The full text of the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" is finally released, and the 10 major updates are here!

*It is only for medical professionals to read for reference.
What has been updated in this "Guide" after 3 years? Since 2003, the Diabetes Branch of the Chinese Medical Association has successively published 5 editions of the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China", which are updated once every three years, and have witnessed the changes in the management of type 2 diabetes in China.

On April 19, 2021, the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)" compiled by the Diabetes Branch of the Chinese Medical Association were published in the Chinese Journal of Diabetes and the Chinese Journal of Endocrinology and Metabolism.

The Endocrinology Channel of the medical community gave a detailed interpretation of the ten main points of this guideline update.

Figure 1 A summary of the 10 major updated points of the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)" are summarized as follows: · Point 1 · The prevalence of diabetes in my country is as high as 11.
2% So far, the prevalence of diabetes in my country is still increasing.

The latest epidemiological survey data published by Professor Teng Weiping's team shows that according to the World Health Organization (WHO standard), the prevalence of diabetes in my country has reached 11.
2%.

Figure 2 The prevalence of diabetes in my country has been on the rise.
Key point 2.
HbA1c is officially included in the diagnostic criteria for diabetes.
Glycated hemoglobin (HbA1c) is an important indicator for measuring blood sugar control.
Professor Zhu Dalong said that for many years, CDS has been committed to including HbA1c in the diagnostic criteria.
The recently launched "China Glycated Hemoglobin Consistency Program (CGSP)" is aimed at optimizing China's HbA1c standardization.

In this guideline update, CDS finally officially included HbA1c in the diagnostic criteria for diabetes, with HbA1c≥6.
5% as the cut-off point to assist in the diagnosis of diabetes.

The new recommendations are specifically: "In laboratories with strict quality control, HbA1c measured by standardized methods can be used as a supplementary diagnostic criterion for diabetes-level B evidence.

"Table 1 Latest Diabetes Diagnosis Standards Note: HbA1c can be used for diabetes diagnosis only after the consistency evaluation is passed · Point 3 · HbA1c individualized control goal setting, you can do this! This guide update refines individualized HbA1c control The main influencing factors for goal setting, it is proposed that: "HbA1c control goals should follow the principle of individualization.
Patients with type 2 diabetes who are younger, shorter in disease course, longer life expectancy, uncomplicated, and not combined with cardiovascular disease, have no low In the case of blood sugar and other adverse reactions, a more stringent HbA1c control target can be adopted, and on the contrary, a relatively loose HbA1c control target-level B evidence can be adopted.

"At this stage, the endocrinology department's management of HbA1c has not yet achieved "precise control".
A schematic diagram has been added to this guideline update to better guide clinicians in the individualized management of patients with HbA1c: Figure 3 Individualized HbA1c In the schematic diagram, the influencing factors of HbA1c individualized goal setting are divided into invariable factors (age, course of disease, diagnostic life span, comorbidities, complications, tolerance to side effects such as hypoglycemia) and possible Variable factors (patients’ subjective willingness, resources and support systems, whether to use drugs that increase the risk of hypoglycemia) two categories, a total of nine subcategories, and provide corresponding adjustment recommendations (to the left is more stringent, and to the right is More lenient).

· Point 4 · Hyperglycemia medications, Class 2 new drugs are approved! In this guide update, life>
At the same time, this guideline update emphasizes the importance of combination therapy.
The latest recommendation is: "A hypoglycemic drug treatment but blood sugar is not Those who reach the target will be treated with a combination of two or even three drugs with different mechanisms of action.

Insulin therapy can also be added—level A evidence.

"This is already covered in the 2017 version of the guidelines.

In recent years, evidence-based evidence of new mechanisms of hypoglycemic drugs represented by glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT-2) inhibitors has gradually Rich, this guide update also has their place-patients with type 2 diabetes with atherosclerotic cardiovascular disease (ASCVD) or high-risk cardiovascular risk, regardless of whether their HbA1c is up to the standard, as long as there is no contraindication, should be in metformin GLP-1 receptor agonists or SGLT-2 inhibitors with evidence of ASCVD benefit were added on the basis of A-level evidence.

Patients with type 2 diabetes with chronic kidney disease (CKD) or heart failure, regardless of whether their HbA1c meets the standard, as long as there are no contraindications, should add SGLT-2 inhibitors to metformin.

For patients with type 2 diabetes with CKD, if SGLT-2 inhibitors cannot be used, GLP-1 receptor agonists may be considered—level A evidence.

These two recommendations mean that the scope of clinical use of GLP-1 receptor agonists and SGLT-2 inhibitors will be wider.

· Point 5 · Diabetes treatment path, updated! In the previous version of the guidelines, HbA1c compliance is a "big mountain" that weighs on the treatment process.
In many cases, compliance directly determines whether to start combination therapy.

Figure 4 The simple path of hyperglycemia treatment recommended by the old guideline.
In this update, HbA1c's binding force on the diagnosis and treatment process has been significantly reduced.
In addition to medication, this is also reflected in the latest diagnosis and treatment path: Figure 5 The new guideline The recommended diabetes treatment path in the new version of the treatment path, after life>
This point coincides with the updates in the 2020 ADA guidelines, suggesting that in the future clinical application scenarios, the application of these two types of drugs will be more advanced than in the past.

