Smooth Insulin Therapy: Prevent Blood Sugar Roller Coasters
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The repeated blood sugar fluctuations like a roller coaster during the "three short and one long" insulin treatment process often become the biggest psychological obstacle for diabetic patients to implement insulin treatment, and are also the main factor affecting the control of blood sugar by diabetic patients. Blood sugar roller coaster-like fluctuations seriously endanger the health of diabetic patients. Usually we use the time within the glucose target range to evaluate the blood sugar fluctuations.
Individualization of blood sugar control targets is the primary measure to avoid blood sugar roller coaster
Individualization of blood sugar control targets is an important progress in the field of diabetes prevention and treatment in recent years. Practice has proved that the formulation of individualized blood sugar control targets for different people can significantly reduce the risk of hypoglycemia in diabetic patients, increase the time within the glucose target range and the control rate of diabetes in diabetic patients, and improve the quality of life of diabetic patients.
In order to avoid the blood sugar roller coaster in the initial stage of insulin treatment, the first measure is to set a feasible individualized blood sugar control target for each diabetic patient according to the condition and specific situation of the diabetic patient.
Most diabetic patients can set the blood sugar control target as fasting blood sugar 4.4~7.0mmol/L and blood sugar 4.4~10.0mmol/L 2 hours after a meal.
Elderly patients with diabetes, especially those with cardiovascular and cerebrovascular complications and poor health, can relax their blood sugar control targets to fasting blood sugar 5.0-8.0mmol/L and 2-hour postprandial blood sugar 5.0-12.0mmol/L.
Young and newly diagnosed diabetic patients who are on short-term intensive insulin therapy, if they do not have risk factors such as cardiovascular and cerebrovascular complications, should set stricter blood sugar control targets in accordance with the goals of short-term intensive insulin therapy: fasting blood sugar 4.4-6.1mmol/L, 2-hour postprandial blood sugar 4.4-7.8mmol/L.
Understand the relationship between insulin and blood sugar - Railway police, each in charge of a section
The insulin or insulin analogs currently used by diabetic patients are basically artificially synthesized using molecular biology technology, so they are all called exogenous insulin (analogs). According to the length of time these exogenous insulins (analogs) play a hypoglycemic effect in the human body, they can be divided into long-acting basal insulin, short-acting recombinant human insulin, rapid-acting insulin analogs and premixed insulin (analogs).
Under normal circumstances, the ability of different insulin preparations to control blood sugar in different periods of time is quite similar to the dispatcher's dispatch of trains coming and going on the railway - the dispatcher at each station only manages and dispatches the trains running on the section of the railway under his/her charge, that is, the railway police, each in charge of a section.
In fact, during insulin treatment, when various insulins are used to regulate blood sugar at different time periods throughout the day, the relationship between insulin and blood sugar is "trains enter the station, each in charge of a section", and each insulin is only in charge of the blood sugar in that time period within its own pharmacokinetic range.
For example: the short/fast-acting insulin (analog) injected before breakfast is only responsible for controlling blood sugar in the morning, the insulin (analog) injected before lunch is only responsible for controlling blood sugar from lunch to dinner, the short/fast-acting insulin injected before dinner is only responsible for controlling blood sugar from dinner to bedtime, and the basal insulin injected before bedtime is responsible for controlling basal blood sugar and fasting blood sugar throughout the day.
Therefore, during insulin therapy, the dose of insulin (analogs) injected before breakfast can be adjusted according to the blood sugar level before lunch and 2 hours after breakfast; the dose of insulin (analogs) before lunch can be adjusted according to the blood sugar level before dinner and 2 hours after lunch; the dose of insulin before dinner can be adjusted according to the blood sugar level before bedtime (10 pm), and the dose of basal insulin can be adjusted according to the fasting blood sugar level.
Master the pharmacokinetics of different types of insulin (analogs)
Since the discovery of the first insulin in January 1922, bovine pancreatic extract, which was successfully used to treat type 1 diabetes, insulin has ushered in a new era of human health and diabetes treatment. Over the past 100 years, insulin preparations have developed from the initial animal pancreatic extract to purified animal insulin. In the late 1980s, transgenic biosynthesized human insulin was developed. In recent years, a series of insulin analogs and various long-acting basal insulins have been widely used in clinical practice, and human understanding and application of insulin have developed rapidly.
