Discuss the general principles of treating type 2 diabetes.

With the deepening of the understanding of diabetes, the treatment concept of type 2 diabetes has also changed greatly. Compared with the traditional treatment scheme, the new treatment concept tends to be more scientific and reasonable, and is closer to the essence of the disease. Its core content is to emphasize early, combined, strengthened and protected islet cells. 1. From simply lowering blood sugar to controlling multiple cardiovascular risk factors. Evidence-based medicine research such as united kingdom prospective diabetes study (UKPDS) shows that although strict control of blood sugar can significantly reduce the microvascular complications of diabetes, it can not significantly reduce the macrovascular complications. As we all know, diabetic patients often gather many cardiovascular risk factors, including hyperglycemia, dyslipidemia, hypertension, abdominal obesity, hypercoagulability and chronic inflammation, which promote the formation of atherosclerosis. At present, it is considered that it is far from enough to control blood sugar in the treatment of type 2 diabetes, and comprehensive control should be carried out for various cardiovascular risk factors to reduce chronic complications of diabetes and improve the prognosis of patients. 2. Try to change from monotherapy to early combination therapy. In the past, when using hypoglycemic drugs, it was often a drug that "fought alone". Until the maximum dose was used and the blood sugar was still not satisfactorily controlled, it was forced to take "joint operations". At present, it is considered that this passive "combined medication" is not conducive to the early protection of islet B cell function, the long-term control of blood sugar and the prevention and treatment of various complications of diabetes. The new treatment model advocates active combined treatment in the early stage of the disease. When half the dose of a single drug (half the maximum allowable dose) can't make the blood sugar under satisfactory control, we should not blindly increase the dose of a single drug, but actively adopt the combination of different drugs. Early combined therapy can give full play to the synergistic effect between different drugs, make blood sugar reach the standard quickly and permanently, and reduce the possible adverse reactions caused by excessive dosage of each drug. 3. Change from the first choice of hypoglycemic agents to early use of insulin. United kingdom prospective diabetes study showed that due to the persistence of insulin resistance, the function of B cells declined progressively with the development of the disease course. At the beginning of the diagnosis of diabetes, islet function has lost 50%, and it will decline at a rate of 4% ~ 5% every year. After about 5 years, the islet function is only 25%, and after 10 years, the islet function is almost completely lost, which leads to the complete failure of sulfonylureas and the increase of blood sugar. At present, the early application of insulin is advocated because it can correct the relative deficiency of endogenous insulin, reduce the toxic effect of hyperglycemia on B cells, reduce the burden of islet B cells, make the damaged islet B cells rest and recover, and improve their insulin secretion function. In addition, by alleviating the "sugar toxicity" and "lipid toxicity", the sensitivity of surrounding tissues to insulin can be improved, which is not only beneficial to the good control of blood sugar, but also can effectively protect blood vessels and reduce or delay the occurrence of various complications. 4. The traditional treatment mode of type 2 diabetes is from "gradual treatment" to "active rational treatment", which is called "step treatment". That is to say, change the lifestyle (diet control and exercise therapy) first, and then take a single oral hypoglycemic drug treatment. If the maximum curative effect is not ideal, then take a combination of drugs, and finally use insulin as a last resort. This gradual treatment mode is too conservative, which is not conducive to the rapid control of blood sugar, and the patient is exposed to hyperglycemia for too long, which is not conducive to preventing or delaying the occurrence of complications. In addition, the late application of insulin may miss the best opportunity to repair islet function, leading to the irreversible decline of B cell function. Therefore, it is urgent to improve the traditional treatment mode. "Active and reasonable treatment" is the latest treatment concept put forward in recent years according to the pathophysiological characteristics of different stages of natural course of type 2 diabetes. The so-called "positive" means giving medication as soon as possible, combining medication as soon as possible, and controlling blood sugar as soon as possible. The so-called "rationality" means respecting the inherent laws of the occurrence and development of diseases and adopting targeted treatment programs according to the pathophysiological characteristics of different stages. Its core contents are as follows: ① thiazolidinediones (insulin sensitizers) which can improve insulin resistance and protect islet B cells and large blood vessels are advocated as first-line drugs for the treatment of type 2 diabetes mellitus and applied to the whole process of the disease; ② According to the degree of islet function decline in different stages, insulin secretagogue or insulin