Type 2 diabetes mellitus (T2DM) is ainsulinCaused by insufficient use or reduced efficiencychronic disease, common in adults, also known as adult onset diabetes.This disease is caused by heredity, environmental factors such as lifestyle, over nutrition, lack of physical activity and other factors.The initial symptoms are often mild, and many people are not found until complications occur or in routine physical examination.
The typical symptom of type 2 diabetes is called "more than three and less", which means drinking more,Overeating，PolyuriaAnd weight loss;But it may be asymptomatic or mild in the early stage of the disease.With the development of the disease, hyperglycemia will become more obvious, so attention should be paid to monitoring.Accompanying symptoms includeweak, easy to fatigue, fatigue, easy to get tired, easy to catch a cold, and weak in spirit,Memory declineEtc.For high-risk groups (including family history of diabetes,Obesity, and those over 45 years of age) should be monitored regularly.Non infectious disease of type 2 diabetes.
The treatment methods for type 2 diabetes are diverse, based on lifestyle adjustment, such as weight control and improving eating habits.When blood glucose cannot be controlled through lifestyle adjustment, drug treatment will be started, including sulfonylureas, glinides, biguanides,Thiazolidinediones，α - glucosidase inhibitorDipeptidyl peptidase-4 inhibitor and sodium glucose cotransporter-2 inhibitor, etc.In high-risk groups, timely interview and participate in regular inspection for early detection and treatment.
In the latest treatment progress, medical professionals may consider metabolic surgery, also known as "weight-loss surgery", for obese adults with type 2 diabetes whose blood sugar continues to be poorly controlled.At the same time, scientists have been looking for the underlying pathogenesis of diabetes in order to find more effective prevention and treatment methods.
TCM disease name
Type 2 diabetes
Alias
Adult onset diabetes
Visiting department
Endocrinology Department, Nephrology Department, Ophthalmology Department
Multiple population
Have obesity, havediabetesFamily history, people over 45 years old
Common causes
Genetic factors, agingOvernutritionInsufficient physical activity, chemical poisons, etc
common symptom
"More than three, less", that is, drink more, eat more, urinate more, lose weight or lose weight in a short time
The etiology of type 2 diabetes is complex, and those who cannot be diagnosed as other types of diabetes (type 1, special type diabetesGestational diabetes）All of them can be temporarily classified as type 2 diabetes.
When the bodyblood sugarAt high levels, islet beta cells secrete insulin to reduce blood sugar.
If β cell function is defective, insulin secretion is insufficient, and it is unable to effectively reduce glucose, the blood sugar level will rise;
Some patients have normal insulin secretion, but the body is not sensitive to insulin and can not effectively use insulin. That is, insulin resistance will also lead to increased blood sugar.
Insulin resistance and islet beta cell dysfunction are the causes of type 2 diabetes. Scientists have been exploring the exact underlying pathogenesis. According to existing research, it can be determined that this kind of disease is caused by genetic factors and environmental factors.
Although there is a genetic susceptibility to type 2 diabetes, the onset and progression of the disease are more affected by the environment.Environmental factors include age growthlife style、OvernutritionInsufficient physical activity, intrauterine environment and stress, chemical poisons, etc.
symptom
Announce
edit
The typical symptoms of type 2 diabetes are commonly known as "more than three and less", that isDrink more、Overeating、Polyuria, emaciation or short-term weight loss.
However, many early patients often have no symptoms or mild symptoms. Because the early symptoms are not typical, some people do not find the disease until there are symptoms of chronic complications or in the routine physical examination.
Typical symptoms
As the disease progresses,blood sugarAs the level gradually rises, the patient will have a typical hyperglycemia symptom of "more than three, less" - eating more, drinking more, urinating more, and losing weight.The patient may have dry mouth, weight loss, etc.
In addition, due to metabolic abnormalities in patients, many patients will feelweak, easy to fatigue.
Accompanying symptoms
Type 2 diabetic patients may have cardiovascular and cerebrovascular diseases and digestive tract dysfunction due to metabolic disorder and decreased resistance, but these symptoms can be completely eliminated by controlling blood sugar and the primary disease.
cardiovascular system: Palpitation, shortness of breath, arrhythmia, orthostatic hypotension, etc.
digestive system: "Eating too much" may be aggravated to show hyperappetite and hunger, but when the disease worsens, digestive tract function will be disordered, and appetite will be decreased, nausea and abdominal distension will appear instead.
