The symptoms of diabetes can be divided into two categories: one is related to metabolic disorder, especially "three more and one less" is related to hyperglycemia, which is more common in 1 type diabetes. Type 2 diabetes is often not obvious or only partially manifested, and the other is related to various acute and chronic complications.
1. polyuria
Because the blood sugar is too high, which exceeds the renal glucose threshold (8.89 ~ 10.0 mmol/L), the glucose filtered through the glomerulus cannot be completely reabsorbed by the renal tubules, forming osmotic diuresis. The higher the blood sugar is, the more urine sugar is excreted, and the more urine volume is. The 24-hour urine volume can reach 5000 ~ 10000 ml, but the elderly and patients with kidney disease have renal sugar threshold.
Drink plenty of water
Mainly due to hyperglycemia, plasma osmotic pressure increased significantly, coupled with polyuria, excessive water loss and intracellular dehydration, which aggravated hyperglycemia, further increased plasma osmotic pressure, stimulated thirst center, led to thirst and polydipsia, and further aggravated polyuria.
Eat more
The mechanism of overeating is not very clear. Most scholars tend to be caused by the decrease of glucose utilization rate (the difference of glucose concentration in arterial and venous blood before and after entering and leaving tissue cells). When normal people are on an empty stomach, the difference of glucose concentration between arterial and venous blood is reduced, which stimulates the feeding center and produces hunger. After eating, the blood sugar increased, the difference between arterial and venous blood glucose concentration increased (above 0.829mmoL/L), the feeding center was inhibited, the satiety center was excited, and the feeding demand disappeared. However, due to the absolute or relative lack of insulin or the insensitivity of tissues to insulin, the ability of tissues to absorb and utilize glucose decreases. Although the blood sugar is at a high level, the concentration difference between arterial blood and venous blood is very small, and tissues and cells are actually in a "hungry state", which stimulates the feeding center and causes hunger and overeating. In addition, the body can't make full use of glucose, and a large amount of glucose is excreted from urine, so the body is actually in a state of semi-starvation, and insufficient energy also causes overeating.
lose weight
Although the appetite and food intake of diabetic patients are normal or even increased, they lose weight, mainly due to the absolute or relative lack of insulin, and the body can't make full use of glucose to generate energy, which leads to increased decomposition of fat and protein, excessive consumption, negative nitrogen balance, gradual weight loss and even emaciation. Once diabetes is properly treated and well controlled, weight loss can be controlled or even rebounded. For example, diabetic patients lose weight continuously or lose weight obviously during treatment, suggesting that metabolic control is possible.
5. fatigue
It is also common in diabetic patients. Because glucose can't be completely oxidized, that is, the human body can't make full use of glucose and release energy effectively, and at the same time, tissue loses water, electrolyte imbalance, negative nitrogen balance and so on. So I feel weak and listless.
6. Visual loss
Many diabetic patients complain of decreased or blurred vision in the early stage, which may be mainly due to the changes of lens osmotic pressure and diopter caused by hyperglycemia. The early stage is usually a functional change. Once the blood sugar is controlled, the vision can return to normal quickly.
The treatment of diabetes includes diabetes education, diet therapy, exercise therapy, drug therapy, blood sugar monitoring and the detection and control of other cardiovascular risk factors.
Once diabetes is diagnosed, it is necessary to educate patients about diabetes, including common sense of diabetes, self-monitoring blood sugar and urine sugar. Use of hypoglycemic drugs, observation and treatment of adverse reactions. And the manifestations, prevention and treatment of various complications.
Main measures of basic treatment for different types of diabetes. The principle of dietotherapy is to control total calories and weight. Reduce the content of fat, especially saturated fatty acids, increase the content of dietary fiber, and make the ratio of carbohydrate, fat and protein in food reasonable. Control the intake of total dietary energy and distribute various nutrients reasonably and evenly. To maintain a reasonable weight, the goal of overweight/obese patients is to lose 5%- 10% within 3-6 months. Patients with emaciation should recover and maintain their ideal weight for a long time through a balanced nutrition plan.
