Lecturer 丨 Li Yanbing First Affiliated Hospital of Sun Yat -sen University
Organize 丨 Polin Li
Source 丨 Medical Circles Endocrine Channel
Insulin played a very large role in the treatment of diabetic patients. With the continuous improvement of clinical needs, the development of insulin preparations has also leapt a huge leap. From animal insulin to human insulin, to insulin analogs, and currently studying Dicanin, insulin, Degu Menwin dual insulin, insulin/GLP-1 composite preparation, etc. Injection devices and injection technology of insulin are also more advanced and convenient. Professor Li Yanbing, director of the Department of Endocrinology, the First Affiliated Hospital of Sun Yat -sen University, explained in -depth insulin therapy.
Start insulin treatment in time
The 2017 version of China Type 2 Diabetes Prevention Guide clearly points out the adaptive crowd of insulin therapy:
1. Type 1 diabetes;
2. Type 2 Diabetes (T2DM) is accompanied by obvious hyperglycemia symptoms, ketone or keto acid poisoning;
3. New diagnostic patients are difficult to type, and difficult to identify with type 1 diabetes;
4. Patients witht2dm patients are treated with lifestyle and oral hypoglycemic drugs, and blood sugar has not been controlled at the standard;
5. Those who have no obvious cause of weight loss during diabetic disease;
6. In special circumstances, insulin application (perioperative surgery, infection, pregnancy);
The natural process of T2DM is the continuous decline in the patient’s β cell function, while the long -term good blood glucose control is conducive to the protection of β cell function. It is generally believed that the treatment of T2DM is from lifestyle intervention to oral hypoglycemic drugs, and then to the stepped treatment of insulin. However, the patient’s blood sugar cannot be controlled in a timely manner to meet the standard; and at the stage of launching insulin therapy, many patients are afraid of using insulin because they do not understand, and they often miss the opportunity. For new diagnosis of T2DM patients, early insulin therapy can protect beta cells, which is conducive to long -term stable control of blood sugar.
T2DM different insulin starting scheme
(1) Starting basic insulin therapy: Continue oral drug treatment without having to stop the promoter; give medium or long -acting insulin, injection before bedtime, start dose 0.1U ~ 0.3U/(kg*d), according to the empty stomach, according to the empty stomach Adjust the dose of blood sugar levels, adjust 2U every 3 days until it meets the standard.
Features: Simulation of physiological basic insulin secretion, the danger of severe hypoglycemia is low, the weight gain is low, the plan is simple, the patient is easy to accept, and the dose adjustment is relatively simple; the main blood glucose is the main effect on the blood glucose after meals.
(2) Start -up premixed insulin treatment: discontinue insulin promotion agent; premix insulin injection before dinner daily, starting dose 0.2U/(kg*d), adjust the frequency and dose of the same basic insulin; Second, the starting dose is 0.2 ~ 0.4u/(kg*d). Press 1: 1: 1 point for breakfast and before dinner, and adjust the dose according to the level of blood glucose before dinner.
Features: The people of our country are mainly carbohydrates, and they often have a peak of blood sugar after a meal. This solution can take care of the control of blood sugar after meals. The plan is relatively simple.
Individualization of insulin solution
The selection of initial insulin is affected by various factors, including clinical and patient personal factors. A suitable solution is required to achieve good hypoglycemic effects. The adjustment of subsequent insulin solutions also needs to consider the impact of these factors.
(1) Sugin hemoglobin level (HBA1C): Reflects long -term blood glucose control indicators. A number of studies have proved that the baseline HBA1C> 8.5%is that compared with basic insulin QD, premix insulin analogs BID hypoglycemic effect is better, and low blood sugar risk is low.
(2) After meals, blood glucose increase (PPG): indicators reflecting short -term blood glucose fluctuations. Premier insulin analog practice guidance (2015) Suggestion PPG> 3mmol/L (57mg/dl) to start premixed insulin therapy; real world research also shows that when PPG increases (3.5mmol/L) Mixed insulin solution.
