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1、糖尿病胰岛素治疗方案（Insulin therapy for diabetes mellitus）The diabetic insulin therapySelection of insulin types* animal insulin is extract from animal pancreas purified through a series of processes such as production, the people belongs to the heterogeneous protein has strong immunogenicity and may cause s
2、ensitization, long-term use may have led to reduced efficacy of antibody.Recombinant human insulin is a biological engineering drug produced by gene recombination technology. It has the same structure and biological activity as human endogenous insulin.* recombinant human insulin analogues of amino
3、acid structure of amino acid modification technology of recombinant human insulin in the human body, can change the pharmacokinetics, accelerate or extend the onset or duration of action in vivo, but because of its structure and human endogenous insulin is not completely consistent, also belong to t
4、he heterologous polypeptide of people it is immunogenic and may cause sensitization, or antibodies lead to less effective.Human insulin should be used in the following groups:A woman who has been pregnant or intending to have a pregnancyAllergic personInsulin resistance is present in animalsInsulin
5、therapy has just begunThose who wish to apply insulin intermittentlyLong term use of human insulin analogues with reduced efficacyA new patient who does not know the type of insulin originally usedInsulin delivery regimen1, insulin physiological supply program, 34 injections per day (intensive treat
6、ment program)Fast / short acting insulin, pre meal injection + medium / long-acting insulin, before going to bed, 4 injections per dayFast / short acting insulin is given 3 times a day before mealsBefore breakfast and before dinner, take a quick / short acting insulin + pre oral oral hypoglycemic ag
7、ent + bedtime medium / long-acting insulin, 3 times a dayPre insulin injection + pre injection / short acting insulin + bedtime injection / medium / long acting insulin, 3 injections per day, before breakfast2, 12 times per day insulin injection (non intensive treatment)BIDO treatment: bedtime injec
8、tion of medium / long acting insulin + oral hypoglycemic agents during the dayPremixed insulin before breakfast + premixed insulin before dinnerBreakfast / quick acting insulin + supper / short acting insulinBreakfast before speed / short acting insulin + bedtime medium / long-acting insulinPre brea
9、kfast middle effect insulin + bedtime medium / long-acting insulinDosage of insulinStarting dose: starting from a small dose of 0.25IU/kg.24h, approximately 1220IU throughout the day.Type 1 diabetes mellitus: 1IU / short acting insulin should be added to each of the target blood glucose levels of ar
10、ound 2.8mmol/L.Type 2 diabetes mellitus: 1IU / short acting insulin should be added to each of the target blood glucose levels of around 1.7mmol/L.Adjust the dose every 12 days.24 hours a day, 6 times the average value of blood glucose 12 mmol/L, the total dose should be increased by 10%; the averag
11、e value of blood sugar 6 mmol/L, the total dose should be reduced by 10%.After injection of insulin 2 hours after the finger blood glucose, 4, mmol/L, the corresponding pre prandial insulin injection should also be reduced by 10%Selection of insulin regimens for various types of diabetesType 1 diabe
12、tes mellitus: the preferred insulin intensive regimen,Intensive treatment is the treatment of simulated insulin secretion, which is the most effective and easiest to control glycemic standard, and is most easily controlled by dosage. More than 50% of patients selected premixed insulin. Premixed insu
13、lin is different from the aging effect of insulin in accordance with a certain proportion of pre mixing, easy to use, but because of the fixed proportion, it is not easy to be dose adjustment, thus reducing the efficacy and effect of blood glucose. Patients with type 1 diabetes should be treated wit
14、h intensive treatment as early as possible, and good glycemic control may help to reduce complications.Type 2 diabetes: early insulin treatment should be appropriateEarly insulin use in type 2 diabetes protects beta cell recovery, prolongs and even reverses beta cell function decay, and improves pro
15、gnosis. Combination therapy in selected patients with oral antidiabetic drugs + insulin (BIDO scheme), but few short duration high blood glucose in normal weight patients, oral hypoglycemic drugs in case of poor results, with intensive insulin treatment for a period of time,Can completely stop the d
16、rug, only diet control can maintain normal blood sugar.When type 1 and type 2 diabetes are identified differently, it is better to be treated with insulin according to type 1.Types, characteristics and indications of existing insulinAt present, the commonly used insulin can be divided into three kin
17、ds: short acting (quick), medium effect and long-acting.1, short acting insulin, that is, our common insulin. It is a transparent, acidic liquid, which takes effect after half an hour of subcutaneous injection. It works best for 2 to 4 hours and keeps for 6 hours. If intravenous injection is effecti
18、ve immediately, intravenous insulin is usually administered at the time of acute metabolic disorder in diabetes mellitus.2, medium acting insulin, or neutral protamine zinc insulin (NPH), is a white suspension of insulin that can only be used for subcutaneous injection. The medicine began to act 3 -
19、 4 hours after subcutaneous injection, with the strongest effect in 8 - 12 hours, and the effect lasted for 18-24 hours.3, long acting insulin, protamine zinc insulin (PZI), is also a white suspension, which, like neutral insulin, can only be injected subcutaneously and cannot be used intravenously.
