After a variety of methods of intermittent treatment, the patient is finally willing to choose to stick to this treatment plan!

*Only for medical professionals to read for reference.
Patient characteristics: 1.
Elderly women, with family history of diabetes.

2.
Diabetes history for 8 years, initial awareness of disease management was not strong, only self-treatment, no life>
4.
Various complications of diabetes have appeared, and urinary tract infections are currently combined.

5.
It belongs to the group with extremely high risk of cardiovascular and cerebrovascular diseases.

 Case details (this case was provided by Dr.
Yan Xuhong) Current medical history: 8 years ago, the fasting blood glucose (FPG) was slightly higher (about 7.
5mmol/L) in the community laboratory test.
“Diabetes” was considered and no further diagnosis and treatment was made.

Because his parents are from a family of Chinese medicine practitioners, he is engaged in traditional Chinese medicine editing, self-administered oral Chinese medicine combined with acupuncture and moxibustion, did not manage his diet, did not exercise well, did not monitor blood sugar, and relieved the symptoms of dry mouth.

Subsequently, the physique gradually weakened, and symptoms of anorexia and fatigue appeared intermittently, and rest could be relieved.

 Two years ago, he was admitted to Hospital A at the request of his family.
The examination considered type 2 diabetes (T2DM), and he was given oral metformin and gliclazide to lower blood sugar.

I heard from a sugar friend outside the hospital and took oral metformin, gliclazide, and acarbose alternately.
He still did not manage his diet, and occasionally measured a random blood glucose of 5.
0-30.
0mmol/L, but did not care.

 One year ago, he had intermittent blurred vision in both eyes.
He was diagnosed with “fundus hemorrhage” at the Eye Hospital and received 4 laser treatments. Nausea and vomiting of stomach contents after eating "celery juice" before 5 months, diagnosed "diabetes with ketosis" in our hospital, and given insulin intensive treatment: 8U biosynthetic human insulin was injected subcutaneously before each meal, and subcutaneous injection before going to bed at night Insulin glargine 16U, diet management, poor exercise, monitoring fasting blood glucose of 7.
0-8.
0mmol/L, 2 hours postprandial blood glucose of 9.
0-13.
0mmol/L, weight increase compared to before (specificity unknown).

 Sudden "high fever and chills" 2 months ago, diagnosed pneumonia and T2DM in Hospital B, adjusted the hypoglycemic regimen, injected loxenatide 0.
1 mg per week, oral metformin tablets 500 mg three times a day (TID), and acarbose tablets 100 mg TID, FPG 7.
0-8.
0mmol/L, 2h postprandial blood glucose (2h-PPG) 10.
0-11.
0mmol/L, weight decreased significantly.

During this period, loxenatide was used subcutaneously before lunch every Wednesday, and anorexia and nausea occurred before dinner, and the symptoms continued until lunch or before dinner the next day.
After that, the patient continued to use it for two months, and appeared after taking the ninth loxenatide Anorexia, nausea, and vomiting.
Symptoms persist for 3 days without remission, and tend to aggravate.
Monitoring FPG 20.
0-22.
0mmol/L, 2h-PPG 21.
0-23.
0mmol/L, unconscious disorder, and admitted to our hospital for further diagnosis and treatment.

Since the onset of the disease, her spirits, appetite, and sleep have all been poor.
She has no abnormal stools, urinates frequently, and her weight has not changed significantly in the past 1 week.

 Past history: a history of hypertension for more than 20 years, the use of antihypertensive drugs is controlled at 130/80mmHg; "nephritis" in adolescence (specifically unknown), no regular review; history of gastric ulcer for several years (time unknown), and regular diagnosis and treatment.

He underwent a unilateral total breast resection for "breast cancer" 13 years ago.

 Family history: Mother has a history of T2DM.

 Physical examination: body temperature 36.
2℃, pulse 68 beats/min, breathing 20 beats/min, blood pressure 136/98mmHg, height 154cm, weight 53kg, BMI 22.
3kg/m2.

No cyanosis of the lips, clear breath sounds in both lungs, no obvious dry and wet rales.

The heart rate was 68 beats/min, the rhythm was uniform, and no pathological murmur was heard in the heart valve area.

The abdomen is soft, no tenderness, rebound pain, liver and spleen are not touched under the ribs.

