤ Subcutaneous insulin dose before breakfast = (large dose of insulin pump before breakfast + sum of basic infusion before breakfast to lunch) × 110%; ➤ Subcutaneous insulin dose before lunch = (pre-meal large dose of insulin pump + sum of basal infusion before lunch to before dinner) × 110%; ➤ Subcutaneous insulin dose before dinner = (large dose of insulin pump before dinner + dinner The total basal infusion before going to bedtime) × 110%; ➤Subcutaneous injection of intermediate-acting insulin dose before going to bed: the sum of the basal infusion before going to bed and before breakfast the next day
.

 (3) Conversion to a pre-mixed insulin regimen twice a day before breakfast injection dose = [insulin pump dose before breakfast + (basic rate of 6: 00-18: 00) + insulin pump before lunch]; pre-dinner dose = [ Pre-dinner dose of insulin pump + (basic rate from 18:00 to 6:00)]
.

Decide to adjust the dose based on the clinical situation
.

 (4) Conversion to basal insulin plan The basic part of the insulin pump is directly converted to the basal insulin dose and increased by 10%
.

During the day, an oral hypoglycemic regimen that controls postprandial blood sugar should be selected according to specific conditions
.

 Guide download link: http://Guide.
medlive.
Cn/Guideline/24107 Reference materials: Chinese Medical Association Endocrinology Branch, Chinese Medical Association Diabetes Branch, Chinese Medical Doctor Association Endocrinology and Metabolism Physician Branch.
Chinese Insulin Pump Treatment Guidelines (2021 Year Edition) [J].
Chinese Journal of Endocrinology and Metabolism, 2021, 37(8): 679-701.