Diabetes is a metabolic disease characterized by hyperglycemia due to defects in insulin secretion or insulin action. Sustained high blood sugar and long-term metabolic disorders can cause damage to tissues and organs throughout the body, especially the eyes, kidneys, cardiovascular and nervous systems, as well as dysfunction and failure. Severe cases can cause acute complications such as dehydration, electrolyte imbalance, and acid-base balance imbalance, such as ketoacidosis and hyperosmolar coma.
The symptoms of diabetes can be divided into two categories: one is related to metabolic disorders, especially the "three more and one less" related to hyperglycemia, which is more common in type 1 diabetes and type 2 diabetes. Diabetes is often not very obvious or has only partial manifestations. Another major category is the manifestations of various acute and chronic complications.
1. Polyuria
It is due to excessive blood sugar, exceeding the renal glucose threshold (8.89~10.0mmol/L), and the glucose filtered out by the glomerulus cannot be completely absorbed by the renal tubules. Reabsorption leads to osmotic diuresis. The higher the blood sugar, the more urinary sugar is excreted and the more urine is produced. The 24-hour urine output can reach 5,000 to 10,000 ml. However, in the elderly and those with kidney disease, the renal glucose threshold is increased and urinary glucose excretion is impaired. , polyuria may not be obvious when blood sugar is mildly or moderately elevated.
2. Polydipsia
Mainly due to the significant increase in plasma osmotic pressure caused by hyperglycemia, combined with polyuria and excessive water loss, intracellular dehydration occurs, aggravating hyperglycemia and causing plasma osmosis. The blood pressure further increases significantly, stimulating the thirst center, causing thirst and polydipsia, and polydipsia further aggravates polyuria.
3. Polyphagia
The mechanism of polyphagia is not very clear. Most scholars tend to think that it is caused by the decrease in glucose utilization (the difference in glucose concentration in arterial and venous blood before and after entering and exiting tissue cells). In normal people, the difference in glucose concentration in arterial and venous blood decreases when fasting, stimulating the feeding center and causing hunger. After eating, blood sugar rises, the concentration difference in arterial and venous blood increases (greater than 0.829mmoL/L), the feeding center is inhibited, and the stomach becomes full. The central nervous system is excited and the requirement for food intake disappears. However, in diabetic patients, due to the absolute or relative lack of insulin or the insensitivity of the tissues to insulin, the ability of the tissues to absorb and utilize glucose decreases. Although the blood sugar is at a high level, the concentration difference of glucose in the arterial and venous blood is very small, and the tissues The cells are actually in a "starvation state", thus stimulating the feeding center, causing hunger and overeating. In addition, the body cannot fully utilize glucose, and a large amount of glucose is excreted in the urine. Therefore, the body is actually in a semi-starved state, and lack of energy also causes hyperphagia. .
4. Weight loss
Although the appetite and food intake of diabetic patients are normal or even increased, weight loss is mainly due to the absolute or relative lack of insulin and the body's inability to fully utilize glucose to produce energy. It leads to enhanced decomposition of fat and protein, excessive consumption, negative nitrogen balance, gradual weight loss, and even weight loss. Once diabetes is properly treated and well controlled, weight loss can be controlled or even rebounded. For example, in patients with diabetes, Continuous weight loss or significant weight loss during treatment may indicate poor metabolic control or other chronic wasting diseases.
5. Fatigue
It is also common in patients with diabetes. Since glucose cannot be completely oxidized, that is, the human body cannot fully utilize glucose and effectively release energy, and the tissue loses water at the same time. , electrolyte imbalance and negative nitrogen balance, etc., resulting in general fatigue and listlessness.
6. Decreased vision
Many diabetic patients complain of decreased or blurred vision when they seek medical treatment in the early stages. This may be caused by changes in the osmotic pressure of the lens caused by high blood sugar and changes in the refractive power of the lens. Generally, the early stage is a functional change. Once blood sugar is well controlled, vision can return to normal quickly.
The treatment of diabetes includes diabetes education, diet therapy, exercise therapy, drug therapy, blood sugar monitoring, and the detection and control of other cardiovascular disease risk factors.
Once diabetes is diagnosed, patients should be educated about diabetes, including general knowledge about diabetes, self-monitoring of blood sugar and urine sugar. Usage of hypoglycemic drugs, observation and treatment of adverse reactions, etc. As well as the manifestations, prevention and treatment of various complications.
