Diabetes should be treated?

(A) treatment

The main objective of diabetes treatment, including: correcting metabolic disorders, elimination of symptoms, to protect (children with) normal growth and development, maintain good study, life and work capacity; the prevention of acute or chronic complications and associated disorders Fasheng, prolonging life to reduce morbidity and mortality. While access to these purposes and should not be too many restrictions on the quality of life of patients. The principles of diabetes treatment: sustained, integrated management. Treatment of diabetes includes not only high blood glucose control, still need the same time for some complications (such as hypertension, dyslipidemia, etc.) and comprehensive treatment of various complications. The treatment of high blood sugar diabetes typically include rational use of diabetes education, diet therapy, exercise therapy, drug treatment and self-monitoring and other means to control glucose metabolism as much as possible so that normal or near normal. Good blood glucose control: fasting blood glucose <6.0mmol / L, postprandial 2h plasma glucose <8.0mmoL / L, HbA1c <7.0% or 6.5%; better blood glucose control: fasting blood glucose 6 ~ 8mmol / L, postprandial 2h plasma glucose 8 ~ 10mmol / L, HbA1c <9.0%; more than the value of poor blood sugar control.

(B) the prognosis

1. Diabetes is a good still no cure but can control the disease, make good use of current therapies, most patients can be as normal as life and work.

2. Diabetes can lead to serious complications, these complications, patients can lose their labor, or even cause death. Some of these complications can be avoided, some can be cured, some can be improved, some development has been slow. Complications, development, and the seriousness of the consequences or not, directly or indirectly related to diabetes control results.

3. Many diabetic patients do not have any symptoms, many patients with diabetes was discovered already have the complications of diabetes.

4. And the development of diabetic complications and high blood sugar than the outside, but also with other factors such as hypertension, hyperlipidemia, obesity, too small to participate in physical activity, diet, genetics. Among these factors, some can control, some can be partially controlled, while others can not control. Control of risk factors for diabetes is very important.

Although in recent years, genetic problems, viral infections, autoimmune and insulin-antagonistic hormones and many other etiological research on the issue, but so far still lack causes treatment measures, cyclosporin A (cyclosporin A) only a small number of cases of early-type Ⅰ effective, islet transplantation and pancreas transplantation only achieved initial success, artificial pancreas (insulin pump), although able to better metabolic control, but still lack long-term prevention of chronic complications of reliable data. Therefore, the clinical aim of treatment for patients with emphasis on strict control of metabolism in disordered, particularly hyperglycemia, correct the coexistence of obesity and high blood pressure disease, and to promote β-cell function, and pregnancy to ensure normal growth and development process, prevent complications, improve quality of life.

93 years since the United States multi-center clinical study Diabetes Control and Complications (DCCT), published since, strictly control high blood sugar can significantly reduce a variety of chronic morbidity in 50% to 70%, has been accepted by national diabetes medical staff no longer suspect .

Specific control measures are as follows:

(A) publicity and education as more than about half of patients with early and asymptomatic or mild symptoms, often can not receive timely diagnosis and prevention, which we must vigorously promote diabetes education to patients about diabetes has been confirmed and become familiar with diet, exercise, drug and urine sugar, blood glucose monitoring and other basic measures of the comprehensive treatment principles, with the medical staff to improve quality control; to> 50-year-old objects, especially the aforementioned high-risk target, once per year 2-hour postprandial blood glucose Shaixuan inspection, so that asymptomatic patients diagnosed as early as possible and do more prevention.

Still need to include educational content in the long-standing importance of diet therapy, urine and blood glucose meter test method, you must pay attention to insulin treatment, should also learn to sterile injection, low blood sugar reactions and initial processing.

Education can be used to open classes, seminars, watching slides, video tapes, movies or even individual technology talk.

(B) appropriate diet diet therapy can reduce the burden of β cells, for older or less body fat and asymptomatic cases of symptoms of light, especially when fasting and postprandial plasma insulin does not lower, often as the main treatment of this disease therapy. For severe or juvenile (Ⅰ Type), or brittle type patients, with the exception of drug treatment, but also should strictly control the diet. Diet must contain sufficient materials and proper nutrition of sugar, protein and fat ratio. According to the specific needs of patients and living habits are estimated as follows:

1. According to patient age, sex, height standard weight derived from Table 2.

Or application of a simple formula calculates standard body:

Standard weight (kg) = height (cm) -105

2. According to the standard weight and nature of work, estimated total daily calories needed: a break for a day calorie per kilogram of body weight 0.1 ~ 0.13MJ (25 ~ 30kcal), light manual 0.13 ~ 0.15MJ (30 ~ 35kcal), moderate manual 0.15 ~ 0.17MJ (35 ~ 40kcal), heavy manual workers 0.17MJ (40kcal) above. Children (0 to 4 years old, the daily per kilogram of body weight 0.2MJ (50kcal), pregnant women, nursing mothers, malnourished and wasting disease should increase, as appropriate, obesity reduce it (could be reduced to a daily 5MJ (1200kcal) by mw ), weight loss of patients to the normal standard of 5% or less, often can be satisfied with control of the disease.