Insulin therapy is only a supplement or replacement for the physiological insulin secretion deficiency of diabetic patients. If there is a cure for diabetes, before this technology is discovered and widely promoted, insulin therapy is still the core treatment for many diabetic patients, especially for high blood sugar that is difficult to control with oral medication. Therefore, it is very necessary for both diabetic doctors and diabetic patients to understand and master the pharmacokinetic knowledge of various insulin preparations, such as the onset time, peak time, and action time.
When choosing the "three short and one long" insulin treatment plan, it is necessary to choose the appropriate insulin (insulin analogue) according to the pharmacokinetic characteristics of different insulin preparations, the needs of treatment, the convenience of drug sources, the safety of treatment, and one's own economic conditions, so as to avoid the roller coaster of blood sugar and achieve safe blood sugar standards.
In the process of adjusting insulin, the patient's diet and exercise need to be regular and quantitative. It is also necessary to strengthen blood sugar monitoring, such as monitoring blood sugar throughout the day for 1 to 2 days a week, that is, blood sugar before three meals, 2 hours after three meals, and before bedtime. Adjust insulin according to blood sugar conditions. If fasting blood sugar is greater than 10.0mmol/L, postprandial blood sugar is greater than 13.0mmol/L or even greater than 15.0mmol/L, it is necessary to adjust basal insulin and pre-meal insulin at the same time.
Close cooperation and mutual trust between doctors and patients are essential.
The first step is to determine the initial treatment plan and give priority to adjusting fasting blood sugar.
When starting the "three short and one long" insulin treatment, the initial treatment plan must be determined first. First, calculate the starting dose of basal insulin at 0.2 units per kilogram of body weight, and use 4 units of short-acting (rapid-acting) insulin (insulin analogs) before three meals as the starting treatment dose before meals. If the patient is obese or has high blood sugar (glycosylated hemoglobin greater than 9.0%, fasting blood sugar greater than 10.0mmol/L), the pre-meal short-acting insulin can be set at 6 to 8 units.
After observing the initial treatment plan for 2 to 3 days, if the fasting blood sugar is still high and has not reached the standard, it is necessary to adjust the basal insulin first according to the different individualized blood sugar control goals set by different patients, and give priority to achieving the fasting blood sugar standard.
After the fasting blood sugar reaches the standard, adjust the dose of short-acting (rapid-acting) insulin (analogs) in the corresponding period according to the blood sugar monitoring results of other periods to achieve the blood sugar standard in other periods.
For young newly diagnosed diabetic patients or non-elderly diabetic patients without cardiovascular and cerebrovascular complications, the dose of basal insulin can be adjusted according to the fasting blood glucose value according to the table below, and adjusted every 2 to 3 days until the fasting blood glucose reaches the target.
For general diabetic patients, elderly diabetic patients and diabetic patients with cardiovascular and cerebrovascular diseases, the following method is better for adjusting the dose of basal insulin.
Pre-set the fasting blood glucose target value for individualized blood glucose control of such diabetic patients, and adjust it according to the difference between the actual fasting blood glucose value monitored after 3 days of treatment with the initial treatment plan.
For example, fasting blood glucose is monitored after 3 days of initial treatment. For every 1.4mmol/L of fasting blood glucose monitored, 1 unit of basal insulin is added; if it is lower than the target value, 2 units of basal insulin are reduced.
For example, the fasting blood glucose target value of an elderly diabetic patient with cerebrovascular disease is set to 8.0mmol/L. The initial treatment plan for this elderly diabetic patient is 12 units of basal insulin/day, 4 units of short-acting insulin are injected before three meals, and the fasting blood glucose monitored after 3 days of treatment is 9.5mmol/L.
Through calculation, we know that the difference between the actual monitored fasting blood sugar and the target blood sugar is 1.5mmol/L. At this time, the dose of basal insulin can be adjusted from the original 12 units to 13-14 units. After adjusting the treatment, observe for a few days, and then make further adjustments according to the changes in fasting blood sugar until the fasting blood sugar reaches the standard.
In the process of adjusting basal insulin and fasting blood sugar, if the blood sugar at lunch, dinner or before bed is lower than normal or hypoglycemia occurs, the dose of the corresponding breakfast, lunch or dinner insulin (meal insulin analog) should be reduced by 2 units for observation. If there are no other special circumstances, the dose of basal insulin is generally not reduced or increased, and the adjustment of basal insulin dose is generally not affected by blood sugar at other times.
