Volume 14 · Issue 11 · 2022

Type 1 diabetes mellitus (T1DM) is difficult to treat and manage due to pancreatic islet failure and absolute insulin deficiency. In the past decade, important progress has been made in the research of T1DM at home and abroad, and the Guidelines for the Diagnosis and Treatment of Type 1 Diabetes in China (2021 Edition) came into being. The 2021 edition of the guidelines is updated and revised on the basis of the first "Guidelines for the Diagnosis and Treatment of Type 1 Diabetes in China" in the 2012 edition, emphasizing individualized precise diagnosis and treatment, promoting the comprehensive application of new knowledge, new concepts, new technologies and new methods, aiming to standardize the diagnosis, treatment and comprehensive management of T1DM in China, improve the control and prevention of T1DM, its blood glucose and complications, and continuously improve the quality of life of patients.

With the expansion of hypoglycemic drugs and the accumulation of clinical research evidence, the treatment concept of type 2 diabetes is constantly evolving from simple hypoglycemic orientation to individualized, comprehensive and patient-centered direction. A large number of efficacy and cardiovascular outcome trial evidence of glucagon-like peptide-1 receptor agonist (GLP-1RA) has driven its rising status in diabetes management guidelines at home and abroad. The author will analyze the reasons and evidence-based evidence for the promotion of GLP-1RA in the guidelines from the perspective of patient-centered treatment concept.

Glucagon-like peptide-1 receptor agonist (GLP-1RA) has pleiotropic protection against diabetic microangiopathy. The author mainly expounds the protective mechanism and clinical research progress of GLP-1RA on diabetic nephropathy, diabetic retinopathy and diabetic peripheral neuropathy. The renal protective mechanisms of GLP-1RA include anti-inflammatory and anti-oxidative stress; Regulate electrolyte balance and promote urinary sodium excretion; Improve hemodynamics and relieve hyperfiltration; It inhibits the formation of renal fibrosis and is influenced by multiple metabolic factors. However, the complex mechanism behind the protection of GLP-1RA diabetic microvascular lesions still needs to be further explored, and more clinical studies are still needed to elucidate.

With the 10-year development and progress of science and technology, significant advances have been made in the field of type 1 diabetes from both domestic and international countries. The emergence of new technologies such as blood glucose monitoring, the evidence of clinical research has been accumulated and enriched. Therefore, the Chinese Diabetes Society, the Chinese Endocrinologist Association, the Chinese Society of Endocrinology, and the Chinese Pediatric Society, have jointly organized experts to update the 2012 edition of guideline for the diagnosis and treatment of type 1 diabetes mellitus in China, and to apply as much high-grade Chinese evidence as possible to develop the guideline for the diagnosis and treatment of type 1 diabetes mellitus in China (2021 edition). The new version guideline includes 20 chapters covering the epidemiology, diagnosis and classification, glucose monitoring, education and management, insulin therapy, medical nutrition therapy, exercise therapy, pancreas and islet transplantation, prevention and treatment of hypoglycemia, acute and chronic complications, clinical management in special stages, psychosocial issues and countermeasures of type 1 diabetes, as well as prediction and prevention. The promulgation of this guideline will help further standardize practical management for type 1 diabetes, and improve patients′ quality of life and clinical outcomes.

To investigate the impact of hemoglobin glycation index (HGI) on the diagnosis of diabetes mellitus.

Using the baseline data from the Risk Evaluation of Cancers in Chinese Diabetic Individuals: a longitudinal (REACTION) study, 9 705 participants with complete data, who were selected from Pingguoyuan community of the Shijingshan district in Beijing between January and August 2012, received questionnaires, physical examination and laboratory tests. Laboratory tests consisted of fasting plasma glucose (FPG), glycated hemoglobin A_1c (HbA_1c), 2-hour plasma glucose (2hPG), and lipid profile. A linear regression equation was fitted based on the scatter plots of HbA_1c against FPG. The HGI was then calculated as the difference between the measured HbA_1c value and that predicted by plugging FPG in the above equation (HGI=measured HbA_1c-predicted HbA_1c). Ultimately, 8 480 participants of aged ≥ 40 years and no history of diabetes were included in the final analysis. The participants were categorized into three groups according to tertiles (low, moderate and high) of HGI. We compared the prevalence of diabetes among the three HGI groups with chi-square test, using HbA_1c and oral glucose tolerance test (OGTT) criteria respectively, and examined the diagnostic concordance between the two measures by Cohen′s kappa test. Factors associated with the high HGI phenotype were identified by order multi-classification logistic regression model.