Another noteworthy detail is that for patients who do not have the above risk factors or comorbidities/complications on the left side, if HbA1c is not up to standard, it is recommended to use dual therapy.
If it is metformin combined with insulin, the basic choice is usually Insulin-This is not defined in the previous version of the guidelines.

· Point 6 ·3 weight management recommendations, formally written into the guide! Overweight/obesity is closely related to type 2 diabetes.
In this update, weight management is also included in the guidelines as an important part of patient management.
The three recommendations respectively standardize the goals and methods of weight management, as follows: Overweight and obese adults The management goal for patients with type 2 diabetes is to lose 5% to 10% of their body weight—level A evidence.

The weight management methods of overweight and obese adults with type 2 diabetes include comprehensive measures such as life>
Obese adults with type 2 diabetes should try their best to use life>
The inclusion of weight management in the guidelines means that the management of patients with type 2 diabetes will be more comprehensive and comprehensive, and it is also no small challenge for clinicians.

· Point 7 · New indicators of blood glucose monitoring: TIR writing guide! With the innovation and maturity of continuous glucose monitoring (CGM) technology, diabetes blood glucose management indicators have also been updated.

The time for blood glucose to stabilize within the target range-TIR has gradually attracted attention.
The latest ADA's latest "Diagnosis and Treatment Standards for Diabetes 2020" pointed out that TIR is an important indicator that reflects the stability of patients' blood glucose and monitors complications.

Figure 6 Recommendations of the ADA guidelines for TIR management of different patients The update of the CDS guidelines mentioned: "TIR should be included in the goal of blood glucose control-level B evidence".

According to the TIR international consensus released in 2019, the TIR control target for patients with type 1 and type 2 diabetes is >70%.

But the TIR goal is not static, it should be highly individualized, while paying attention to hypoglycemia and blood sugar fluctuations.

For a large number of clinicians, TIR is still a new thing and a new standard.
It takes time to explore its clinical guidance value.
In addition, due to the accessibility of CGM, not all endocrinologists can easily obtain patients.
Therefore, this update is more like a forward-looking recommendation.

· Point 8 · There is a grading standard for hypoglycemia since then! my country’s hypoglycemia classification standards have always lacked relevant evidence-based medical evidence, but the classification of hypoglycemia is very important for the risk management of patients.
Therefore, in this update of the CDS guidelines, the editorial board experts refer to the classification of hypoglycemia in the ADA guidelines.
The standard has established the following classification criteria-Figure 7 Hypoglycemia classification of the new version of the guideline · Key point 9 · For CKD patients, the condition determines the number of reexaminations! CKD is a common complication of type 2 diabetes.
For CKD patients with different disease progression, individualized follow-up time should be set to ensure timely monitoring of the patient's disease progression and adjustment of management plans.

This revision of the guidelines makes clear recommendations on the time of follow-up visits for different patients in the form of a table: Table 2 CKD progression risk and frequency of visits Note: The number in the table is the recommended number of rechecks per year; the background color represents the risk of CKD progression: green It is low risk, yellow is medium risk, orange is high risk, and red is very high risk.

In this recommendation, the original eGFR classification is used for the progression risk of CKD patients.
According to the eGFR situation, the CKD staging still adopts 1 to 5 stages, and the 3 stages are subdivided into 3a and 3b stages.

· Point 10 · Severe acidosis treatment with alkali supplementation, the pH index drops slightly! Diabetic ketoacidosis (DKA) is a syndrome of severe disorders of sugar, fat, and protein metabolism caused by insufficient insulin and improperly elevated glucocorticoids.
It is clinically characterized by hyperglycemia, hyperketones, and metabolic acidosis.
, Divided into mild, moderate and severe.

 Severe DKA refers to acidosis with disturbance of consciousness (DKA coma), or although unconscious disturbance, but serum bicarbonate is lower than 10mmol/L.

Severe metabolic acidosis may cause serious complications such as myocardial damage, cerebrovascular expansion, severe gastrointestinal complications, and coma, so alkali supplementation is needed.

 The 2017 version of the guidelines has pointed out that severe acidosis (pH <7.
0) requires appropriate supplementation of sodium bicarbonate solution.

In this guideline update, it is recommended to consider appropriate alkali supplementation only in patients with pH ≤ 6.
9.

The blood pH value was measured every 2 hours until it remained above 7.
0.

Strengthen review during treatment to prevent overdose.

· Other points · In addition to the above core points, this guide update also incorporates the content of nutrition management, adding a daily energy supply table to the guide, providing a powerful tool for the individualized nutrition management of diabetic patients.

In addition, this guideline update also updated the injection technology and insulin pump in the diabetes-related technology section; added the role of artificial intelligence (AI) in DR screening and graded diagnosis in the diabetic retinopathy (DR) section.

·Summary·In general, the 2020 "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" is updated based on the actual application scenarios of clinicians, extensively borrowing from international guidelines (such as ADA guidelines), and has reached the standards of international guidelines .