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    Home > Active Ingredient News > Endocrine System > "The Lancet" sub-issue in depth: Diabetes "sugar control concept" to change!

    "The Lancet" sub-issue in depth: Diabetes "sugar control concept" to change!

    • Last Update: 2022-01-26
    • Source: Internet
    • Author: User
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    ▎WuXi AppTec content team editor Glycated hemoglobin (HbA1c) is one of the main indicators to evaluate the long-term blood sugar control level, which can reflect the average blood sugar level and the overall situation of blood sugar metabolism in the past 2-3 months
    .

     However, with the advancement of diabetes diagnosis and treatment technology and the evolution of disease management concepts, the standard of blood sugar control has quietly changed
    .

    A recent review article published in The Lancet Diabetes & Endocrinology pointed out that HbA1c alone is not sufficient to comprehensively assess glycemic control in diabetic patients
    .

     This review highlights a new concept of glycemic control: not only controlling HbA1c and fasting blood glucose, but also paying attention to postprandial blood glucose, blood glucose fluctuations (variability), and time to maintain blood glucose within target normal range (TIR)
    .

    In addition, the review articles provide a detailed overview of new technologies and new drug therapies for glycemic control
    .

    Screenshot source: The Lancet Diabetes & Endocrinology focuses on three major indicators and prevents hypoglycemia Hourly blood glucose was used as a standard for postprandial blood glucose, and the method used data from studies related to the diagnosis of diabetes mellitus by the oral glucose tolerance test (OGTT)
    .

    2-hour postprandial blood glucose levels were associated with retinopathy risk
    .

     However, there is also evidence that the 1-hour postprandial blood glucose value in the OGTT is more accurate in predicting the development or diagnosis of diabetes than the 2-hour postprandial blood glucose value, and it is an independent risk factor for cardiovascular disease
    .

    It is worth mentioning that the blood glucose concentration in the OGTT correlates with the impaired glucose tolerance observed in standard diet and home glucose monitoring, or blood glucose concentration in diabetic patients
    .

     The 1-2 hour postprandial blood glucose target values ​​recommended by major academic institutions in the field of diabetes vary slightly: American Diabetes Association: <10mmol/L (180mg/dL), American Association of Clinical Endocrinologists (AACE): <7.
    8mmol/L ( 140mg/dL), International Diabetes Federation (IDF): <9mmol/L (160mg/dL)
    .

     2.
    Glucose fluctuation (variability) There is increasing evidence that blood glucose variability is an independent risk factor for diabetes complications, especially cardiovascular complications
    .

    Typically, blood glucose variability is defined by measuring fluctuations in blood glucose or other parameters related to blood glucose homeostasis over a given time interval
    .

     Two broad categories of measures were presented in the review: (1) short-term glycemic variability, including intraday and day-to-day glycemic variability; and (2) long-term glycemic variability, measured by HbA1c or fasting blood glucose (or both), during longer periods of time.
    continuous measurement over a period of time
    .

     The use of short-term glycemic variability in long-term studies can be difficult because its values ​​are obtained in a relatively short period of time and the time required for comorbid disease progression is longer
    .

    Despite limitations, the 2017 International Consensus on the Use of Continuous Glucose Monitoring at the Advanced Technology and Treatment of Diabetes (ATTD) Congress proposed a 33%-36% coefficient of variation cutoff to differentiate between stable and unstable short-term glucose variability Control the situation
    .

    ▲Historical milestones of diabetes blood sugar management indicators (1975-2021) (Image source: Reference [1]) 3.
    Time within target range (TIR) ​​Time within target range is an intuitive indicator that indicates that blood sugar concentration has dropped to the expected target The proportion of time in the range (usually 3.
    9-10.
    0 mmol/L [3.
    5-7.
    8 mmol/L in gestation])
    .

    The normal blood sugar range in healthy individuals is usually between 3.
    9 mmol/L and 7.
    8 mmol/L
    .

