World Diabetes Day: Dear Diabetes Patients, Please Check the Standard Management of Diabetes

Author: Liu Bing, deputy chief physician, Department of Endocrinology, Beijing Friendship Hospital, Capital Medical University

Reviewer: Yuan Mingxia, Chief Physician, Department of Endocrinology, Beijing Friendship Hospital, Capital Medical University

November 14th of each year is World Diabetes Day. The theme of this year's World Diabetes Day is "Know the Risks, Know the Responses." Let's take a look at the common complications of diabetes and the important goals of diabetes management through two examples.

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I have seen all kinds of patients in the diabetes clinic for many years, and two of them left a deep impression on me: one is an old professor with a 20-year history of diabetes, and the other is a middle-aged manager with a 20-year history of diabetes. The former has been taking hypoglycemic drugs since the early diagnosis of diabetes, strictly following the doctor's requirements for diet control, exercise, blood sugar monitoring and regular check-ups. After 20 years, he still uses the original drugs and the original dose, and has no complications of diabetes; the latter did not pay attention to the early stage of the disease, resulting in large-scale fundus hemorrhage in the 15th year of the disease. After multiple surgical treatments by ophthalmologists, he barely retained a little vision. These two cases show us two completely different clinical outcomes of "strict blood sugar control and poor blood sugar control."

In recent years, the prevalence of diabetes in my country has increased significantly, with the prevalence of adult diabetes as high as 11.2%. China has become the country with the largest number of diabetes patients in the world. Diabetes is a chronic metabolic disease characterized by high blood sugar. Strict control of blood sugar can reduce the risk of microvascular, macrovascular and neuropathy in diabetic patients. Many patients believe that as long as there are no symptoms, there are no complications. This is a very wrong understanding, because a slight increase in blood sugar levels is not enough to cause serious symptoms for most people, and various complications do not have obvious clinical manifestations in the early stages, but once typical symptoms appear, it may no longer be in the early stages. So, how can we effectively prevent the occurrence and development of diabetic complications?

1. What are the common complications of diabetes?

Common chronic complications of diabetes mainly include macrovascular, microvascular and neuropathy. Cardiovascular disease is the main cause of death in diabetic patients, diabetic retinopathy (DR) is the leading cause of blindness in adults, diabetic nephropathy (DKD) is the leading cause of end-stage renal disease, and diabetic neuropathy is the leading cause of non-traumatic distal amputation.

1. Cardiovascular disease

The risk of cardiovascular disease in patients with diabetes increases by 2 to 4 times, and diabetes is also an independent risk factor for cardiovascular disease. In fact, strict blood sugar control alone has limited effect on reducing the incidence of cardiovascular disease and the risk of death in patients with type 2 diabetes, especially in patients with a long course of disease, older age, and those who have already developed cardiovascular disease or have multiple cardiovascular risk factors. Only comprehensive intervention of multiple risk factors can significantly improve the incidence and mortality risks of cardiovascular disease in patients with diabetes. When diabetes is diagnosed and thereafter, cardiovascular disease risk factors should be assessed at least once a year, including cardiovascular disease history, age, smoking, hypertension, dyslipidemia, obesity, especially abdominal obesity, family history of premature cardiovascular disease, kidney damage (increased urinary albumin excretion rate, etc.), and atrial fibrillation (which can lead to stroke).

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2. Diabetic nephropathy

In my country, 20% to 40% of diabetic patients have diabetic nephropathy. Patients with type 2 diabetes should be screened for kidney disease at the time of diagnosis, and should be screened at least once a year thereafter, including routine urine tests, urine albumin/creatinine ratio (UACR) and serum creatinine (calculation of glomerular filtration rate). Patients with type 1 diabetes generally develop diabetic nephropathy after 5 years. If the patient has some changes in his condition, he needs to consider going to the nephrology department for further treatment, such as diabetic nephropathy progressing to stage 4-5, a rapid decrease in glomerular filtration rate in a short period of time, a rapid increase in proteinuria in a short period of time, abnormal renal imaging manifestations, and combined with refractory hypertension.

3. Diabetic retinopathy

Patients with type 2 diabetes should undergo their first eye screening after diagnosis. Patients with type 1 diabetes should undergo a comprehensive eye examination within 5 years of diagnosis. Those without diabetic retinopathy should have a follow-up examination at least once every 1 to 2 years, while those with diabetic retinopathy should increase the frequency of examinations. Diabetic retinopathy and diabetic nephropathy are strongly correlated, and it is recommended that patients with type 2 diabetes undergo diabetic retinopathy screening when they develop diabetic nephropathy. Patients with moderate or above non-proliferative diabetic retinopathy and proliferative diabetic retinopathy found during screening should be further diagnosed and treated by an ophthalmologist.

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4. Diabetic neuropathy

Diabetic neuropathy is the most common chronic complication of diabetes, including diffuse neuropathy, mononeuropathy, radiculopathy and autonomic neuropathy. Diabetic neuropathy screening should be performed when type 2 diabetes is diagnosed and 5 years after type 1 diabetes is diagnosed, and then at least once a year. Those with typical symptoms are easy to detect and diagnose. The most common early symptoms include pain and paresthesia, but up to 50% of patients may be asymptomatic, which requires early detection through physical examination and neuroelectrophysiological examination.

