"China Type 2 Diabetes Prevention Guidelines (2020 Edition)" is officially released!

Edited by Yimaitong, please do not reprint without authorization.

Guide: On April 19, 2021, the full version of "Chinese Type 2 Diabetes Prevention Guidelines (2020 Edition)" was officially published online simultaneously in "Chinese Journal of Diabetes" and "Chinese Journal of Endocrinology and Metabolism".

The new version of the guide includes a total of 19 chapters.
Compared with the 2017 version of the guide, it has been revised and updated in many ways.
This article summarizes 11 key updates for teachers' reference.

Image source: Novo Nordisk Medical Information.
The download link of the full version of the guide is at the end of the article.
Please download it from the magazine's official website.

Update point 1: The prevalence rate of type 2 diabetes in my country has risen to 11.
2%, and the awareness rate, treatment rate, and control rate have improved.
According to the latest data, according to the WHO diagnostic criteria, the prevalence rate of type 2 diabetes in my country has risen to 11.
2 %.

 In terms of the epidemiological characteristics of diabetes, my country is dominated by type 2 diabetes (T2DM accounts for more than 90% of the diabetic population), type 1 diabetes and other types of diabetes are rare, and males are higher than females (2015-2017 national survey results were 12.
1% and 10.
3 %), the prevalence of diabetes varies greatly among ethnic groups.

The prevalence of diabetes in economically developed regions is higher than that in moderately developed and underdeveloped regions.

Although diabetes awareness rate (36.
5%), treatment rate (32.
2%) and control rate (49.
2%) have improved, they are still at a low level.

 Update point 2: For the first time, "glycated hemoglobin" is included in the diabetes diagnostic criteria.
The 2020 version of the guidelines will formally include "glycated hemoglobin" in the diabetes diagnostic criteria for the first time: In a laboratory with strict quality control, use standardized detection methods to determine glycosylated hemoglobin ( HbA1c) can be used as a supplementary diagnostic criterion for diabetes.

(B) See Table 1 for the latest diagnostic criteria.

 Table 1 Diagnosis criteria for type 2 diabetes Note: Typical symptoms of diabetes include polydipsia, polyuria, polyphagia, and unexplained weight loss; random blood glucose refers to blood glucose at any time of the day regardless of the last meal time, and cannot be used Diagnose impaired fasting blood glucose or impaired glucose tolerance; fasting state refers to no calorie renewal for at least 8 hours.
Key 3: New "major influencing factors" for setting individualized HbA1c control goals The 2020 version of the guidelines states: HbA1c control goals should follow the principle of individualization , That is, implement hierarchical management according to the patient’s age, course of disease, health status, risk of adverse drug reactions and other factors, and scientifically evaluate the risk/benefit ratio and cost/benefit ratio of blood glucose control in order to achieve the most reasonable balance .

T2DM patients with younger age, shorter course of disease, longer life expectancy, no complications, and no cardiovascular disease can adopt more stringent HbA1c control goals (such as <6.
5%, Even as close to normal as possible).

 Patients with type 2 diabetes who are younger, have a shorter course of disease, have a longer life expectancy, have no complications, and do not have cardiovascular disease can adopt more stringent HbA1c control goals without hypoglycemia and other adverse reactions, and vice versa.
Relatively loose HbA1c target.

(B) Figure 1 The main influencing factors of individualized HbA1c control goal setting for adult type 2 diabetes Adjustment: ➤Life>
Life>
If there are no contraindications, metformin should always be kept in the diabetes treatment plan.

(A) ➤For those who are treated with a hypoglycemic drug and the blood sugar is not up to standard, use 2 or even 3 kinds of drugs with different mechanisms of action for combined treatment.

It can also be treated with insulin.

(A) ➤Patients with type 2 diabetes with ASCVD or high risk of cardiovascular risk, regardless of whether their HbA1c meets the standard, as long as there is no contraindication, GLP-1RA or SGLT2i with evidence of ASCVD benefit should be added to metformin.

(A) ➤Patients with type 2 diabetes with CKD or heart failure, regardless of whether their HbA1c meets the standard, as long as there is no contraindication, SGLT2i should be added to metformin.

For patients with type 2 diabetes in Hejing CKD, if they cannot use SGLT2i, GLP-1RA may be considered.