Psychological symptoms: most patients have emotional instability, anxiety, depression, and may also haveinsomnia、abnormal sweating, easy to wake up and other symptoms.
Medical treatment
Announce
edit
In case of typical "more than three and less" symptoms or signs of fatigue, dry mouth, infection not healing, wound difficult to heal, etc., seek medical advice in time.
People with high risk factors of diabetes, such asObesityIf you have a family history of diabetes and are over 45 years old, you should regularly monitor blood sugar for early detection and treatment.
Visiting department
This disease needsEndocrine DepartmentFor diagnosis and treatment, if there are other complications, it may be necessary to consult the corresponding departments, such as nephrology, ophthalmology, cardiovascular medicine, etc. according to the specific symptoms and the doctor's recommendations.
In addition, ifDiabetic ketoacidosis(manifested as loss of appetite, nausea and vomiting, dizziness, brain distension, mental depression, rotten apple smell of breath, etc.), hyperosmotic hyperglycemia (manifested as dry lips, decreased blood pressure, shock and disturbance of consciousness, etc.) and other emergencies, which need emergency treatment.
Relevant inspection
Due to the differences in instruments, reagents, calibration standards, etc. of medical institutions, the standard values of all inspection indicators fluctuate to a certain extent. Fortunately, most hospital inspection reports are attached with normal ranges, and sometimes symbols are used to indicate whether the indicators are rising or falling.
Urine sugar test: the urine sugar of normal people is negative.Positive urine glucose is an important clue to diagnose diabetes, but negative urine glucose cannot completely exclude diabetes.
Determination of plasma glucose (blood sugar)
Fasting blood glucose: The blood glucose value measured after fasting for at least 8 hours, the normal value should be ≤ 6.1mmol/L, and higher than 7.0mmol/L can be diagnosed as type 2 diabetes;
Blood glucose 2 hours after meal (blood glucose 2 hours after sugar load in OGTT): The blood glucose value measured 2 hours after taking the first meal or taking 75g glucose water orally should be ≤ 7.8mmol/L.When it is higher than 11.1 mmol/L, type 2 diabetes is highly suspected. If there are typical symptoms of type 2 diabetes, it can be diagnosed;If the symptom is not typical, it must be retested another day. If it is still higher than 11.1 mmol/L, it can be diagnosed;
Random blood glucose: blood glucose value measured at any time of the day, higher than 11.1 mmol/L and combined with typical diabetes symptoms, can be diagnosed as type 2 diabetes.
Oral glucose tolerance test (OGTT)
OGTT is generally the gold standard for the diagnosis of diabetes, and also an important method to judge the function of pancreatic islets.When the blood sugar is higher than the normal range but does not meet the diagnostic criteria for diabetes, OGTT is required.
OGTT suggests that it should be carried out accurately in the morning. It is recommended that adults take 75g glucose orally (prescribed by a doctor), dissolve it in 250~300ml of water, and drink it within 5 minutes.Empty abdominal blood before taking sugar, and take blood every 30 minutes after taking sugar, four times in total, and draw glucose tolerance curve according to the blood sugar level of each time.
Determination of glycosylated hemoglobin (HbA1c)
Hemoglobin A1c (HbA1c) is an important indicator to judge the situation of blood sugar control. In the process of treatment, HbA1c below 7.0% is often used to measure whether the blood sugar control is up to standard.The 6th edition of the Guidelines for the Prevention and Treatment of Type 2 Diabetes in China formally included glycosylated hemoglobin in the diagnostic criteria of diabetes, with HbA1c ≥ 6.5% as the cut-off point to assist in the diagnosis of diabetes.
Biochemical examination of blood lipid, blood pressure, uric acid, etc
It is used to monitor complications or other metabolic indicators, which is conducive to better choice of medication.
It can understand the function of pancreatic islet β cells, which is helpful for diabetes classification, disease judgment and follow-up treatment guidance.
The positive urine ketone body of type 2 diabetes patients often indicates that there is an acute metabolic disorder. If the patients are being treated, it indicates that the curative effect is poor.Negative urine ketone body cannot rule out ketoacidosis.
differential diagnosis
Type 2 diabetes is mainly differentiated from type 1 diabetes, generally from the onset age. However, as the onset age of type 2 diabetes tends to be younger, it is still necessary to differentiate between the two from multiple aspects.