It should be noted that before fasting blood sugar reaches the standard, do not rush to control blood sugar at other times such as before lunch, before dinner, and before bed. This refers to the case where the patient's blood sugar after three meals and before bed is not too high. If the blood sugar after meals and/or before bed is very high, such as higher than 13.0mmol/L, the insulin before meals should still be adjusted at the same time. Otherwise, there is a risk of hyperglycemia, and patients are often anxious and unwilling to accept a treatment plan that simply adjusts basal insulin.
It should be noted that if there is insufficient experience, in order to achieve the target blood sugar before lunch, dinner, and bedtime, the treatment dose of insulin before meals is frequently increased and adjusted before fasting blood sugar is adjusted to meet the target, which often or repeatedly leads to blood sugar fluctuations.
The second step is to adjust the blood sugar before lunch, dinner, and bedtime after the fasting blood sugar is basically reached.
After completing the adjustment of fasting blood sugar to meet the target through the first step, the next step is to adjust the corresponding dose of short-acting insulin before breakfast, before lunch, and before dinner (mealtime insulin analogs) according to the blood sugar monitoring results before lunch, before dinner, and before bedtime.
When adjusting the pre-meal insulin dose, refer to the individualized blood sugar control target value for each diabetic patient.
For every 2.0mmol/L of blood sugar above the target value, increase the dose by 1 unit. If the pre-meal blood sugar is lower than the target value, reduce it by 2 units each time, and adjust it once every 3 days or so to achieve the target blood sugar before meals and before bedtime.
Newly diagnosed young diabetic patients or diabetic patients without cardiovascular and cerebrovascular diseases can also refer to the table below to adjust their postprandial blood sugar, and adjust it every 2 to 4 days until the blood sugar before three meals reaches the standard.
Step 3: Adjust blood sugar 2 hours after meal
After adjusting in the first and second steps, after the blood sugar before three meals and before bedtime reaches the standard, do not rush to adjust the postprandial blood sugar.
In most cases, with the release of stress, the disappearance of high sugar toxicity and high fat toxicity, and the reduction of insulin resistance during continued treatment, the postprandial blood sugar of most patients will gradually reach the standard during continued treatment.
A small number of diabetic patients whose postprandial blood sugar does not reach the standard can choose the following measures to observe according to the situation to achieve the purpose of adjusting postprandial blood sugar: choose foods with low glycemic index; moderately delay the time from injection to meal, and appropriately extend the meal time for observation; increase 2 units of pre-meal/meal insulin (analogs) for observation; take acarbose, voglibose, miglitol, etc. that can delay carbohydrate absorption during meals for observation.
Adjusting insulin according to postprandial blood sugar can easily cause large blood sugar fluctuations
The endocrine system of newly diagnosed severe diabetic patients and diabetic patients with poor blood sugar control is in a state of serious disorder. Metabolic disorders such as hyperglycemia, hyperlipidemia, and hyperinsulinemia seriously affect the pancreatic function of patients, resulting in reduced insulin secretion and delayed insulin secretion in the body, increased glucagon secretion, and a disordered state in which the blood sugar level is high and fluctuates 2 hours after a meal, and the difference between pre-meal and post-meal blood sugar is large.
In the initial stage of insulin treatment, if the pre-meal exogenous insulin dose is increased in large doses according to the falsely high blood sugar level 2 hours after a meal, the supplemented exogenous insulin is superimposed on the delayed endogenous insulin secretion in the body, which can easily lead to pre-meal hypoglycemia of the next meal.
Recurrent post-meal hyperglycemia and pre-meal hypoglycemia caused by improper handling of the insulin treatment dosage period are common causes of blood sugar roller coaster-like fluctuations when using insulin treatment.
After insulin treatment, blood sugar is stabilized in the normal range for a period of time, and the endocrine disorder in the body of diabetic patients is basically corrected, endogenous insulin secretion is delayed, glucagon is significantly improved, and even the biphasic secretion of insulin is fully or partially restored. At this time, the insulin dose is adjusted according to the blood sugar 2 hours after the meal, and the blood sugar fluctuation will definitely not be so large.