(A) Update point 5: Update the "Diagnosis and Treatment Pathway of Diabetes" The 2020 version of the guidelines has updated the "Diagnosis and Treatment Pathway for Type 2 Diabetes".
Among them, the status of life>
 Note: a, high-risk factors refer to age ≥55 years with at least one of the following: coronary artery or carotid artery or lower extremity artery stenosis ≥50%, left ventricular hypertrophy; b, usually choose basal insulin; c, add ASCVD, heart failure Or GLP-1RA or SGLT2i with evidence of CKD benefit; d, those with heart failure don’t need TZD.
Figure 2 Type 2 diabetes diagnosis and treatment pathway update point 6: New chapter "Weight management for type 2 diabetes patients" Overweight and obesity are type 2 diabetes (T2DM) An important risk factor for the onset of disease.

Patients with T2DM are often accompanied by overweight and obesity.
Obesity further increases the risk of cardiovascular disease in patients with T2DM.

Weight management is not only an important part of T2DM treatment, but also helps delay the progression of pre-diabetes to T2DM.

 For this reason, the 2020 version of the guidelines adds a new chapter "Weight Management for Patients with Type 2 Diabetes", and gives recommendations: ➤The management goal for overweight and obese adults with type 2 diabetes is to reduce body weight by 5%-10%.

(A) ➤The weight management methods for overweight and obese adults with type 2 diabetes include life>
(A) ➤ Obese adults with type 2 diabetes should be treated with life>
(B) Update point 7: "Glucose Monitoring Chapter" incorporates TIR into the blood glucose control goal.
The 2020 version of the guidelines recommends: Time within the glucose target range (TIR) ​​should be included in the blood glucose control goal.

(B) The recommended TIR control target for patients with T1DM and T2DM is >70%, but it should be highly individualized, while paying attention to hypoglycemia and blood glucose fluctuations.

 The new indicator glucose target time within the target range (TIR) ​​or the percentage of glucose reaching target time refers to the time (in min) or percentage of glucose within the target range (usually 3.
9~10.
0 mmol/L) within 24 h , Can be calculated from CGM data or SMBG data (at least 7 blood glucose monitoring per day).

A number of observational studies have shown that TIR is significantly related to diabetic microvascular complications, surrogate markers of cardiovascular disease, and pregnancy outcome.

In addition, a large cohort study showed that TIR was significantly associated with cardiovascular death and all-cause death in T2DM patients.

 Update point 8: New definition of "hypoglycemia classification" The 2020 version of the guidelines adds "hypoglycemia classification": ➤Grade I hypoglycemia: blood sugar <3.
9mmol/L and ≥3.
0mmol/L; ➤Grade II hypoglycemia: blood sugar＜ 3.
0mmol/L; ➤Grade III hypoglycemia: There is no specific blood sugar limit, severe events accompanied by conscious and/or physical changes, and low blood sugar that requires help from others.

 In addition, for the management of hypoglycemia, the new version of the guidelines recommends: ➤ Patients at risk of hypoglycemia should ask whether they have symptoms of hypoglycemia each time they visit a doctor.

(C) ➤Patients treated with hypoglycemic agents at risk of hypoglycemia should be evaluated and screened for asymptomatic hypoglycemia.

(C) ➤If diabetic patients develop hypoglycemia, 15~20g glucose should be given and blood glucose should be tested 15 minutes later.

(B) ➤If patients undergoing insulin therapy have asymptomatic hypoglycemia or one grade 3 hypoglycemia or uninduced grade 2 hypoglycemia, blood glucose control goals should be relaxed, and hypoglycemia should be strictly avoided within a few weeks in order to partially reverse the symptoms.
Symptomatic hypoglycemia and reduce the risk of future hypoglycemia. (A) Update point 9: Update the risk of CKD progression and the frequency of visits.
The 2020 version of the guidelines supplements the recommendations on the risk of CKD progression and the frequency of visits.

 After the diagnosis of diabetic nephropathy is confirmed, the severity of CKD should be further judged based on eGFR.

The Global Prognosis Guidelines for Improving Kidney Diseases (KDIGO) recommends combining CKD staging and albuminuria staging to assess the risk of progression of diabetic nephropathy and the frequency of follow-ups (Table 2).

For example, diabetic patients with eGFR of 70ml/min/1.
73 m^2 and UACR of 80mg/g are considered as G2A2 of diabetic nephropathy.
The risk of CKD progression is medium risk and should be reviewed once a year.