Type 1 diabetes
Type 2 diabetes
Age of onset
More than 30 years old
More than 40 years old
Mode of onset
More sharp, less slow
Slow and Hidden
Weight at onset
Multi normal
Obesity
Ketoacidosis
incident
Not easy to happen
Nephropathy
Incidence rate: 35%~40% (main cause of death)
Incidence rate 5%~10%
Complicated cardiovascular disease
less
>70% (main cause of death)
Complicated cerebrovascular disease
less
More
Insulin and C-peptide release test
Low or lacking
Peak delay or insufficient
Insulin treatment and reaction
Dependent on exogenous insulin, sensitive to insulin
Insulin independent survival and insulin resistance
Type 2 diabetes is characterized byinsulin resistance 、insulinCaused by relative lackhyperglycemia, this is the same asType 1 diabetesAbsolute insulin deficiency in is quite different, the latter is becauseislet cellsDamage.andGestational diabetesIt is the new hyperglycemia during pregnancy.Type 1 and type 2 diabetes can usually be distinguished according to clinical manifestations.If there is doubt about the diagnosis, antibody test may be helpful to determine type 1 diabetes,C-peptide(C-peptide) level is helpful to judge type 2 diabetes.
treatment
Announce
edit
The reasonable treatment strategy for type 2 diabetes is "comprehensive", which not only includes hypoglycemic treatment, but also needs to reduce blood pressure, regulate blood lipids, antiplatelet, control weight and improve lifestyle according to the patient's individual complications.
Acute treatment
The acute treatment of type 2 diabetes mainly refers to severe hyperglycemia complicated with ketoacidosis, which generally requires immediate emergency treatment, rapid fluid replacement, correction of acid-base imbalance and other treatments.
Type 2 diabetes may also have hypoglycemia, which can be alleviated by taking sugared water and eating foods with high sugar content. In case of severe hypoglycemic reactions such as coma and disturbance of consciousness, you should go to the emergency department immediately, and the doctor will give intravenous sugar supplement, maintain vital signs and other treatments.
General treatment
For patients who have been diagnosed with type 2 diabetes, general treatment strategies include weight control and lifestyle improvement.
nutritional support
Maintain healthy weight: The goal of weight loss for overweight/obese patients is to reduce 5%~10% of their weight in 3-6 months, and ordinary or emaciated patients can achieve and maintain their ideal weight for a long time through reasonable nutrition plans.
Quantitative diet and balanced nutrition: the energy provided by carbohydrate in the diet should account for 50%~65% of the total energy;Protein accounts for 15%~20%, ensuring that the proportion of high-quality protein exceeds one third;Fat accounts for 20%~30%. The intake of saturated fatty acids should not exceed 7% of the total energy in the diet. Try to reduce the intake of trans fatty acids.
Reasonable dietary pattern: a diversified diet consisting mainly of cereal, high dietary fiber intake, low salt (daily salt intake shall not exceed 6g), low sugar and low fat.
Exercise therapy
Indications: People with blood sugar below 16.7mmol/L, especially obese people, should pay attention to physical exercise.
Exercise can increase the muscle content of patients, improve insulin sensitivity, strengthen physique, and be more conducive to stable control of blood sugar.
Adults with type 2 diabetes have at least 150 minutes of moderate intensity exercise per week (such as fast walking, shadowboxing, cycling, table tennis, badminton and golf);Exercise upper, lower limbs and trunk muscles 2-3 times a week, and develop the habit of daily exercise.
medication
Lifestyle intervention is the basis of diabetes treatment. If the blood sugar control is not up to the standard (glycosylated hemoglobin ≥ 7.0%), the patients will enter the drug treatment.
Injectable preparations include insulin and insulin analogues, glucagon like peptide-1 receptor agonist (GLP-1 receptor agonist).
Biguanides
Representative drug: metformin
Drug effect and indication: first-line drugs for type 2 diabetes can reduce the production of glucose in the liver, increase the body's sensitivity to insulin, and also reduce weight, so they are especially suitable for obese patients.
Adverse reactions: gastrointestinal symptoms such as dry mouth, bitter mouth, nausea, vomiting, diarrhea, anorexia, etc.
Drug effect and indication: It can promote the body to produce more insulin.If biguanides cannot effectively control blood sugar or can not tolerate the side effects of biguanides, sulfonylureas can be considered.