Participants were categorized into three groups according to their HGI values: low HGI (HGI<-0.197 3, 2 841 cases) group, moderate HGI (-0.197 3≤HGI<0.135 9, 2 979 cases) group, and high HGI (HGI≥0.135 9, 2 660 cases) group. Among patients with diabetes detected by HbA_1c alone, the high HGI group accounted for 74.8% (677/905), which was much higher than the moderate (15.5%, 140 cases) and the low (9.7%, 88 cases) HGI groups. The agreement between HbA_1c and OGTT for the diagnosis of diabetes was poor (κ=0.488), which was mostly influenced by HGI. The high HGI phenotype was correlated with age, female gender, body mass index, low-density lipoprotein cholesterol, 2 h plasma glucose during an OGTT, and lipid-regulating drug.

Using HbA_1c alone for diagnosis could lead to overdiagnosis in high HGI patients and underdiagnosis in low HGI patients.

To evaluate the relationship between different obesity indexes and the risk of diabetic kidney disease (DKD) in patients with type 2 diabetes mellitus (T2DM), and to compare their predictive effects on DKD.

This study was a prospective cohort study. We selected the patients with T2DM who received regular physical examinations from the database of 6 centers of the Lee United Clinic in Taiwan, China from January 1, 2006 to December 12, 2019. General patients′ data and laboratory examination indicators were collected, and body mass index (BMI), waist hip rate (WHR), lipid accumulation product (LAP), visceral adiposity index (VAI), and body roundness index (BRI) were calculated. Patients were divided into either DKD or no DKD (NDKD) groups based on their DKD status at the end of follow-up. Differences between both groups were compared by t test, Mann-Whitney U test or χ² test. Cox regression analysis was used to assess the relationship between five indicators of obesity and the occurrence of DKD. Receiver operating characteristic (ROC) curve was used to analyze the effectiveness of obesity indicators in predicting DKD risk.

A total of 2 628 patients with T2DM were enrolled. After a mean follow-up of (7.53±3.10) years, 840 patients with DKD were detected, with a detection rate of 31.9%. Compared with NDKD group (1 788 cases), DKD group had more male patients, older patients, higher proportion of hypertension, longer course of diabetes and more patients without hypoglycemic treatment (all P<0.05). Cox regression analysis showed that BMI, WHR, VAI, LAP, BRI were closely correlated with DKD after adjusting confounding variables (P<0.05). The ROC curve results showed that among the five obesity indicators, LAP had a better effect on predicting DKD [area under curve (AUC)=0.616, 95%CI 0.592-0.639], while BMI was the weakest (AUC=0.550, 95%CI 0.526-0.574). There was statistically significant difference between traditional obesity indicators (BMI, WHR) and new obesity indicators (LAP, VAI, BRI) AUC (P<0.05).

BMI, WHR, VAI, LAP, and BRI increase the risk of DKD in patients with T2DM, and LAP has a better effect on predicting the DKD.

To investigate the predictive effect of remnant cholesterol (RC) on early diabetic kidney disease (DKD).

A total of 978 patients with type 2 diabetes mellitus (T2DM) who were hospitalized in the Department of Endocrinology, Affiliated Hospital of Xuzhou Medical University from January 2020 to July 2021 were retrospectively collected and divided into training set (685 cases) and test set (293 cases) by simple random sampling method with 7∶3 ratio. The general data and laboratory parameters of the subjects were collected, and the RC and urinary albumin to creatinine ratio (UACR) were calculated. In the training set, Spearman correlation was used to analyze the correlation between RC and UACR and renal function indexes, and receiver operating characteristic curve (ROC) was used to analyze the clinical value of each lipid index in predicting early DKD. Univariate logistic regression analysis was performed for each clinical variable, and univariate significant variables were included in multivariate stepwise regression analysis. The selected variables were used to construct the nomogram and verified in the test set. The area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow test and decision curve analysis (DCA) were used to evaluate the efficacy of nomogram.