(3) During the course of disease and β cells: Patients with shorter basic insulin diseases are more likely to meet the standards.
(4) Patient’s subjective factors: If you eat a large amount of carbohydrates at 1-2 main meals, the lifestyle is more regular (meals, working hours), and unwilling to accept the foundation-meal time scheme, you can choose to start a pre-mixed insulin solution Essence
(5) Use oral hypoglycemic drugs: Fully consider the types and dosage of currently applying oral hypoglycemic drugs.
(6) Patient’s economic situation.
Short -term insulin strengthening treatment
2017 China Type 2 Diabetes Prevention Guide Recommended 3 types of people with short -term insulin intensive treatment:
(1) New diagnosis of T2DM patients HBA1C ≥9.0%or empty blood glucose> 11.1 mmol/L, accompanied by obvious symptoms of hyperglycemia;
(2) Using more than 2 oral hypoglycemic drugs for maximum tolerance doses for more than 3 months, HBA1C is still> 9.0%;
(3) Using basic insulin or premix insulin twice a day, full dose adjustment> 3 months, HBA1C> 7.0%or repeatedly developed hypoglycemia;
There are 3 types of short -term insulin reinforcement treatment schemes
(1) Premier insulin injection daily 2-3 times a day;
(2) Basic+insulin injection during meals: Disable insulin promotion agent; calculate the total amount of insulin 0.5U/(kg*d) all day, 60%of the meal and 40%basis, of which insulin is based on breakfast according to breakfast 30%, 35%lunch, and 35%dinner, adjust the corresponding insulin dose according to the level of blood sugar before bedtime and three meals; The amount is 0.5-0.8u/(kg*d). The basic quantity and meals are allocated in the same above.
For the new diagnosis of T2DM patients, the purpose of strengthening the treatment of short -term insulin strengthening is to remove hypertrophic toxicity, repair β cell function, and simplify subsequent treatment plans;
For T2DM patients who have used other hypoglycemic solutions and have not reached the standard standards, the purpose of short -term insulin strengthening treatment is to alleviate high glucose toxicity, restore part of the islet function, maintain long -term blood glucose to meet the standards, and delay the occurrence of complications.
In the speech, Professor Li Yanbing also introduced a research results of his team. The results showed that insulin pump strengthened therapy can restore blood sugar in patients with severe hyperglycemia; normalization of blood glucose within 2 weeks can restore the function of the ball β cells; intensive treatment 17 In the year, the relief rate increased and the treatment was simplified; in terms of hypoglycemic targets, it could be reduced by 0.4mmol/L each compared with the current indicators, that is It is believed that it can be expanded to patients with oral drug failure, and the sensitivity of drugs may be restored after short -term insulin reinforcement treatment.
Education of patients with insulin therapy
(1) Diet: Scientific balanced diet structure, regular and quantitative meals;
(2) Exercise: regular exercise, do not exercise strenuous before meals. It
(3) Blood glucose monitoring: record monitoring results and indicate dietary exercise;
(4) Knowledge of hypoglycemia prevention: I can identify the symptoms of hypoglycemia, carry sugar -containing food with you;
(5) Insulin injection skills: During the hospitalization, the church patients correctly undergo insulin skin injection.
Insulin is an important means to control high blood sugar. In the treatment of hypoglycemic treatment of diabetes, it is necessary to start and continuously optimize and adjust the insulin programs in a timely manner;
<!-2586: Diabetic terminal page
The ideal insulin treatment plan needs to be individualized, taking into account the efficacy, safety and convenience of treatment;
Selecting an insulin treatment plan needs to guide and encourage patients to monitor blood sugar, control high blood sugar and prevent the occurrence of hypoglycemia to achieve the goal of blood glucose control.
(This article organizes Professor Li Yanbing, the First Affiliated Hospital of Sun Yat -sen University in the CDS2018 conference, lectures on PPT and recording)