Timely identification and treatment of hypoglycemia, improve the time of glucose in the target range (TIR)
The terrible scene of sudden hypoglycemia is the main reason for many diabetic patients to have psychological resistance when considering accepting insulin treatment. The repeated roller coaster-like fluctuations of blood sugar during insulin treatment often become the biggest psychological obstacle for diabetic patients and diabetic doctors who implement insulin treatment, and are also the main factors affecting diabetic patients to control blood sugar. Therefore, timely identification and treatment of hypoglycemia during insulin treatment is particularly important for improving the time of glucose in the target range (also known as the proportion of time to reach the target, which refers to the percentage and time of glucose readings between 3.9 and 10.0 mmol/L), blood sugar reaching the target rate and quality of life of diabetic patients.
The clinical manifestations of hypoglycemia are varied. In addition to common symptoms such as palpitations, sweating, hand tremors, dizziness, fatigue, weakness, impaired consciousness, and coma, if diabetics have sudden, difficult-to-explain symptoms or strange abnormal behaviors (such as chattering and unstoppable storytelling, repeated extremely exaggerated facial expressions, etc.), they must be alert, as hypoglycemia may have occurred.
When hypoglycemia is suspected, the patient's blood sugar should be measured in time. If the blood sugar is lower than 3.9mmol/L, the diagnosis of hypoglycemia is clear, and the following measures should be taken immediately for treatment. For patients with hypoglycemia who are conscious, 15 to 30 grams of sugar food (preferably glucose) or starchy food should be quickly given.
For patients with hypoglycemia and impaired consciousness, 60 ml of 50% glucose solution should be injected intravenously or 1 mg of glucagon should be injected intramuscularly immediately; establish an intravenous channel for intravenous drip of 5% glucose injection solution to maintain, re-measure fingertip blood sugar after 15 minutes, and repeat the injection of 60 ml of 50% glucose solution if necessary until the blood sugar is greater than 3.9mmol/L. Patients who use insulin pump therapy should suspend the insulin pump, check whether the insulin pump is working properly, whether the program is set correctly, check the time of insulin infusion, basic infusion rate, pre-meal large dose, and daily total amount; check the status screen and medicine reservoir. If the amount of insulin in the medicine reservoir is less than the amount displayed on the status screen, the insulin pump may be over-infused.
Adjusting insulin is a technical job
In recent years, the discovery of glucagon analog-1 and its application in the field of diabetes treatment have opened up new targets for diabetes treatment. The multiple benefits shown by glucagon-like peptide-1 receptor agonists in diabetes treatment have innovatively opened up new directions for diabetes treatment.
At present, in China, insulin treatment is still one of the main methods for controlling blood sugar and the most effective method for controlling severe hyperglycemia. In recent years, the three-short and one-long insulin treatment plan has gradually becomeIt is the main method for primary hospitals to quickly reduce the hyperglycemia toxicity of diabetic patients and increase the time of glucose in the target range and the blood sugar reaching the standard rate.
Although it is not recommended for diabetic patients to adjust the insulin dose at home, in real life, due to various reasons, some diabetic patients who have mastered certain diabetes knowledge can adjust the insulin dose at home under the guidance of doctors.
It must be remembered that adjusting insulin is a technical job, and the treatment process of insulin is always accompanied by the risk of hypoglycemia.
In order to avoid the roller coaster-like fluctuations of blood sugar during the treatment of three short and one long insulin and reduce the risk of hypoglycemia in patients, doctors and diabetic patients receiving three short and one long insulin treatment must understand, learn and master some relevant knowledge. Patients receiving the three short and one long insulin treatment plan should not only eat and exercise regularly, maintain a good attitude, actively cooperate with doctors, and regularly monitor blood sugar at various time points during the treatment process, but also doctors and patients who implement the treatment plan should understand the relevant pharmacokinetics of various insulin preparations used.
Before starting insulin treatment, the target value of blood sugar control should be determined scientifically and individually. When adjusting insulin, the relationship between insulin and blood sugar should be followed. According to the three-step method mentioned above, fasting blood sugar, pre-meal blood sugar and post-meal blood sugar should be adjusted in three steps. During the treatment of three short and one long insulin, the symptoms of hypoglycemia should be identified and treated in time.
