Diabetes is obviously a very common disease in any specialty, and how to lower the sugar is a problem that troubles many doctors, and asking for an endocrine consultation every time is not the way to go. It is important to master the method of lowering sugar by yourself.
(A) Indications for the use of insulin
(1) T1DM (2) DKA, hyperglycemic hyperosmolarity (3) acute and chronic complications of severe DM (4) T2DM with marked beta cell decompensation (5) surgery, pregnancy (6) certain special types of DM.
(B) Commonly used brands and dosage forms of insulin
What Novolin, what Novolac, what Special Charge, what 30R, N, this is a problem that troubles all surgeons and most non-endocrine internal medicine doctors.
Brand, the bigger brands are Novo and the company, I think, out of Novolin and Novo and sharp; like our hospital and Eli Lilly and Company out of Urolim, it is said that Bayer is also planning to come.
The following is mainly from the role of time to classification.
(1) short-acting – the symbol letter R (Rapid). Formulation (brand): Novolin R, Novolac, Eugenol R, RI (ordinary insulin) (Note: only write Novolac without the word R is short-acting, more special), insulin only such can be used intravenously (other medium and long-acting can only subcutaneous), 0.5h onset of effect, 1.5h peak, maintenance 3-6h.
(2) Medium-acting – sign letter N. Preparations (brands): Novolin N, Eugenol N. 2h onset of action, lasting 10-18h.
(3) Pre-mix – preparations (brand): Rui and Rui 30, Novolin 30R, Urolene (premix), where Novolin 30 is 30% super short-acting + 70% medium-acting, so the effect is 15′ after use, 15′ before meals; and 30R or premix is short-acting + medium-acting, 30′ before meals to play. It peaks at 2-8h and can be maintained for 24h (-Endocrinology, but others think it is 10-18h, I am biased towards the latter).
(4) Long-acting – glargine insulin, which is maintained for 24h. Dosing is subcutaneous at bedtime, usually starting with 10U and then adjusting according to blood sugar.
No matter what agent is good, how they will be combined to come, the ultimate purpose is to control blood sugar in each hour of the 24 hours, and DM the highest blood sugar in a day generally after three meals.
From the above it is not difficult to understand: short-acting fast-acting, short duration, for three meals before playing to control post-prandial blood sugar. The medium-acting and long-acting insulins last for a long time and are used to be taken before bedtime to control blood sugar at night or throughout the day.
Supplementary: In addition to the form and brand of insulin, the word “special filling” often appears, for example, “Novolin 30R (special filling)”, which is actually the same as Novolin 30R, but the special filling comes with a disposable pen, which can be thrown away after playing the 300U, instead of The special charge will have to buy another Novo pen (300 yuan / piece), these 30R loaded on this pen to play, after playing a 30R can continue to use this pen loaded.
Still do not understand look at this chart, I serve so thoughtful also draw a chart, because I had been troubled by this problem, and encounter this problem had been very obscene, I hope you understand no longer obscene.
(C) how to set the program
1, the more commonly used combinations are as follows.
(1) morning and dinner before each play a premix (Novolin 30R, Novo Rui 30, Urolene premix)
(2) three meals before each play a Novolac 30 (and other premix, such as Novolin 30R generally do not play three times)
(3) three short and one medium, three short and one long: one short-acting shot before each of the three meals + one medium-acting or long-acting shot before bedtime.
(4) One long-acting shot before bedtime (alone or + oral hypoglycemic agents)
(5) Insulin pump: short-acting insulin can be pumped continuously for 24 hours and the amount of each time period is investigated in advance on the pump, which is usually available only for endocrine specialists, more than 100 yuan/day.
What specific patients choose which regimen to use? Some literature suggests that the choice can be based on patient compliance and blood glucose levels. For example, (4) only once a day is better for compliance, but blood glucose is obviously too high to control; (1) only twice a day is also relatively easy to get cooperation, but it may be easy to be hypoglycemic at 11:00 and high after lunch. (3) is the best to control blood sugar, more commonly used, but playing four times a day is painful after all, but for the blood sugar is more difficult to control there is no way. (5) After all, it is expensive, generally used for a short period of time during hospitalization, and after discharge, it comes to be dismantled and counted back to regular usage.
2.Dosage and distribution
Total pancreatectomy patients need 40-50U per day, most patients can start from 18-24U/d, and then adjust according to blood sugar. Foreign advocates T1DM by 0.5-0.8U/kg, not more than 1.0; T2DM by 0.3-0.8U/kg.
Breakfast more (25-30%), dinner medium (20-25%), bedtime small (20%) medium, meal less (15-20%).
Insulin pump: 40% as basal amount continuously subcutaneously; the other 60%, 20%, 15%, 15%, 10% each in the morning, midday and evening at bedtime (we often give only three times i.e. before three meals).