3. Food, sugar, protein, fat distribution ratio (by calorimetry)

⑴ protein per kg per day according to the standard adult body weight 0.8 ~ 1.2g (average 1.0g) basis, approximately 15% of total calories to 20%. Pregnant and lactating women, malnourished and with wasting disease can Zhuojia to 1.5g or so, as required.

⑵ subtract from the total calories for protein calories as the sugar and fat calories, fat mass, according to signs, blood lipid level and dietary habits need to be, the daily per kg standard body weight of about 0.6 ~ 1.0g, 30 total heat % ~ 35%. The rest is carbohydrate, 50% of total calories to 65%. By our people's living habits, amount of common staple foods (carbohydrates) 250 ~ 400g / d, diabetes can eat 200 ~ 350g or more, fat is about 40 ~ 60g. Such as obese patients, especially those who have blood lipoprotein levels, coronary heart disease or atherosclerosis such as those fat intake should be appropriately controlled 30% of total calories. Such as high cholesterol or high blood hyperlipoproteinemia type Ⅱ, daily cholesterol intake should be less than 300mg, such as triglycerides are too high or hyperlipoproteinemia type Ⅳ who are advised to limit calories and sugar and fat intake. If chylomicrons hyperlipidemia persons (Ⅴ, Ⅰ type) should preferably limit on the total calorie and fat intake. To slow down to a normal standard weight of 5% down. The use of suitable fat to unsaturated fatty acids. Resting patient first d staple 200 ~ 250g (rice or pasta), light manual 250 ~ 300g, the manual 300 ~ 400g, weight 400 ~ 500g or more manual workers.

4. Calorie meals distribution of heat distribution is approximately 1 / 5 2 / 5, 2 / 5, or divided into four meals, 1 / 7, 2 / 7, 2 / 7, 2 / 7, according to the patients lifestyle and disease controls to adjust, such as drug use or the brink of hunger after the hypoglycemic condition who can eat or reduce the dose slightly.

5. Follow-up, adjust the long-term treatment Cheng Zhongyi according to urine, blood glucose, HbA1c, body weight and symptoms of specific disease control efficacy of follow-up observation, and adjust food intake according to specific circumstances. To restrict food intake by the obese body weight gradually declined the last organization to restore the sensitivity to insulin may decrease blood glucose and blood lipid, so the obese patients with type Ⅱ diet often more effective therapies, often without drug treatment can control blood sugar. Thin patients can be followed up under the weight, etc. in the appropriate increase in food intake.

6. Crude fiber diet can slow down the absorption of sugar, reduce blood sugar lipids. Foreign use of Guar, pectin (Pectin), etc., the domestic trials of marine plants, corn stalk leaves, initial results. And can be constipation, relieve constipation. Major components of common foods is shown in table 3.

Table 2, the main ingredient commonly used in food table

Food sugar (g/100g) Protein (g/100g) fat (g/100g)

Can the white rice 777.81.2

Belarus japonica 786.70.9

Millet 779.71.7

Refined white flour 787.21.3

Wheat flour (rich and powerful powder) 759.41.3

Wheat flour (standard powder) 749.91.8

Wheat bran 5613.91.2

Kaoliang cereals (sorghum) 778.22.2

Corn 738.54.3

Rice (standard meters) 272.80.5

Noodles 577.41.4

Bread (1 August powder) 496.10.2

Oatmeal 6814.07.0

Millet gruel 70.90.2

Soybean 2536.318.4

Beans 4829.41.8

Tofu 34.71.3

Tofu 718.87.6

Milk 46.80.8

Bean sprouts 711.52.0

Mung bean sprouts 43.20.1

Sprouting bean 1913.00.8

Vermicelli (dry) 880.60.2

Vermicelli 85.00.30

Fresh green beans 7.013.65.7

Sweet potatoes 29.02.30.2

Potato 16.01.90.7

Taro 17.02.20.1

Turnip 6.00.60

Onion 8.01.80

Vegetables 2 42.00.1 0.3

Melon 2 ~ 60.4 ~ 1.50.1 ~ 0.3

Peanut (raw) 2226.239.2

Lean pork 1.116.728.8

Lean beef 1.720.26.2

Lean lamb 0.517.313.6

Chicken 023.31.2

Ap 0.116.57.5

Eggs 0.514.811.6

Large yellow croaker (fresh) 117.60.8

Hairtail 118.17.1

River fish 19.51.1 ~ 1 ~ 0.113.0 ~ 5.2

Shrimp 017.50.6

Milk 63.13.5

Liver 320.14.0

Pig 0.11.30.2

(From 1963, the Chinese Academy of Medical Sciences Health Research Institute of Nutrition, "Food Composition Table")