Only by mastering the technology of adjusting insulin can the confidence of diabetic patients in accepting insulin treatment be improved, and the blood sugar fluctuations like a roller coaster can be avoided during the treatment of three short and one long insulin, so as to ensure the effectiveness and safety of insulin treatment.
Individualization of blood sugar control targets is the primary measure to avoid blood sugar roller coaster
Individualization of blood sugar control targets is an important progress in the field of diabetes prevention and treatment in recent years. Practice has proved that the formulation of individualized blood sugar control targets for different people can significantly reduce the risk of hypoglycemia in diabetic patients, increase the time within the glucose target range and the control rate of diabetes in diabetic patients, and improve the quality of life of diabetic patients.
In order to avoid the blood sugar roller coaster in the initial stage of insulin treatment, the first measure is to set a feasible individualized blood sugar control target for each diabetic patient according to the condition and specific situation of the diabetic patient.
Most diabetic patients can set the blood sugar control target as fasting blood sugar 4.4~7.0mmol/L and blood sugar 4.4~10.0mmol/L 2 hours after a meal.
Elderly patients with diabetes, especially those with cardiovascular and cerebrovascular complications and poor health, can relax their blood sugar control targets to fasting blood sugar 5.0-8.0mmol/L and 2-hour postprandial blood sugar 5.0-12.0mmol/L.
Young and newly diagnosed diabetic patients who are on short-term intensive insulin therapy, if they do not have risk factors such as cardiovascular and cerebrovascular complications, should set stricter blood sugar control targets in accordance with the goals of short-term intensive insulin therapy: fasting blood sugar 4.4-6.1mmol/L, 2-hour postprandial blood sugar 4.4-7.8mmol/L.
Understand the relationship between insulin and blood sugar - Railway police, each in charge of a section
The insulin or insulin analogs currently used by diabetic patients are basically artificially synthesized using molecular biology technology, so they are all called exogenous insulin (analogs). According to the length of time these exogenous insulins (analogs) play a hypoglycemic effect in the human body, they can be divided into long-acting basal insulin, short-acting recombinant human insulin, rapid-acting insulin analogs and premixed insulin (analogs).
Under normal circumstances, the ability of different insulin preparations to control blood sugar in different periods of time is quite similar to the dispatcher's dispatch of trains coming and going on the railway - the dispatcher at each station only manages and dispatches the trains running on the section of the railway under his/her charge, that is, the railway police, each in charge of a section.
In fact, during insulin treatment, when various insulins are used to regulate blood sugar at different time periods throughout the day, the relationship between insulin and blood sugar is "trains enter the station, each in charge of a section", and each insulin is only in charge of the blood sugar in that time period within its own pharmacokinetic range.
For example: the short/fast-acting insulin (analog) injected before breakfast is only responsible for controlling blood sugar in the morning, the insulin (analog) injected before lunch is only responsible for controlling blood sugar from lunch to dinner, the short/fast-acting insulin injected before dinner is only responsible for controlling blood sugar from dinner to bedtime, and the basal insulin injected before bedtime is responsible for controlling basal blood sugar and fasting blood sugar throughout the day.
Therefore, during insulin therapy, the dose of insulin (analogs) injected before breakfast can be adjusted according to the blood sugar level before lunch and 2 hours after breakfast; the dose of insulin (analogs) before lunch can be adjusted according to the blood sugar level before dinner and 2 hours after lunch; the dose of insulin before dinner can be adjusted according to the blood sugar level before bedtime (10 pm), and the dose of basal insulin can be adjusted according to the fasting blood sugar level.
Master the pharmacokinetics of different types of insulin (analogs)
Since the discovery of the first insulin in January 1922, bovine pancreatic extract, which was successfully used to treat type 1 diabetes, insulin has ushered in a new era of human health and diabetes treatment. Over the past 100 years, insulin preparations have developed from the initial animal pancreatic extract to purified animal insulin. In the late 1980s, transgenic biosynthesized human insulin was developed. In recent years, a series of insulin analogs and various long-acting basal insulins have been widely used in clinical practice, and human understanding and application of insulin have developed rapidly.
