Diabetes is a chronic disease that is widely prevalent and serious and cannot be completely cured. However, as research into diabetes continues to advance, the concept of diabetes treatment has changed significantly.
Compared with the traditional treatment model, the new treatment concept is more scientific and rational, and closer to the essence of the disease. The core elements of the concept are early combination of drugs, active intensive treatment, comprehensive control of multiple risk factors to achieve the standard, protection of pancreatic islet function, and reduction or delay of chronic complications.
Specifically, there are ten changes in the following aspects.
First, the initial treatment from “a single lifestyle intervention” to “lifestyle and drug interventions in a two-pronged approach”
For the treatment of newly diagnosed diabetic patients, the traditional approach is often to start with a single lifestyle intervention, after a period of time (usually 1 to 2 months) of observation, blood glucose control is still not ideal before starting drug therapy.
However, this approach has at least two drawbacks.
1. It is not conducive to the early control of patients’ blood glucose to reach the standard.
2. Because the “glucotoxicity” is not lifted in time, the best time to reverse and repair the patient’s islet function is often missed.
Moreover, it is not easy to make patients change their original lifestyles and adhere to them for a long time. In fact, most patients still need to rely on the help of glucose-lowering drugs to effectively control their blood sugar.
In view of this, the latest domestic and international guidelines for the prevention and treatment of type 2 diabetes require that once diagnosed, type 2 diabetic patients should start lifestyle intervention and drug therapy at the same time, and metformin is recommended as the first-line treatment drug with lifestyle intervention.
Change from “stepwise treatment” to “early intensive treatment
The traditional treatment model for type 2 diabetes is the so-called “ladder treatment”. In other words, it starts with lifestyle changes (diet control and exercise therapy), then a single oral hypoglycemic drug, then a combination of drugs, and finally insulin as a last resort. This step-by-step treatment mode is too conservative, which is not conducive to the rapid control of blood glucose to the standard, and the patient is in a state of hyperglycemia for a long time, which is not conducive to delaying or preventing the occurrence of complications.
In addition, if insulin is applied too late, the best time to repair islet function may be missed, resulting in an irreversible trend of progressive decline in b-cell function.
“Early intensive treatment” is a new treatment concept based on a large number of evidence-based medical research results in recent years, and its benefits are mainly reflected in two aspects: 1.
1. Intensive treatment can effectively protect, improve and repair the patient’s own islet function.
Many domestic and foreign studies have confirmed that for newly diagnosed diabetic patients whose diet control alone is ineffective, taking short-term (about 2 weeks) insulin intensive treatment, some of these patients can obtain long-term good glycemic control without drugs and only by diet control. Another study found that some patients who have developed secondary failure to oral hypoglycemic drugs can regain their control of oral hypoglycemic drugs after a period of intensive insulin therapy.
They can regain the efficacy of oral hypoglycemic drugs and stop using insulin. All of this proves that early intensive insulin therapy can really help patients to recover their pancreatic islet function.
2. Intensive therapy can significantly reduce chronic complications of diabetes, especially microvascular complications.
The follow-up study of DCCT (i.e. EDIC study) also found that more than ten years after the end of the DCCT study, although the HbA1c in the intensive treatment group and the general treatment group were at the same level, there was a significant difference in the incidence of microvascular and macrovascular disease between these two groups, with the incidence of chronic complications in the group that had received intensive treatment being only The incidence of chronic complications was only half of that in the conventional treatment group.
This fact tells us that there is a “metabolic memory effect” in glycemic control, and that early intensive treatment can provide long-lasting benefits in terms of reduced microvascular disease, cardiovascular events and death, even years after intensive treatment is stopped.
The ACCORD trial confirmed that in elderly patients with type 2 diabetes who have a long history of disease, cardiovascular risk factors or existing cardiovascular disease, strict glycemic control does not reduce but increases the incidence of cardiovascular events and mortality.
This is because this group is less tolerant of hypoglycemia, and severe hypoglycemia can increase the risk of cardiovascular death. Generally speaking, intensive therapy is more suitable for diabetic patients with first-onset, young, and no vascular disease.
