A friend left me a message saying: Dr. Zhang, I have type 2 diabetes, the doctor actually prescribed me 3 kinds of hypoglycemic drugs, is this reasonable? Today we will talk about this aspect.
Type 2 diabetes mellitus is a clinically common noncommunicable disease of glucose lipid metabolism disorders due to impaired insulin secretion or insulin resistance. Poorly controlled blood glucose levels can easily lead to chronic complications, common ones are coronary heart disease, angina, myocardial infarction, kidney failure, cerebral infarction, blindness, malignant tumors, etc.
<h1 class="pgc-h-arrow-right" > what are the causes of type 2 diabetes? </h1>
Blood glucose compliance is key to preventing complications of type 2 diabetes. Early strict glycemic control reduces macrovascular and microvascular complications. Moreover, this benefit is carried over to subsequent treatments, known as the "metabolic memory" effect.
Therefore, type 2 diabetes requires early and long-term blood glucose standards to effectively reduce the occurrence of complications. Studies have shown that the blood glucose compliance rate of type 2 diabetes patients in China is only 32.6%.
Type 2 diabetes involves multiple tissues, organs, and hormones, and has complex mechanisms. There are at least 8 pathophysiological abnormalities also known as "octets", including:
Decreased insulin β cell function;
Decreased glucose uptake in muscle tissue;
Increased glucose output from the liver;
Abnormal lipid metabolism;
Weakening of the incretin-stimulating effect;
Elevated glucagon levels;
The kidneys deal with glucose disorders;
Neurotransmitter dysfunction.
Although there are many kinds of current hypoglycemic drugs, there is no drug that can completely control blood sugar from 8 mechanisms.
< h1 class="pgc-h-arrow-right" why is it recommended to combine hypoglycemic drugs > for type 2 diabetes mellitus? </h1>
Treatment of type 2 diabetes relies primarily on lifestyle modifications and taking hypoglycemic medications. In the past, friends used to take a single hypoglycemic drug (mainly metformin) to control blood sugar, but with the advancement of medicine, doctors found that the blood glucose compliance rate was very low with a single hypoglycemic drug.
For this reason, the American Association of Endocrinologists/American Endocrinology Society recommends that diabetic patients with high glycosylated hemoglobin should adopt a combination therapy regimen.
Therefore, doctors began to treat patients with two hypoglycemic drugs, but after 6 months of observation, it was found that 40% to 60% of patients still had glycosylated hemoglobin that did not meet the standard. Moreover, with the extension of time, the compliance rate will decrease significantly. A third drug was added to this end, and it was found that the hypoglycemic effect could be significantly improved. It will also generate more additional benefits.
Therefore, for patients with type 2 diabetes mellitus with glycosylated hemoglobin greater than 9%, the initiation of triple therapy can control blood glucose levels in the short term, make blood glucose meet the standard and achieve long-term control, effectively reducing the occurrence of complications. At present, the use of triple hypoglycemic drugs has become more common in patients with type 2 diabetes.
<h1 class="pgc-h-arrow-right" > which 3-link hypoglycemic reduction scheme is recommended by Dr. Zhang? </h1>
Metformin is a first-line hypoglycemic agent recommended by numerous guidelines and is usually based on metformin when combined. There are currently at least 10 treatment options based on metformin.
In the 2021 Chinese expert consensus on the optimization scheme of oral hypoglycemic drugs in adult patients with type 2 diabetes mellitus, it is recommended that the use of metformin + dipeptyl peptidase 4 inhibitor (so-and-so statin) + sodium-glucose co-transporter 2 inhibitor (so-and-so columnin). Dr. Zhang is more respectful of this plan. Because these three drugs are used in combination, they can complement each other in the mechanism of action.
Metformin exerts hypoglycemic effect by inhibiting hepatic gluconeogenesis, reducing hepatic sugar output and intestinal absorption of glucose, increasing the uptake of glucose by peripheral tissues, inhibiting lipolysis and reducing free fatty acids.
The mechanism of action of dipeptidyl peptidase 4 inhibitors is to stimulate insulin secretion, inhibit glucagon secretion, thereby inhibiting liver glucose output, and promoting the use of glucose by the liver and muscles to exert hypoglycemic effects.
Sodium-glucose co-transporter 2 inhibitors lower blood sugar by inhibiting the reabsorption of glucose by the kidneys and promoting the excretion of glucose in the urine. Moreover, this mechanism of action does not depend on insulin and does not cause a hypoglycemic reaction.
We can see that the mechanism of action of the 3 drugs is different, therefore, the complementarity of the effects is achieved in the hypoglycemic effect, thereby enhancing the hypoglycemic effect.
The 3 hypoglycemic drugs act on multiple targets, covering 7 targets of diabetic pathophysiology, and have a good hypoglycemic effect on the vast majority of patients with type 2 diabetes.
At present, the time for the application of triple hypoglycemic drugs has been greatly advanced. The consensus is that if after three months of adequate metformin monotherapy, glycosylated hemoglobin is still higher than 1% to 2% of the target value, and if there is no contraindication or intolerance, triple therapy can be carried out.
For metformin + insulin therapy, glycosylated hemoglobin has reached the standard patients, in order to reduce the risk of hypoglycemia, and to achieve the purpose of cardiovascular and renal function protection, can be converted to triple hypoglycemic drugs. Not only, effectively reduce glycosylated hemoglobin, treatment for 52 weeks, blood glucose control is still satisfactory, moreover, reduce body weight, there is no risk of hypoglycemia, hypoglycemic effect is comparable to metformin + insulin effect.
What are the benefits of <h1 class="pgc-h-arrow-right" >? </h1>
The combination of 3 drugs also has many unexpected benefits, mainly in 5 aspects:
Low risk of hypoglycemia: 3 drug combination therapy does not increase the risk of hypoglycemia while lowering glucose, and can also reduce blood glucose fluctuations. Blood glucose fluctuations are more damaging to organs than prolonged increased blood sugar. Therefore, triple therapy can achieve a good protective effect.
Organ protection: sodium-glucose-for-transporter 2 inhibitors may reduce the risk of cardiovascular events and have a significant protective effect on the heart. There are also reports that triple drugs can protect the heart and kidneys at the same time.
Protection of islet function: islet is an important structure of insulin secretion, triple medication by improving high blood sugar, reducing the load of islet β cells, indirectly protect the function of β cells, reduce the apoptosis of β cells, effectively save the number of β cells, thereby effectively delaying the progression of the disease.
Additional benefits: In addition to lowering blood sugar, the combined application of these 3 drugs can also reduce weight, lower blood pressure, and reduce the fat content of the liver and internal organs, resulting in a variety of additional benefits.
Easy to use: At present, these 3 drugs have long-acting preparations, so it is very convenient to use. There are already 2 kinds of drug compound preparations in China, and there are already 3 kinds of drug compound preparations in the world.
It is precisely because of the existence of these advantages that more and more friends use this program to control their blood sugar.
< h1 class="pgc-h-arrow-right" > summary</h1>
For most people with diabetes, getting their blood sugar up to date early and staying stable for a long time is key to preventing complications. The use of triple hypoglycemic drugs can effectively achieve this goal and is of great help in the treatment of diabetes.
Today's question we will talk about here, if it is helpful to you, please pay attention to me, I will take you to understand the most cutting-edge medical knowledge in China. I'm Dr. Zhang, see you next time.
bibliography
［1］ Holman RR，Paul SK，Bethel MA ，et al. 10‐year follow‐up of intensive glucose control in type 2 diabetes. N Engl J Med， 2008，359：1577‐1589.
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