Insulin therapy is only a supplement or replacement for the physiological insulin secretion deficiency of diabetic patients. If there is a cure for diabetes, before this technology is discovered and widely promoted, insulin therapy is still the core treatment for many diabetic patients, especially for high blood sugar that is difficult to control with oral medication. Therefore, it is very necessary for both diabetic doctors and diabetic patients to understand and master the pharmacokinetic knowledge of various insulin preparations, such as the onset time, peak time, and action time.
When choosing the "three short and one long" insulin treatment plan, it is necessary to choose the appropriate insulin (insulin analogue) according to the pharmacokinetic characteristics of different insulin preparations, the needs of treatment, the convenience of drug sources, the safety of treatment, and one's own economic conditions, so as to avoid the roller coaster of blood sugar and achieve safe blood sugar standards.
In the process of adjusting insulin, the patient's diet and exercise need to be regular and quantitative. It is also necessary to strengthen blood sugar monitoring, such as monitoring blood sugar throughout the day for 1 to 2 days a week, that is, blood sugar before three meals, 2 hours after three meals, and before bedtime. Adjust insulin according to blood sugar conditions. If fasting blood sugar is greater than 10.0mmol/L, postprandial blood sugar is greater than 13.0mmol/L or even greater than 15.0mmol/L, it is necessary to adjust basal insulin and pre-meal insulin at the same time.
Close cooperation and mutual trust between doctors and patients are essential.
The first step is to determine the initial treatment plan and give priority to adjusting fasting blood sugar.
When starting the "three short and one long" insulin treatment, the initial treatment plan must be determined first. First, calculate the starting dose of basal insulin at 0.2 units per kilogram of body weight, and use 4 units of short-acting (rapid-acting) insulin (insulin analogs) before three meals as the starting treatment dose before meals. If the patient is obese or has high blood sugar (glycosylated hemoglobin greater than 9.0%, fasting blood sugar greater than 10.0mmol/L), the pre-meal short-acting insulin can be set at 6 to 8 units.
After observing the initial treatment plan for 2 to 3 days, if the fasting blood sugar is still high and has not reached the standard, it is necessary to adjust the basal insulin first according to the different individualized blood sugar control goals set by different patients, and give priority to achieving the fasting blood sugar standard.
After the fasting blood sugar reaches the standard, adjust the dose of short-acting (rapid-acting) insulin (analogs) in the corresponding period according to the blood sugar monitoring results of other periods to achieve the blood sugar standard in other periods.
For young newly diagnosed diabetic patients or non-elderly diabetic patients without cardiovascular and cerebrovascular complications, the dose of basal insulin can be adjusted according to the fasting blood glucose value according to the table below, and adjusted every 2 to 3 days until the fasting blood glucose reaches the target.
For general diabetic patients, elderly diabetic patients and diabetic patients with cardiovascular and cerebrovascular diseases, the following method is better for adjusting the dose of basal insulin.
Pre-set the fasting blood glucose target value for individualized blood glucose control of such diabetic patients, and adjust it according to the difference between the actual fasting blood glucose value monitored after 3 days of treatment with the initial treatment plan.
For example, fasting blood glucose is monitored after 3 days of initial treatment. For every 1.4mmol/L of fasting blood glucose monitored, 1 unit of basal insulin is added; if it is lower than the target value, 2 units of basal insulin are reduced.
For example, the fasting blood glucose target value of an elderly diabetic patient with cerebrovascular disease is set to 8.0mmol/L. The initial treatment plan for this elderly diabetic patient is 12 units of basal insulin/day, 4 units of short-acting insulin are injected before three meals, and the fasting blood glucose monitored after 3 days of treatment is 9.5mmol/L.
Through calculation, we know that the difference between the actual monitored fasting blood sugar and the target blood sugar is 1.5mmol/L. At this time, the dose of basal insulin can be adjusted from the original 12 units to 13-14 units. After adjusting the treatment, observe for a few days, and then make further adjustments according to the changes in fasting blood sugar until the fasting blood sugar reaches the standard.
In the process of adjusting basal insulin and fasting blood sugar, if the blood sugar at lunch, dinner or before bed is lower than normal or hypoglycemia occurs, the dose of the corresponding breakfast, lunch or dinner insulin (meal insulin analog) should be reduced by 2 units for observation. If there are no other special circumstances, the dose of basal insulin is generally not reduced or increased, and the adjustment of basal insulin dose is generally not affected by blood sugar at other times.
