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: Optimized treatment strategies
for patients with long-course type 2 diabetes mellitus with poor blood glucose control on fasting, significant postprandial blood glucose rise, and 4 injections of insulin intensive therapy.
glycemic control.
Lack of regular diet, exercise, and regular doctor
visits.
Overweight
.
Encourage patients to actively control diet and exercise appropriately; Patients treated with basal-mealtime insulin for poor glycemic control, and metformin was added to improve insulin resistance;
2.
Patients are overweight, insulin function is slightly worse, with the drop of blood sugar, islet function gradually improves, after giving basal insulin supplementation, minimize the use of mealtime insulin, add sodium-glucose co-transporter-2 inhibitors (SGLT-2i, empagliflozin) to help control body weight, for easier control of PPG , in combination with dipeptide peptidase-IV inhibitors (DPP-4i, linagliptin);
3.
The patient has the appeal to reduce injection, and it is adjusted to Degu aspart double insulin + oral hypoglycemic drugs;
4.
Diabetes needs comprehensive treatment, and lipid-lowering and stabilizing plaque treatment
are given while lowering glucose.
.
Islet function deviation.
There are various complications
such as diabetic nephropathy, diabetic retinopathy, and diabetic peripheral neuropathy.
It is also complicated by hypertension, hyperlipidemia, and arteriosclerosis with plaque
.
The patient was previously treated with basal insulin and had poor glycemic control, and after admission, the intensive treatment strategy of basal insulin plus rapid-acting insulin before three meals was applied, and metformin was added to improve insulin resistance;
2.
The patient's laboratory test results showed a large amount of proteinuria, there were diabetic microvascular and macrovascular complications, and the patient was overweight, close to obesity, accompanied by hypertension, so the combination of glucagon-like peptide-1 receptor agonist (GLP-1RA) and SGLT-2i was combined to help reduce urine protein, control weight and blood pressure;
3.
After the patient's blood sugar is initially controlled, considering the patient's compliance and the convenience of injection, with the assistance of other drugs, 4 injections of insulin per day are simplified to 1 insulin as a day;
4.
Patients have a variety of complications and comorbid diseases, in addition to actively giving hypoglycemia, comprehensive treatment
such as blood pressure, lipid reduction, plaque stabilization, urine protein reduction, nutritional nerve and anti-platelet aggregation should also be given.
Based on the above two cases, what are the characteristics of the patients, and what are the common characteristics that make you consider using Degu Aspart insulin for them?
Dr.
Tang Swee Fen
Based on the case and your clinical experience, which patients are suitable for insulin aspart? How to choose the number of daily injections of insulin Degu Aspart? How did you choose the number of injections and the dose for the above two cases? Dr.
Tang Swee Fen
In both cases, the patients were combined with a variety of oral hypoglycemic drugs when using insulin degu aspart, what should be paid attention to for the combination of insulin degu aspart combined with oral hypoglycemic drugs? Dr.
Tang Swee Fen
is only used to provide scientific information to medical and health professionals,
does not represent the position of the platform"
: Optimized treatment strategies
for patients with long-course type 2 diabetes mellitus with poor blood glucose control on fasting, significant postprandial blood glucose rise, and 4 injections of insulin intensive therapy.
Case Introduction 1
Patient, male, 50 years old
.
Complaints: 13 years
of elevated blood glucose.
History of present illness: patients who found elevated blood glucose 13 years ago took metformin 0.
5 g orally three times daily (TID).
10 years ago, poor blood sugar control, adjusted hypoglycemic regimen (that is, current drug use) recombinant human insulin injection 6-6-6u, injection before meals, insulin glargine 10u, subcutaneous injection before bedtime, irregular use of plain drugs, poor diet control, occasional exercise, irregular monitoring of blood sugar and medical visits
.
Fasting blood glucose (FPG) 10-13mmol/L
was measured by chance in the past 1 week.
Family history: Mother, aunt, grandfather had diabetes
.
Personal history and past history are not special
.
Physical examination:
Yu's general condition and systematic specialist examination showed no abnormalities
.