The primary measure for basic treatment of various types of diabetes. The principle of dietary treatment is: control total calories and weight. Reduce the fat content in food, especially saturated fatty acids, increase the fiber content of food, and make the proportion of carbohydrates, fats and proteins in food reasonable. Control total dietary energy intake and distribute various nutrients in a reasonable and balanced manner.
To maintain a reasonable weight, the goal of weight loss for overweight/obese patients is to lose 5%-10% of body weight within 3-6 months. Patients with wasting should restore and maintain their ideal weight over the long term through a balanced nutritional plan.
① Fat: The energy provided by fat in the diet does not exceed 30% of the total energy, and the intake of saturated fatty acids does not exceed 10% of the total energy. Cholesterol intake from food is <300mg/day.
②Carbohydrates: The energy provided by carbohydrates in the meal should account for 50%-60% of the total energy. Food should be rich in dietary fiber.
③Protein: For people with normal renal function, the recommended protein intake accounts for 10%-15% of total energy. For patients with overt proteinuria, the protein intake is <0.8g/kg body weight/day. ; Starting from the time when GFR decreases, a low-protein diet <0.6g/kg body weight/day should be implemented, and compound a-keto acid preparations should be supplemented at the same time.
④Drinking alcohol: It is not recommended for patients with diabetes to drink alcohol. No more than 1-2 standard servings per day (a standard serving is: 350ml of beer, 150ml of red wine or 45ml of low-alcohol liquor, each containing approximately 15g of alcohol)
⑤ Salt: The salt intake is limited to Within 6g per day, patients with high blood pressure should strictly limit their intake.
It is generally recommended that the protein in the daily diet should be given at 0.6-0.8 g/kg of standard body weight, and the proportion of high-quality protein should be increased within the limit. Patients in stages 3 and 4 of diabetic nephropathy should master the quality and quantity of daily protein intake while adhering to other principles of diabetes nutritional therapy.
Patients with diabetic nephropathy do not formulate a scientific and reasonable diet plan for themselves. Once the renal function is impaired, it may range from an increase in blood pressure and general fatigue; to severe renal dysfunction, edema, male impotence and testicular atrophy. etc; in severe cases, the ability to take care of oneself is completely lost, and life may even be taken away.
1. Eat less fruit
Fruits contain more fructose and glucose, which can be quickly absorbed by the body, causing blood sugar to increase. Therefore, patients with severe diabetes should not eat too much fruit.
2. Do not drink alcohol
Alcohol contains 14.64 kilojoules (3.5 kilocalories) per gram. It is a high-calorie food and has the effect of consuming body heat. Excessive alcohol can cause hyperlipidemia or metabolic disorders, which will increase the burden on the liver. When diabetic patients drink alcohol and eat some carbohydrate foods, their blood sugar can rise, causing diabetes to lose control. Regular drinking without eating food can inhibit the decomposition of liver glycogen, reduce the amount of glucose in the blood, and cause symptoms of hypoglycemia. Therefore, patients with severe diabetes and hepatobiliary disease, especially those who are taking insulin and oral hypoglycemic drugs, are strictly prohibited from drinking alcohol.
3. Eat less high-sugar and high-salt foods
For the understanding of diabetes, doctors usually regard dietary restriction, especially the restriction of eating high-sugar foods, as an important prevention and treatment measure. methods to guide patients. However, less attention has been paid to limiting salt intake. Modern medical research shows that too much salt can enhance amylase activity to promote starch digestion (digestion of food), and promote the absorption of free glucose in the small intestine, which can cause an increase in blood sugar concentration and aggravate the condition. Therefore, diabetic patients should not eat more salt.
Exercise therapy
is also one of the basic treatments for diabetes. Appropriate exercise programs should be selected based on the patient's actual situation, within one's ability, and in a step-by-step manner. The most important thing is support. The mode, intensity, and frequency of exercise should be determined based on the patient's actual condition. Moderate-intensity aerobic exercise (such as brisk walking, Tai Chi, cycling, golf, and gardening) is generally recommended for at least 150 minutes per week. People with blood sugar >14-16mmol/L, obvious hypoglycemia or large blood sugar fluctuations, acute metabolic complications of diabetes, and severe chronic complications of various heart, kidney, and other organs are not suitable for exercise.
Quit smoking
Smoking is harmful to health, especially for patients with type 2 diabetes who are at high risk of macrovascular disease. Every diabetic patient who smokes should be advised to stop smoking, which is one of the important components of lifestyle intervention.