(C) Exercise the right to participate in recreational activities, sports and manual labor, can promote the use of sugar, reduce the burden of islets, one effective treatment based disease. Unless the patient has ketoacidosis, active tuberculosis, severe complications such as cardiovascular disease, or diabetes do not have too much rest. Obese patients with type Ⅱ, in particular, may encourage exercise and proper manual. But the need to avoid fatigue and nervous tension, sports competitions, in order to avoid exciting the sympathetic and islet α cells, etc., cause glycogen breakdown and gluconeogenesis, resulting in hyperglycemia.

Identified by the physician, patients can exercise exercise exercise per week, at least 5 to 6 times, each time about half an hour or so, when the proper heart rate training is about 170 per minute minus age of the remainder. Should feel comfortable after exercise.

(D) drug treatment

Oral anti-diabetic drugs

Rapid development in recent years, from the original sulfonylurea (sulfonylurea) and metformin (biguanide), the existing Category 3 α-glucosidase inhibitors (α-glucosidase inhibitor) for clinical application, type 4 insulin sensitizer (insulin sensitizer) will soon be introduced to China. The Category 5 glucagon inhibitors (insulin antagonist inhibitor) and 6 of the gluconeogenesis inhibitor class of (gluconeogenesis inhibitor) is still experimental and small clinical trial stage, this section omitted.

In the above-mentioned anti-diabetic drugs, sulfonylureas hypoglycemic drug system, can cause low blood sugar reactions, metformin and α-glucosidase inhibitor is not caused by low blood sugar reactions, known as anti-hyperglycemic drugs.

1. Sulfonylurea drugs in this group there are several. The first generation of drugs is still commonly used as tolbutamide (tolrutamide D860), chlorsulfuron C urea (chlorpropamide) because of its toxicity to the liver and long-lasting, easy to hypoglycemia and should not be optional, vinegar and sulfur have been urea (acetohexamide ), and Allah sulfonylurea (tolazamide), etc. are also less at home. Second-generation drug glibenclamide (glibenclamide, glibenclamide, gliclazide (gliclazide, a sulfonylurea imidacloprid urea, gliclazide), glipizide carry her sea ╣ lipizide, pyridine sulfur ring has urea, or glipizide You da ling), Ge Liebo urea (glibornuride), gliquidone (gliquidone, Gliquidon) and other drugs, the dose and time in table 4. Currently more use Diamicron, glipizide and glibenclamide and other second-generation drugs. Gliquidon main metabolite excreted from the bile and only about 5% from the kidney, and therefore different from other sulfonylurea drugs can also be used for consolidation in patients with mild renal insufficiency, but the glomerular filtration rate fell to 30 % or so should be banned. First-generation drugs in the D-860 is still often used.

Table 3 Classification of oral anti-diabetic drugs and the characteristics of

Name of the drug per tablet weight

(Mg) dose range

(Mg / d) efficacy of time

(H) the number of daily medication to the role of time (h)

Start strongest sustained

The first generation sulfonylureas tolbutamide (D-860) 500500 ~ 30006 ~ 82 ~ 30.54 ~ 66 ~ 12

Vinegar, sulfur has been urea 500 500 ~ 15004 ~ 111 ~ 21 ~ 2312 ~ 18

Torah urea 250 100 ~ 100 071 ~ 24 ~ 64 ~ 812 ~ 14

Second-generation glyburide (glibenclamide) 2.5

52.5 ~ 2010 ~ 151 ~ 616 ~ 24 ~ 20.52

Gliclazide (Diamicron) 8080 ~ 240 121 ~ 2512 ~ 24

Glipizide (glipizide or superior da ling) 52.5 ~ 303 ~ 61 ~ 211.5 ~ 212 ~ 24

Gliquidone (Gliquidon) 3030 ~ 1801 ~ 28

Biguanide phenformin (phenformin) 25

5025 ~ 1006 ~ 71 ~ 3

Metformin (metformin) 250 500 ~ 20005 ~ 62 ~ 3 23 ~ 4

Grape glycosides α inhibitor acarbose (acarbose) 50 100 ~ 300 2 ~ 3

Mechanism of the hypoglycemic effect of sulfonylureas pancreas can be divided into two parts within the pancreatic:

⑴ stimulate pancreatic β cells release insulin, the evidence is: ① Ⅰ type cutting pancreas of animals and service to this group of patients to antibiotics; ② increase in plasma insulin after oral sulfonylurea; ③ After taking β cells were decreased, and with proportional to the amount of insulin secretion; ④ this group drug can stimulate β cell proliferation. Acting on the β cell membrane sulfonylurea receptor can inhibit K + escaped to strengthen depolarization, thereby promoting Ca2 + by the intracellular Ca2 + channel infiltration by the role of cAMP activation of phosphate has been synthesized to promote insulin release ( exocytosis). The second phase of insulin release had no effect.

⑵ pancreatic intensive insulin to its receptor to promote the use of sugar: Practical and clinical studies suggest may improve the sulfonylurea in patients with type Ⅱ diabetes mellitus and insulin receptor (or receptor defects), thus increasing the target tissue cells to insulin sensitivity.

The main indication is a single class with dietary treatment and appropriate exercise training can not get a good control of Type Ⅱ diabetes; or daily insulin requirement of 30 units or less; not sensitive to insulin in patients with combined drugs can be tested. Ⅰ patients and patients with severe infections, to liver and kidney dysfunction associated with major surgery or patients do not apply Gliquidon on patients with mild renal insufficiency can be closely observed by the trial. Diabetic pregnancy and does not apply.

Certain drugs due to decreased glucose gluconeogenesis, or lower and plasma protein binding and changes in liver and kidney metabolism, may increase the hypoglycemic effects, such as salicylic acid preparations, sulfa drug, aminopyrine, reserpine, β- adrenergic blocker. Some drugs for inhibition of insulin release or antagonize the role of the latter can reduce the hypoglycemic effect.

In the application of drugs, should pay attention to their side effects, including low blood sugar reactions and the digestive system, hematopoietic system, skin and other side effects. With diet, exercise too much, over dose easily induced hypoglycemia, particularly common in elderly patients, and may still recurrent hypoglycemia after treatment, lasted for 1 to 2 days. Gastrointestinal side effects are dyspepsia, nausea, cholestatic jaundice and liver dysfunction. Hematopoietic system to reduce the relatively large number of white blood cells see, a small number of agranulocytosis, aplastic anemia, thrombocytopenia. Performance itching and skin rashes and other allergic reactions. Corporations are more rare side effects of the event should be taken seriously, withdrawal or for appropriate treatment.

2. Biguanide phenformin clinical applications are there (phenformin) and metformin (metaformin) two, see Table 4. As the chemical structure of the characteristics of the toxicity of phenformin significantly larger than metformin, the effective dose and dose very close to the side effects, often more obvious gastrointestinal symptoms such as anorexia, nausea, vomiting, diarrhea, and even can be severe lactic acidosis, particularly in the liver, kidney and heart and lung function in patients, Guer has little clinical use, even in some European countries, is disabled. Metformin side effects was significantly lower than phenformin, as long as the strict control of its indications and contraindications, dosage should not pay attention too much, lactic acidosis occurs little chance, only stomach discomfort, anorexia, diarrhea and rash, medication use among meal or meals can reduce gastrointestinal side effects, which in recent years has re-accepted, widely used in clinical obtain good results.

Metformin Indication: light, especially in obese type Ⅱ diabetes, through diet and exercise effects, effects were not satisfied; need to lose weight can be classified as drug of choice for patients; use of drugs, the effect is unsatisfactory may be associated with this class drugs; Ⅰ patients in the course of treatment with insulin, blood glucose fluctuations in patients with larger; on IGT's object can be used to prevent its development into diabetes.

Contraindications are: Where to insulin treatment of type Ⅰ, particularly with ketosis, severe infections, trauma, high fever, surgery, pregnancy and childbirth late. Chronic gastrointestinal disease, chronic diarrhea, weight loss, malnutrition, etc. who should not use metformin; where the verge of failure, liver and kidney function, heart and lung failure, myocardial infarction, blood loss, dehydration and other hemorrhagic shock, alcoholism who should not use This group of drugs, so as not to induce lactic acidosis.

Mechanism of metformin no hypoglycemic effect on normal people, it alone will not cause low blood sugar reactions; metformin does not stimulate insulin secretion, it does not cause hyperinsulinemia; extrinsic muscle tissue to promote glucose uptake, accelerated anaerobic glycolysis; may promote post-receptor effects and the role of glucose transporter; may have a suppressive effect of glucose and gluconeogenesis delay intestinal absorption of sugar in; role in reducing body weight.