① Fat: The energy provided by fat in diet does not exceed 30% of total energy, and the intake of saturated fatty acids does not exceed 65,438+00% of total energy. Cholesterol intake in food
② Carbohydrates: The energy provided by carbohydrates in the diet should account for 50%-60% of the total energy. Food should be rich in dietary fiber.
③ protein: For patients with normal renal function, it is suggested that the intake of protein should account for 65,438+00%-65,438+05% of the total energy, and the intake of protein should be suggested for patients with obvious proteinuria.
④ Drinking: It is not recommended for diabetics to drink alcohol. No more than 1-2 standard portions per day (one standard portion is 350ml of beer, 50ml of red wine 150ml or 45ml of low-alcohol liquor, each containing about 15g of alcohol).
⑤ Salt: The intake of salt should be limited to 6g per day, especially for patients with hypertension.
Generally speaking, protein in daily diet should be given according to the standard weight of 0.6-0.8g/kg, and the proportion of high-quality protein should be increased within a limited range. Patients with diabetic nephropathy in the third and fourth stages should grasp the quality and quantity of daily protein intake while adhering to other principles of nutritional treatment for diabetes.
Patients with diabetic nephropathy have not made a scientific and reasonable diet plan for themselves, so once the renal function is damaged, blood pressure will rise and the whole body will be weak; Severe renal insufficiency, edema, male impotence, testicular atrophy, etc. In other words, they have completely lost their ability to take care of themselves and may even be killed.
1, eat less fruit
Fruit contains more fructose and glucose, which can be quickly absorbed by the human body, leading to an increase in blood sugar. Therefore, patients with severe diabetes should not eat too much fruit.
2, can't drink
Alcohol contains 14.64 kilojoules (3.5 kilocalories) per gram, which is a high-calorie food and has the function of consuming calories in the body. Excessive drinking will cause hyperlipidemia or metabolic disorder, which will increase the burden on the liver. When diabetics drink alcohol, they eat some carbohydrate foods, which can increase their blood sugar and make diabetes out of control. Regular drinking without eating food will inhibit the decomposition of liver glycogen, reduce the sugar content of grapes (grape foods) in the blood, and appear hypoglycemia (blood sugar foods) symptoms. Therefore, patients with severe diabetes complicated with hepatobiliary diseases, especially those who are taking insulin and oral hypoglycemic drugs, should strictly prohibit drinking.
3. Eat less food with high sugar and salt.
For the understanding of diabetes, doctors usually regard restricting diet, especially restricting eating foods with high sugar content, as an important prevention and treatment method to guide patients. However, people pay little attention to limiting salt intake. Modern medical research shows that excessive salt can enhance amylase activity, promote starch digestion (food digestion), and promote the absorption of free glucose in small intestine, which can lead to the increase of blood sugar concentration and aggravate the disease. Therefore, diabetic patients should not eat more salt.
motortherapy
It is also one of the basic treatments for diabetes. According to the actual situation of patients, it is very important to choose appropriate exercise, do what you can, step by step, and support. The way, intensity and frequency of exercise should be determined according to the actual situation of patients. Generally speaking, moderate-intensity aerobic exercise (such as brisk walking, playing Tai Ji Chuan, cycling, playing golf and gardening) is recommended, and the exercise time is at least 150 minutes per week. When the blood sugar is >: 14- 16mmol/L, it is obviously hypoglycemia or blood sugar fluctuates greatly, and the acute metabolic complications of diabetes and the chronic complications of heart, kidney and other organs are serious, it is not suitable for exercise for the time being.
give up smoking
Smoking is harmful to health, especially for type 2 diabetic patients with high risk of macroangiopathy. Every diabetic smoker should be advised to quit smoking, which is one of the important contents of lifestyle intervention.