In the training set, Spearman correlation analysis showed that RC was positively correlated with UACR (r=0.418), urinary α1-microglobulin (r=0.124), serum creatinine (r=0.128) and uric acid (r=0.292) (all P<0.001). The AUC of RC for predicting early DKD was 0.779 (95%CI 0.746-0.810), the sensitivity was 65.90%, the specificity was 72.85%, and the best diagnostic value was 0.81 mmol/L. Multivariate stepwise regression analysis showed that diabetic retinopathy (OR=1.778, 95%CI 1.170-2.702), duration of diabetes (OR=1.05, 95%CI 1.024-1.076), systolic blood pressure (OR=1.009, 95%CI 1.001-1.018), glycated hemoglobin (OR=1.163, 95%CI 1.065-1.270), uric acid (OR=1.002, 95%CI 1.000-1.005), RC (OR=1.860, 95%CI 1.389-2.491) were the influencing factors of early DKD in T2DM patients, and the differences were statistically significant (all P<0.05). The AUC (95%CI) of ROC curve for predicting the risk of early DKD in patients with T2DM in the training set and the test set were 0.740 (0.698-0.782) and 0.737 (0.666-0.808), respectively. Hosmer-lemeshow test showed that the nomogram model had a good fit (χ²=12.16, P=0.144). The DCA method showed that the net benefit of predicting the risk of early DKD in T2DM patients was higher when the probability of early DKD risk threshold was between 8%-58% and 10%-50% in the training and test sets, respectively.

RC has a high predictive value for early DKD. The constructed nomogram can better predict the occurrence of early DKD.

To explore the effect of hypoglycemia on self-management behavior and its function route in patients with type 2 diabetes mellitus (T2DM).

This study was a cross-sectional study. A total of 1 180 patients who were hospitalized in Tianjin Medical University Chu Hsien-I Memorial Hospital from March to August 2019, were investigated by convenient sampling. The subjects were surveyed by the questionnaires including the self-designed General Demographic Information Questionnaire, the Chinese version of Hypoglycemia Fear Survey Ⅱ-Worry Scale (CHFSII-WS), hypoglycemia perception impairment-Gold method, and the Summary of Diabetes Self Care Activities (SDSCA). The path analysis model was conducted to explore the relationship between hypoglycemia and self-management behavior in T2DM patients. The t test and one-way analysis of variance (ANOVA) were used for comparison between groups. Multiple linear regression analysis was used to analyze the impact of hypoglycemia on self-management with T2DM. The path analysis was conducted using AMOS 22.0 software. Nonparametric percentile Bootstrap method of bias correction was adopted to test indirect effects.

The total score of SDSCA was (32.1±14.2) points. Single factor analysis showed that the scores of self-management behavior in T2DM patients was significantly associated with the frequency of hypoglycemia, type of hypoglycemia, hypoglycemia prevention education, fear of hypoglycemia, hypoglycemia awareness state (all P<0.001). Multiple linear regression analysis showed that pseudo-hypoglycemia, documented symptomatic hypoglycemia, hypoglycemia prevention education and the scores of CHFSII-WS≥10 points, no experience of hypoglycemia were the influencing factors of self-management behavior (β=-0.216-0.218, all P<0.05) in T2DM patients. Hypoglycemia prevention education, hypoglycemia types had direct and indirect effects on the self-management behavior of T2DM patients, with the total effect values of 0.257 and 0.177, respectively. The effect value of fear of hypoglycemia had a direct effect of 0.155, and the effect value of hypoglycemia awareness state had an indirect effect of 0.032.

Hypoglycemia prevention education, hypoglycemia types, fear of hypoglycemia and hypoglycemia awareness state have a positive effect on the self-management behavior of T2DM patients.

To establish and validate a nomogram prediction model for acute ischemic stroke in patients aged 60 years and over with type 2 diabetes mellitus (T2DM).