Main oral hypoglycemic drugs
According to different mechanisms of action, they are divided into insulin secretagogues (sulfonylureas, glinides), biguanides, and thiazolidinedione insulins Sensitizers, α-glycosidase inhibitors, diyl peptidase-IV (VDPP-IV) inhibitors, etc. Drug selection should be considered based on the two main pathophysiological changes of type 2 diabetes—insulin resistance and impaired insulin secretion. In addition, the patient's blood sugar fluctuation characteristics, age, weight, and important organ functions are also important factors that should be fully considered when selecting drugs. When used in combination, drugs with complementary mechanisms should be used to increase efficacy and reduce the incidence of adverse reactions.
1． Biguanides: These drugs can reduce hepatic glucose production, promote glucose uptake by peripheral tissues such as muscles, accelerate the anaerobic glycolysis of sugar, and reduce the absorption of sugar in the intestine. It has lipid-lowering and uric acid-lowering effects. It is suitable for type 2 diabetes, especially for obese people. It should be the first choice drug. Preparations include ① phenformin; ② metformin. The most commonly used drug currently is metformin. A rare serious side effect of biguanides is lactic acidosis. Metformin causes very few cases, and biguanide drugs are contraindicated in renal insufficiency (serum creatinine level in men >1.5mg/dL, in women >1.4mg/dL or glomerular filtration rate <60ml/min/1.73m2), liver insufficiency , severe infection, hypoxia or patients undergoing major surgery. Metformin should be temporarily discontinued when iodinated contrast agents are used for contrast examinations. The main side effects of metformin are gastrointestinal effects. Gastrointestinal symptoms are seen in 10% of patients, including abdominal discomfort, anorexia, nausea, diarrhea, and occasionally dry mouth or metallic taste.
2. Sulfonylureas: These drugs mainly act on the sulfonylurea receptors on the surface of pancreatic islet B cells to promote insulin secretion. Suitable for diabetic patients with functional pancreatic islet B cells but no severe liver or kidney dysfunction. Improper use of sulfonylureas can lead to hypoglycemia, especially in elderly patients and those with liver and kidney dysfunction; sulfonylureas also Can cause weight gain. Clinical trials have shown that sulfonylureas can reduce HbA1c by 1%-2%, and are currently recommended in the diabetes guidelines formulated by many countries and international organizations as the main medication to control hyperglycemia in patients with type 2 diabetes.
Sulfonylureas include tolbutamide; glibenclamide; gliclazide; glipizide; glaqidone; glimepiride, etc. Sulfonylureas also have some sustained-release and controlled-release dosage forms, such as gliclazide sustained-release tablets, glipizide controlled-release tablets, etc.
3. Benzoic acid derivative secretagogues: including repaglinide and nateglinide. This type of drug mainly reduces postprandial blood sugar by stimulating the early secretion of insulin. It has the characteristics of fast absorption, fast onset and short action time, and can reduce HbA1c by 0.3%-1.5%. These drugs need to be taken immediately before meals and can be used alone or in combination with other antidiabetic drugs (except sulfonylureas). Common side effects of meglitinides are hypoglycemia and weight gain, but hypoglycemia is less frequent and less severe than that of sulfonylureas.
4. Alpha-glucosidase inhibitor: It can selectively act on the glucosidase on the brush border of the small intestinal mucosa, inhibit the decomposition of polysaccharides and sucrose into glucose, delay the digestion of carbohydrates, and reduce glucose absorption. Can improve blood sugar peak after meals. Mainly include ① acarbose ② voglibose, etc. Alpha-glycosidase inhibitors can reduce HbAlc by 0.5%-0.8%. The common adverse reactions of alpha-glycosidase inhibitors are gastrointestinal reactions.
5. Thiazolidinediones (insulin sensitizers): By activating the nuclear receptor PPARγ, they enhance the sensitivity of peripheral tissues to insulin, such as increasing the absorption and transport of glucose in adipose tissue, inhibiting the release of plasma FFA, inhibiting the release of glycogen, and strengthening bones. Muscles synthesize glucose, etc. to reduce insulin resistance. Adapted to obese type 2 diabetes dominated by insulin resistance. Clinical trials have shown that thiazolidinediones can reduce HbA1c by 1.0%-1.5%. Mainly include ① rosiglitazone; ② pioglitazone. Weight gain and edema are common side effects of thiazolidinediones. Thiazolidinedione use is also associated with an increased risk of fractures and heart failure.