There is no edema in both lower limbs, skin temperature is slightly lower, and the fluctuation of bilateral dorsal foot arteries is fair and consistent.

 Laboratory examination: Pancreatic islet function: (2 months before admission, outside the hospital) Upon admission (2020-07-14 11:00 in our hospital) immediate blood sugar 21.
1mmol/L, blood ketone 0.
3mmol/L; glycosylated hemoglobin (HbA1c): 9.
8 %; GAD65, IAA -, ICA +.

ECG: sinus tachycardia, T wave changes (leads V4-V6).

Lung CT: There are multiple inflammatory cords in both lungs, and the left heart is enlarged.

Abdominal color Doppler ultrasound: chronic cholecystitis with multiple small stones in the gallbladder, no obvious abnormalities in the liver, pancreas, spleen, kidney, adrenal glands, and portal vein.

Head + cerebrovascular NMR: bilateral hemisphere white matter lacunar cerebral infarction, imaging of cerebral arteries shows no abnormalities.

Color vascular ultrasound: bilateral carotid arteriosclerosis, bilateral subclavian arteriosclerosis with plaque formation on the right side; no abnormalities in the arteries and veins of the lower limbs.

Sensory threshold measurement: peripheral neuropathy; ABI 1.
0-1.
4.

Fundus examination: stage III diabetic retinopathy in the left eye and stage IV diabetic retinopathy in the right eye.

Renal dynamics: normal perfusion, impaired function; glomerular filtration rate 38.
3ml/min.

 Diagnosis: 1.
Type 2 diabetes with multiple complications combined with diabetic nephropathy A3G3 combined with diabetic retinopathy stage III-IV (left eye stage III, right eye stage IV) combined with vascular disease bilateral carotid atherosclerosis bilateral subclavian atherosclerosis with right Lateral plaque formation 2.
Hypertension grade 3 (very high risk) 3.
Lacunar cerebral infarction 4.
Dyslipidemia, chronic cholecystitis with multiple small gallbladder stones 5.
Hypoxemia, hypoalbuminemia, hypokalemia The formulation of the treatment plan for hyperemia.
The patient has poor health awareness and multiple diseases coexist.
How should we manage it? 1) Disease health education and life>
The patient has diabetes, hypertension, and cerebrovascular disease, has not been regularly diagnosed and treated in the past, and has experienced various complications.
It is a high-risk group of cardiovascular and cerebrovascular diseases.
It is necessary to strengthen the patient's understanding of the disease and its risks, standardize daily behaviors, and enhance self-management ability.

 2) Comprehensive management and goals: Antihypertensive treatment, blood pressure is controlled at about 130/80mmHg; anti-platelet aggregation, regulating fat and stabilizing plaque, protecting gastric mucosa; nourishing nerves, improving microcirculation; anti-infection; symptomatic treatment: oxygen inhalation, blood monitoring Oxygen saturation; potassium supplement to correct electrolyte disorders.

 3) Hypoglycemic program: Phase 1: The patient's fasting and postprandial blood sugar are both high, HbA1c reaches 9.
8%, and there is high glucose toxicity; at the same time, gastrointestinal discomfort, urinary tract infection, and the body is in a state of stress, which is not suitable for oral medication Lowering blood sugar requires insulin therapy, and the patient himself is willing to use an intensive program to control the condition as soon as possible.

Therefore, the patient was given continuous subcutaneous insulin infusion (CSII) with an insulin pump for short-term intensive treatment.
The total amount of insulin at meals was 18U, which was divided equally to 6U before the three meals; the total amount of basal insulin was 12U, and then adjusted according to the blood sugar situation (dose The adjustment and blood glucose status are shown in the figure below): Figure 2nd stage of the patient’s CSII treatment: the patient’s general condition is OK, the symptoms of anorexia, nausea, and vomiting are alleviated, the urinary tract infection improves, and the blood sugar is stable.
I have experienced gastrointestinal discomfort in the past, and I have a certain fear of GLP-1RA.
Therefore, I need to continue insulin hypoglycemia outside the hospital.

After blood glucose testing and medication adjustments, before being discharged from the hospital, the patient was given a subcutaneous injection of insulin deglubber 18 U before breakfast and 16 U before dinner, combined with acarbose 50 mg TID.