5. Diabetic lower limb arterial disease and diabetic foot

Lower extremity arterial disease (LEAD) is a component of peripheral arterial disease, manifested as stenosis or occlusion of the lower extremity arteries. Compared with non-diabetic patients, diabetic patients have a 2-fold increased risk of developing lower extremity arterial disease, and the prevalence increases with age. For diabetic patients over 50 years old, lower extremity arterial disease screening should be performed routinely, and diabetic patients with risk factors for lower extremity arterial disease (such as cardiovascular and cerebrovascular diseases, dyslipidemia, hypertension, smoking or diabetes for more than 5 years) should be screened at least once a year. Diabetic foot usually occurs on the basis of lower extremity arterial disease and neuropathy, with infection, ulcers and tissue destruction of the foot, and the consequences are extremely serious. Therefore, all diabetic patients should undergo a comprehensive foot examination every year to evaluate the current symptoms of neuropathy and lower extremity vascular disease to determine the risk factors for ulcers and amputations.

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What are the important goals in diabetes management?

Patients with type 2 diabetes often have one or more components of metabolic syndrome, such as hypertension, dyslipidemia, obesity, etc., which significantly increase the risk, progression rate and harm of complications of type 2 diabetes. Therefore, the treatment of type 2 diabetes should be comprehensive, including the control of blood sugar, blood pressure, blood lipids and weight.

1. Blood sugar target

At present, the most important indicator reflecting the blood sugar control status in clinical practice is glycated hemoglobin (HbA1c), which represents the average blood sugar level of the patient in the last 3 months. The glycated hemoglobin control target should follow the principle of individualization, and stratified management should be implemented according to factors such as the patient's age, course of disease, health status, and risk of adverse drug reactions. The guidelines recommend that the glycated hemoglobin control target for most non-pregnant adult patients with type 2 diabetes is <7%. For type 2 diabetes patients who are younger, have a shorter course of disease, have a longer life expectancy, have no complications, and do not have cardiovascular disease, a stricter glycated hemoglobin control target, such as <6.5%; for patients who are older, have a longer course of disease, have a history of severe hypoglycemia, have a shorter life expectancy, and have significant microvascular or macrovascular complications or severe complications, a broader control target, such as 7.5% to 8.0%, is required. Of course, glycated hemoglobin is not a panacea. We also need daily self-blood sugar monitoring, that is, monitoring finger blood sugar through a blood glucose meter. The control target for fasting blood sugar is 4.4-7.0mmol/L, and the non-fasting blood sugar target is <10.0mmol/L. Like glycated hemoglobin, the control target for finger blood sugar also needs to be individualized.

2. Blood pressure target

The blood pressure control target for diabetic patients should also be individualized. Generally, for diabetic patients with hypertension, the blood pressure target is <130/80 mmHg. For elderly diabetic patients or those with severe coronary heart disease, a relatively loose blood pressure target can be determined. When the blood pressure level of diabetic patients is >120/80 mmHg, lifestyle intervention should be started to prevent the occurrence of hypertension. When the blood pressure is ≥140/90 mmHg, antihypertensive drug treatment can be considered. When the blood pressure is ≥160/100 mmHg or higher than the target value by 20/10 mmHg, antihypertensive drug treatment should be started immediately, and a combined treatment plan should be applied.

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3. Blood lipid target

Lowering total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels can significantly reduce the risk of macrovascular disease and death in diabetic patients, and is the main goal of lipid-lowering treatment for diabetes. Lowering LDL cholesterol is the primary goal, and LDL cholesterol should be reduced to the target value based on the patient's risk of atherosclerotic cardiovascular disease (ASCVD). For patients at very high risk of atherosclerotic cardiovascular disease, the control target for LDL cholesterol is <1.8mmol/L, and for patients at high risk of atherosclerotic cardiovascular disease, the control target for LDL cholesterol is <2.6mmol/L. Diabetic patients should have their blood lipids (including total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol) checked at least once a year. For those receiving lipid-lowering drug treatment, check the patient's compliance, lifestyle, and blood lipid changes after 4 to 12 weeks. By rechecking blood lipids, understand the patient's response to lipid-lowering drugs and detect adverse drug reactions as early as possible. Repeat once every 3 to 12 months as needed.

4. Weight Management

Patients with type 2 diabetes are often overweight and obese. Obesity is closely related to insulin resistance, which affects blood sugar control in diabetes and further increases the risk of cardiovascular disease in patients with type 2 diabetes. The short-term weight loss goal for overweight and obese diabetic patients is to lose 5% to 10% of body weight within 3 to 6 months. When choosing hypoglycemic drugs, these patients should consider the effect of the drugs on body weight and try to reduce the use of hypoglycemic drugs that increase weight. Some patients may consider using weight loss drugs. Obese adult patients with type 2 diabetes should first adopt lifestyle and drug treatment. For those who fail to lose weight and have poor blood sugar control, metabolic surgery can also be considered.

At present, diabetes is still a long-term chronic incurable disease. With the extension of the course of the disease, the gradual decline of pancreatic islet function and poor blood sugar control, the greatest harm to patients is various complications. In the management of diabetes, the patient's daily behavior and self-management ability are one of the key factors affecting the control of diabetes. For various complications of diabetes, we must keep in mind "early detection and early treatment". If every patient has a correct understanding of the standardized management of diabetes and manages blood sugar scientifically and rationally, they can be like the old professor I mentioned at the beginning, even after 20 years or more of diabetes, they can still maintain a "healthy" state.

References

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