Laboratory tests:
Note: Postprandial blood glucose (PPG), glycated hemoglobin (HbA1c), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), triglycerides (TG).
Diagnosis:
Type 2 diabetes with poor glycemic control
Hyperlipidemia
Arteriosclerosis with plaque (neck, both lower extremities).
Case characteristics:
glycemic control.
Lack of regular diet, exercise, and regular doctor
visits.
Overweight
.
Treatment options:
Encourage patients to actively control diet and exercise appropriately; Patients treated with basal-mealtime insulin for poor glycemic control, and metformin was added to improve insulin resistance;
2.
Patients are overweight, insulin function is slightly worse, with the drop of blood sugar, islet function gradually improves, after giving basal insulin supplementation, minimize the use of mealtime insulin, add sodium-glucose co-transporter-2 inhibitors (SGLT-2i, empagliflozin) to help control body weight, for easier control of PPG , in combination with dipeptide peptidase-IV inhibitors (DPP-4i, linagliptin);
3.
The patient has the appeal to reduce injection, and it is adjusted to Degu aspart double insulin + oral hypoglycemic drugs;
4.
Diabetes needs comprehensive treatment, and lipid-lowering and stabilizing plaque treatment
are given while lowering glucose.
The specific adjustment plan is as follows:
Note: Twice daily (bid), once daily (QD), once nightly (QN)
Changes in blood glucose before and after treatment:
Case Introduction 2
Patient, female, 65 years old
.
Complaints: Elevated blood glucose was found for 20 years
.
History of present illness: elevated blood glucose was detected 20 years ago, oral metformin and acarbose for 17 years, FPG intermittently fluctuated at 7-8mmol/L
.
3 years ago, blood glucose control was poor, adjust the hypoglycemic regimen (that is, the current drug use) :(1) metformin, oral, 0.
5g, TID; (2) Acarbose, oral, 50mg, TID; (3) Insulin glargine, subcutaneous injection, 10u, qn
.
PPG fluctuates between 9-10mmol/L
.
The FPG was 16.
38mmol/L
2 days ago.
Admitted to hospital
for further treatment.
Anamnesis: High blood pressure for 30 years
.
Hyperlipidemia for 1 year
.
Family history: Deny a family history
of diabetes.
Physical examination:
Cardiopulmonary and abdominal examination showed no abnormalities
.
Mild edema of both lower extremities, positive 10 g nylon wire test and tuning fork vibration perception test
.
Laboratory tests:
Ancillary examinations:
Ophthalmologic consultation: suggests stage III diabetic retinopathy
Vascular ultrasound shows atherosclerosis of the carotid arteries and both lower extremities with plaque
Diagnosis:
Type 2 diabetes with poor glycemic control
Diabetic retinopathy stage III
Diabetic nephropathy G1A3
Diabetic peripheral neuropathy
hypertension
Hyperlipidemia
Arteriosclerosis with plaque (neck, both lower extremities).
Case characteristics:
.
Islet function deviation.
There are various complications
such as diabetic nephropathy, diabetic retinopathy, and diabetic peripheral neuropathy.
It is also complicated by hypertension, hyperlipidemia, and arteriosclerosis with plaque
.
Treatment options:
The patient was previously treated with basal insulin and had poor glycemic control, and after admission, the intensive treatment strategy of basal insulin plus rapid-acting insulin before three meals was applied, and metformin was added to improve insulin resistance;
2.
The patient's laboratory test results showed a large amount of proteinuria, there were diabetic microvascular and macrovascular complications, and the patient was overweight, close to obesity, accompanied by hypertension, so the combination of glucagon-like peptide-1 receptor agonist (GLP-1RA) and SGLT-2i was combined to help reduce urine protein, control weight and blood pressure;
3.
After the patient's blood sugar is initially controlled, considering the patient's compliance and the convenience of injection, with the assistance of other drugs, 4 injections of insulin per day are simplified to 1 insulin as a day;
4.
