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Diabetes Mellitus: Outpatient Treatment

Diagnostic Criteria for Diabetes and Pre-Diabetes Current treatment, level of adherence
Lifestyle assessment
Diabetes History of glycemic control
Any of the followingconfirm by repeat testing on a History of hypoglycemia, hypoglycemia
different day: unawareness, or severe events requiring
Symptoms of hyperglycemia, plus random emergency care
plasma glucose > 200 mg/dl or History of chronic complications
Fasting blood sugar (FBS) (no caloric intake for Smoking status
at least 8 hours prior to laboratory
determination) > 126 mg/dl or Physical Examination
Two-hour post-prandial plasma glucose Height, weight, BP, pulses
> 200 mg/dl during a fasting 75-gram Oral Glucose Eye, oral, thyroid, cardiac, abdominal
Tolerance Test (OGTT). (hepatomegaly), hand / finger, bare foot, neuro,
HbA1c >6.5% skin exam
Indications for secondary diabetes
Pre-Diabetes (hemochromatosis, pancreatic disease, and
Impaired Fasting Glucose (IFG) - FBS endocrine disorders such as acromegaly,
100-125 mg/dl pheochromocytoma, Cushings syndrome)
Impaired Glucose Tolerance (IGT) - 2-h. plasma
glucose 140 -199 mg/dl
Management Plan
Hgb A1c 5.7-6.4%
Consider age; daily schedule; physical activity;
Screening for Pre-Diabetes and Diabetes in eating patterns; health, social, personality, and
Asymptomatic, Undiagnosed Individuals cultural factors; capacity to understand and carry
out treatment plan.
Testing presumably healthy individuals for type 1 Establish short- and long-term goals.
diabetes is not recommended. All patients should be referred to general diabetes
Routine testing for individuals 45 years of age education classes at diagnosis and periodically
for type 2 diabetes with FBS or OGTT. If normal, thereafter.
repeat every 3 years. Recommend medical nutrition therapy (MNT);
Consider testing in all adults, and retest yearly, lifestyle changes (exercise, smoking cessation);
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with BMI > 25 kg/m , and/or: self-management and problem-solving training;
o Physical inactivity annual dilated eye exam; dental hygiene; mental
o First-degree relative with diabetes health professional.
o High-risk ethnic population (African Advise to exercise 150 min / week moderate
American, Latino, Native American, intensity aerobic activity; consider resistance
Asian American, Pacific Islander) training 3 times/week.
o Delivered a baby weighing > 9 lb or Instruct on glucose monitoring (at least 3 or 4
gestational diabetes times/day for patients on insulin, individualized
o Hypertension (> 140/90 mmHg or on otherwise) and recording or downloading
treatment for hypertension) measurements.
o HDL cholesterol < 35 mg/dl and/or
triglycerides > 250 mg/dl
Measure Target*
o Previously at risk for DM (IFG, IGT, or
A1c > 5.7%) HbA1c 7%
o Women with PCOS Pre-meal glucose 70-130 mg/dl
o Other risk factors (severe obesity,
acanthosis nigricans, history of CVD) Peak Post-meal glucose 180 mg/dl

Outpatient Visit for Known Diabetes *Glucose targets should be individualized according
to risk of hypoglycemia, comorbidities and life
Medical History expectancy.
Review:
Family planning.
History of diagnosis (age, characteristics, initial
Prescribe medications (see Appendix).
treatment, diabetic education etc.)
Glucose monitoring may be used to guide therapy
History of acute complications (DKA,
in patients with less frequent injections, on non-
hypoglycemia)
insulin therapies, or medical nutrition therapy
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Type 1 Diabetes
Basic treatment plan to consist of: Class % HbA1C Primary Cautions
o multiple-dose insulin injections or insulin Reduction Effect
pump therapy Metformin 1.1-3.0 Reduce Renal, CHF,
o matching pre-meal insulin to hepatic liver disease
carbohydrate intake, pre-meal glucose, glucose
and anticipated activity production
Patients not meeting treatment goals on injections TZD 1.5-1.6 Sensitizer Liver disease,
CHF, osteo-
should be considered for Endocrinology referral
porosis,
and continuous subcutaneous insulin infusion edema
and/or real-time continuous glucose monitoring. Sulfonylurea 0.9-2.5 Secretagogue Renal, liver
Start with 0.5-0.6 units/kg/d, with 50% of insulin disease
as basal and 50% as bolus. Repaglinide 1.0-2.0 Secretagogue Renal, liver
Advise patients on urinary ketone testing and disease
use of glucagon. Nateglinide 0.5 Secretagogue Renal, liver
disease
Alpha- 0.6-1.3 Block Renal, liver,
Preparation Action Peak Action glucosidase glucose malabsorption
Onset Duration inhibitor absorption syndromes