After determining the patient’s indication for insulin use, the specific amount of high blood glucose is not mentioned in the literature, probably based on personal experience, but if you are not sure or blood glucose is not very high, from a small amount, such as 18U/d and then adjusted according to blood glucose may be safer. And more often than not, patients who have been on insulin for many years now have to be readjusted, or have to be readjusted when their blood sugar is not good during hospitalization. So usually it is more about “adjustment”.
In addition, we must pay attention to the patient’s diet, blood sugar is greatly affected by diet, if the patient’s diet is not regular, it is impossible to regulate blood sugar. Although some patients have a regular diet, their blood sugar is fragile, that is, a little more high blood sugar, a little less low blood sugar, it is also very difficult to adjust.
To give two of the most common examples.
The first diagnosis of T2DM male 50kg, the first two days before three meals, bedtime blood sugar for 17, 12, 16, 10 and 15, 15, 20, 16, considering that blood sugar is not very high, we first give 0.5U/kg, that is, 26U / d, to “Novalis 30, 14, 14, 15′ before breakfast and dinner.
15′ before breakfast and dinner
”It can be seen that the blood sugar before breakfast and meal is slightly low and may even have the risk of hypoglycemia, while lunch and dinner is high before. The peak of premix is in 2-8h, so we should add the amount before breakfast, reduce the amount before dinner, and change to “Novalax 30, 16.
15′ before breakfast and dinner”, after using blood sugar is 5.8, 7, 8.1, 5.0, more ideal!
T2DM male 60kg, currently using “Novalis 10U, 10U, 10U before three meals
Glycine insulin 12U before bedtime iH”. The blood glucose before three meals and bedtime was 11, 7.2, 8.4, 8.5. He felt slightly high throughout the day, and it was obvious before breakfast, so he was given an extra dose of short-acting before breakfast and an extra dose of long-acting, which was changed to “Novalax 10U, 10U before three meals iH+glycine insulin 14U before bedtime iH”.
Usage of DKA or hyperglycemic hyperosmolar RI
0.1U/kg.h. In case of shock or severe acid replacement, 10-20U can be injected first. It is appropriate to reduce blood glucose by no more than 6mmol/L per hour, and if blood glucose is <13.9, sugar water + RI can be used instead.
Micro-pump, for example, the patient 50kg. that need 10U /h. that survey to 10ml/h) 23.3-33.3 – 0.15 U/kg.h, that survey to 2.5 <7.8 If ketosis is not corrected to use, 1U/h, that is, to adjust to 1.
(D) control how to be considered to meet the standard?
Simply put, it is fasting <7 and postprandial <10 and not hypoglycemia is ideal! Some people think that the older the age should be more lenient: 60 years old6, 70 years old7, 80 years old8.
Internists also need to remember this phrase: “A single severe medically induced hypoglycemia or resulting cardiovascular event may offset the benefits of a lifetime of maintaining blood glucose in the normal range.” After all, hypoglycemia kills; hyperglycemia does not.
(E) Oral hypoglycemic drugs
Not the focus of this article, briefly mentioned.
1, pro-insulin secretagogues: no special contraindications
As the name implies, that requires the body to have a considerable number of islets? cells in order to promote insulin.
Sulfonylurea
Non-fattening; disease duration <5 years (a significant number of islet cells is guaranteed)
Damacell (Glipizide extended release tablets) 30mg-120mg qd before breakfast
Glimepiride 2mg qd (Chen: 2mg = 90mg of Damecam)
Glinide
For elderly with high early postprandial
Novaluron (Repaglinide) often 1mg tid (Chen: diabetes and kidney disease if all to use oral hypoglycemia, only recommended Novaluron)
2.Biguanide
No significant wasting with lipid abnormalities, hypertension first-line drugs, or T1DM combined with insulin.
High fever, cardiopulmonary, hepatic and renal decompensation are contraindicated.
Gevalia (metformin) 0.5 Tid (extended-release tablets 0.5 bid)
Side effects are gastrointestinal symptoms: malignant vomiting, diarrhea. Preparation for injection of contrast agent should be stopped first.
3.Insulin sensitizer (Glitazone class)
Can improve blood lipids, vascular endothelial function, improve fibrinolytic activity, etc., and protect the heart and kidney. However, edema, weight; heart disease, heart failure tendency or liver disease are not used or used with caution.
Pioglitazone
Rosiglitazone (Vindia) seems to have been banned due to a clear increase in the risk of cardiovascular accidents.
4. a Glucomannase inhibitor
For postprandial high.
Adverse reactions: bloating exhaust diarrhea.
Acarbose (Bactrim) 50-100mg Tid first bite after meal.