Follow-up: 3 months after discharge, the patient’s blood glucose was up to standard and there was no hypoglycemia.
The urine protein showed a downward trend, but the weight increased by about 10Kg.
It is recommended that the patient recheck the glomerular filtration rate next time, and the condition allows , As appropriate, add metformin, sodium-glucose cotransporter 2 inhibitor (SGLT-2i), and other GLP-1RA.

  Medical community: As far as this patient is concerned, why did such an individualized treatment plan be formulated? Dr.
Yan Xuhong: The treatment of this patient is divided into two stages. In the first stage, the admission treatment stage, the patient is an elderly woman with a history of diabetes for 8 years, poor awareness of glucose control, poor blood glucose control, high fasting and postprandial blood glucose, HbA1c as high as 9.
8%, high glucose toxicity, and accompanied by There are gastrointestinal discomforts, urinary tract infections and other problems, so we use continuous subcutaneous insulin infusion insulin pump for short-term intensive treatment.
As the treatment progresses, the patient's blood sugar gradually stabilizes and reaches the standard.
Intestinal discomfort and urinary tract infections are somewhat different.
Get better.

 At the second stage of treatment, that is, the transitional period of the out-of-hospital hypoglycemic program, the patient's blood glucose level gradually stabilized after the insulin pump treatment, and various symptoms have improved.
At this time, it is necessary to consider the out-of-hospital treatment program after discharge.

Considering that the patient’s previous total insulin dosage has reached 42 U/day, combined with macrovascular, microvascular and neuropathy, especially microvascular disease, but due to gastrointestinal discomfort, the patient has a fear of GLP-1RA, combined with the patient’s fasting and meal After the blood sugar needs to be controlled, the basic-meal insulin regimen should be used.
However, considering that the complicated regimen is not conducive to improving patient compliance, combined with clinical research and real-world evidence [1-3], we finally chose Germany Guasparto insulin is injected before breakfast and dinner, 2 injections per day (BID).

 After treatment with Degu aspart insulin, the patient’s fasting blood glucose had dropped to 5.
2 mmol/L during the hospitalization, and his blood glucose dropped to 8.
1-9.
9 mmol/L 2 hours after a meal.

Follow-up 3 months after discharge, the patient's blood glucose was greatly improved, HbA1c decreased from 9.
8% to 7.
3%, and no hypoglycemia event occurred.

 The medical profession: How to set the dose for converting from CSII to Degu aspartic insulin? Dr.
Yan Xuhong: According to the instructions of Degu aspart insulin, the dosage of Degu aspart insulin should be adjusted according to the patient's individual situation when the plan is changed.
Usually, the same unit of basal insulin is used as the starting dose.

In this case, we converted the insulin pump treatment to Degu aspartic insulin BID, and in order to avoid the occurrence of hypoglycemia, we reduced the total insulin dose by about 20%.

Three months after being discharged from the hospital, the follow-up found that with the increase of consciousness, under the supervision of family members and their own efforts, the patient not only reached the standard of blood sugar, but also reduced the amount of insulin by 2-4U.

 Medical circle: Which patient population do you think Degu aspart is suitable for? Dr.
Yan Xuhong: First of all, the blood glucose index meets the criteria for initial insulin therapy[4].
T2DM patients who need to start insulin can use degluaspartin once or twice a day (QD/BID) as the initial treatment plan.
.

Secondly, as the first dual insulin, the two components are independent of each other in the preparation and do not affect each other.
After subcutaneous injection, the two components can also maintain independent action without interfering with each other, which is especially suitable for simultaneous needs.
Patients who control fasting and postprandial blood sugar, as well as those who have a tendency to eat main meals.

Third, for patients who are treated with human insulin but often have low blood sugar, or who want a simple and flexible injection regimen, degluaspart diinsulin can be used.

Finally, patients with T2DM who use basal insulin or basal-meal insulin regimens can also be converted to degluaspart insulin in combination with the actual situation [5].

  References: [1]Onishi Y, et al.
Diabetes Obes Metab.
2013;15:826–832.
[2]Franek E, et al.
Diabet Med.
2016;33(4):497-505.
[3] Kaneko S, et al.
Adv Ther.
2021;38(3):1638-1649.
[4] Chinese Type 2 Diabetes Prevention Guidelines (2017).
Chinese Journal of Diabetes.
2018;10(1):4-67.
[ 5]Mehta R, et al.
Diabetes Obes Metab.
2020 Jul; 3.
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