It should be noted that before fasting blood sugar reaches the standard, do not rush to control blood sugar at other times such as before lunch, before dinner, and before bed. This refers to the case where the patient's blood sugar after three meals and before bed is not too high. If the blood sugar after meals and/or before bed is very high, such as higher than 13.0mmol/L, the insulin before meals should still be adjusted at the same time. Otherwise, there is a risk of hyperglycemia, and patients are often anxious and unwilling to accept a treatment plan that simply adjusts basal insulin.
It should be noted that if there is insufficient experience, in order to achieve the target blood sugar before lunch, dinner, and bedtime, the treatment dose of insulin before meals is frequently increased and adjusted before fasting blood sugar is adjusted to meet the target, which often or repeatedly leads to blood sugar fluctuations.
The second step is to adjust the blood sugar before lunch, dinner, and bedtime after the fasting blood sugar is basically reached.
After completing the adjustment of fasting blood sugar to meet the target through the first step, the next step is to adjust the corresponding dose of short-acting insulin before breakfast, before lunch, and before dinner (mealtime insulin analogs) according to the blood sugar monitoring results before lunch, before dinner, and before bedtime.
When adjusting the pre-meal insulin dose, refer to the individualized blood sugar control target value for each diabetic patient.
For every 2.0mmol/L of blood sugar above the target value, increase the dose by 1 unit. If the pre-meal blood sugar is lower than the target value, reduce it by 2 units each time, and adjust it once every 3 days or so to achieve the target blood sugar before meals and before bedtime.
Newly diagnosed young diabetic patients or diabetic patients without cardiovascular and cerebrovascular diseases can also refer to the table below to adjust their postprandial blood sugar, and adjust it every 2 to 4 days until the blood sugar before three meals reaches the standard.
Step 3: Adjust blood sugar 2 hours after meal
After adjusting in the first and second steps, after the blood sugar before three meals and before bedtime reaches the standard, do not rush to adjust the postprandial blood sugar.
In most cases, with the release of stress, the disappearance of high sugar toxicity and high fat toxicity, and the reduction of insulin resistance during continued treatment, the postprandial blood sugar of most patients will gradually reach the standard during continued treatment.
A small number of diabetic patients whose postprandial blood sugar does not reach the standard can choose the following measures to observe according to the situation to achieve the purpose of adjusting postprandial blood sugar: choose foods with low glycemic index; moderately delay the time from injection to meal, and appropriately extend the meal time for observation; increase 2 units of pre-meal/meal insulin (analogs) for observation; take acarbose, voglibose, miglitol, etc. that can delay carbohydrate absorption during meals for observation.
Adjusting insulin according to postprandial blood sugar can easily cause large blood sugar fluctuations
The endocrine system of newly diagnosed severe diabetic patients and diabetic patients with poor blood sugar control is in a state of serious disorder. Metabolic disorders such as hyperglycemia, hyperlipidemia, and hyperinsulinemia seriously affect the pancreatic function of patients, resulting in reduced insulin secretion and delayed insulin secretion in the body, increased glucagon secretion, and a disordered state in which the blood sugar level is high and fluctuates 2 hours after a meal, and the difference between pre-meal and post-meal blood sugar is large.
In the initial stage of insulin treatment, if the pre-meal exogenous insulin dose is increased in large doses according to the falsely high blood sugar level 2 hours after a meal, the supplemented exogenous insulin is superimposed on the delayed endogenous insulin secretion in the body, which can easily lead to pre-meal hypoglycemia of the next meal.
Recurrent post-meal hyperglycemia and pre-meal hypoglycemia caused by improper handling of the insulin treatment dosage period are common causes of blood sugar roller coaster-like fluctuations when using insulin treatment.
After insulin treatment, blood sugar is stabilized in the normal range for a period of time, and the endocrine disorder in the body of diabetic patients is basically corrected, endogenous insulin secretion is delayed, glucagon is significantly improved, and even the biphasic secretion of insulin is fully or partially restored. At this time, the insulin dose is adjusted according to the blood sugar 2 hours after the meal, and the blood sugar fluctuation will definitely not be so large.