Bolus Insulin DPP-IV 0.8 Increase Pancreatitis,


inhibitors Incretin activity c-cell tumors
Regular q.a.c. 30 min 2-4 hr 6-10 hr GLP-1 0.8-1.5 Incretin Renal disease,
Aspart q.a.c. 5-15 min 1-2 hr 4-6 hr agonists replacement c-cell tumors,
pancreatitis,
Glulisine q.a.c. 5-15 min 1-2 hr 4-6 hr gastro-
Lispro q.a.c. 5-15 min 1-2 hr paresis
4-6 hr Pramlintide 0.3-0.6 Amylin Gastro-paresis
Basal Insulin replacement
SGLT-2 0.5-1.0 Block renal Renal/liver
NPH daily or bid 1-2 hr 4-8 hr 10-20 hr Inhibitors glucose disease,
reabsorption candidiasis
Detemir daily or 3-4 hr Flat Approx
bid 24 hr
NOTE: For detailed information about prescribing
Glargine daily 3-4 hr Flat Approx medications, see the Appendix.
24 hr
Other
Continuing Care for Known Diabetes
70/30, 75/25, 5-15 min 1-2 hr 10-20 hr
50/50 bid Quarterly Exam (until treatment goals are achieved)
Height, weight, BP.
Type 2 Diabetes Eye and bare foot exam.
Glucose resultshyperglycemia / hypoglycemia.
Lifestyle interventions in patients with pre- Other illnesses, current meds and adherence,
diabetes or diabetes include MNT, and psychosocial issues / screening, lifestyle changes,
exercise for goal weight loss of 7% and smoking cessation.
attention to cardiovascular risk factors. Adjustments / problems with therapeutic regimen.
Consider Metformin in patients with pre-diabetes Symptoms suggesting development of
or an A1c 5.7-6.4% if: complications.
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o BMI >35 kg/m and/or HbA1c if treatment changes / patient not meeting
o age <60 years of age and/or goals (or twice a year if stable).
o history of gestational diabetes
Initiate metformin at diagnosis, unless Annual Exam
contraindicated; begin combination therapy if
A1C 8-10% and initiate insulin if A1C > 10% or Comprehensive visual exam.
in patients that are overtly symptomatic with Dental exam biannually
A1C < 10%. TSH if type 1 diabetes, dyslipidemia or females
Individualize therapy based upon cost, risk for >50 years of age
severe hypoglycemia, and cautions and Microalbumin measurement and creatinine
contraindications (listed in the following table). Liver panel and Lipid profile, with follow-up tests
as needed.
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Special Considerations Hypertension


