Most of the diabetic patients do not reach the standard of blood glucose control, the main reasons are lack of knowledge about diabetes, insufficient attention and systematic monitoring, followed by failure to control diet and reasonable exercise, and some patients do not reach the standard of blood glucose due to inappropriate selection of drugs or poor economic status, and long-term complications will affect the quality of life of patients.
In order to improve the effect of glucose lowering and high quality control of blood glucose, six points should be achieved: Smooth, Early, Long-term, Effective, Combination and Total Risk Reduction, referred to as The six points of “SELECT” for high quality blood glucose control. Nia Zhang, Department of Endocrinology, Jiangsu Provincial Hospital of Integrative Medicine
1. Smooth blood sugar control – avoid hypoglycemia and reduce blood sugar fluctuations
Glycosylated hemoglobin (HbA1c) is a good indicator of the average blood sugar level, but it cannot fully reflect the size of blood sugar fluctuations Diabetic patients with similar HbA1c levels have different blood sugar fluctuations and different risks of complications, and increased blood sugar fluctuations are a sign of increased disorders of glucose metabolism.
With the deeper understanding of diabetes, the best blood glucose control should not only achieve the HbA1c standard, but also reduce the blood glucose fluctuation of diabetic patients. This requires the selection of therapeutic drugs to balance the reduction of hyperglycemia and reduce the risk of hypoglycemia.
2. Early glycemic control – eliminating insulin toxicity and reducing microvascular complications
The UKPDS study confirmed that the risk of microvascular complications in type 2 diabetic patients with intensive treatment was significantly less than that of patients in the conventional treatment group. Patients with type 2 diabetes in the intensive treatment group were followed for 10 years, from 1997 to 2007, and were divided into three groups, 2118 in the sulfonylurea or insulin treatment group, 880 in the conventional treatment group and 279 in the metformin treatment group, with an overall mortality rate of 44% and a lost-to-review rate of 3.5% after 10 years. The results confirmed that although the difference in HbA1c between the groups disappeared at 1 year of follow-up, the risk of microvascular complications, myocardial infarction and sudden death events, and mortality continued to decline over the 10-year follow-up, and that obese patients continued to benefit from metformin treatment. These findings also suggest that the “metabolic memory” effect is associated with good early glycemic control.
Early glucose-lowering therapy has a positive impact on the long-term protection of islet function. Early and aggressive treatment and sustained glycemic compliance can slow down the decay of β-cells, relieve glucotoxic effects, reduce the damage caused by lipid metabolism disorders, delay the occurrence of complications, and enable patients to benefit early. Therefore, as long as hypoglycemia does not occur in newly diagnosed type 2 diabetes, the goal of blood glucose control should be as close to normalization as possible, and HbA1c should preferably reach 6.5%.
3.Long-term blood sugar control–Improve the effect of “metabolic memory” and correct the vascular toxic effect
The duration of diabetes is directly proportional to the risk of cardiovascular events. The longer the duration of diabetes, the greater the impact on the complications of diabetes. The Brownlee hypothesis of the metabolic memory effect suggests that mitochondria can increase intracellular production of reactive oxygen species (ROS) under hyperglycemic conditions, and that ROS can interact with nitric oxide in vascular endothelial cells, either alone or in combination, to break single strands of DNA and activate poly ADP nucleotide polymerase, which is modified to reduce the activity of glyceraldehyde 3 phosphate dehydrogenase, thereby triggering diabetic complications.
Aggressive glycemic control requires timely and effective combination therapy. In the VADT study, the patient’s HbA1c had progressed to 9.4% in the long term due to the natural progression of diabetes mellitus by continuing to fail to meet the blood glucose standard for 10 years, and the intensive glycemic control for 5 years was not only ineffective for macrovascular complications but also for microvascular complications after 10 years of standardized treatment to maintain the HbA1c below 7%. This is because the body’s “metabolic memory” effect has already planted the seeds of germinated complications in the body.
4.Effective control of blood sugar – reduce vascular complications, reduce medical costs and improve patient compliance
Studies in the late 1990s confirmed that for every 1% reduction in HbA1c, microvascular events were reduced by 37% and macrovascular events by 14%. Therefore, once type 2 diabetes is diagnosed, a reasonable treatment plan should be used to reduce HbA1, to less than 7% and maintain it for a long time, which is an effective sugar reduction.
The medical costs of diabetic patients can rise with an increase in HbA1c. Foreign studies selected 3017 cases of adult diabetic patients with more than 4 years of health care organization (HMO) and assessed 3-year costs between $10,439 and $44417. Through analysis, it was concluded that medical costs rose alarmingly for every 1 percentage point rise in HbA1c starting from 7%. l patients with HbA1 values of 6%, HbA1 values rose continuously, and each l% rise resulted in a 4% rise in costs , 10%, 20.0%, and 30%. So an increase in HbA1c, value will lead to medical costs costs.
5. Combination therapy for sugar control – overcoming the barriers of blood sugar control and protecting the function of pancreatic beta cells
In the previous diabetes treatment model, the first intervention in lifestyle, control diet and strengthen exercise, followed by taking monotherapy, and then combined medication, but also can not make the blood sugar standard before using insulin treatment. This is clearly contrary to the principle of high-quality glucose lowering, and there are many problems with this treatment model. The two most serious problems are that the phased treatment approach often leads to unstable long-term glycemic control, and the second is that monotherapy cannot cope with the dual damage of type 2 diabetes.
Current evidence suggests that with monotherapy, the expected reduction in HbA1c, fluctuates between 0.5% and 1.5%. In a foreign study, patients with type 2 diabetes were divided into 3 treatment groups, two groups were glipizide controlled-release tablets and metformin alone, and the third group was a combination of glipizide controlled-release tablets and metformin. The results showed that the combination treatment group had the best glycemic control, and the HbA1c, decreased by 2.5% from baseline, indicating that combination glucose lowering can further strengthen glycemic control and can effectively reduce insulin resistance, improve and protect patients’ own β-cell function, and can further strengthen HbA1c control. In a study to observe the efficacy and safety of the combination of glipizide controlled-release tablets and acarbose in the treatment of first-episode type 2 diabetes, it was confirmed that the combination of glipizide controlled-release tablets and acarbose in the treatment of first-episode type 2 diabetes has good effect in controlling blood glucose and blood lipids with mild side effects, and also effectively reduces HbA1c.
6.Low total risk factors–standardized treatment, all standards met
The risk factors of type 2 diabetes comorbidity include HbA1c＞7%, proteinuria, hypertension, hyperlipidemia, obesity, smoking, etc. In order to delay and prevent the occurrence of diabetic complications, early detection and how to modify the above risk factors for macroangiopathy are equally important. Because of the multifactorial nature of type 2 diabetes, treatment should also be multipronged. Effective treatment is currently confirmed to include: ① control of blood glucose; ② control of blood pressure; ③ control of blood lipids; ④ use of aspirin; ⑤ regular monitoring; and ⑥ strengthening diabetes education to improve patients’ knowledge of diabetes, regulate behavior and consciously control blood glucose.
In conclusion, efficient glycemic control in type 2 diabetes can be briefly summarized as one center: centering on β-cell function protection; 2 basic points: ① avoiding hypoglycemia and adverse metabolic effects; ② early control of risk factors of vascular lesions. To serve to improve the quality of life of type 2 diabetic patients.