    Except during pregnancy, most people with type 1 diabetes have difficulty controlling blood glucose concentrations in the 3.
    9-7.
    8 mmol/L range for most of the day
    .

    Therefore, in addition to comparing the glycemic range of healthy individuals, the selection of the upper and lower TIR limits has other considerations: the upper limit (10.
    0 mmol/L) reflects the recommended upper limit of postprandial blood glucose peaks in diabetic patients, and the lower limit (3.
    9 mmol/L) is related to hypoglycemia.
    Thresholds are closely related
    .

    At the same time, hypoglycemia needs to be paid attention to in the daily life of diabetic patients.
    Achieving good glycemic control and avoiding the risk of hypoglycemia are the main challenges
    .

    Hypoglycemia is associated with an increased risk of cardiovascular events, brain injury, and worsening retinopathy
    .

    In addition, hypoglycemia is considered a risk factor for atherosclerosis
    .

     Blood sugar fluctuations (variability) are associated with an increased risk of hypoglycemia
    .

    Evidence suggests that hyperglycemia following recovery from hypoglycemia (often iatrogenic) leads to worsening endothelial function, oxidative stress, and inflammation, both in healthy individuals and in patients with type 1 diabetes; This phenomenon was not observed when returning to normoglycemia
    .

    Potential legacy effects of blood glucose variability Previous studies have confirmed that if early normoglycemia can be well controlled, long-term benefits can be achieved; however, if early hyperglycemia in diabetic patients cannot be controlled in a timely and effective manner, even if measures are taken later to control it well, prone to chronic complications of diabetes
    .

    This phenomenon is known as the "legacy effect", also known as "metabolic memory"
    .

    Long-term follow-up study of the Diabetes Control and Complications Trial (DCCT) confirms for the first time the existence of a 'legacy effect' of hyperglycemia
    .

    The results demonstrate the importance of strict glycemic control in preventing and reducing complications in patients with type 1 diabetes
    .

    These benefits persisted after the DCCT study ended, although these patients were less tightly controlled than they had been
    .

     At the same time, the UK Prospective Diabetes Study (UKPDS) also found similar results in people with type 2 diabetes, and early intensive blood sugar control can bring long-lasting benefits for up to 10 years, including a 24% reduction in microvascular events and a 15% reduction in myocardial infarction risk.
    %, and the overall risk of death was reduced by 13%
    .

     However, no evidence of a "legacy effect" was observed in patients with long-term diabetes and pre-existing macrovascular disease, as observed in diabetes trials of similar design
    .

     As discussed above, each glycemic marker change has a specific degree of prognostic value for the development of diabetic complications, even after controlling for or adjusting for HbA1c and other risk factors
    .

    However, whether these measures independently predict the development of complications remains to be studied
    .

    Image source: 123RF Emphasis on Applications: A review of new technologies for blood sugar control mentions the need for high-frequency blood sugar testing to assess all aspects of blood sugar control
    .

    In daily life, self-control of blood sugar, regular and standardized blood sugar monitoring, are of great help to the management of diabetes
    .

     The advent of continuous glucose monitoring and intermittent scanning glucose monitoring has helped clinicians and diabetics overcome not only the limitations of HbA1c, but also the limitations of self-monitoring of blood glucose
    .

     Studies in people with type 1 diabetes and type 2 diabetes have shown that intermittent scanning continuous glucose monitoring can improve blood sugar control
    .

    Higher scan frequency was associated with greater reductions in HbA1c, but was also associated with significant improvements in other measures, such as time to hypoglycemia, time to hyperglycemia, and time to in-range
    .

    10-14 days of continuous glucose monitoring data provide a good estimate of the 3-month continuous glucose monitoring indicators
    .

    If 70% of continuous glucose monitoring data are available, it can be used to estimate HbA1c
    .

    Real-time continuous glucose monitoring data can guide individuals to understand how their blood glucose levels fluctuate with different types of diet and exercise
    .