Table 2 CKD progression risk and frequency of visits.
Key points 10: Point out that e-cigarettes also have health hazards and emphasize the importance of quitting smoking.
Smoking is not only an important risk factor for cancer, respiratory system and cardiovascular and cerebrovascular diseases, but is also associated with diabetes and its complications The occurrence and development of the disease are closely related.

Smoking also increases the risk of various complications of diabetes, especially macrovascular disease.

In recent years, e-cigarettes have gained public attention and welcome, but e-cigarettes may cause lung damage, vascular endothelial dysfunction, oxidative stress, etc.
, and also bring health risks.

 Therefore, the new guide recommends that all diabetics not smoke and use other tobacco products and e-cigarettes, and minimize exposure to second-hand smoke.

(A); For diabetic patients who smoke and use electronic cigarettes, smoking cessation counseling and other forms of treatment should be included in routine diabetes diagnosis and care.

(A) Update point eleven: A separate chapter is set up for "Cardiovascular Disease and Risk Factor Management".
Cardiovascular diseases of diabetic patients mainly include atherosclerotic cardiovascular disease (ASCVD) and heart failure.
ASCVD includes coronary heart disease, Cerebrovascular disease and peripheral vascular disease, cardiovascular disease in diabetic patients are also the main cause of death in diabetic patients.

Therefore, the new version of the guidelines sets up separate chapters for the relevant content of "Cardiovascular Diseases and Risk Factor Management", emphasizing the importance of screening and controlling risk factors.

Antihypertensive treatment 1.
The blood pressure control goal of diabetic patients should be individualized.
In general diabetic patients with hypertension, the antihypertensive goal is <130/80mmHg (1mmHg=0.
133kPa).

(B) 2.
Elderly or diabetic patients with severe coronary heart disease can determine a relatively loose blood pressure target value.

(B) 3.
For pregnant women with diabetes and hypertension, the recommended blood pressure control target is ≤135/85mmHg.

(B) 4.
Diabetes patients with blood pressure level> 120/80mmHg should start life>
(B) 5.
Diabetic patients with blood pressure ≥140/90mmHg may consider starting antihypertensive medication.

When the blood pressure is ≥160/100mmHg or higher than the target value of 20/10mmHg, antihypertensive medication should be started immediately, and a combined treatment plan should be applied.

(A) 6.
Five types of antihypertensive drugs (ACEI, ARB, calcium channel blockers, diuretics, selective β-receptor blockers) can be used for patients with diabetes and hypertension.

(A) Lipid-lowering treatment 1.
Decrease LDL-C as the primary goal, and reduce LDL-C to the target value according to the patient's ASCVD risk.

(A) 2.
Statins are the first choice for lipid-lowering drugs in clinical practice.

(A) 3.
Medium-strength statins should be used initially, and the dose should be adjusted appropriately according to the individual's lipid-lowering efficacy and tolerance.
If the cholesterol level cannot reach the target, other lipid-lowering drugs can be combined.

(B) 4.
ASCVD high-risk and very high-risk patients have been treated with standard lipid-lowering drugs for 3 months, and it is difficult to reduce LDL-C to the required target value, you can consider reducing LDL-C by 50% from the baseline as an alternative target .

(B) 5.
If fasting TG>5.
7mmol/L, in order to prevent acute pancreatitis, first use TG-lowering drugs.

(C) 6.
Perform blood lipid monitoring every year, and regularly monitor blood lipid changes during drug treatment. (C) Antiplatelet therapy 1.
Diabetes patients with ASCVD need to use aspirin (75~150mg/d) as secondary prevention, and at the same time, the bleeding risk needs to be fully evaluated.

(A) 2.
Patients who are allergic to aspirin need to use clopidogrel (75mg/d) as secondary prevention.

(B) 3.
Aspirin (75~150mg/d) as a primary prevention indication for high-risk patients with diabetes and ASCVD is ≥50 years of age with at least one major risk factor (family history of early-onset ASCVD, hypertension, Dyslipidemia, smoking or chronic kidney disease/proteinuria), no high risk of bleeding.

(C) Chinese Journal of Diabetes: http://rs.
yiigle.
com/CN115791202104/1315489.
htm Chinese Journal of Endocrinology and Metabolism: http://rs.
yiigle.
com/CN311282202104/1315505.
htm Reference: Chinese Medical Association Diabetes Chapter, Chinese Type 2 Diabetes Prevention and Control Guidelines (2020 Edition) [J].
Chinese Journal of Diabetes, 2021, 13 (4): 315-409.
DOI: 10.
3760/cma.
j.
cn115791-20210221-00095.