Mainly oral hypoglycemic agents
According to the different mechanisms of action, it can be divided into insulin secretagogues (sulfonylureas and glinides), biguanides, thiazolidinedione insulin sensitizers, α -glucosidase inhibitors and dipeptidase-Ⅳ (VDPP-Ⅳ) inhibitors. Drug selection should be based on two main pathophysiological changes of type 2 diabetes-insulin resistance and impaired insulin secretion. In addition, the characteristics of blood sugar fluctuation, age, weight and function of important organs of patients are also important factors that need to be fully considered when choosing drugs. Drugs with complementary mechanisms should be used in combination to increase the curative effect and reduce the incidence of adverse reactions.
1. biguanides: these drugs can reduce the production of sugar in the liver, promote the uptake of glucose by peripheral tissues such as muscles, accelerate the anaerobic glycolysis of sugar, and reduce the absorption of sugar in the intestine. Has the effects of reducing blood lipid and uric acid. Suitable for type 2 diabetes, especially obese people should be the first choice. The preparation comprises ① phenformin; ② Metformin. At present, metformin is the most commonly used. The rare and serious side effect of biguanides is to induce lactic acidosis. Metformin rarely causes renal insufficiency, and biguanides are prohibited (men with serum creatinine level >; 1.5mg/dl, female >:1.4mg/dl or glomerular filtration rate.
2. sulfonylureas: These drugs mainly act on sulfonylureas receptors on the surface of islet B cells and promote insulin secretion. It is suitable for diabetic patients with islet B cells still functioning but without severe liver and kidney dysfunction. If used improperly, sulfonylureas can lead to hypoglycemia, especially in elderly patients and patients with hepatic and renal insufficiency. Sulfonylurea drugs can also cause weight gain. Clinical trials show that sulfonylureas can reduce HbA 1c 1%-2%, which is the main drug recommended by many countries and international organizations to control hyperglycemia in patients with type 2 diabetes.
Sulfonylurea drugs include tolbutamide; Glibenclamide; Submerged zinc ore; Glipizide; Gliquidone; Glimepiride and others. There are also some sustained-release and controlled-release formulations of sulfonylurea drugs, such as gliclazide sustained-release tablets and glipizide controlled-release tablets.
3. Benzoic acid derivative secretagogues: including repaglinide and nateglinide. These drugs mainly reduce postprandial blood sugar by stimulating the early secretion of insulin, which has the characteristics of fast absorption, quick onset and short action time, and can reduce HBA 1C by 0.3%- 1.5%. These drugs should be taken immediately before meals and can be used alone or in combination with other hypoglycemic drugs (except sulfonylureas). The common side effects of glinide are hypoglycemia and weight gain, but the frequency and degree of hypoglycemia are less than sulfonylureas.
4. α -glucosidase inhibitor: Glucosidase that can selectively act on the brush border of small intestinal mucosa, inhibit the decomposition of polysaccharide and sucrose into glucose, delay the digestion of carbohydrates and reduce the absorption of glucose. Can improve the postprandial blood sugar peak. It mainly includes ① acarbose ② voglibose, etc. α -glucosidase inhibitors can reduce HBA1c by 0.5%-0.8%, and the common adverse reaction of α -glucosidase inhibitors is gastrointestinal reaction.
5. Thiazolidinedione (insulin sensitizer): By activating PPARγ, it can enhance the sensitivity of surrounding tissues to insulin, such as increasing the absorption and transport of glucose in adipose tissue, inhibiting the release of FFA in plasma, inhibiting the release of sugar in liver, and strengthening the synthesis of glucose in skeletal muscle, thus reducing insulin resistance. It is suitable for obese type 2 diabetes with insulin resistance as the main factor. Clinical trials show that thiazolidinediones can reduce HbA 1c 1.0%- 1.5%. Mainly includes ① rosiglitazone; ② Pioglitazone. Weight gain and edema are common side effects of thiazolidinediones. The use of thiazolidinediones also increases the risk of fracture and heart failure.
Remarks: About the use of rosiglitazone:
The safety of rosiglitazone is still controversial, and its use is strictly restricted in China. For diabetic patients who have never used rosiglitazone and its compound preparation, rosiglitazone and its compound preparation can only be considered if other hypoglycemic agents cannot be used or the goal of blood sugar control cannot be achieved by using other hypoglycemic agents. For patients who have already used rosiglitazone and its compound preparations, the risk of cardiovascular disease should be assessed and the advantages and disadvantages of the drugs should be weighed before continuing to use them.
