1.Patients with type 1 diabetes require insulin therapy at the onset of the disease and need lifelong insulin replacement therapy.
2.Insulin therapy can be preferred for patients with new onset type 2 diabetes if they have obvious symptoms of hyperglycemia, occurrence of ketosis or ketoacidosis. The subsequent treatment plan will be determined according to the condition after the blood sugar is well controlled and the symptoms are significantly relieved.
3.Insulin therapy can be preferred when it is difficult to differentiate newly diagnosed diabetic patients from type 1 diabetes. After the blood sugar is well controlled, the symptoms are significantly relieved, and the typing is determined, the subsequent treatment plan will be formulated according to the typing and the specific condition.
4.Patients with type 2 diabetes can start the combination therapy of oral hypoglycemic agents and insulin if their blood sugar still does not reach the control target based on the combination therapy of lifestyle and oral hypoglycemic agents. Generally, when HbA1c>7.0% even after a larger dose of multiple oral medication combination therapy, insulin therapy can be considered to be started.
5. In the course of diabetes (including newly diagnosed type 2 diabetes), insulin therapy should be used as early as possible when there is significant weight loss without obvious causes.
6. Depending on the patient’s specific situation, basal insulin or premixed insulin can be used to start insulin therapy.
(1) The use of basal insulin in the initiation of insulin therapy
(1) Basal insulin includes medium-acting human insulin and long-acting insulin analogues. When only basal insulin is used for treatment, the original oral hypoglycemic drugs are retained and there is no need to stop using insulin stimulants.
②How to use: Continue oral hypoglycemic therapy, combined with intermediate-acting human insulin or long-acting insulin analogues injected at bedtime. The starting dose is 0.2 U?kg-1?d-1. Adjust the insulin dosage according to the patient’s fasting blood glucose level, usually every 3~5 days, and adjust 1~4 U each time according to the blood glucose level until the fasting blood glucose standard is reached.
(3) If fasting glucose control is satisfactory but HbA1c is not reached after 3 months, adjustment of insulin treatment regimen should be considered.
(2) The use of premixed insulin in the initial treatment
(1) Premixed insulin includes premixed human insulin and premixed insulin analogues. Depending on the patient’s blood glucose level, an injection regimen of one to two times daily can be selected. When using the 2 times daily injection regimen, insulin stimulants should be discontinued.
②1-time daily premixed insulin: The starting insulin dose is usually 0.2?kg-1?d-1 and is injected before dinner. The insulin dosage is adjusted according to the patient’s fasting blood glucose level, usually every 3~5 days, and 1~4 U each time according to the blood glucose level until the fasting blood glucose standard is reached.
(iii) Pre-mixed insulin twice daily: The starting insulin dose is usually 0.2~0.4?kg-1?d-1, distributed in a 1:1 ratio before breakfast and before dinner. The insulin dosage before breakfast and dinner was adjusted according to fasting blood glucose and pre-dinner blood glucose, respectively, every 3~5 days, and the dosage was adjusted by 1~4 U each time according to the blood glucose level until the blood glucose standard was reached.
④ Premixed insulin can be used for a short period of time during the honeymoon phase of type 1 diabetes with 2~3 injections daily. Premixed insulin should not be used for long-term glycemic control in type 1 diabetes.
(3) Short-term insulin intensive treatment program
For newly diagnosed type 2 diabetes patients with HbA1c>9.0% or fasting blood glucose>11.1mmol/L, short-term insulin intensive therapy can be implemented, and the duration of treatment is appropriate from 2 weeks to 3 months, with the treatment goal of fasting blood glucose 3.9-7.2mmol/L and non-fasting blood glucose ≤10.0mmol/L. HbA1c attainment can be temporarily excluded as the treatment goal. Intensive insulin therapy should be accompanied by medical nutrition and exercise therapy, and education of diabetic patients should be enhanced. Intensive insulin therapy regimens include basal-meal insulin regimens [multiple subcutaneous insulin injections or continuous subcutaneous insulin infusion (CSII)] or premixed insulin regimens of 2 or 3 injections per day. The specific use is as follows.
①Multiple subcutaneous insulin injections: basal + mealtime insulin 1 to 3 injections per day. The blood glucose monitoring protocol requires 3 to 4 points of blood glucose monitoring per day at least 3 days per week. The insulin dosage before bedtime and three meals will be adjusted according to the blood glucose level before bedtime and three meals, respectively, once every 3~5 days, and the dosage will be 1~4 U each time according to the blood glucose level until the blood glucose standard is reached.
②2~3 times daily premixed insulin (premixed human insulin twice daily and premixed insulin analogues 2~3 times daily): The blood glucose monitoring protocol requires 3~4 points of blood glucose monitoring at least 3 days per week. The insulin dose is adjusted according to the bedtime and mealtime blood glucose levels, once every 3~5 days, and the dose is 1~4 U per adjustment according to the blood glucose level until the blood glucose standard is reached.
(③) CSII: The blood glucose monitoring program requires at least 3 days per week, with 5-7 points of blood glucose monitoring per day. Adjust the dose according to the blood glucose level until the blood glucose standard is reached.
For patients who fail to induce remission with short-term intensive insulin therapy, whether to continue insulin therapy or switch to other medications should be determined by the diabetes specialist according to the patient’s specific situation. For those who reach the standard of treatment and are in clinical remission, they can be monitored with regular follow-up (e.g. 3 months); when the blood glucose rises again, i.e.: fasting blood glucose >7.0 mmol/L or 2h postprandial blood glucose >10.0 mmol/L patients restart drug therapy.