Goal for adults > 18 years of age: BP
Intercurrent Illness <140/90 mmHg.
If erratic glycemic control, obtain more frequent ACE inhibitor or ARB preferred first line therapy.
monitoring of blood glucose and urine ketones. especially in patients with kidney disease. If one
class is not tolerated, the other should be
If marked hyperglycemia, temporarily adjust
treatment. substituted.
If accompanied by ketosis, involve diabetes care In African American patients, thiazide or calcium
channel blocker is preferred first line therapy.
team.
If treated with oral glucose-lowering agents or Second line therapy is otherwise a thiazide
MNT alone, consider insulin temporarily. diuretic.
Two or more drugs at maximal dose are usually
Assure adequate fluid and caloric intake.
required to achieve BP target.
Consider hospitalization for ketosis, infection, or
dehydration. Retinopathy
Severe or Frequent Hypoglycemia Screening with dilated retinal exam annually.
For type 2 diabetes, begin shortly after
May be due to defective counter-regulation, diagnosis; for type 1, within 5 years of diagnosis.
hypoglycemic unawareness, insulin dose errors, Risks for retinopathy include duration of diabetes,
excessive alcohol intake. chronic hyperglycemia, presence of nephropathy,
If due to therapeutic regimen of patient who hypertension.
uses insulin, evaluate management plan,
readjust as needed, and provide patient / family NOTE: For retinopathy and nephropathy: Optimization
re-education. of blood sugar and blood pressure control is key to
prevention of development / progression
Cardiovascular Disease (CVD)
Nephropathy
Correction of obesity, smoking, hypertension,
sedentary lifestyle, dyslipidemia, poorly Screening with microalbumin/creatinine ratio
regulated diabetes in addition to specific annually. For type 2 diabetes, to begin shortly
treatment of the cardiovascular problem. after diagnosis; for type 1, within 5 years of
Recommend low dose (75-162mg) daily aspirin as diagnosis.
primary prevention for men > 50 and women > 60 Assess annual creatinine clearance with serum
years old who have one or more of the following creatinine.
risk factors: In hypertensive patients, lower BP to < 140/90 to
o current smoker decrease progression of diabetic nephropathy
o hypertension (see hypertension section for treatment).
o hyperlipidemia Institute protein-restricted meal plans designed
o family history of early CVD or albuminuria by a registered dietitian (0.8-1.0 gm/kg/d for
(10 year CVD risk of > 10%) early stages and 1.0 gm/kg/d for later stages of
Consider daily low dose aspirin for primary nephropathy).
prevention in younger patients with one or more When using ACE-I / ARB, or diuretic, monitor
risk factors, or older patients without additional risk creatinine and potassium; monitor urine albumin
factors. (10 year CVD risk 5-10%) excretion for response and progression.
Recommend daily aspirin as secondary Consider referral to a nephrologist.
prevention.
Neuropathy
Dyslipidemia Screening for distal symmetric polyneuropathy
performed at diagnosis and annually in all patients.
Fasting lipid profile annually in adults unless
low-risk lipid profiles, then every 2 years. Distal symmetric polyneuropathy screen using
pinprick, vibration (128-hertz tuning fork), 10-gm
Advise weight loss if indicated; a meal plan
monofilament, deep tendon reflexes (pick 2).
designed to lower glucose levels and to alter
lipid patterns; and increased physical activity as Autonomic neuropathy, screen for symptoms of
appropriate. resting tachycardia, exercise intolerance,
constipation, gastroparesis, erectile dysfunction,
High intensity statin should be started in patients
hypoglycemic unawareness, impaired
with overt CVD or in patients 40 years of age
neurovascular function.
with 10 year CVD risk of > 7.5%.
Consider:
Moderate intensity statin should be started as
o Special diagnostic testing and
primary prevention in patients 40 to 75 years of
consultation with medical specialist.
age with an LDL 70-189.
In patients <40 years of age, estimate 10 year o Medications, alterations in MNT,
CVD risk to determine if statin beneficial. specialized procedures, and check B12
level.
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Foot Care Quality Measures


Foot exam with every visit, including light touch,
vibratory sensation, palpation and visual Percent of patients that receive:
examination. o HbA1c
Educate about potential foot problems and o Lipid panel
regularly reinforce lifetime surveillance and o Microalbumin / creatinine ratio
precautions. Percent of patients with each of the following
Risk of ulcers are increased with: referrals:
o diagnosed with diabetes for >10 years o Dietary or nutrition
o male o Weight management
o poor glucose control o Cardiology
o cardiovascular, renal, neuropathic or retinal o Sleep medicine
complications Average value quarterly:
o history of previous ulcer o A1c
o severe nail pathology o blood pressure
o bony deformities o LDL cholesterol
Consider referral to podiatrist, orthopedic o BMI
surgeon, vascular surgeon, or rehabilitation Report use of ACE inhibitor/ARB with
specialist. concomitant hypertension diagnosis
Report use of statin for >age 40.
Referral for Diabetes Management Number of hits to guideline on EBP OneSource
website
If desired goals not met, consider referral to
endocrinologist, co-management with diabetes
Guideline Authors
team, or enhanced education.
Kathleen Dungan, MD, MPH
References Benjamin ODonnell, MD
David Bradley, MD
American Association of Clinical
Endocrinologists Comprehensive Diabetes
Guideline Approved
Management Algorithm 2013. Endocrine
Practice,19(1):1-48
April 23, 2014. Fourth Edition
Inzucchi SE, et al. (2012). Management of
hyperglycemia in type 2 diabetes: a patient-
centered approach: position statement of the Disclaimer: Clinical practice guidelines and algorithms at The
American Diabetes Association (ADA) and the Ohio State University Wexner Medical Center (OSUWMC) are
European Association for the Study of Diabetes standards that are intended to provide general guidance to
(EASD). Diabetes Care, 35(6): 1364-79. clinicians. Patient choice and clinician judgment must remain
James PA, et al. (2014). Evidence-Based central to the selection of diagnostic tests and therapy.
Guideline for the Management of High Blood OSUWMCs guidelines and algorithms are reviewed
Pressure in Adults: Report From the Panel periodically for consistency with new evidence; however, new
developments may not be represented.
Members Appointed to the Eighth Joint National
Committee (JNC 8). Journal of the American Copyright 2014, The Ohio State University Wexner Medical
Medical Association, 311(5):507-520. Center. No part of this publication may be reproduced in any
Pignone M, et al. (2010). Aspirin for primary form without permission in writing from The Ohio State
prevention of cardiovascular events in people University Wexner Medical Center.
with diabetes -- A position statement of the
American Diabetes Association, a scientific
statement of the American Heart Association,
and an expert consensus document of the
American College of Cardiology Foundation.
Diabetes Care, 33(6):1395-1402.
Standards of Medical Care in Diabetes 2014 -
Diabetes Care, 7(1) S14-80.
Stone NJ, et al. (2013). ACC/AHA Cholesterol
Guideline Panel- Treatment of blood cholesterol
to reduce atherosclerotic cardiovascular disease
risk in adults: Synopsis of the 2013 ACC/AHA
cholesterol guideline. Annals of Internal
Medicine, 160(5):339-343.
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Appendix: Diabetes Mellitus Medication Table