Timely identification and treatment of hypoglycemia, improve the time of glucose in the target range (TIR)
The terrible scene of sudden hypoglycemia is the main reason for many diabetic patients to have psychological resistance when considering accepting insulin treatment. The repeated roller coaster-like fluctuations of blood sugar during insulin treatment often become the biggest psychological obstacle for diabetic patients and diabetic doctors who implement insulin treatment, and are also the main factors affecting diabetic patients to control blood sugar. Therefore, timely identification and treatment of hypoglycemia during insulin treatment is particularly important for improving the time of glucose in the target range (also known as the proportion of time to reach the target, which refers to the percentage and time of glucose readings between 3.9 and 10.0 mmol/L), blood sugar reaching the target rate and quality of life of diabetic patients.
The clinical manifestations of hypoglycemia are varied. In addition to common symptoms such as palpitations, sweating, hand tremors, dizziness, fatigue, weakness, impaired consciousness, and coma, if diabetics have sudden, difficult-to-explain symptoms or strange abnormal behaviors (such as chattering and unstoppable storytelling, repeated extremely exaggerated facial expressions, etc.), they must be alert, as hypoglycemia may have occurred.
When hypoglycemia is suspected, the patient's blood sugar should be measured in time. If the blood sugar is lower than 3.9mmol/L, the diagnosis of hypoglycemia is clear, and the following measures should be taken immediately for treatment. For patients with hypoglycemia who are conscious, 15 to 30 grams of sugar food (preferably glucose) or starchy food should be quickly given.
For patients with hypoglycemia and impaired consciousness, 60 ml of 50% glucose solution should be injected intravenously or 1 mg of glucagon should be injected intramuscularly immediately; establish an intravenous channel for intravenous drip of 5% glucose injection solution to maintain, re-measure fingertip blood sugar after 15 minutes, and repeat the injection of 60 ml of 50% glucose solution if necessary until the blood sugar is greater than 3.9mmol/L. Patients who use insulin pump therapy should suspend the insulin pump, check whether the insulin pump is working properly, whether the program is set correctly, check the time of insulin infusion, basic infusion rate, pre-meal large dose, and daily total amount; check the status screen and medicine reservoir. If the amount of insulin in the medicine reservoir is less than the amount displayed on the status screen, the insulin pump may be over-infused.
Adjusting insulin is a technical job
In recent years, the discovery of glucagon analog-1 and its application in the field of diabetes treatment have opened up new targets for diabetes treatment. The multiple benefits shown by glucagon-like peptide-1 receptor agonists in diabetes treatment have innovatively opened up new directions for diabetes treatment.
At present, in China, insulin treatment is still one of the main methods for controlling blood sugar and the most effective method for controlling severe hyperglycemia. In recent years, the three-short and one-long insulin treatment plan has gradually becomeIt is the main method for primary hospitals to quickly reduce the hyperglycemia toxicity of diabetic patients and increase the time of glucose in the target range and the blood sugar reaching the standard rate.
Although it is not recommended for diabetic patients to adjust the insulin dose at home, in real life, due to various reasons, some diabetic patients who have mastered certain diabetes knowledge can adjust the insulin dose at home under the guidance of doctors.
It must be remembered that adjusting insulin is a technical job, and the treatment process of insulin is always accompanied by the risk of hypoglycemia.
In order to avoid the roller coaster-like fluctuations of blood sugar during the treatment of three short and one long insulin and reduce the risk of hypoglycemia in patients, doctors and diabetic patients receiving three short and one long insulin treatment must understand, learn and master some relevant knowledge. Patients receiving the three short and one long insulin treatment plan should not only eat and exercise regularly, maintain a good attitude, actively cooperate with doctors, and regularly monitor blood sugar at various time points during the treatment process, but also doctors and patients who implement the treatment plan should understand the relevant pharmacokinetics of various insulin preparations used.
Before starting insulin treatment, the target value of blood sugar control should be determined scientifically and individually. When adjusting insulin, the relationship between insulin and blood sugar should be followed. According to the three-step method mentioned above, fasting blood sugar, pre-meal blood sugar and post-meal blood sugar should be adjusted in three steps. During the treatment of three short and one long insulin, the symptoms of hypoglycemia should be identified and treated in time.
Only by mastering the technology of adjusting insulin can the confidence of diabetic patients in accepting insulin treatment be improved, and the blood sugar fluctuations like a roller coaster can be avoided during the treatment of three short and one long insulin, so as to ensure the effectiveness and safety of insulin treatment.