Change from “preferred oral hypoglycemic agents” to “early application of insulin
UKPDS study shows that due to the persistence of insulin resistance, the function of pancreatic b-cells declines progressively as the disease progresses. By the time diabetes is diagnosed, more than half of the islet function has been lost, and it will decrease at a rate of 4-5% per year.
In the past diabetes treatment, often one-sided pursuit of glucose-lowering effect without paying attention to the protection of islet function, a large number of long-acting, strong insulin promoter (such as euglycemia), this “whip the sick cow” type of practice, accelerated the patient’s islet b-cell failure, followed by the secondary failure of drugs. The early supplementation of insulin can not only make the blood glucose control reach the standard quickly, but also reduce the burden of its own pancreatic islet b cells, which is conducive to improving and repairing its own pancreatic islet function and maintaining normal blood glucose for a long time, thus reducing or delaying the occurrence of various complications.
Change from “insulin promoter” to “insulin sensitizer
At present, it is believed that the main cause of type 2 diabetes is “insulin resistance” (that is, the body is insensitive to insulin), while “insulin deficiency” is of secondary importance. In addition, the former is the source of various metabolic abnormalities such as dyslipidemia, hypertension, hypercoagulability, abdominal obesity, and chronic complications such as cardiovascular disease. Therefore, the treatment of type 2 diabetes must start at the source, address “insulin resistance”, and then achieve control of hyperglycemia and other cardiovascular risk factors, protect pancreatic b-cells, delay the progression of type 2 diabetes, and reduce the incidence of chronic (macrovascular and microvascular) complications of diabetes.
Inappropriate overuse of insulin sensitizers (e.g., euglycemia) not only fails to protect pancreatic islet b-cells, but also accelerates islet b-cell failure, leading to secondary failure of glucose-lowering drugs. On the contrary, insulin sensitizers (such as thiazolidinediones) can directly attack insulin resistance and protect both pancreatic islet b cells and large blood vessels, which not only helps to achieve long-term stable glycemic control and delay the progression of type 2 diabetes, but also reduces the incidence of diabetic microvascular and macrovascular lesions.
V. Transformation from “ordinary insulin stimulant” to “early phase insulin stimulant
Early phase (first phase) insulin secretion is very important for normal glucose metabolism in the body, and its main function is to inhibit hepatic glucose output and lipolysis. Defective insulin secretion in the early phase leads to inhibition of hepatic glucose output after meals, accelerated lipolysis and increased gluconeogenesis, resulting in postprandial hyperglycemia and hyperinsulinemia, and accelerated islet b-cell failure.
It is known that early-phase insulin secretion defect occurs in the early stage of type 2 diabetes, and early-phase insulin secretagogues (such as Novaluron and Tangli) have the advantage of “fast in and fast out”, which can significantly improve early-phase insulin secretion of pancreatic b-cells and produce a pattern similar to physiological insulin secretion, so it can better reduce the patient’s Therefore, the postprandial blood glucose level of patients can be lowered, and the continuous over-stimulation of pancreatic islet b cells by drugs can be avoided.
Change from “single drug treatment” to “early combined drug use
In the past, when using hypoglycemic drugs, generally use a drug “alone”, to be used to the maximum dose and blood sugar is still not satisfactory control, only then forced to take “joint war”. At present, it is believed that this kind of passive “combination drug” is not conducive to the rapid control of blood glucose and the protection of the patient’s pancreatic islet function, and is not conducive to the effective prevention and treatment of various complications of diabetes.
The new treatment model recommends early combination therapy, that is, when the half dose of a single drug (half of the maximum allowable dose) cannot bring blood glucose under satisfactory control, the dose of a single drug is no longer increased, but the combination therapy of non-identical drugs is actively taken.
Early combination therapy can give full play to the complementary effects of different drugs and enhance the efficacy of hypoglycemia; reduce the possible side effects caused by the excessive dose of each drug; help improve insulin resistance, protect the function of pancreatic b-cells and prevent the “secondary failure of oral hypoglycemic drugs”; and effectively delay or reduce the occurrence and development of chronic complications. The International Diabetes Federation (IDF) The latest International Diabetes Federation (IDF) global guidelines for type 2 diabetes recommend metformin as the drug of choice and the basis of monotherapy and combination therapy for type 2 diabetes.