20、 The drug began to act 3-4 hours after subcutaneous injection, with the strongest effect for 14-20 hours and maintained for 24-30 hours.Indications for the use of insulin therapy are:1, all type I diabetes mellitus.2 and type 2 diabetes mellitus were treated with diet and oral antidiabetic drugs, an
21、d those who had not been well controlled by physical exercise and diet therapy could also be treated with insulin directly.3 diabetes acute metabolic disorders: ketoacidosis, hyperosmolar coma and lactic acidosis.4, patients with diabetes mellitus complicated with severe infection or wasting disease
22、, complications, such as retinopathy, neuropathy, glomerular sclerosis, or complicated with acute myocardial infarction and cerebrovascular accident are suitable syndrome of insulin treatment.5 diabetic patients with surgical disease, perioperative.6 diabetes patients include gestational diabetes me
23、llitus, pregnancy and delivery.7 malnutrition associated diabetes.The insulin therapyInsulin is the hormone secreted by beta cells of the human pancreatic islet, and new insulin formulations have been produced since it was extracted in 1922,Diabetes treatment has been significantly improved, especia
24、lly in patients with type 1 diabetes, significantly longer life.Types of insulinThey are divided into bovine insulin, porcine insulin and human insulin. At present, the classification is mainly based on the duration of efficacy;The short acting insulin, rapid onset and short duration of action. Comm
25、on (regular) insulin, crystalline zinc, insulin, and semi slow insulin are short acting insulin, which are transparent.The effect of insulin on the onset time, peak value and action time is long short acting insulin. The NPH and the slow acting insulin belong to the medium effect insulin.The long-ac
26、ting insulin, slow onset, longer effect, but no peak. PZI (protamine zinc insulin) and extra slow insulin are long-acting insulin.Indications for insulin therapyThe type 1 diabetes mellitusThis is the main indication of insulin. Whether there are any acute or chronic complications, lifelong insulin
27、replacement therapy is required and should not be terminated abruptly.The type 2 diabetes mellitus1, complicated with diabetic ketoacidosis, diabetes mellitus, hyperosmolar coma, lactic acidosis;2, accompanied by serious heart, liver, kidney, brain and eye acute or chronic complications;3, after die
28、t control, adequate exercise and adequate oral hypoglycemic drugs failed, and the course of disease is long, the decline of pancreatic function;4, trauma, surgery, acute or chronic infection and other stress state;5, diabetes patients in pregnancy, in order to avoid fetal congenital malformations, t
29、he use of insulin treatment.6, early onset of diabetes type 2, especially lean type.The other: secondary diabetes mellitus, insulin gene mutation diabetes etc.The use of insulin(1) how to estimate its initial dosage?:Patients with diabetes should be treated with short acting insulin at the start of
30、insulin use. Moreover, it must be relatively stable on the basis of diet and exercise,Estimate the initial dosage according to the following methods and then adjust them according to the condition monitoring result.1, according to fasting blood sugar estimation:The daily dosage of insulin (U N) fast
31、ing blood glucose (mg/dl-100) x 10 x weight (kg) x 0.6 / 1000 / 2;Note: 100 for normal blood sugar; higher than normal blood glucose * 10 conversion per liter of fluid; * 0.6 is the body fluid volume is 60% / 1000; blood glucose mg is converted to 2 grams, 2 grams of glucose; using 1 insulin. In ord
32、er to avoid hypoglycemia, the actual amount of 1/2-1/3 is used.2, according to 24 hour urine estimation: no light condition, diabetic nephropathy, renal glucose threshold of normal, per 2 grams of glucose to 1 mu insulin.3, according to weight calculation: blood sugar is high, the condition is heavy
33、, 0.5-0.8 mu /Kg; the condition is light, 0.4-0.5 mu /Kg; the condition is heavy, stress state should not exceed 1 mu /Kg.4, according to 4 estimates: no glycosuria diabetic nephropathy, renal glucose threshold is basically normal, according to the qualitative urine before each meal + estimated, usu
34、ally a + to 4 mu insulin.5, comprehensive estimation: there are many factors in vivo effects of insulin action, individual differences, the calculation may not be consistent with the actual condition, it should be comprehensive, blood glucose and urine glucose, first to a certain amount, and then ac
35、cording to the condition changes gradually adjust.(two) how to allocate insulin dosage?:According to these estimates, daily meals 1530 minutes before injection, to assign to before breakfast, lunch, dinner before bedtime, before the amount, because the hormone before breakfast in vivo antagonizes in
36、sulin secretion is more, so the amount of insulin should be larger; and short acting insulin with the peak time of 24 hours, so before lunch the smallest amount; most of the patients sleep no longer use insulin, and then to the next morning, so before dinner and lunch than before a large amount of.
