For patients with poor blood sugar control, proteinuria, and non-alcoholic fatty liver disease, please check if there is a new plan!

*For medical professionals to read and reference, the glycated hemoglobin level of 11%, diabetic nephropathy, and non-alcoholic fatty liver disease are all gathered togeth.
Who will "save" him? Case patient, male, 42 years o.
Chief complaint: dry mouth, polydipsia, polyuria, and weight loss for 2 yea.
History of present illness: The patient lost 7kg in weight in the past 2 years, significantly increased urine output, and had dry mouth and polydips.
Fasting blood glucose was measured at 14 mmol/L in the outpatient department of our hospital, but postprandial blood glucose was not detect.
Abdominal color Doppler ultrasound diagnosis of fatty liv.
Past history: no history of viral hepatitis such as hepatiti.
Personal history: No long-term history of alcoholi.
Family History: None ▌ Physical Examination: Note: Body Mass Index (BM.
Body temperature: 35℃, heart rate: 78 beats/min, blood pressure: 135/89mm.
Physical examination: The body is uniform and obese, and there is no abnormality in the heart, lungs, and abdom.
▌ Auxiliary examination: laboratory test (normal range) Note: glycosylated hemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-c), high density lipoprotein cholesterol (HDL) -c), urine microalbumin (mAlb), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), r-glutamyltransferase (r -GT), total bilirubin (TBIL)▌ physical examination transient elastography + fatty liver controlled attenuation parameter examination hospitalization diagnosis:Metabolic syndrome type 2 diabetes (T2DM) diabetic nephropathy A2G1 stage non-alcoholic fatty liver disease high Lipidemia▌ Treatment plan: Stage 1: Pre-hospital treatment regimen After the patient's self-conscious blood sugar control was still poor after metformin 500 mg three times a day (TID), the drug was discontinued voluntarily Stage 2: Post-hospital treatment regimen semaglutide 25 mg Subcutaneous injection once a week (QW), after three weeks of treatment, gradually increase the dose to 5mg QW vitamin E capsules▌ Blood glucose profile (mmol/L) increase the dose of semaglutide to 5mg QW▌ Follow-up: 3 days after treatment Changes in data after one month★ Doctor interview: The medical community: Could you please talk about the patient's situation, and why did you choose semaglutide, a hypoglycemic drug, for the patient? Could you please share with us the impact of this program on the patient's blood sugar control? .
Xu Xuejuan: From the patient's medical history, we can see that this is a young and middle-aged male with poor blood sugar control (fasting blood sugar 10mmol/L, postprandial blood sugar 11mmol/L, HbA1c up to 10%), hyperlipidemia Diabetic nephropathy (DKD) and nonalcoholic fatty liver disea.
Therefore, when we formulate a hypoglycemic program, we hope to meet the following characteristics at the same time: effective glucose control, renal benefit, and improvement of metabolic indicato.
In terms of potent hypoglycemic, if there are no other potent hypoglycemic drugs, we give priority to short-term intensive insulin therapy (SIIT), which can remove the harm caused by high glucose toxicity to patien.
However, this treatment plan may have the risk of weight gain, which is not conducive to the treatment of this obese patient (BMI=24kg/m2), so we rejected this pl.
Then we turned our attention to other hypoglycemic dru.

Glucagon-like peptide-1 receptor agonist (GLP-1RA) was classified as a potent hypoglycemic drug by the "Criteria for Diabetes Care" issued by the American Diabetes Association (AD.

a cla.

As a weekly preparation of GLP-1RA, semaglutide can exert a glucose-lowering effect in a glucose concentration-dependent manner by activating the GLP-1 receptor, effectively reducing glucose without increasing the risk of hypoglycem.

The results of the SUSTAIN China study show [1], among Chinese T2DM patients, the average HbA1c rate of patients treated with semaglutide reached 8%, and 81% of patients reached the target of HbA1c <7% blood sugar control, which has superior hypoglycemic effe.

curative effe.

In terms of renal benefit, we initially considered using SGLT-2i for patients, but we did not choose this regimen due to poor compliance and reluctance to accept daily oral medication, which would affect the effica.

The results of the SUSTAIN 6 study [2] showed that the renal composite risk (persistent macroalbuminuria, persistent serum creatinine doubling, continuous renal replacement therapy, and death due to renal disease) in T2DM patients treated with semaglutide was significantly higher than that in the placebo gro.

