To achieve better insulin intensive treatment effects, you need this good helper!

*It is only for medical professionals to read and refer to this fast-acting insulin that is fast-absorbing, efficient, safer and not easy to sensitize.
Let’s understand~ China has the world’s largest group of diabetic patients, and the prevalence of adult diabetes in mainland China has risen to 12.
8%.
About 130 million patients [1]; however, the treatment rate of diabetes is only 25.
8%, and the rate of blood glucose control compliance is only 39.
7% [2].

 Type 2 diabetes mellitus (T2DM) patients face different blood sugar control problems at different stages of the disease: some patients have obvious hyperglycemia when they are newly diagnosed; some patients have a certain course of disease and use two or more oral hypoglycemic drugs in combination However, the blood glucose is still significantly higher after treatment; some patients have started insulin therapy and have undergone sufficient dose adjustment, but the blood glucose has not yet reached the target or the blood glucose fluctuates greatly.

 High blood sugar or excessive blood sugar fluctuations can bring great harm to patients, such as macrovascular complications including coronary heart disease and stroke; small blood vessel complications such as diabetic nephropathy and diabetic retinopathy; and diabetic foot, diabetic neuropathy, etc.
A variety of complications that seriously endanger health and quality of life.

 Therefore, the need to strengthen blood sugar management should not be underestimated.

The aforementioned three types of patients often require short-term intensive insulin therapy to improve blood sugar control.

Studies have shown that intensive blood glucose control can reduce the incidence of macrovascular events by 9% and the incidence of myocardial infarction by 15% [3].

 How should diabetic patients undergo intensive treatment to strengthen blood sugar control? Intensive insulin therapy is one of the important methods to strengthen blood sugar control.

Intensive short-term insulin therapy requires fine adjustment of the treatment plan and insulin dose to reduce adverse events of hypoglycemia, and generally requires hospitalization.

So how should inpatients undergo intensive insulin therapy? "Clinical Expert Guidance Opinions on Short-term Intensive Insulin Therapy for Type 2 Diabetes" (hereinafter referred to as "Opinions") [2] gives detailed guidance.

■ What is an intensive insulin treatment program? Intensive insulin treatment refers to diet control and exercise therapy, through a daily basal insulin (1 time) + rapid-acting insulin (1 to 3 times) injection program, or continuous subcutaneous use of an insulin pump Insulin infusion (CSII) is a treatment method to achieve satisfactory control of blood sugar.

 ■ The blood glucose control goal of intensive insulin therapy According to the "Opinions", the treatment course of short-term intensive insulin therapy for T2DM patients is relatively short.
Therefore, the goal of diabetes hemoglobin (HbA1c) is not the treatment goal.
The focus of blood glucose control is fasting blood glucose (FPG) and meals.
Posterior blood glucose (PPG).

 Generally speaking, the FPG control target is 4.
4～7.
0mmol/L, and the non-fasting blood glucose is ≤10mmol/L; the young, short course, and uncomplicated newly diagnosed T2DM patients, the FPG is controlled at 4.
4～6.
1mmol/L, and the non-fasting blood glucose At ≤8.
0mmol/L, it is easier to obtain clinical remission.

 Studies on the advantages and benefits of intensive insulin therapy have shown that short-term intensive insulin therapy for newly diagnosed T2DM patients for 2 to 3 weeks can significantly repair the patient’s β-cell function and reshape the first phase; half of the patients have obtained more than 1 year of intensive insulin therapy.
Clinical relief of blood glucose [4].

This means that patients do not need to use hypoglycemic drugs, and only rely on life>
 It is currently believed that for newly diagnosed T2DM patients with obvious symptoms of hyperglycemia, short-term intensive insulin therapy can maximize the control of blood sugar to normal or close to normal, which can remove the damage of high glucose toxicity to pancreatic islet cells and significantly repair β cell function , To improve insulin resistance, and finally nearly half of the patients get a clinical remission period of more than 1 year.

For patients who fail to obtain clinical remission, this treatment also helps to simplify their follow-up treatment plan [3].

 In clinical practice, we often use the “strengthen first and simplify” treatment mode.
Some young patients with no serious complications and good pancreatic β-cell function have failed oral medications.
After this mode of treatment, the original oral medications can even be restored.
Sensitivity, maintain the original oral hypoglycemic treatment regimen.  Choose a more ideal intensive insulin treatment plan ■ What are the common intensive insulin treatment plans? There are 3 common insulin intensive treatment plans, including basal-meal insulin, CSII and 3 times a day premixed insulin analogues (Table 1) .

The "Opinions" believes that both the basic-meal insulin regimen and CSII can well simulate physiological insulin secretion.
These two regimens are preferred during the patient's hospitalization.
Their advantage is that they can make the patient's blood sugar safe and quickly recover to a stable standard.
State, shorten the length of hospitalization, and high patient satisfaction with treatment [3].

 However, the insulin pump used in the CSII program is relatively expensive and not suitable for patients with limited economic conditions.

In contrast, the basic-meal insulin regimen, as a classic insulin intensive treatment regimen, is more economical and cost-effective.