Remarks: About the use of rosiglitazone:
The safety of rosiglitazone is still controversial, and its use is strictly restricted in my country.
For diabetic patients who have never used rosiglitazone and its compound preparations, the use of rosiglitazone and its compound preparations can only be considered when other hypoglycemic drugs cannot be used or the blood sugar control goals cannot be achieved with other hypoglycemic drugs. Compound preparations. For patients who are already taking rosiglitazone and its compound preparations, the risk of cardiovascular disease should be assessed, and the benefits and risks of taking the medication should be weighed before continuing to take the medication.
6. Diyl peptidase-VI (DPP-VI) inhibitors: DPP-IV inhibitors reduce the inactivation of GLP-1 in the body and increase GLP by inhibiting dipeptidyl peptidase-IV. -1 levels in the body. GLP-1 enhances insulin secretion and inhibits glucagon secretion in a glucose concentration-dependent manner. In clinical trials including patients with type 2 diabetes, sitagliptin has been shown to reduce HbA1c by 1.0%.
Insulin treatment
1. Types of insulin
Classified by source, there are animal insulin (pig, cow) and genetically recombinant human insulin. Human insulin preparations have a milder immune response and are less likely to produce antibodies.
Preparations are divided into different types according to their onset time.
① Short-acting insulin has a quick onset of action and a short action time. Regular is a short-acting insulin. The preparation is transparent.
②Intermediate-acting insulin has shorter onset time, peak value and longer action time than the shorter-acting islets. The most commonly used is NPH.
③Premixed insulin: 50R: a mixture of 50% NPH insulin and 50% regular insulin; 30R: a mixture of 70% NPH insulin and 30% regular insulin
④Super Short-acting insulin analogues: Synthetic insulin analogues that are injected with meals and have a short duration of action. There are two types: insulin lispro and insulin aspart.
⑤Long-acting insulin analogs: Synthetic insulin analogs, which have a long acting time and are used as a supplement to the basal amount of insulin. Such as insulin glargine and insulin detemir.
⑥Ultra-long-acting insulin analogs: synthetic insulin analogs with longer acting time, such as insulin degludec.
2. Initiation of Insulin Treatment
Patients with type 1 diabetes require lifelong insulin replacement therapy.
In patients with type 2 diabetes, when HbA1c is still greater than 7.0% after combined treatment with larger doses of multiple oral drugs, insulin therapy can be considered.
Insulin should be used as the first-line treatment for thin diabetic patients with new onset of diabetes who are difficult to differentiate from type 1 diabetes.
When there is weight loss without obvious inducement during the course of diabetes, insulin treatment should be used as early as possible.
Application of insulin under special circumstances:
Hyperglycemia in newly diagnosed diabetic patients, perioperative period, infection, pregnancy
3. How to use insulin:
Short-acting insulin can be used for intravenous infusion to treat severe diabetes such as ketoacidosis. Once diagnosed, type 1 diabetes still requires lifelong subcutaneous insulin treatment. Type 2 diabetes can be treated with insulin supplementation or replacement. There are several steps below.
① For patients whose oral hypoglycemic drugs have failed or partially failed, continue to use oral hypoglycemic drugs, and subcutaneously inject medium-acting or long-acting insulin before going to bed. The initial dose is 0.1 to 0.2U/kg. Monitor For blood sugar, adjust the dose after 3 days, and adjust the amount each time to 2U-4U.
② Inject premixed insulin twice a day, morning and evening. The initial insulin dose is generally 0.4-0.6 units/kg body weight/day, distributed before breakfast and before dinner in a 1:1 ratio. The advantage is that it is convenient and reduces the inconvenience of injecting before lunch, but blood sugar fluctuates greatly during lunch and is difficult to control.
③Based on the above initial treatment with insulin, after sufficient dose adjustment, if the patient's blood sugar level still does not reach the target or repeated hypoglycemia occurs, the treatment plan needs to be further optimized. You can use mealtime + basal insulin: adjust the insulin dosage before bedtime and before three meals respectively according to the blood sugar levels before bedtime and before three meals.
④Insulin pump treatment. The main applicable groups are: patients with type 1 diabetes; diabetic women who plan to conceive and are pregnant; patients with type 2 diabetes who need intensive insulin treatment.
4. Side effects: Mainly hypoglycemic reactions.