A retrospective analysis was performed on 445 T2DM patients hospitalized in the Department of Geriatrics and Neurology, Lanzhou University Second Hospital from January 2018 to August 2021. Patients were divided into modeling group and validation group according to 3∶1 ratio. A total of 334 patients treated from January 2018 to August 2020 were selected as the modeling group. We screened for the best predictors of acute ischemic stroke in elderly T2DM patients by Lasso regression. The R software was used to construct the nomogram model. The Bootstrap method was used to internal verification, and to draw receiver operating characteristic (ROC) curve. The C-index was calculated to evaluate the predictive performance of the nomogram model. A total of 111 elderly T2DM patients from September 2020 to August 2021 were enrolled as the validation group, external verification of the nomogram model. The calibration curves were drawn and C-index, brier score, calibration intercept and calibration slope were calculated.

In the modeling group, Lasso combined with logistic regression analysis showed that diabetes mellitus with hypertension course(OR=1.05, 95%CI 1.01-1.10), systolic blood pressure (OR=2.40, 95%CI 1.74-3.40), high monocyte to high-density lipoprotein-cholesterol ratio (OR=1.34, 95%CI 1.14-1.58), free triiodothyronine (OR=0.36, 95%CI 0.20-0.64), carotid artery plaque area (OR=1.45, 95%CI 1.19-1.79), degree of intracranial arterial stenosis (OR=4.77, 95%CI 2.60-9.81) were the best predictors of acute ischemic stroke in elderly T2DM patients. ROC curve results showed that the C-index of the modeling group was 0.862 (95%CI 0.824-0.900), internal verification was carried out by Bootstrap method, the C-index corrected to 0.852 (95%CI 0.812-0.895), the sensitivity was 80.1%, and the specificity was 76.1%. The C-index of external validation was 0.867 (95%CI 0.803-0.932), the sensitivity was 82.0%, and the specificity was 75.4%. The Brier-score was 0.149, the calibration intercept was -0.149, and the calibration slope was 1.096.

The nomogram prediction model constructed in this study has good discrimination and calibration, which has good value for early prediction of acute ischemic stroke in elderly patients with T2DM.

To systematically review the efficacy and safety of dual glucagon-like peptide-1 (GLP-1)/gastric inhibitory polypeptidel (GIP) receptor agonist Tirzepatide in the treatment of type 2 diabetes mellitus (T2DM), and to provide evidence-based references for clinical rational drug use.

Databases including PubMed, Embase, the Cochrane Library, Web of Science, Sinomed, CNKI, WanFang Data and VIP database were searched to collect the randomized controlled trials (RCT) about the efficacy and safety of dual GLP-1/GIP receptor agonist Tirzepatide in the treatment of T2DM (inception to April, 2022).

A total of 6 RCT involving 6 528 patients with T2DM were included. The results of meta-analysis showed that compared with placebo, GLP-1 receptor agonist (GLP-1RA) and insulin, Tirzepatide could effectively reduce the level of glycated hemoglobin A_1c (HbA_1c) [the weighted mean difference (WMD) of placebo group, GLP-1RA group and insulin group were -1.84% (95%CI -2.05%--1.63%), -0.61% (95%CI -0.83%--0.39%) and -0.90% (95%CI -1.06%--0.75%), respectively, all P<0.01], reduce fasting serum glucose (FSG) level [the WMD of placebo group and GLP-1RA group were -2.79 mmol/L (95%CI -3.49--2.09 mmol/L) and -0.93 mmol/L (95%CI -1.28--0.58 mmol/L), respectively, both P<0.01], increase the rate of HbA_1c compliance [The odds ratio (OR) of placebo group, GLP-1RA group, and insulin group were 32.36 (95%CI 24.10-43.44), 2.33 (95%CI 1.59-3.44), 5.71 (95%CI 3.99-8.18), respectively, all P<0.01]. In addition to the hypoglycemic effect, Tirzepatide could also reduce body weight, blood pressure, and blood lipids levels. Compared with the control group, the incidence of hypoglycemia, drug allergy and serious adverse reactions in the tirzepatide group did not increase during the treatment, but the incidence of gastrointestinal adverse reactions in the tirzepatide group was higher than that in the control group(P<0.05).

