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In order to achieve full chronic disease management of diabetes, these are the things we should do

2024/1/21 14:57:11

With the development of society and the improvement of living standards, diabetes has gradually developed into one of the major diseases that seriously jeopardize human health. It is noteworthy that, according to the latest version of the International Diabetes Federation (IDF) data, there are 537 million people with diabetes in the world, and the number of Chinese people with diabetes is as high as 141 million, which is steadily ranked first in the world .

Among the large diabetes population in China, the elderly is the key population for diabetes prevention and treatment. The Chinese Guidelines for the Diagnosis and Treatment of Diabetes Mellitus in the Elderly (2021 Edition) state that elderly patients with diabetes mellitus are characterized by atypical symptoms, more co-morbidities, higher risk of hypoglycemia, and limited self-management ability, and thus are also different from non-elderly patients with diabetes mellitus in terms of glycemic management, therapeutic goal-setting, and selection of glycemic lowering strategies.

Therefore, when endocrinologists are confronted with elderly diabetic patients during their check-ups, abnormal blood glucose is no longer a separate issue, so how to control all abnormal metabolic indexes safely and maximize the benefits to slow down the disease progression? Today, the editorial of "Medical World" went into the Department of Endocrinology of the Fourth Clinical Hospital of China Medical University, and brought you to see the whole process of Prof. Du Jian's checkups, and sought the answers to the above questions during the checkups.

Case Review ——65 years old

Elderly female patient with diabetes mellitus with numerous comorbiditie

Patient, 65-year-old female.

Complaint：The patient was admitted to the hospital for one week due to conscious polydrinking, polyuria, and fatigue.

Brief history： 1 week ago, the patient had no trigger for self-consciousness of thirst, polydrinking, drinking about 6,000 milliliters of water per day, with a corresponding increase in urine output, accompanied by obvious fatigue, without obvious polyphagia and emaciation. He was admitted to our outpatient clinic for systematic diagnosis and treatment. Fasting blood glucose was 17.13 mmol/L, postprandial 2-hour blood glucose was 26.01 mmol/L, and glycosylated hemoglobin (HbA1c) was 13.0%.

Ancillary tests: alanine aminotransferase 52U/L, glutamine aminotransferase 37U/L, transketolase 127U/L, total cholesterol 5.87mmol/L, LDL 4.50mmol/L, renal function and uric acid were normal, score 0 insulin 12.65μU/mL. electromyography suggested a peripheral neuropathy, bone mineral density suggested a minimum T value of -1.6, and an electrocardiogram suggested a sinus rhythm, Suspected abnormal Q waves in lead III, urine microalbumin to creatinine ratio (ACR) 40mg/g, urine microalbumin 34.1mg/L, blood routine was normal, glucose (fasting) 10.82mmol/L, amylase 165U/L, urine routine showed leukocytes (high magnification field of view) 103.17/HPF, urinary proteins -, ketone bodies -.

Diagnosis：

1.2 type 2 diabetes mellitus

2. diabetic polyneuropathy

3. painful peripheral neuropathy

4. Hypertension grade 3

5. Dyslipidemia

6. High and low density lipoprotein cholesterolemia

7. Hepatic insufficiency

8. Urinary tract infection

9. autoimmune thyroid disease (normal thyroid function stage)

10. Low bone mas

Diagnostic and therapeutic thinking analysis——

Correcting hyperglycemic toxicity and treating diabetic comorbidities

Regarding the choice of treatment plan, the bedside doctor pointed out that in order to correct the patient's hyperglycemic toxicity, we firstly gave the patient continuous subcutaneous insulin infusion (CSII) treatment plan for intensive hypoglycemia. Three days after admission, considering that the patient's blood glucose showed a significant downward trend and hyperglycemic toxicity was corrected, CSII was discontinued, and since the patient's glycemic control was still unsatisfactory despite the use of multiple oral medications and insulin, the patient was replaced with a pre-mixed insulin - Mentholatum insulin 30 - together with Metformin and Acarbose glucose-lowering regimen for the patient's treatment. At the same time, the patient was given tilmisartan tablets to lower blood pressure, atorvastatin calcium tablets to lower lipids, aspirin to fight against platelet aggregation, and symptomatic and supportive treatments such as nutrient nerves and improvement of microcirculation.

Director Du Jian emphasized that, in fact, complications in elderly diabetic patients are not necessarily caused by high blood sugar. However, it is certain that the risk of chronic complications of diabetes mellitus may increase with age and duration of the disease, and the increased risk of death associated with peripheral neuropathy, chronic liver disease, and female reproductive disorders are also closely related to the development of diabetes mellitus. Therefore, in the follow-up process, not only the treatment of diabetes, a series of concomitant disease management is "not to be ignored".