Adverse reactions: hypoglycemia, weight gain, etc.
Drug effect and indication: Mainly applicable to patients with high postprandial blood glucose level.
Adverse reactions and contraindications: The main adverse reactions were abdominal distention, abdominal pain, diarrhea, increased exhaust volume, etc.Patients with cirrhosis and peptic ulcer cannot use it.
Thiazolidinediones
Representative drugs: rosiglitazone, pioglitazone
Drug effect and indication: It is suitable for type 2 diabetic patients with severe insulin resistance.
Adverse reactions: weight gain, anemia, increased risk of heart failure, etc.
Glinides
Representative drugs: repaglinide, nateglinide
Drug action and indication: similar to sulfonylureas, but with faster onset and shorter duration.
Adverse reactions and contraindications: hypoglycemia, weight gain, etc.
Drug effect and indication: It is helpful to control the blood sugar of adult patients with type 2 diabetes mellitus. It does not increase the risk of hypoglycemia when used alone.
Adverse reactions and contraindications: may cause headache, induce pancreatitis, pharyngitis and upper respiratory tract infection;Not recommended for children, pregnant women and lactating women.
Drug effect and indication: It can increase the excretion of sugar in urine and also reduce weight.
Adverse reactions and contraindications: increase the risk of urinary tract infection.
GLP-1 receptor agonists and their analogues
Representative drugs: exenatide, lilalutide, lisenatide and benalutide
Drug effect and indication: It can enhance insulin secretion, inhibit glucagon secretion, delay gastric emptying, and reduce food intake through central appetite inhibition.It is suitable for type 2 diabetic patients who cannot control their blood sugar when two oral hypoglycemic drugs are used together.
Adverse reactions and contraindications: gastrointestinal symptoms (such as nausea, vomiting, etc.) are mainly seen in the initial treatment, and the adverse reactions can gradually reduce with the extension of treatment time.It is strictly prohibited for patients with type 1 diabetes, renal insufficiency and severe gastrointestinal diseases.
Insulin therapy
On the basis of lifestyle and combined treatment with oral hypoglycemic drugs, if the blood sugar of patients with type 2 diabetes does not reach the control goal, the doctor will arrange to start insulin treatment as soon as possible (3 months).
For newly diagnosed diabetic patients with HbA1c ≥ 9.0% or fasting blood glucose ≥ 11.1 mmol/L and obvious symptoms, sometimes doctors will give insulin treatment at the beginning.
The initial treatment of insulin for patients with type 2 diabetes mellitus can use insulin 1-2 times a day, and the use of insulin should be conducted under the guidance of medical staff, including the time of initial use, the type of use, the method of use, and the corresponding blood glucose monitoring.
Insulin can be divided into ultra short acting insulin analogues, conventional (short acting) insulin, medium acting insulin (NPH), long-acting insulin, long-acting insulin analogues, premixed insulin and premixed insulin analogues. The use combination, scheme and requirements of insulin are different, and must be strictly in accordance with the guidance of medical staff.
Insulin treatment mainly includes the following treatment schemes:
Initial treatment plan of basic insulin or premixed insulin
The adverse reactions of insulin treatment mainly include hypoglycemia and allergy.
surgical treatment
Obese adults with type 2 diabetes try to adopt lifestyle and drug treatment. However, when the blood sugar continues to be poorly controlled, medical professionals can consider metabolic surgery after evaluation, which is often referred to as "weight loss surgery" and "weight loss surgery".
Operation indications: for patients aged between 18 and 60 years old with good general condition, the operation risk is low;For patients with body mass index (BMI) ≥ 32.5 kg/㎡, or 27.5 kg/㎡ ≤ BMI ≤ 32.5 kg/㎡ and unable to effectively control blood sugar, metabolic surgery can be considered for treatment.
Clinical evidence shows that metabolic surgery can significantly improve the blood sugar control of obese patients with type 2 diabetes, and even make some diabetic patients' diabetes "alleviate".In 2016, the International Diabetes Organization issued a joint statement that metabolic surgery was included in the clinical treatment path of type 2 diabetes for the first time.
Metabolic surgery mainly includes the following methods:
Sleeve gastrectomy;
Gastric bypass;
Adjustable gastric banding;
Biliary pancreatic bypass.
Surgical treatment of obesity with type 2 diabetes has certain short-term and long-term risks. Therefore, surgery is generally completed through the cooperation of endocrinologists and surgeons. Strict diet management and postoperative follow-up are also required after surgery.
