Compared with oral hypoglycemic drugs, insulin has broader indications and can be applied to almost all kinds of people and all types of diabetic patients, but it does not mean that there is a uniform treatment plan. For some special groups, such as children, the elderly, pregnant women, people with liver and kidney insufficiency, and surgical patients, etc., due to their own characteristics and the specificity of their conditions, they need to be treated individually when formulating insulin treatment plans. Below, we will talk about the use of insulin in special populations in the hope that it will be helpful to you. Question 1: How to use insulin in patients with renal insufficiency? A: Diabetic nephropathy is one of the most common chronic complications in diabetic patients, and once the kidney function of diabetic patients is impaired, the use of oral hypoglycemic drugs is greatly restricted, especially in patients with severe renal insufficiency, only insulin can be chosen to control blood sugar. As we know, kidney is one of the main places for insulin inactivation and degradation. With the decline of kidney function, the kidney’s degradation ability of insulin is also reduced, and the patient’s demand for exogenous insulin is reduced accordingly. Therefore, in the process of using insulin, patients with kidney disease should strengthen blood glucose monitoring and adjust the dosage of insulin in time to prevent inducing severe hypoglycemia and endangering the patient’s life. Question 2: How to use insulin in patients with chronic liver disease? A: The liver is another very important glucose regulating organ in the body besides the pancreas. Liver damage can cause a decrease in hepatic glycogen synthesis and abnormal glucose tolerance, and some of these patients will eventually progress to diabetes, which is clinically referred to as “hepatogenic diabetes” secondary to liver damage. Unlike primary diabetes, patients with hepatogenic diabetes should be treated with insulin, which not only effectively lowers blood sugar, but also helps hepatocyte repair and recovery of liver function; the use of oral hypoglycemic drugs is prohibited, otherwise it will aggravate liver function damage and even lead to liver failure, which can be life-threatening. Patients with “hepatogenic diabetes” generally have mainly elevated postprandial blood glucose, while fasting blood glucose is mostly normal or only mildly elevated, therefore, short-acting insulin preparations are generally chosen and injected subcutaneously before three meals respectively. In addition, insulin dosage will be slightly higher in patients with liver disease because of the obvious insulin resistance. It should be reminded that since liver glycogen reserves are insufficient in patients with liver disease, the risk of hypoglycemia is higher in fasting state (especially at night), therefore, in general, medium- and long-acting insulin should not be injected at bedtime as much as possible, and if necessary, the dose should not be too high, and attention should be paid to strengthen blood glucose monitoring. Of course, for hepatogenic diabetes, treatment of liver disease and improvement of liver function are the most important. As the liver disease improves, the blood sugar can drop or even return to normal. Question 3: How to use insulin for pregnant women with high blood sugar? A: If a pregnant woman has been diagnosed with diabetes before pregnancy, it is called “diabetes combined with pregnancy”; if high blood sugar is found after pregnancy, it is called “gestational diabetes”. In terms of treatment, whether it is “diabetes combined with pregnancy” or “gestational diabetes”, it is not advisable to take oral hypoglycemic drugs to avoid adverse effects on the fetal organ development. In addition to dietary treatment, insulin is the main means to control high blood sugar in pregnant women, and it is recommended to use human insulin as much as possible. In the early stage of pregnancy, when the rise and fluctuation of blood sugar are not too significant, premixed insulin can be chosen and injected twice a day before breakfast and dinner; in the middle and late stage of pregnancy, when blood sugar is higher, combined short- and medium-acting insulin intensive treatment can be taken, i.e. short-acting insulin injected before three meals + medium-acting insulin injected before bedtime. Generally speaking, with the end of delivery, most gestational diabetic patients’ blood sugar can return to normal and insulin can be discontinued; while patients with diabetes combined with pregnancy need to continue to give glucose-lowering treatment, and can continue to use insulin or switch to oral hypoglycemic therapy according to the specific situation. Question 4: How to use insulin for diabetic patients taking hormones? A: Glucose changes caused by glucocorticoids are related to the pharmacokinetic properties of the hormones used (including the onset of action, peak time of effect, maintenance time, half-life of the drug, etc.) and the drug usage. Since most patients using hormones take the whole day’s hormone dosage at 8:00 a.m., the hormones mainly affect the blood glucose between lunch and bedtime, therefore, patients with “steroidal diabetes” mainly show higher blood glucose after lunch and dinner, while fasting blood glucose from the latter half of the night to early morning is mostly normal or slightly Therefore, patients with “steroidal diabetes” mainly have high blood glucose after lunch and dinner, while fasting blood glucose is mostly normal or slightly increased in the latter half of the night and early morning. In such cases, short-acting (or fast-acting) insulin can be injected before lunch and dinner or an alpha-glucosidase inhibitor can be taken at the same time. If the patient is already diabetic, taking hormones will lead to further aggravation of the disease, and both fasting and postprandial blood glucose