3.α-glucosidase inhibitors competitively inhibit the small intestinal brush membrane of α-glucosidase, delayed sucrose. Dextrin, maltose, etc. broken down into simple sugars and polysaccharides in intestinal absorption, so the main reduction and mitigation of postprandial hyperglycemia hyperinsulinemia. This class is those who use drugs as acarbose (acarbose, acarbose) and miglitol, etc., now commonly used as acarbose (see Table 1). The drug trial by the country suitable for light to moderate type Ⅱ diabetes, alone, in the heavier degrees who can be with other combination oral medication or insulin; in impaired glucose tolerance object can also be used acarbose intervention treatment. Clinical dose when the attention started young age, such as 50mg2 ~ 3 times / d, after gradually to 100mg three times / d, can reduce the side effects; medication and the first port when food intake at the same time, achieve the proper effect.

The main side effects drugs as flatulence, intestinal and light drum diarrhea, low-dose began to reduce medication, medication in and can be adapted.

Gastrointestinal disease and had had gestational diabetes should not be combined application of the drug.

Oral administration of insulin sensitizer, such as troglitazone (CSO 45), foreign countries have been clinical reports of obesity on insulin resistance in impaired glucose tolerance can reduce insulin resistance and improve glucose tolerance. Dose of 200mg twice / d.

Insulin

Insulin can prevent acute complications and metabolic disorders and improve the resistance against various infections, improve nutrition, promote the growth of such children; such as use of insulin therapy, strict control of hyperglycemia, microvascular and large vessel in place on the basis of there are certainly a number of chronic complications, control effect, such as the aforementioned DCCT results.

1. Indication of any type Ⅰ patients, especially young people, children, weight loss or malnutrition are dependent on insulin for a living, once suspended or interrupted, a life-threatening ketosis bound to happen, it must be added for long life; but Ⅱ type LADA patients when diet and oral hypoglycemic agents can not control, we also have long-term supplementary insulin to better control the symptoms and high blood sugar. Ⅱ patients to be gradually restore β cell reserve function of the gradual reduction after a few months, and even oral medication and diet therapy to restore. Must be strictly controlled by insulin intake to avoid obesity, even on insulin resistance; and malnutrition-related diabetes, or type Ⅲ; diabetes with ketoacidosis, nonketotic hyperosmolar coma, lactic acidosis , severe infections, fever and wasting disease, acute stress such as myocardial infarction; both before and after major surgery surgical patients will be OK, even if the original use of oral insulin treatment are also required to use (or temporary use), in order to prevent ketosis and other complications; gestational diabetes or pre-diabetes stage of pregnancy and childbirth and childbirth in order to use the proper amount of insulin, hypoglycemic agents should not be used; secondary diabetes, especially pituitary diabetes, pancreatic diabetes; diabetes patients with severe liver disease (such as cirrhosis, hepatitis), kidney disease with renal failure, with the majority of chronic complications (such as retinal and renal disease, neurological disease, fatty liver, lower limb gangrene, etc.) and other endocrine diseases.

2. Insulin preparations classified according to speed and duration of insulin action can be divided into three categories, as shown in table 5. One quick-include regular insulin, insulin zinc crystal, semi-slow insulin zinc suspension, the three can be by subcutaneous, intramuscular or intravenous injection; but can not be made in efficiency and long-acting injection, by subcutaneous or intramuscular injection only. Regular insulin (RI), crystalline zinc insulin (CZI) and globin insulin, pH 3.0 to 3.8, the rest is 7.2, so with long-acting protamine zinc (PZI) or NPH in effect when combined with different pH were mixed as must be used quickly and not stay for long. NPH and PZI1 copies for the RI2 were a mixture, in order to meet the condition of patients, can be a variety of short-acting agents such as long-term or intermediate-acting formulations and into various joint preparations, such as the RI or the CZI and PZI were mixed in as PZI protamine excess absorption part of the RI or the CZI, into a long-lasting effect, or in class, so RI and PZI ratio of 1:1 is similar to its role PZI; such as PI and PZI ratio of 2:1, then its role as NPH; if more than 2:1, its role in similar CZI + NPH. CZI and PZI in the mixture can be in any ratio, depending on the condition needs flexibility. CZI with any slow or intermediate-acting insulin mixed into a variety of different proportions, but the mix can not stay long. Such mixtures can only subcutaneous or intramuscular injection, not intravenously. In order to reduce allergic reactions in recent years has been the single peak of high purity and high purity preparation of pure single component (monocomponent) agents, sources from the bovine insulin and porcine insulin, through the semi-synthetic or man insulin genetic engineering technology, and has been made about the neutral pH 7.3 preparation. Import current clinical application of insulin in, actrapid HM (Novolin R) that is fast efficient system of human insulin; protaphane and monotard HM (Novolin N) system in the effect of human insulin; mixtard 30 HM (Novolin 30R) Department 30% and 70% in the short-acting effect of premixed human insulin preparations, in order to remove the temporary preparation of trouble.