Patients have a variety of complications and comorbid diseases, in addition to actively giving hypoglycemia, comprehensive treatment
such as blood pressure, lipid reduction, plaque stabilization, urine protein reduction, nutritional nerve and anti-platelet aggregation should also be given.
The specific adjustment plan is as follows:
Note: Once a week (QW)
Changes in blood glucose before and after treatment:
Doctor shares
★ Medical profession
Based on the above two cases, what are the characteristics of the patients, and what are the common characteristics that make you consider using Degu Aspart insulin for them?
Dr.
Tang Swee Fen
Case 1 patient is a middle-aged man with a course of 13 years, and the use of 4 injections per day (basal + mealtime) insulin regimen does not meet the blood glucose control standard, and FPG and PPG are significantly
increased.
Case 2 is an elderly woman with diabetes for up to 20 years, and the previous oral hypoglycemic drugs plus basal insulin were poorly controlled, and FPG and PPG were significantly increased
.
The course of disease, age, and previous treatment regimens of the two patients were different, but there were common characteristics: islet function was all biased, and FPG, PPG, and HbA1c were high
.
For both patients, we first used intensive insulin therapy to improve hyperglycemia, and adjuvant drugs to improve insulin resistance, thereby promoting the improvement of the patient's own islet function and optimizing the patient's subsequent treatment plan
.
Based on the common characteristics of both patients, exogenous insulin supplementation that combines FPG and PPG control is necessary, taking into account patient adherence
.
After many considerations, we chose the Degu Aspart insulin regimen for the patient to comprehensively manage the patient's blood sugar
.
Later follow-up data also showed that the patient's blood glucose was well controlled
throughout the day.
Degospart double insulin is a new type of insulin preparation composed of a new generation of basal insulin analog insulin degludec and rapid-acting insulin analogue insulin aspart, 1~2 injections per day can control fasting and postprandial blood glucose at the same time, to meet the glucose control needs of the above patients, compared with the basal-mealtime insulin regimen and reduce the number of injections, more convenient, help to increase patient compliance [ 1-3], at the same time, insulin despartis can be injected
directly without mixing.
The effectiveness and convenience of the protocol are the reasons
why we chose Degu Aspart insulin for these two patients.
★ Medical profession
Based on the case and your clinical experience, which patients are suitable for insulin aspart? How to choose the number of daily injections of insulin Degu Aspart? How did you choose the number of injections and the dose for the above two cases? Dr.
Tang Swee Fen
The two cases shared this time were basic - mealtime insulin injection (glargine + recombinant human insulin) and basal insulin injection regimen with poor glycemic control, and after 4 injections of intensive insulin therapy converted to degu aspart double insulin regimen
.
In fact, the application of disaspart insulin can be widely used in a wide range of people, whether it is initial insulin therapy or basal insulin, premixed insulin, basal-mealtime insulin and other regimens are poorly controlled, can be converted to digoaspart insulin
.
According to the Expert Guidance on the Clinical Application of Degu Aspart Disin [4]:
Patients with type 2 diabetes who have a combination of lifestyle and oral hypoglycemic agents have a combination of HbA1c ≥7.
0%, and for patients already treated with basal insulin or premixed insulin qd, if blood glucose control is still not satisfactory and hypoglycemia is frequent, or if the patient does not want to increase the number of injections per day or needs flexible injection timing
, a degou aspart insulin qd regimen may be used.
Short-term (2 weeks to 3 months) may be considered for newly diagnosed type 2 diabetes mellitus in patients with HbA1c≥9.
0% or FPG ≥11.
1 mmol/L with significant hyperglycaemic symptoms (including polydipsia, polydipsia, polyuria, polyphagia, and unexplained weight loss).
Insulin intensive therapy, if inpatients can consider basal + mealtime insulin therapy as appropriate, if most outpatients prefer to receive premixed insulin intensive therapy, such as Degu aspart double insulin; After 3 months of basal insulin combined with oral hypoglycemic drugs, HbA1c≥7.