36% lower, showing its renal benef.

At the same time, semaglutide is safe and effective in lowering blood sugar, and also has the effects of reducing body weight, improving blood lipid profile and lowering blood pressure [3], which is a suitable drug for this patie.

In addition, the patient requested that the treatment regimen be as convenient as possib.

The half-life of semaglutide is as long as 7 days, and once a week injection can effectively control glucose, which just meets the needs of patients [
After various considerations, we finally chose semaglutide, a hypoglycemic drug, for the patie.
The patient's blood sugar decreased significantly after the application of semagluti.

After 3 months, the HbA1c reached the standard, from 10% to 8%, a decrease of up to 2%, and the fasting and postprandial blood sugar decreased significant.

A surprising hypoglycemic effe.

At the same time, the patient's urine protein turned negative, the metabolic indicators such as blood lipids and body weight were improved, and the waist circumference was also significantly reduc.

The patient's DKD and fatty liver have also been relieved to a great extent, and the patient's satisfaction is high, indicating that this program can be adhered to for a long ti.

Medical community: In this case, the patient has non-alcoholic fatty liver disea.

In this case, how do you consider when choosing medication for the patient? .

Xu Xuejuan: Non-alcoholic fatty liver disease is an insidious disease, and most of them have no obvious symptoms before cirrhosis and liver canc.

In recent years, with the improvement of health care awareness, we found that the population of nonalcoholic fatty liver disease is very large and the incidence rate is increasing year by ye.

At the same time, the disease also has the risk of directly developing into liver cancer without going through the stage of non-alcoholic steatohepatitis or cirrhosis, which deserves extensive attention of clinicia.

Studies have shown [5] that non-alcoholic fatty liver disease is a metabolic stress-induced liver injury closely related to insulin resistance and genetic susceptibility gen.

It can be seen that both the disease and T2DM share a common pathogenic "soil" - insulin resistance, and share many genetic susceptibility gen.

Therefore, improving insulin resistance is "imminent" for this patie.

Traditional drugs for improving insulin resistance include metformin and thiazolidinedion.

However, this patient was unable to adhere to metformin before and the effect was not go.
In addition, thiazolidinediones also have adverse effects on patients such as edema and weight gain, and they also face the inconvenience of requiring daily medicati.

So in the end we chose the GLP-1RA weekly formulation for the patie.

Studies have shown that GLP-1RA weekly preparation semaglutide can improve insulin resistance from many aspects, such as suppressing appetite, reducing fat accumulation, up-regulating adiponectin levels, reducing free fatty acid and cytokine levels, and increasing GLUT-4 expressi.

To help relieve non-alcoholic fatty liver disease [6-
At the same time, weight loss is thought to play an important role in the treatment of NAF.

The "Practice Guidelines for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease" clearly pointed out [10] that a weight loss of more than 3% to 5% can reduce liver steatosis, and a weight loss of 10% can even improve the degree of liver inflammation and necros.

In addition, some studies have shown that GLP-1RA may reduce triglyceride and cholesterol levels and reduce the synthesis of low-density lipoprotein, thereby delaying the progression of fatty liver [1
The results of the SUSTAIN series of studies have shown that 1mg of semaglutide per week can significantly reduce weight up to 5kg, and it also has the properties of improving blood lipid profile (lowering triglycerides, cholesterol, and low-density lipoprotei.

At the initial stage of admission and after 3 months of treatment, the patients were examined for controlled attenuation parameters of fatty liver and liver stiffness values, respective.

The controlled attenuation parameter of fatty liver was reduced from the initial 328db/m to 232db/m, and the liver stiffness value also returned to norm.

From this point of view, semaglutide in this patient reflects the characteristics of "multiple birds with one stone" and multiple benefits, and is a more suitable choice, and it is expected that more and more patients can benefit from .
★ Director's comment: Medical field: The epidemic situation of DKD has become more and more severe in recent yea.

Based on this, I would like to ask you to share with us, what advice do you have on the clinical management of patients with diabetes and kidney disease? Professor Chen Jinsong: DKD is one of the most common chronic complications of diabetes, and it is also the main cause of end-stage renal disease [1
With the change of people's life>
Therefore, early prevention and treatment of DKD is particularly important for delaying its development and improving the quality of life of patien.