Table 4, duration of action of various insulin

The role of category type injected with insulin after the injection of insulin action time (h) the injection time

Start the strongest sustained

Fast (short) regular insulin (Regular insulin, RI) subcutaneous vein ½ ~ 1

Immediately 2 to 4

½ 6 ~ 8

2 fasting 1/2h, 3 ~ 4 times / d ketoacidosis

Crystalline zinc insulin (Crystalline zincinsulin, CZI) subcutaneous vein ½ ~ 1

Immediately 4 to 6

½ 6 ~ 8

2 fasting 1/2h, 3 ~ 4 times / d ketoacidosis

Semi-slow insulin zinc suspension (Semilente insulin) subcutaneous veins immediately before meal 2 612 16 1/2h, 3 ~ 4 times / d

Slow insulin zinc suspension in effect (Lente insulin) subcutaneously 26 ~ 1218 ~ 24, plus breakfast or dinner before the 1h, 1 ~ 2 times / d

2:1 mixture of insulin (regular insulin 2, protamine zinc insulin 1) subcutaneous 412 ~ 1624 ~ 36 Ibid

Neutral protamine zinc insulin (NPH) subcutaneously 3 ~ 48 ~ 1218 ~ 24 Ibid

Slow (long) Special slow insulin zinc suspension (Ultralente insulin) subcutaneously 16 ~ 1830 ~ 36 breakfast or dinner before the 1h, 1 times / d

Protamine zinc insulin (Protamine Zinc insulin, PZI) subcutaneously 3 ~ 414 ~ 2024 ~ 36 Ibid

In the role of drugs in the glibenclamide fast and strong, the hypoglycemic effect of D-860 is about 500 ~ 1000 times, and its effect on insulin secretion in a more sustained clinical response to low blood sugar more easily, though after drug withdrawal there may be intermittent, should attract attention, especially in elderly patients. D-860, gliclazide, glipizide and Gliquidon moderate hypoglycemic effect, gliclazide on the role of microvascular disease when there are certain, are applicable to elderly patients. Small doses of sulfonylurea drug treatment should begin at breakfast before the 1 / 2 hours to take, according to blood sugar, urine sugar for reference, increasing the dose once a week if necessary, can be changed 2 times a day until the results achieved. The heavier the condition can also be started from 2 times a day medication.

The already satisfactory results, a few years later becoming invalid and with no other reason can be explained, it is called secondary treatment failure. Medication in the original basis in conjunction with other types of oral medication, such as metformin or (and) acarbose, or combined with low dose insulin treatment to Yangzhangbuduan again made effective.

Note: 1.NPH Department of Neutral Protamine Hagedorn of short, for every 100 units of insulin in 0.3 ~ 0.6mg of protamine and 0.016 ~ 0.04mg of zinc.

2. Slow insulin zinc suspension containing 30% and 70% of the special semi-slow slow insulin zinc suspension.

3. The table of time, only for reference, because insulin absorption, degradation is affected by many factors.

3. The principle of selection and use of insulin preparations and insulin treatment options suitable preparation conditions must be closely considered so that a rapid and sustained elimination of hyperglycemia, diabetes, urinary ketones and other metabolic disorders, to avoid low blood sugar reactions, and promote the body use sugar, to ensure nutrition; to blood glucose, plasma insulin concentration fluctuations close to the physiological range, that is, except the maintenance of blood glucose and insulin levels in the base, there postprandial peak value, nor have high blood sugar caused by over-stimulate the β cell hyperinsulinemia. General principles are as follows: ① need insulin therapy with short-acting categories, such as diabetes, ketosis and other acute complications, acute infection, major surgery before and after the pre-delivery and delivery periods of time. Type Ⅰ or type Ⅱ stage of initial treatment of severe dose not clear when the dose and treatment programs to explore, should be used short-acting class in fasting 1 / 2 hour injection, 3 to 4 times a day, the dose depending on severity, urine sugar, blood sugar , generally with a subcutaneous or intramuscular injection to mimic the postprandial insulin release due to the plasma peak. ② long-acting formulations can be used at breakfast before the injection or the agonist injection at bedtime at 10 pm (and into the late-night snacks) to maintain the basal level of plasma insulin and make next morning blood glucose (dawn phenomenon) better control. ③ In order to reduce the number of injections can use PZI and NPH and CZI RI or mixture, twice a day morning and evening before meals, this mixture of short-acting and long (middle), the ratio of those who can be effective flexibility, as the blood sugar, urine sugar control needs. In order to avoid time in the preparation of mixtures of protamine zinc into the RI bottle, should be taken first RI, and PZI. ④ If a serious condition associated with circulatory failure, skin absorption or resistance to be very dose, often use regular insulin or CZI intravenous drip, ⑤ new agents with high purity decreased slightly when the dose should be 30% to 30% . ⑥ Ⅰ type of fluctuation is harder to control blood sugar or type Ⅱ in insulin resistance are sometimes combined treatment trial with oral medication.