From “fasting blood sugar control only” to “fasting blood sugar and postprandial blood sugar together”
Studies have confirmed that postprandial hyperglycemia plays a key role in macrovascular disease (mainly cardiovascular disease), which can cause a series of pathophysiological changes such as oxidative stress, early-phase insulin secretion defects, increased insulin resistance and endothelial dysfunction, leading to the formation of atherosclerotic plaques and vascular damage.
Compared with fasting glucose, detection of postprandial glucose not only helps to detect diabetes at an early stage, but also can better predict the risk of cardiovascular events. the STOP-NIDDM study showed that early intervention of postprandial glucose can significantly reduce the incidence of cardiovascular events and enable patients to achieve better clinical regression. Therefore, in terms of blood glucose management, we must not neglect the monitoring and control of postprandial blood glucose.
Change from “controlling high blood sugar” to “controlling blood sugar fluctuation
Research shows that glycosylated hemoglobin (HbA1c) is the golden indicator reflecting the average level of glycemic control of patients, and the higher the HbA1c of patients, the greater the risk of chronic complications of diabetes. The researchers also noted that two groups of patients with the same HbA1c level did not have the same risk of complications. Later, it was found that the magnitude of blood glucose fluctuations in these two groups of patients differed significantly despite similar HbA1c.
It was concluded that the occurrence and development of chronic complications of diabetes mellitus are not only related to the overall increase of blood glucose level, but also closely related to the fluctuation of blood glucose, the higher the fluctuation of blood glucose, the greater the risk of chronic complications, and the sudden high and low blood glucose is more harmful than stable high blood glucose.
Therefore, the goal of modern blood glucose control is not only to strive to achieve the HbA1c standard (quantitative control), but also to reduce the fluctuation of blood glucose of patients as much as possible (qualitative control), in other words, “not only to reduce sugar, but also to stabilize sugar”.
Change from “simple blood sugar control” to “control of multiple cardiovascular risk factors
Diabetes is a major cardiovascular disease as the outcome of the disease, about 3/4 of type 2 diabetic patients eventually die of cardiovascular disease. Evidence-based studies such as the UK Prospective Diabetes Study (UKPDS) have shown that while strict glycemic control can significantly reduce microvascular complications of diabetes (e.g. diabetic nephropathy, diabetic eye disease), macrovascular complications (mainly cardiovascular disease) are not significantly reduced in patients.
It is now known that diabetes, as part of the metabolic syndrome, aggregates numerous cardiovascular disease risk factors, including hyperglycemia, lipid metabolism disorders, hypertension, abdominal obesity, hypercoagulation and chronic inflammatory states, among others, which together contribute to the formation of atherosclerosis.
Therefore, it is believed that type 2 diabetes should go beyond the treatment concept centered on blood glucose control and replace it with comprehensive control of various cardiovascular risk factors, so as to reduce chronic complications of diabetes and improve the prognosis of patients.
Ten, from “treatment rather than prevention” to “prevention and treatment with equal emphasis” change
“Pre-diabetes” refers to the transitional stage between normal blood sugar and diabetic, individuals in pre-diabetes have a high risk of diabetes in the future, most of these people have insulin resistance, accompanied by hypertension, lipid metabolism disorders, etc., more likely to occur than people with normal blood sugar macrovascular lesions. Early intervention (lifestyle intervention or pharmacological intervention) for people with “pre-diabetes” can reduce not only the incidence of diabetes but also the incidence of cardiovascular disease.
The latest IDF (International Diabetes Federation) guidelines include “self-monitoring” of patients as part of lifestyle interventions, as safe and effective interventions require blood glucose monitoring. Evidence-based medical trials have confirmed that lifestyle interventions are more effective and economical than pharmacological interventions, and are worthy of strong advocacy and have great clinical significance and practical value.