Tirzepatide is able to reduce the levels of HbA_1c, FSG and body weight, to improve the compliance rate of HbA_1c, and to reduce blood pressure and blood lipid levels, however, it does not increase the incidence of hypoglycemia, drug allergy and serious adverse reactions.

A case of adult type 3 diabetes mellitus with adolescent onset caused by heterozygous mutation of hepatocyte nuclear factor 1 α gene c.1137delT p.Val379fs is reported. The patient, a 28-year-old female, was admitted to hospital with the main complaint of "blood sugar increased for 4 and a half years and visual acuity decreased for 3 and a half years". She was blind in her left eye and had no light sensation. After a clear diagnosis, the glucose control regimen was adjusted to gliquidone and saxagliptin combined with night long-acting insulin to control blood sugar, and it is now well controlled. Patients' retinopathy progresses rapidly, and special attention needs to be paid to the screening, diagnosis and treatment of ocular complications in such patients.

One case was reported in this articleGATA6Clinical characteristics of adolescent onset diabetes mellitus caused by heterozygous mutations in genes and review of the literatureGATA6Case characteristics of diabetes mellitus with genetic mutations. A 16-year-old male with a 6-year diagnosis of type 1 diabetes mellitus and a history of congenital heart disease was analyzed by whole exon sequencing and verified by Sanger sequencing. Gene sequencing results showed that the patientGATA6There was a heterozygous mutation of c.1367G>A in exon 4 of the gene, and the same mutation was not found in the parents of the patient, which was a spontaneous mutation. Further imaging examination revealed partial pancreatic hypoplasia and absence of gallbladder. The patient had frequent hypoglycemia and positive insulin autoantibodies during insulin use, and was considered to be complicated with exogenous insulin autoimmune syndrome. The above results provide ideas for clinicians to diagnose juvenile onset diabetes with multiple organ damage, and avoid misdiagnosis and misdiagnosis.

To report the diagnosis and treatment of a patient with chronic severe renal insufficiency and poor glycemic control treated with semaglutide. The patient was a 49-year-old male diagnosed with type 2 diabetes mellitus (T2DM) for 18 years. The condition was complicated and he had severe renal insufficiency. Under the condition that oral hypoglycemic drugs, insulin and oral sodium-glucose cotransporter 2 inhibitors were not effective, the patient was treated with semaglutide for 40 days, and the blood glucose and glycosylated hemoglobin reached the standards, and oral hypoglycemic drugs and short-acting insulin were stopped. At the same time, the effects of weight loss, lipid reduction and blood pressure reduction were achieved. The progressive deterioration of the patient's renal function was changed. The diagnosis and treatment of this patient reminds us that for patients with T2DM, the multiple protective effects of long-acting glucagon-like peptide-1 receptor agonist make it meet the needs of integrated treatment of renal failure, and it is an effective, safe and convenient medication choice for patients with severe renal insufficiency.

This article retrospectively analyzed the diagnosis and treatment process of a patient with type 2 diabetes mellitus complicated with multiple cardiovascular diseases who was treated with oral hypoglycemic drugs and switched to semaglutide, a weekly preparation of long-acting glucagon-like peptide-1 (GLP-1) receptor agonist, after being treated with oral hypoglycemic drugs, and reviewed the literature. The patient was a 56-year-old male who was admitted to the hospital because he "found that his blood sugar was elevated for 18 years and his blood sugar was not well controlled for half a month". After admission, various examinations were completed and he was clearly diagnosed with type 2 diabetes mellitus complicated with multiple atherosclerotic cardiovascular diseases. Insulin pump combined with oral metformin hypoglycemic therapy, gradually simplified regimen to metformin 0.5 g, 3 times/d, semaglutide 1 mg, 1 time/week, blood glucose control was good, the patient was satisfied. Semaglutide is a new long-acting GLP-1 receptor agonist, which can achieve the goal of smooth hypoglycemic use in combination with other oral hypoglycemic drugs, and once-a-week use is compared with short-acting preparations of GLP-1 analogs. Patients have good compliance and bring more benefits to patients with combined hypertension and cardiovascular disease.