 Table 1.
Comparison of 3 short-term insulin intensive treatment options ■ What are the common fast-acting insulins and clinically common fast-acting insulins include insulin aspart, insulin lispro, and insulin glulisine.

Among them, insulin glulisine is a rising star that has gradually gained fame in recent years.

 Despite the "low qualifications", compared with several "predecessors" in the fast-acting insulin world, insulin glulisine has the following multiple advantages: ■ As the only fast-acting insulin analogue that does not contain zinc, it has fast absorption and rapid onset of action: ANDM Compared with insulin glulisine, insulin glulisine is absorbed 9 minutes faster and takes effect 8 minutes faster [5] (Figure 1); compared with insulin lispro, insulin glulisine is absorbed in people with different body mass index (BMI) Faster [6] (Figure 2).

Figure 1.
Comparison of the absorption and onset speed of insulin glulisine and insulin aspart Figure 2.
Comparison of the absorption speed of insulin glulisine and insulin lispro ■ Treatment of postprandial blood glucose fluctuations: using insulin glulisine, blood glucose fluctuations after a meal are comparable to using gate Winter insulin is reduced by 18% [7], and overall blood glucose fluctuations are lower than the use of insulin lispro by 12% [8] (Figure 3).

Figure 3.
Insulin glulisine treatment postprandial blood glucose fluctuations are smaller ■ Achieve postprandial blood glucose compliance as soon as possible, and the rate of compliance is increased: when insulin glargine combination therapy is taken, the use of insulin glulisine can achieve a meal 1 day earlier than the use of insulin aspart After blood glucose is up to standard, and the proportion of patients meeting the standard is higher [9] (Figure 4). Figure 4.
Using insulin glulisine earlier and a higher percentage of postprandial blood glucose reaching the target ■ The overall blood glucose control is also faster and the rate of reaching the target is higher: combined with insulin glargine therapy, the use of insulin glulisine can significantly shorten the overall body compared with the use of insulin aspart The time required for blood glucose to reach the standard, and the proportion of patients reaching the standard is also higher [9] (Figure 5).

Figure 5.
Insulin glulisine can shorten the overall blood glucose compliance time and increase the proportion of patients meeting the standard.
■ Low risk of hypoglycemia and good safety: In monotherapy or 1+3 regimen, the incidence of hypoglycemia of insulin glulisine is lower than that of insulin aspart [10] (Figure 6); Long-term treatment, compared with insulin lispro and insulin aspart, the incidence of hypoglycemia with insulin glulisine is also lower [11] (Figure 7).

Figure 6.
The risk of hypoglycemia with insulin glulisine is lower.
Figure 7.
The risk of hypoglycemia with long-term use of insulin glulisine is lower.
■ Less allergic: Because it does not contain zinc and phenol, the allergic reaction to insulin glulisine treatment is less [12] (Figure 8).

Figure 8.
The left picture shows the rash caused by insulin lispro treatment, and the right picture shows the rash disappeared after switching to insulin glulisine.
Therefore, it can be said that insulin glulisine is an ideal medication for patients with T2DM for intensive insulin therapy.

 Summary There are a large number of diabetic patients in China, but less than half of them have reached the standard of blood glucose control, and there is an urgent need for more effective blood glucose management programs.

The short-term insulin intensive treatment plan of daily basal insulin (1 time) + fast-acting insulin (1 to 3 times) can bring more benefits to patients with T2DM, such as repairing β-cell function and improving insulin resistance, and is economical.

Among the fast-acting insulins, insulin glulisine has the advantages of fast onset absorption, zinc-free, not easy to sensitize, low risk of hypoglycemia, good safety, not easy to cause postprandial blood glucose fluctuations, and faster overall blood glucose standards.
It is necessary to strengthen the reduction A better choice for sugar patients. References: [1]Li YZ, et al.
BMJ.
2020; 369: m997.
[2]Li Yanbing, et al.
Drug Evaluation.
2017;14(9):1672-2809.
[3]Action to Control Cardiovascular Risk in Diabetes Study Group, Turnbull FM, Abraira C, et al.
Diabetologia.
2009;52:2288-2298.
[4]Weng J, et al.
Lancet.
2008;371(9626):1753-1760.
[5]Arnolds S , et al.
Exp Clin Endocrinol Diabetes.
2010;118:662-664.
[6]Helse T, et al.
Diabetes Obes Metab.
2007;9:746-753.
[7]Bolli GB, et al.
Diabetes Obes Metab 2011;13(3):251-257.
[8]Luzio SD, et al.
Diabetes Res Clin Pract.
2008;79:269-275.
[9]Guo Shulong, et al.
Chinese Journal of Clinical Pharmacology.
2017;33 (23):2361-2363+2386.
[10]Tanaka N, et al.
Endocr J.
2015;62(5):411-416.
[11]Lak V, et al.
Diabetes Ther.
2016;7(3 ):561-573.
[12]Watanabe K, et al.
Acta Diabetol.
2016;53(5):845-848.
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