    Image credit: 123RF In addition to providing average blood glucose concentrations, continuous glucose monitoring curves provide more detailed information on blood glucose fluctuation patterns, as well as potentially dangerously high or low blood glucose concentrations that are often overlooked by patients during self-monitoring of blood glucose
    .

     A meta-analysis confirms the critical role of continuous glucose monitoring in improving glycemic control
    .

    The analysis showed that continuous glucose monitoring reduced HbA1c concentrations and duration of hypoglycemia
    .

    A randomized controlled trial showed that real-time continuous glucose monitoring was also effective in patients with type 2 diabetes who were only treated with basal insulin
    .

    A cohort analysis of patients with type 1 diabetes or type 2 diabetes showed a significant clinical benefit of continuous glucose monitoring in improving metabolic control and reducing acute complications
    .

    New Therapies: Drugs Targeting Glycemic Instability While the current assessment of glycemic efficacy is based on lowering of HbA1c, this single approach has changed: a super-rapid-acting insulin has been developed that significantly improves 1-hour postprandial glycemic variability
    .

    Compared with U100 insulin glargine, insulin degludec and U300 insulin glargine were more effective in reducing nocturnal hypoglycemia
    .

     GLP-1 receptor agonists play an important role in lowering blood sugar, and there is evidence that they can reduce HbA1c, postprandial blood glucose, blood glucose variability, and hypoglycemia; in addition, SGLT-2 inhibitors can also achieve similar effects, And their use can significantly prolong the time it takes for blood sugar to reach the normal range
    .

    Meanwhile, GLP-1 receptor agonists and SGLT-2 inhibitors have been shown to have protective effects on the heart and kidneys
    .

     The novel hybrid closed-loop insulin delivery system for patients with type 1 diabetes is a safe and effective treatment modality that maintains glycemic stability within 70% or more of the target range with very short periods of hypoglycemia and hypoglycemia variability
    .

    Image source: 123RF conclusion review shows that the blood sugar management of diabetic patients should not only consider HbA1c, but only focus on achieving and maintaining the best HbA1c concentration as soon as possible, and other indicators should also be paid attention to, which provides clinicians with new ideas and new ideas for clinical practice path
    .

    Each new approach to glycemic control in this review has a direct impact on the development of diabetic complications
    .

    New technology could help develop a viable strategy for effective blood sugar control, especially if artificial intelligence can provide recommendations for treatment decisions
    .

    In addition, new pharmacotherapies can help achieve this goal with modern, comprehensive management of diabetes glycemic control in a continuum of care setting
    .

    Related reading "The Lancet" is heavy! Changes in the concept of diabetes treatment: weight control should be the primary treatment goal! "The Lancet" sub-issue depth: These innovative treatments are expected to change the future of type 2 diabetes treatment "The Lancet" sub-issue: Dapagliflozin reduces new diabetes by 33%, and two key studies add evidence of benefit! ADA's latest diabetes guidelines: It is recommended that everyone start screening at the age of 35.
    Metformin may not be the "first choice".
    .
    .
    1 person dies of diabetes every 5 seconds, and 1/4 of the patients are in China! References for the latest global diabetes map release [1] Antonio Ceriello, Francesco Prattichizzo, Tadej Battelino, et al.
    (2021).
    Glycaemic management in diabetes: old and new approaches.
    The LancetDiabetes & Endocrinology.
    DOI: https://doi.
    org /10.
    1016/S2213-8587(21)00245-X Disclaimer: The WuXi AppTec content team focuses on introducing global biomedical health research progress
    .

    This article is for information exchange purposes only, and the views expressed in this article do not represent WuXi AppTec's position, nor do they represent WuXi AppTec's support or opposition to the views expressed in this article
    .

    This article is also not a treatment plan recommendation
    .

    For guidance on treatment options, please visit a regular hospital
    .

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