Director Du Jian shared with us that elderly diabetic patients need to pay extra attention to the choice of insulin, after stopping CSII, we chose to apply Mentholatum insulin 30 for this patient, this conversion is in line with the characteristics of most of our type 2 diabetic patients with postprandial hyperglycemia, the premixed insulin contains mealtime and basal components, a pen to take care of the fasting and postprandial blood glucose. Meanwhile, the number of daily injections can be adjusted appropriately according to the individualization of patients. In addition, for geriatric diabetes mellitus, the whole process of management should not be neglected, and diet therapy and exercise therapy should also be covered in addition to drug therapy. Detailed patient education needs to be provided to patients during check-ups during hospitalization, so that patients can reach the blood glucose standard during hospitalization, and also master how to have a healthy diet, exercise in moderation, and take medication reasonably after discharge, as well as recognize the importance of timely review and follow-up.

Director Du Jian recalled, "I have been working in the Department of Endocrinology and Metabolic Diseases since I graduated from China Medical University in 1985, and this is my 37th year. I chose to study medicine not only because of my family's influence, but also because I harbor high admiration for the profession of doctor, and it is my ideal and goal to become a good doctor, so over the years, I have never regretted my original choice. "

The process of checking the room not only allows doctors to further familiarize themselves with the current status of patient treatment, but is also a teaching process for higher-level doctors to lower-level doctors. Director Du Jian introduced: "Room study can be divided into teaching room study and medical room study, but no matter what kind of room study, its core content is the same.

First, one should start with the actual condition of the patient. Check the medical history with the subordinate doctor, including the patient's symptoms, physical examination results, laboratory tests and various auxiliary tests, and only after a detailed and prepared check of this information can we move on to the next process.

Secondly, the second step of the checkup should start with the diagnosis. The superior doctor, based on various descriptions, clarifies whether the diagnosis of the patient's main disease is correct and whether the diagnosis of its complications is comprehensive. "Taking diabetes as an example, diabetes management is an integrated process of multiple risk factor management centered on correcting hyperglycemia. So at the therapeutic level, our first choice may be to correct hyperglycemia. Also on top of the glycemic control program, we have to meet the management of multiple risk factors, such as for blood pressure, lipids, hypercoagulable state, uric acid, and weight, which is getting more and more attention in the clinic."

Third, additions to the comorbidity treatment plan during the course of the checkup. In the case under appeal, the patient was an elderly female diabetic with comorbidities such as low bone mass and other age-accelerating conditions, in addition to diabetic microangiopathy, which is specifically associated with hyperglycemia. Her comorbidities may also be related to the "patient's immunocompromise associated with menopause and aging", and coexisting chronic diseases can lead to many problems, such as dysfunction, taking multiple therapeutic medications, and reduced patient compliance, all of which cause severe psychological stress for patients with coexisting chronic diseases, and an excessive burden of treatment can lead to poor quality of life and treatment compliance. lead to a decrease in patients' quality of life and treatment adherence. Therefore, when checking the room, the precautions, advantages and disadvantages of the remaining or non-hyperglycemia-related comorbidities should be analyzed.

Finally, long-term patient management and patient education. Diabetes mellitus is a lifelong disease, after perfecting the diagnosis and treatment with the lower-level doctors, we must popularize the concept of long-term management of diabetes mellitus in-hospital combined with out-of-hospital, and timely tracking and follow-up after the patients are discharged from the hospital, timely adjustments to the treatment plan, and implementation of the principle of individualized treatment.

Prof. Du Jian exclaimed, "With the progress of technology, our knowledge of the disease and diagnosis level are getting higher and higher, which can be reflected in more and more individualized and intelligent treatment plans. As the country with the highest incidence of diabetes, it can be said that Chinese data are increasingly integrated into major domestic and international guidelines, which is undoubtedly a 'gospel' for our patients. And we also feel during the checkups that patients' right to know about their disease is getting stronger and stronger, while their personal demands for improved quality of life are getting stricter and stricter, which is a good thing."

Diabetic patients, if their own knowledge of diabetes lacks a certain degree of understanding, it will be easier to ignore the disease. For diabetic patients, if they miss the best time for treatment, it will lead to many complications. Therefore, clinicians in the process of checking the patient's actual condition, should also take into account the patient's educational background, family economic situation, as well as his adherence to the treatment program. Under the premise of respecting the patient's wishes, the optimal treatment and follow-up plan should be formulated after comprehensive consideration.

Finally, Director Du Jian gave some advice to young doctors about the conditions that may arise during the checkups, she emphasized: "Young doctors should have a full, comprehensive and detailed understanding of the patients they are responsible for, including the symptoms, signs, laboratory tests, and data from auxiliary tests. On this basis, they should also have their own thinking, not just simply report the data, but form their own diagnosis and treatment thinking while reporting the data. For example, think about whether the patient needs what other tests? Is the diagnosis not yet complete? Worse, what tests do not fit the diagnosis? After thinking about it, combine with their own diagnosis and treatment thinking to propose individualized diagnosis and treatment plan, which is what the young doctors lack, and what they need to learn in the next few years in the clinic and in the checkup."