should be supplemented in time. 5. Transition from "insulin secretagogue" to "insulin sensitizer" At present, it is believed that insulin resistance is the main cause of type 2 diabetes and the chief culprit leading to chronic complications such as cardiovascular diseases. Insulin resistance runs through the whole process of the occurrence and development of type 2 diabetes. Therefore, the treatment of type 2 diabetes must start from the source and solve the key problem of "insulin resistance", so as to control cardiovascular risk factors such as hyperglycemia, protect islet B cells, delay the progress of type 2 diabetes and reduce the incidence of chronic complications of diabetes. Improper and excessive use of insulin secretagogue (such as glibenclamide) is not only harmful to the protection of islet B cells, but also may accelerate the failure of islet B cells, leading to the secondary failure of hypoglycemic drugs. Thiazolidinedione insulin sensitizer can directly attack insulin resistance and protect islet B cells and macrovessels, which is not only beneficial to realize long-term stable blood sugar control and delay the progress of type 2 diabetes, but also can reduce the incidence of diabetic microangiopathy and macroangiopathy. 6. Changing from "common insulin secretagogue" to "early insulin secretagogue" Early (first phase) insulin secretion is very necessary for normal glucose metabolism in the body, which can reduce the sugar output of the liver, inhibit lipolysis and quickly control postprandial hyperglycemia. Early insulin secretion defect has appeared in the early stage of type 2 diabetes mellitus, which leads to postprandial hyperglycemia and subsequent compensatory delayed hyperinsulinemia, and accelerates the failure of islet B cells. Early insulin secretagogue (such as Novolone) has the advantage of "fast forward and fast out", which can obviously improve the early insulin secretion of islet B cells and produce a pattern similar to physiological insulin secretion, so it can better reduce the blood sugar level during and after meals, and at the same time avoid the continuous excessive stimulation of drugs on islet B cells, which has a certain protective effect on islet B cells. 7. Changing from "routine therapy" to "intensive therapy" can effectively protect islet B cells and make the damaged islet B cells rest and repair, thus restoring and improving the insulin secretion function of patients themselves; It can also effectively protect blood vessels and reduce or delay the occurrence of various complications. After active intensive treatment, about 10% of patients with early diabetes can stop taking oral drugs. This intensive treatment is not only suitable for newly diagnosed diabetic patients, but also suitable for those patients whose blood sugar is seriously exceeding the standard, but whose oral drugs are not effective, so that they can return to normal as soon as possible. 8. From "exhausting fish" to "protecting islet cells", the decline of islet function is an important sign of the deterioration of type 2 diabetes. In the past, in order to pursue rapid hypoglycemic effect, long-acting and powerful insulin secretagogue was often used. This short-sighted behavior of "killing the chicken to get the egg" is not conducive to the protection of islet B cells, which will accelerate the failure of islet function and eventually lead to the secondary failure of drugs. The following measures can be taken to delay or avoid premature failure of B cells: ① long-term ideal control of blood sugar; ② Avoid long-term high-dose use of insulin secretagogue, especially powerful stimulants (such as glibenclamide); ③ Rational use of drugs to improve insulin resistance and reduce "lipotoxicity", such as thiazolidinediones; ④ Advocating the use of early insulin secretagogue; ⑤ Early combined use of oral hypoglycemic agents; ⑥ Early combination or insulin therapy. 9. One-sided emphasis on drugs while ignoring diet and exercise therapy is a prominent problem in the prevention and treatment of diabetes. As we all know, the prevention and treatment of diabetes can not be separated from the "troika". Specifically, diet therapy is the foundation, exercise therapy is the means, drug therapy is the key, disease monitoring is the guarantee, diabetes education is the foundation, and the "troika" is indispensable. Only close cooperation can achieve satisfactory results. Especially worth mentioning is diabetes education, which is very important. Through diabetes education, diabetic patients can correct their wrong ideas, update their treatment ideas, actively cooperate with treatment, and better manage themselves in daily life. 10. The transition from "paying more attention to treatment than prevention" to "paying equal attention to prevention and treatment" means that blood sugar is in the transition stage between normal people and diabetic patients, including impaired glucose tolerance (IGT), abnormal fasting blood sugar (IFG) and IGT+IFG. Individuals with pre-diabetes are at high risk of developing diabetes in the future, and these people are often accompanied by hypertension and lipid metabolism disorder. Early intervention (lifestyle intervention or drug intervention) can not only reduce the incidence of diabetes, but also reduce the incidence of cardiovascular diseases. Evidence-based medicine experiments have proved that lifestyle intervention is more effective and economical than drug intervention, and it is worth popularizing.