37、Such as before going to bed once, then before dinner to reduce, and before bedtime use less, in case of nocturnal hypoglycemia.(three) how to adjust insulin dosage?:In the estimation of initial amount of observation for 23 days, further adjust the dosage according to the disease, blood glucose and u
38、rine glucose to.1, according to the 4 qualitative urine adjustment, applies only to the unconditional and blood glucose in patients with normal renal glucose threshold. Adjusted on the basis of the 4 qualitative urine 34 days before the amount of insulin before breakfast before lunch before lunch on
39、 urine glucose, insulin dosage according to urine before dinner, dinner according to the amount of insulin before bedtime or the next morning urine (including the urine).2, according to blood sugar adjustment: diabetes patients, especially type 1 diabetes and kidney sugar threshold abnormal patients
40、, should be based on three meals before and after bedtime blood sugar value to adjust the amount of insulin, see the table below:?Glycemic index, mmol/L, mg/dl, pre prandial insulin, decrement, other treatment 2.8 50, reduce 23, eat immediately2.83.9 5070 reduces 12 Mu3.97.2 70130 primary dose7.28.3
41、 130150 plus 1 mu8.311.1 150200 plus 2 mu11.113.9 200250 plus 3 mu13.916.6 250300 plus 46 MuThe amount of 16.619.4 300350 plus 810 was increased and decreased before meal12 min or meal; pre mealMomentum reduction, plus 12 MuNotes on insulin injectionsDiabetes is a lifelong disease, insulin treatment
42、 is a long-term treatment, and even many times a day to inject, so patients must pay attention to their own, master the injection of insulin, skilled injection skills.(I) preparation before injection:1. Prepare the necessary equipment and articles: insulin treatment is a long-term treatment, even a
43、day of repeated injections, so there are many types of patient syringes, such as 1ml glass syringes, 1ml disposable plastic syringes.2, check the insulin preparation: whether in the validity period, whether sealed, lossless. Short acting insulin should be clarified. If cloudy, it can not be used, wh
44、ile medium and long acting insulin is normal.When you use the long-acting insulin, you should mix the insulin evenly and put it between your hands, rub it gently, and dont push it up and down.3, the choice of insulin injection site:(1) the choice of injection site is not only related to the absorpti
45、on of drugs and complications, but also relieves pain,Conducive to long-term treatment.(2) the best part of human subcutaneous injection: the upper buttock, the anterolateral, the lower limb, the outside of the bone, the 1/4 area outside the hip (i.e. intramuscular injection site), the abdomen (arou
46、nd the navel and around the waist), the abdominal absorption of the fastest.(3) if you need to exercise immediately after injection, you should avoid injections in the upper and lower limbs, so as to avoid excessive absorption, causing hypoglycemia.(4) alternate injection sites: divide each injectio
47、n into the area of 2 * 2cm, so around the turn of injection, avoid continuous injection in the same box inside.4, pumping insulin: wash hands after disinfection with alcohol gum cover, remove poison after pumping syringe, the right amount of air, the needle bolt is pushed to the scale of the first i
48、nsulin, insulin bottle upward, the syringe into the bottle, into the air, and then inverted the insulin bottle down gently, accurate scale pull out the needle bolt to the required dose of insulin.Such as mixing two kinds of insulin, must first smoke short effect, after pumping in, long-term effect, otherwise short effect mixed with medium and long acting insulin will be muddy appearance, efficacy is