TCM treatment
The clinical treatment of type 2 diabetes mellitus with traditional Chinese medicine is mainly based on dialectical treatment, which can be divided into two types, namely, "spleen dan" (obesity) and "eliminating dan" (emaciation). According to different stages, it can be divided into four stages, namely, "stagnation of heat and deficiency of energy".
The following treatment suggestions are written in the Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2018 Edition), but the specific medication needs to be prescribed by professional doctors according to personal conditions.
It is suggested that Tianqi Jiangtang capsule should be taken orally on the basis of lifestyle intervention;
On the basis of the poor efficacy of metformin alone in the treatment of type 2 diabetes mellitus with deficiency of both qi and yin, it is recommended to add oral Jinlida granules.
Type 2 diabetes early and middle intestinal damp heat syndrome, it is recommended to take Gegen Linglian Decoction orally.
In the early and middle stage of type 2 diabetes, it is recommended to take Dachaihu Decoction orally.
New "early insulin" therapy
In June 2024, the joint research team of the University of Science and Technology of China, Southern Medical University and Peking University led by Professor Weng Jianping of Anhui Medical University, through 24 years of observation on the treatment of 5424 patients with type 2 diabetes in China, proved for the first time that patients who used the new "early insulin" therapy had a 31% lower risk of stroke than those who received the traditional "ladder" therapy,The risk of hospitalization for heart failure was reduced by 28%.[10]
prognosis
Announce
edit
Type 2 diabetes is a lifelong disease, which cannot be cured fundamentally, but it can be prevented from various complications through long-term control of blood sugar, so that the disease can be relieved for a long time and a good quality of life can be obtained.
However, if the blood sugar is not controlled to the standard for a long time, it is equivalent to that all kinds of tissues and organs of people are "soaked" in sugar water, and it is conceivable that various serious complications will occur.
Acute complications
ketoacidosis(DKA): It is a hyperglycemic crisis caused by severe insulin deficiency and inappropriate elevation of glucocorticoid (glucagon, etc.).DKA is less likely to occur in patients with type 2 diabetes mellitus, but it may occur under certain incentives (acute infection, inappropriate reduction or withdrawal of insulin, excessive or insufficient diet, alcoholism, mental stimulation, etc.).Once it happens, it should be treated in time, otherwise it will endanger life.
Hypertonic hyperglycemic state (HHS): HHS occurs in elderly patients with type 2 diabetes mellitus, and is also one of the hyperglycemic crises.The onset of HHS is hidden, and it usually takes 1~2 weeks from the onset to the appearance of consciousness disorder.Diabetes symptoms, such as thirst, polyuria and fatigue, often appear first, and the disease gradually worsens with typical symptoms, mainly dehydration and nervous system symptoms.When the plasma osmotic pressure of the patient is more than 320 mOsm/L, symptoms such as dull expression and progressive lethargy may occur;When plasma osmotic pressure>350mOsm/LDisorientation、hallucination, flapping rough tremor of upper limbs, epileptic seizurehemiplegia、Hemianopia、aphasia、Visual impairment、comaAnd positive pathological signs.
Chronic complications
Diabetic retinopathy(DRP): The incidence rate of patients with a history of more than 15 years is as high as 78%, which is the most common diabetic microvascular complication, and can lead to blindness in severe cases.
diabetic nephropathy : Hyperglycemia can damage renal microvessels, and patients will have symptoms such as foam urine, leg or body swelling.
atherosclerosis: It can cause coronary heart disease, hypertension, and lower limb coldness, pain, and intermittent claudication when lower limb arteries are involved.
Diabetic neuropathy: numbness of extremities, sensation of acupuncture, burning, hypoesthesia, etc.
Diabetic dermatosis: Bullae, dark red papules, oval patches, etc. appear on the skin.
Infected: For example, skin and mucous membrane infection (furuncle, carbuncle, tinea corporis, tinea pedis, etc.), cystitis, pyelonephritis, emphysematous cholecystitis, tuberculosis, etc., the probability of infection in diabetic patients is far higher than that in normal people, and it is easy to recur and will not heal for a long time.
Diabetic foot: The sensation of the patient's foot is reduced, and it is difficult to detect when injured. Small scratches and blisters may also lead to ulcers, infections, necrosis, and gangrene in the severe cases.