6. Dipeptidyl peptidase -VI(DPP-VI) inhibitor: DPP-IV inhibitor can reduce the inactivation of GLP- 1 and increase the level of GLP- 1 in vivo by inhibiting dipeptidyl peptidase -IV. GLP- 1 enhances insulin secretion and inhibits glucagon secretion in a glucose concentration-dependent manner. Clinical trials including patients with type 2 diabetes show that sitagliptin can reduce HbA 1c 1.0%.
Insulin therapy
1. Type of insulin
According to the source classification, there are animal insulin (pig, cow) and recombinant human insulin. The preparation of human insulin has a light immune response and is not easy to produce antibodies.
According to the onset time, it is divided into different types of preparations.
① Short-acting insulin takes effect quickly, but the action time is short. Routine belongs to short-acting insulin. The preparation is transparent.
② The onset time, peak value and action time of intermediate insulin are longer than those of short-acting islets. The most commonly used is NPH.
③ Premixed insulin: 50r: a mixture of 50% NPH insulin and 50% conventional insulin; 30r: A mixture of 70% NPH insulin and 30% ordinary insulin.
④ Ultra-short-acting insulin analogues: synthetic insulin analogues, injected during meals, with short action time. It depends on two kinds of insulin: breast insulin and aspart insulin.
⑤ Long-acting insulin analogues: synthetic insulin analogues, with long-acting time, are used as supplements to the basic amount of insulin. Such as insulin glargine and insulin detemir.
⑥ Ultra-long-acting insulin analogues: synthetic insulin analogues have a longer action time, such as solid insulin.
2. Initial treatment of insulin
1 Diabetes patients need lifelong insulin replacement therapy.
When the HbA 1c of patients with type 2 diabetes is still greater than 7.0% after taking large doses of oral drugs, insulin therapy can be considered.
Insulin should be used as the first-line treatment for newly diagnosed wasting diabetes patients who are difficult to distinguish from 1 type diabetes.
When there is no obvious reason for weight loss in the course of diabetes, insulin should be used as soon as possible.
The application of insulin under special circumstances:
Keywords hyperglycemia in newly diagnosed diabetic patients, perioperative period, infection, pregnancy
3. The usage of insulin:
Short-acting insulin can be used to treat severe diabetes, such as ketoacidosis, by intravenous drip. 1 once diabetes is diagnosed, it still needs lifelong subcutaneous insulin treatment. Type 2 diabetes can be treated by insulin supplementation or replacement therapy. There are the following steps.
① For patients whose oral hypoglycemic agents have failed or partially failed, continue to use oral hypoglycemic agents, and subcutaneously inject moderate or long-acting insulin before going to bed. The initial dose was 0. 1 ~ 0.2U/kg, and blood sugar was monitored. After 3 days, adjust the dosage, and each adjustment amount is 2U-4U.
② Inject premixed insulin twice a day in the morning and evening. The initial insulin dose is generally 0.4-0.6 unit/kg body weight/day, and it is distributed at the ratio of 1: 1 before breakfast and dinner. The advantage is that it is convenient and reduces the inconvenience of injection before lunch, but the blood sugar fluctuates greatly at lunch and is difficult to control.
③ On the basis of the above-mentioned initial insulin therapy, after sufficient dose adjustment, if the patient's blood sugar level is still not up to standard or there are repeated hypoglycemia, it is necessary to further optimize the treatment plan. Edible meal+basic insulin: according to the blood sugar level before going to bed and three meals, adjust the insulin dosage before going to bed and three meals respectively.
④ Insulin pump therapy. The main applicable groups are: 1 type diabetic patients; Planned pregnancy and pregnant women with diabetes; Patients with type 2 diabetes who need intensive insulin therapy.
4. Side effects: mainly hypoglycemia.