Generic Name Brand Starting Dose Max Dose Cost*


Name

Biguanides
Metformin Glucophage 250 mg p.o. bid 1000 mg p.o. bid #60 500 mg = $15 (generic)
#60 1000 mg = $25 (generic)
Sulfonylureas
Glipizide Glucotrol 5 mg/day 40 mg/day #60 5 mg = $9 (generic)
#60 10 mg = $9 (generic)
Glyburide DiaBeta, 2.5-5 mg/day in single/ 20 mg/day #30 1.25 mg = $9 (generic)
Micronase (regular) divided doses #30 2.5 mg = $7 (generic)
#30 5 mg = $7 (generic)
Gynase, PresTab 1.5-3 12 mg/day
(micronized) mg/day in single/ divided
doses
Glimepiride Amaryl 1-2 mg/day 8 mg/day #30 1 mg = $21 (generic)
#30 2 mg = $30 (generic)
#30 4 mg = $49 (generic)
Combination Agents
Metformin/ Glucovance 250 / 1.25 daily 2000/10 mg/day #60 2.5/500 mg = $82 (brand only)
glyburide #60 5/500 = $85 (brand only)
Thiazolidinediones
Pioglitazone Actos 15 mg/day 45 mg/day #30 15 mg = $180 (brand only)
#30 30 mg = $274 (brand only)
#30 45 mg = $283 (brand only)
Rosiglitazone Avandia 4 mg/day 8 mg/day #30 2 mg = $91 (brand only)
#30 4 mg = $143 (brand only)
#30 8 mg = $250 (brand only)
-Glucosidase Inhibitors
Acarbose Precose 25 tid 50-100 mg tid #90 25 mg = $74 (generic)
#90 50 mg = $79 (generic)
#90 100 mg = $81 (generic)
Miglitol Glyset 25 tid 100 mg tid #90 25 mg =$111.99
#90 50 mg = $120.00
#90 100 mg =$125.99 (brand only)
Meglitinides
Repaglinide Prandin 0.5-2 mg by mouth q.a.c. 16 mg/day #90 0.5 mg $40 (brand only)
#90 1 mg = $60 (brand only)
#90 2 mg = $60 (brand only)
Nateglinide Starlix 60 mg by mouth q.a.c. 120 mg q.a.c. #90 60 mg = $65 (generic)
#90 120 mg = $65 (generic)
DPP-4 Inhibitors/combinations
Sitagliptin Januvia 100 mg by mouth daily #30 25 mg = $305 (brand only)
#30 50 mg = $253 (brand only)
#30 100 mg = $212 (brand only)
Sitagliptin/ Janumet 50 / 500 mg bid 100 / 2000 mg/day #60 50/500 mg = $213 (brand only)
metformin #60 50 / 1000 mg = $245 (brand only)
Saxagliptin Onglyza 2.5 mg daily 5 mg daily #30 2.5 mg = $300 (brand only)
#30 5 mg = $300 (brand only)
Saxagliptin/ Kombiglyze@ 2.5 / 500 mg daily 5/1000 mg/day #60 2.5/500 mg = $209 (brand only)
Metformin
Linagliptin Tradjenta 5 mg daily 5 mg daily #30 5 mg = $300 (brand only)
GLP-1 Analogues/Receptor Mimetics
Exenatide Byetta 5 mcg SQ bid 10 mcg SQ bid #1 5 mcg pen = $275 (brand only)
#1 10 mcg pen = $340 (brand only)
Exenatide once Bydureon 2 mg SQ once weekly 2 mg SQ once
weekly weekly
Liraglutide Victoza 0.6 mg SQ daily for 1 1.8 mg/day #1 2 pens of 18 mg/3 ml solution = $384
week (brand only)
Miscellaneous
Pramlintide Smylin 60 mcg SQ q.a.c. 120 mcg SQ q.a.c. #1 5.4 ml of 1000 mcg/ml solution =
$461.64 (brand only)

*Prices obtained January 2014 from www.Drugpriceinfo.com or www.drugs.com