will increase significantly. In this case, it is often necessary to readjust the patient’s treatment plan, especially to strengthen blood glucose control between lunch and bedtime (e.g., increase the dosage of short-acting insulin before lunch and dinner) to counteract the glucose-raising effect of hormones. Long-term, high-dose application of glucocorticoids can raise blood glucose in normal people or cause them to develop diabetes. Therefore, diabetic patients must be cautious in the use of glucocorticoids, not using them as much as possible, and reducing them in time when they should be reduced. Question 5: How to use insulin in perioperative diabetic patients? A: Good glycemic control can help reduce the risk of surgery and promote wound healing. In principle, if a diabetic patient who intends to undergo surgery (here mainly refers to major surgery) is previously treated with oral hypoglycemic drugs, he or she should stop using oral hypoglycemic drugs 3 days before surgery and switch to insulin treatment, the specific plan can be taken as “premixed insulin” injected subcutaneously twice a day before breakfast and dinner, or it can be taken as “Three short and one long” or insulin pump insulin intensive treatment, and strive to reduce the patient’s blood sugar to normal before surgery. During the implementation of surgery, insulin needs to be changed from subcutaneous injection to intravenous drip, and the insulin drip rate should be adjusted at any time according to the results of dynamic blood glucose monitoring to control the patient’s intraoperative blood glucose at 5.0-11 mmol/L. After surgery, since the patient cannot resume normal diet immediately yet, intravenous supplementation of glucose solution with a certain proportion of insulin and potassium chloride is needed to meet the necessary energy demand of the body. In order to keep the blood glucose stable, the ratio of glucose and insulin (glucose:insulin ≈ 2-5 g:1 U) needs to be adjusted at the right time according to the results of blood glucose monitoring. After the patient resumes normal diet, the treatment can be changed to subcutaneous insulin, and after the wound heals, the treatment can be adjusted to oral hypoglycemic drugs. Question 6: How to use insulin in patients with diabetic ketoacidosis? A: Ketoacidosis is one of the most common acute complications in diabetic patients. For the treatment of diabetic ketoacidosis, small doses of insulin intravenous drip method are used, which is simple, effective and safe, and can greatly reduce the incidence of hypoglycemia, hypokalemia and cerebral edema. The specific steps are as follows: (1) The first stage. If the patient’s blood glucose is high (≥16.7mmol/L), add normal insulin to saline intravenously and continue to drip at a dose of 4-8U per hour. 2 hours later, review the blood glucose and double the amount of insulin if the drop is less than 30% of the level before drip, or continue to drip at the original amount until the blood glucose drops to about 13.9mmol/L if the drop is greater than 30%. The second stage of treatment. (2) Second stage. When blood glucose drops to about 13.9mmol/L, the original saline can be changed to 5% glucose solution 5% glucose saline with ordinary insulin, the ratio of glucose to insulin is 2 to 4:1 (that is, every 2 to 4g of glucose to give a unit of insulin) until the blood glucose drops to about 11.1mmol/l, when the ketone body turns negative, can be transitioned to the usual treatment. However, one hour before stopping the intravenous insulin drip, a short-acting insulin (usually 8 U) should be injected subcutaneously to prevent blood glucose rebound. Question 7: How to use insulin in elderly diabetic patients? A: The majority of elderly diabetic patients are type 2 diabetic, and they still have some insulin secretion function, plus the elderly often have renal decompensation, and insulin degradation and excretion by the kidneys is reduced. which can lead to coma or even death. In view of the low perception and poor tolerance of hypoglycemia in the elderly, it is appropriate to relax the blood glucose control standard for elderly diabetic patients, with fasting blood glucose <7.8mmol/L and 2 hours postprandial blood glucose <11.1mmol/L. Question 8: How to use insulin for children with diabetes? A: At present, diabetes in children in China is still mainly type 1 diabetes and mainly relies on insulin treatment. Type 1 diabetes in children can be divided into "acute metabolic disorder", "remission" (also called "honeymoon"), "intensive" and "permanent diabetes" according to the course of the disease. "The dosage of insulin needs to be adjusted in time according to the different stages of the disease. During the "acute metabolic disorder" period at the beginning of the disease, the insulin dosage of the child is large, and it is necessary to control the blood sugar to a satisfactory level as soon as possible; soon afterwards, the child enters the "remission period (honeymoon period)" ranging from 3 to 12 months, when the insulin dosage of the child is significantly reduced. In order to avoid hypoglycemia, the insulin dosage may only be 2-4 units/day or even less, but it is generally not recommended to stop the medication completely; after the "intensive period", the insulin dosage needs to be increased again according to the child's blood glucose condition to control blood glucose; eventually, children with diabetes will enter the "permanent Children with diabetes eventually enter the "permanent diabetic phase", relying entirely on exogenous insulin to maintain life and prevent ketoacidosis. Children with diabetes in adolescence need to increase insulin dosage due to increased secretion of sex hormones, growth hormone and other insulin antagonistic hormones, and their blood glucose is very volatile and unstable at this stage. After puberty, insulin dosage will be reduced and the disease will gradually stabilize.