4. Insulin dose must be individualized. As the complexity of the factors affecting dosage, it can not be reduced to formula. ① factors affecting food intake; ② physical activity, exercise, exercise can reduce it more than muscle insulin requirements; ③ mental and emotional tension to increased requirements; ④ insulin, bovine and porcine insulin than human insulin antibodies easily have antibodies often have to increase the dose; ⑤ Many drugs have synergistic or antagonistic hypoglycemic effect of increasing blood sugar can affect the dose; ⑥ insulin custody case, the summer hot season to be 4 ~ 10 ℃ cold; ⑦ complications, if any heat , ketoacidosis, purulent infection, when the receptor affinity of various stress drop, the dose to be increased; ⑧ obesity and body weight, fat cell number and affinity of such receptors often inversely proportional to plasma insulin, obesity is less dose is often too sensitive, thin were more sensitive to dose too small; ⑨ other endocrine diseases and pregnancy, there is the pituitary gland, adrenal gland, hyperthyroidism who often have to be increased last three months of pregnancy often increased; ⑩ liver and kidney functional status, mainly in the liver and kidney in the destruction of insulin can reduce, when the liver and kidney failure, the destruction can be reduced, in theory, can reduce insulin requirements, but sometimes being offset with resistance.

Who meet the indications for insulin application type Ⅰ and type Ⅱ patients, diet therapy should be based on the use of insulin. In type Ⅱ diabetic patients, can first use of insulin, injected subcutaneously once daily before breakfast, initial dose of 0.2 ~ 0.3U/kg weight, or quick and the efficiency (1:2) mixture to the mixed use or Monotard 30HM preparation . According to results of urine and blood glucose measured every 5 ~ 6d reference to the former 1 ~ 2d adjust the dose until satisfactory control. If morning fasting blood sugar high, to a daily injection of insulin twice a day before breakfast accounting for the total dose of 2 / 3 dose before dinner, 1 / 3. Available and the effect can be applied (1:2) mixture of late second injection. Type Ⅰ diabetes control the disease if not yet satisfied, we can use intensive insulin therapy: ① available before breakfast and the insulin injection, quick injection of insulin before dinner, supper before the injection of insulin. ② breakfast, lunch and dinner available before the injection of insulin, insulin injections before supper. ③ breakfast and dinner available before the injection and long-acting insulin injection before lunch available insulin, such as 3Am have high blood sugar, can be a quick increase in insulin before supper.

Intensive insulin therapy in type Ⅱ or in the application of insulin have to pay attention to hypoglycemia and low blood glucose response after the high blood glucose (Somogyi phenomenon). Monitoring of blood glucose several times at night to help identify asymptomatic low blood glucose response and high blood sugar. With intensive therapy should have blood glucose self-monitoring and close observation in order to adjust diet and insulin dose, and strictly control high blood sugar, prevent hypoglycemia, so as to avoid excessive occurrence of obesity agent.

Application of micro-adjustable insulin pump program available computer controlled subcutaneous insulin infusion to simulate the continuous insulin secretion and ate the basis of pulse-release, can be controlled by setting the computer program, so strong of blood sugar treatment closer to physiological levels of a These can be used in patients with type Ⅰ. As the micro-computer technology and a dedicated room for improvement in insulin preparations, not yet widely used in China.

Recent, but also in clinical application of insulin pens, insulin matching specific, quantitative correct injection convenient for elderly patients and patients with poor vision is particularly convenient.