Regarding the early prevention of DKD, the "China Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)" (hereinafter referred to as the "Guidelines") clearly pointed out [6] that patients with T2DM should be screened for renal lesions at the time of diagnosis, and at least every year thereaft.

Screening once, including urine routine, urine albumin/creatinine ratio and serum creatinine, can help to detect early kidney damage and identify some other common non-diabetic nephropat.

At the same time, comprehensive management including adverse life>
During drug treatment, drugs that can effectively lower blood sugar and have renal benefits such as GLP-1RA and sodium-glucose co-transporter-2 inhibitor (SGLT-2i) can be select.

GLP-1RA can reduce the occurrence of massive proteinuria in patients with T2DM, delay the decline of glomerular filtration rate, and may not depend on its hypoglycemic mechanism, and has a renoprotective effect that is independent of hypoglycemic effect[1
At the same time, studies have shown [2] that compared with placebo, semaglutide can significantly reduce the risk of renal composite endpoint by 36%
It can be seen that the application of semaglutide is not affected by renal function, and it can protect the renal function of patients in the long r.

The medical community: The latest data from the International Diabetes Federation shows that the number of T2DM patients in China has reached 141 million [13], and the current situation of diabetes management in China is not optimist.

Please share with us based on your clinical experience, how to give patients an ideal hypoglycemic treatment in this context? Professor Chen Jinsong: The huge diabetic population brings a heavy burden to medical ca.

In recent years, domestic and foreign guidelines have emphasized individualized management strategies for diabetes, and the formulation of clinical programs also needs to be combined with the characteristics and needs of patients [6, 1
Faced with the current status of diabetes management in China, an ideal hypoglycemic drug should meet the following three characteristics: effective hypoglycemic, multiple benefits, and simple and convenient medicati.

It is particularly important to choose a drug that meets the above requirements for diabetes manageme.

From the earliest insulin, to later metformin, sulfonylurea drugs, the development of hypoglycemic drugs is changing with each passing d.

In recent years, the emergence of new hypoglycemic drugs such as GLP-1RA and SGLT-2i has brought more powerful means for diabetes treatme.

The first-line treatment of T2DM should depend on comorbidities, patient-centered treatment factors, and management nee.

In terms of the choice of hypoglycemic drugs, the "Guidelines" clearly states [6] that regardless of whether the HbA1c level is up to standard, T2DM patients with atherosclerosis For patients with acute cardiovascular disease (ASCVD), high risk of ASCVD, heart failure, or chronic kidney disease, it is recommended to first combine GLP-1RA or SGLT-2i with evidence of benefit in cardiovascular disease and chronic kidney disea.

Early, active application of new and potent hypoglycemic drugs that can be comprehensively intervened in multiple directions may bring more benefits to patien.
References: [1]Ji L,et .

Diabetes Obes Met.

2021 Feb;23(2):404-41[2]Marso SP,et .

NEJM 2016;375(19):1834-184[ 3] Zinman B, et .

Lancet Diabetes Endocrin.

2019; 7(5): 356-36 [4] Kapitza C, et .

J Clin Pharmacol 2015; 55: 497-50 [5] Li Chunjun, Yu De M.

Tianjin Medicine; 2015, 43(11): 1230-123 [6] Diabetes Branch of Chinese Medical Associati.

Chinese Journal of Diabet.

2021; 13(4): 315-40 [7] Hu W, et .

J Clin Endocrinol Met.

2013;98(1):290-[8]Ahrén B,et .

Lancet Diabetes Endocrin.

2017 May;5(5):341-35[9]Chen LN,et .

Int J Mol M.

2013 Oct; 32(4): 892-90 [10] Shi Xiaoy.

Journal of Practical Diabet.

2015; 11(03): 13-1 [11] Huang Linchuan, Feng Shengga.

Chinese Integrative Medicine Journal of Nephrolo.

2021; 22(10): 935-93 [12] Hao Chuanming, Zhang M.

Chinese Journal of Practical Internal Medici.

2017; 37(03): 195-19 [13] IDF Diabetes Map 2021 Edition https:// diabetesatl.

org/data/en/country/42/.

html[14]American Diabetes Associati.

Diabetes Ca.

2022;45(Sup.

1):S1–S26-End-" Professionals provide scientific information and do not represent the platform's positi.

" For submission/reprint/business cooperation, please contact: pengsanmei@y.

o.

cn