A patient with long-course type 2 diabetes mellitus (T2DM) at high risk of cardiovascular disease (CVD) who was hospitalized in the Department of Endocrinology and Metabolism of Henan Provincial People's Hospital was treated with liraglutide and semaglutide after intensive insulin therapy was retrospectively analyzed and the literature was reviewed. The patient was a 60-year-old female with obesity, hypertension and dyslipidemia. She had a history of T2DM for 15 years. After long-term insulin hypoglycemic therapy, pancreatic islet function and CVD risk were assessed, the treatment plan was adjusted to liraglutide (1.2 mg/d), combined with metformin 0.5 g (3 times/d) and canagliflozin 100 mg (1 time/d) at discharge. During the follow-up period, liraglutide was adjusted to semaglutide 0.5 mg (once/week). After 3 months of observation, the patient's blood glucose was stable, the body weight was up to standard, and the compliance was good. For patients with T2DM with high risk factors for CVD or atherosclerotic cardiovascular disease, the long-acting glucagon-like peptide-1 receptor agonist (GLP-1RA) semaglutide can be combined with other hypoglycemic drugs to simplify medication, steadily lower glucose, and achieve CVD benefits at the same time.

A patient with newly diagnosed type 2 diabetes mellitus (T2DM) with obesity who was switched to semaglutide for oral medication in the Department of Endocrinology of Zhongshan Hospital affiliated to Xiamen University was reported. A 26-year-old female patient saw a doctor mainly for "irregular menstruation, and blood sugar was found to rise for 7 months". Family history of hereditary disease denied. Fasting venous plasma glucose>7.0 mmol/L, glycosylated hemoglobin>6.5%, body obesity, body mass index 31.9 kg/m²No family history of diabetes, no symptoms of "three more and one less" during the course of the disease, no tendency to diabetic ketoacidosis, and negative diabetes-related antibodies, no obvious abnormalities in thyroid function, parathyroid function, circadian cortisol rhythm, renin-angiotensin-aldosterone system, sex hormones, etc., and the diabetes classification diagnosis was T2DM. The patient refused intensive insulin therapy, added semaglutide to the oral medication, starting from 0.25 mg (once/week) and gradually increasing to 1.0 mg (once/week), discontinued oral medication, fasting and postprandial blood glucose were well controlled, weight loss was approximately 3.5 kg, and menstruation was normal.

Incretins are endocrine factors produced by the gastrointestinal tract, including glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), whose main role is to increase insulin secretion after glucose stimulation. The incretin effect is attenuated or disappeared in patients with type 2 diabetes mellitus (T2DM). GIP alone cannot reduce blood glucose in patients with T2DM, but when used in combination with GLP-1, it produces a synergistic effect. It enhances insulin secretion by dual action on pancreatic islet β cells, and produces a stronger appetite suppression effect on the activation of two receptor signaling pathways in the brain. At the same time, GIP enhances the lipid buffering capacity of adipose tissue and improves insulin resistance, thereby improving the efficacy of hypoglycemic, weight and lipid reduction with fewer adverse reactions. This article reviews the synergistic effects of GIP and GLP-1 in the treatment of T2DM, especially the research progress of the complexity of GIP in regulating lipid metabolism.

Ferroptosis is an iron-dependent and regulable pattern of cell death attributed to the accumulation of lipid peroxidation and redox imbalances. In recent years, more and more studies have indicated that ferroptosis may play an important role in the development and development of diabetes and its complications, but its specific pathophysiological process and exact effect as a therapeutic target are still unclear. This article reviews the research progress of ferroptosis and its role in diabetes mellitus and related complications.

This paper introduces the concept of delayed consultation of patients with diabetic foot and its current research status at home and abroad, summarizes the influencing factors of delayed consultation of patients with diabetic foot from patients and social aspects respectively, and summarizes the current intervention methods to reduce delayed consultation of patients with diabetic foot, in order to provide reference for building intervention programs to reduce delayed consultation of patients with diabetic foot in China.