0%, and the patient had an increase in PPG in ≥ meals; Premixed insulin therapy with QD or BID, blood glucose is not up to target and hypoglycemia occurs frequently after dose escalation; When basal insulin combined with 2~3 injections of mealtime insulin therapy and blood glucose control is stable, you can try to switch to Degu aspart insulin bid treatment
regimen on the premise of understanding the patient's β cell function and treatment intention.
Regarding the dosage issue, the daily dose of the QD treatment regimen of Degu Aspart insulin is recommended to start from 10U or 0.
1~0.
2U·kg-¹·d-¹, and inject Degoo Aspart insulin before the main meal, obese or HbA1c>8.
0% patients can choose a higher dose to start, and after the start, mainly according to the FPG level, adjust the dose until the FPG reaches the standard
.
In people who switched from the previous regimen to disparagus insulin BID, in general, equal doses were switched to dispart dispart therapy; If the patient's previous blood glucose control is not satisfactory, the dose of Degu Aspart insulin can be appropriately increased by 10% to 20% on the basis of the original total dose to help the patient control blood sugar
faster and better.
Since it takes 48~72h to reach steady state after daily injection of insulin Deglude, it is not recommended to adjust the dose before reaching steady state, and pay attention to closely monitoring the patient's blood sugar
.
These are the general lessons we have learned in our clinical work, but the choice of dose and the adjustment of treatment regimen need to be individualized and different adjustment protocols
should be developed for different patients.
★ Medical profession
In both cases, the patients were combined with a variety of oral hypoglycemic drugs when using insulin degu aspart, what should be paid attention to for the combination of insulin degu aspart combined with oral hypoglycemic drugs? Dr.
Tang Swee Fen
Clinically, many patients use a shot of insulin + oral drug treatment plan, patients can inject insulin at home in the morning or evening, and oral drugs are used during the day for hypoglycemic therapy, which is a more acceptable strategy for patients in terms of effectiveness, safety and convenience, including the treatment
regimen of Degu aspart insulin combined with a variety of oral hypoglycemic drugs.
Patients taking care of this combination regimen should pay attention to:
For metformin, α-glycosidase inhibitors, and DPP-4i, direct combination of insulin
despartis can be used.
For SGLT-2i, when combined with dispart insulin, the dose of insulin dispart should be reduced by 10% to 20%.
When insulin despartis is combined with pioglitazone, pioglitazone
should be discontinued in heart failure, severe oedema, and fracture.
For sulfonylureas (SU), when treated with dispart disin qd, the SU dose is appropriately reduced, and the two cannot be administered at the same meal; When treated with dipinsulin BID, it is not recommended to use secretagogues
in combination.
The two cases shared by Dr Tang are both identical and different
.
The differences were those who had poor glycemic control with previous basal-mealtime insulin injections (glargine + recombinant human insulin) and basal insulin injection regimens; The similarity is that the islet function of both patients is biased, and the control of FPG and PPG is not ideal
.
Faced with such a situation, the two patients first underwent 4 injections of intensive insulin therapy at the beginning of admission, and then considered the individualized situation of the patients, the treatment plan was adjusted to Degu Aspart double insulin therapy, and finally the patient's blood glucose was well controlled throughout the day, and the number of injections was reduced, which helped improve the patient's compliance
.
Dr.
Tang's full case explanation can be found in the video below:
Dr.
Deng Ruifen
Attending physician of the Department of Endocrinology, China-Japan Friendship Hospital, he graduated from Peking University Health Science Center for eight years
Visiting diabetes, parathyroid disease, osteoporosis clinic for many years;
Undertake 1 hospital-level project related to MODY diabetes;
He has published several papers at home and abroad
References:
1.
Haahr H, et al.
Clin Pharmacokinet.
2017 Apr; 56(4):339-354.
2.
Degu aspart disin instruction manual (2020 edition).
3.
Singh AK, et al.
Expert Rev Endocrinol Metab.
2015 Jan; 10(1):65-74.
4.
Zhu D.
, et al.
Chinese Journal of Diabetes.
2021; 13(7):695-701.
is only used to provide scientific information to medical and health professionals,
does not represent the position of the platform"