5. Insulin response with two types of systemic and local reactions. Systemic reactions are:

⑴ low blood sugar reaction: the most common. Prevalent in the fragile type Ⅰ or type Ⅱ type of heavy, especially in thin persons. General physical activity as exercise too much, or even eating too little, reducing the timing is wrong or overdose. When there is hunger, dizziness, weakness, sweating, a lingering fear, and even neurological symptoms, such as orientation disorders, irritability, incoherent, laughing and crying impermanence, and sometimes more serious, and even fainting, pumping take hold, the shape of epilepsy, coma awake, even death. Governance process should be familiar with the reaction of the church at any time the patient vigilance, early feeding sugar or sugar water to ease the pastry, should be immediately heavier 50% glucose intravenously for more than 40ml, followed by intravenous infusion of 10% glucose water until awake; sometimes the first injection of glucagon, each time the skin or muscle 1mg, such as low blood sugar reaction lasted longer in severe cases can also be used hydrocortisone per 100 ~ 300mg in 5% ~ 10% glucose in water intravenously. When low blood sugar reaction is estimated to be careful after the resumption of the next dose of disease to prevent recurrence. Because after repeated hypoglycemia in islet α cells and stimulate the adrenal gland can occur in response to hyperglycemia (Somogyi effect), this often leads to brittle type, must be avoided.

⑵ allergic reactions: a small number of patients have allergic reactions such as urticaria, angioedema, purpura, very few have anaphylactic shock. As the preparation of such reaction generally due to impurities. Light can cure it with anti-histamine drugs, re-agents are required to exchange high-purity single component, such as human insulin, due to its amino acid sequence with the same endogenous insulin, and the impurities contained in very small, extremely rare allergies, or switch to oral medication. Necessary Shihai can use low-dose subcutaneous insulin desensitization treatment more than Peter.

⑶ insulin edema: uncontrolled diabetes, often before the loss of water loss of sodium, cells, glucose decreased 4 to 6, after controlling sodium and water retention can occur while the edema may be related to insulin to promote renal tubular sodium absorption of the back, known as insulin edema .

⑷ refractive disorders: patients with insulin treatment process is sometimes a sense of blurred vision, due to the rapid decline in blood sugar during treatment, affecting the lens and vitreous osmotic pressure, so the lens and the refraction rate of decline of water escape occurred hyperopia. However, this is a temporary change, usually with blood glucose levels returned to normal and quickly disappear, thus preventing permanent changes. Such refractive mutation more common in the volatile blood sugar juvenile patients.

Local reactions are: ① injection of local skin irritation, fever and subcutaneous nodules have occurred more common in the early treatment phases of NPH or PZI weeks, due to presence of protein and other impurities caused by changes in attention to go away after part, does not affect the efficacy. ② subcutaneous fat atrophy or hyperplasia, fat atrophy into a depression, lack of sebum, more common in young women and children thigh, abdominal wall so the injection site; subcutaneous tissue by generation of debris and more common in male buttocks so the injection site, numbness tingling and sometimes were, can affect absorption, to be replaced at the injection site and to ensure treatment.

6. Insulin resistance is a small number of patients with insulin resistance, insulin requirements than 200U, which lasted 48 hours or more, while no cause ketoacidosis and other endocrine disease secondary to diabetes called insulin resistance. This group does not include obesity, infection, liver disease, hemochromatosis, leukemia, rheumatoid arthritis, diabetes, fatty atrophy due to resistance. According to various studies in recent years, most of that is insulin resistant to immune responses such as insulin in the blood after the production of anti-insulin antibody, generally within the IgG class, particularly prone to bovine insulin. Thus, here do not insulin resistance and the pathophysiology of insulin resistance and confusion.

In recent years, also found that diabetic cardiomyopathy in severe heart failure and cardiac arrhythmias Qi Fasheng ago, only low and flat T wave inversion, should be strictly controlled diabetes and hypertension as early as possible, application of coenzyme Q10 and the second-generation calcium channel blockers, etc. 1 - carnitine can improve heart function can also try.

ACEI has been widely used at present with normal renal function even in early macroalbuminuria in patients with diabetic kidney disease, especially in the former satisfactory results. Must strictly control high blood pressure also help control kidney. Appropriate intake of low protein diet in patients with advanced renal failure, dialysis therapy should be used to peritoneal dialysis safer and can be used for end-stage renal transplantation.

Previous trial of vitamin B family, B12, B6, B1, B2, NAA and other suspicious effect.

A platelet aggregation may try to aspirin, but the results suspicious. Laser therapy can be divided into focal and diffuse two, depending on the condition of patients to choose.

As with other chronic complications of stroke can be prevented. Socks should be soft but not broken or the patch, shoes should be relaxed, to check their shoes before wearing shoes with or without sharp foreign bodies such as hard. Special insoles can be applied to reduce the pressure on the local protruding parts. When necessary, with antibiotics, vasodilators, and blood circulation and other therapy, Ulcers can trim necrotic tissue, apply to the blood and new drugs, try not to amputation