Transcript Detection & Treatment

1-44
Type 2: Management During Pregnancy
Maternal Monitoring
• Baseline: Thyroid functions, if not done
• Each visit: Dipstick UA; UC as appropriate; verify SMBG
• Every 4 weeks: HbA1c
• First trimester: Eye exam with dilation by Ophthalmologist
(follow-up as indicated); screen for albuminuria
If complications exist or develop, refer patient to Diabetes
Specialist and other specialists as necessary
Nutrition
• Increase calories 300/day in the second and third trimesters
• Adequate weight gain according o table below
% DBW
BMI
90%
< 19.8
90-120
19.8-26
> 120
> 26
DBW = Desirable Body Weight
BMI = Body Mass Index (wt/ht2= kg/m2)
Self-management Education
• Emphasize hypoglycemia prevention/treatment
• Instruct family member on glucagon
administration
• Instruct on self adjustment of insulin as
administration
• Importance of not skipping meals
GAIN
28-40 1bs
20-35 1bs
15-25 1bs
Type 2: Management During Pregnancy
1-43
(continued on next page)
• Urgent referral (with in 3-4
days) to Diabetes Specialist and
specialist in high risk pregnancy
Patient is pregnant
SMBG and/or HbA1c
within target range
for 1 month prior to
conception?
YES
Management Guidelines
• If on Food Plan stage only,
continue therapy
• If on any oral agent,
discontinue and start
Insulin Stage 3A or 4A
(with human insulin)
• If on insulin, continue
current therapy
• If patient is currently
using LP insulin consult
with a Diabetes
Specialist
Refer for nutrition and
diabetes education
Follow-up
Medical: Phone 1-2
times/week;
office visit at
least every 2
weeks
Education: One visit
each
trimester
(minimum)
NO
• Assess diabetes control and
make adjustments as necessary
(SMBG, urine ketones, HbA 1c )
• Determine gestational age
•Hospitalization may be necessary
SMBG Targets
• Fasting: 60-95 mg/dL
• Pre-meal: 60-105 mg/dL
• Post-meal: < 120 mg/dL 2 hours after
start of meal
• Bedtime: 100-140 mg/dL
• No severe (assisted) or nocturnal
hypoglycemia
HbA1c Target
• Within normal range
Urine Ketones Target
• Negative
SMBG Frequency
• Test 4-7 times/day;
before and 2 hours
after start of meals and at bedtime
• Check 3 AM as needed
Urine Ketones
Monitoring
•Test if ill
Type 2: Preconception Planning
Patient planing pregnancy
History, physical exam, and
laboratory evaluation by clinician
• History: Diabetes therapy and
control, miscarriages, fetal
anomalies, macrosomia, LGA
• Medications: If hypertensive,
switch to Methyldopa or
Hydralazine; ACE inhibitors
and beta blockers contra-indicated in pregnancy
• Complications: Hypoglycemia
unawareness; retinopathy;
nephropathy; neuropathy
• Discuss pregnancy-related risks
including association of hyperglycemia with maternal and
fetal complications
• Physical exam: Include funduscopic eye exam with dilation by
Ophthalmologist
• Stop Troglitazone,
Sulfonylurea, Metformin,
Acarbose; start insulin
• Consult Diabetes Specialist if
considering Lispro
• Laboratory: CBC; UA/UC;
thyroid studies; 24-hour urine
for creatinine clearance and
albumin; HbA1c;EKG
SMBG and/or HbA1c
within target range?
SMBG Targets
• More than 50% of SMBG
values within range
• Pre-meal: 70-100 mg/dL
• Post-meal: < 140 mg/dL 1
hour after start of meal;
< 120 mg/dL 2 hours after
start of meal
• No severe (assisted) or
nocturnal hypoglycemia
Goals may be changed for
hypoglycemia unawareness
HbA1c Target
• At ;east 2 values 1 month
apart within normal range
Monitoring
• SMBG: Up to 7
times/day; before and 2
hours after start of meals
and at bedtime
• HbA1c:At least 2 values
1 month apart
YES
Stop birth control and
continue current insulin
stage; maintain SMBG
and HbA1C within target
range until pregnancy
confirmed
Move to Management
During Pregnancy
NO
Work with patient to establish BG control
• Reassess current therapy
• Strt or adjust intensified regimen as needed; see Insulin Stage 3 A or 4A
• Continue with birth control
• Consider co-management with a Diabetes Secialist
1-42
1-2
Type 2: SMBG and HbA1c Targets
SMBG Targets
• More than 50 % of values within target range
• Pre-meal: 80-140 mg/dL
• Post-meal (2 hours after start of meal): < 160 mg/dL
• Bedtime: 100-160 mg/dL
• No severe (assisted) or nocturnal hypoglycemia
Adjust target upward if frail elderly, decreased life
expectancy, cognitive disorders, or other
medical concerns
HbA1c Target
• Within 1.5 percentage points of upper limit of normal
SMBG Frequency
• Test 2-4 times/day; before and 2 hours after start of
meals and at bedtime
Lispro Insulin (LP) Considerations
• 1 unit of LP = 1 unit of Regular insulin
• Administer within 15 minutes before the meal due to
rapid action
• May need to increase basal insulin dose
• Use both pre-meal and post-meal SMBG data to make
LP dose adjustments
• May have reduced need for snacks between meals
Type 2: Screening and Diagnosis
1-3
Fasting plasma glucose (FPG): No
caloric intake for at least 8 hours
or
Casual plasma glucose (CPG): Any
time of day without regard to time
of last meal
FPG < 110
mg/dL
or
CPG < 140
mg/dL
No diabetes
With risk
factors:
Screen
annually
No risk factors: Screen
every 3 years
FPG 110-125
mg/dL
(if CPG is
140-199 mg/dL,
consider OGTT)
FPG > 126
mg/dL
or
CPG >
200
mg/dL
Urine
ketones
present?
Diagnosis of
impaired
glucose
homeostasis;
move to
Impaired
Glucose
Homeostasis
/Start
NO
YES
See
Type 1:
Screening
and
Diagnosis
Repeat FPG
in 7 days
NO
FPG > 126
mg/dL?
YES
Diagnosis of type 2 diabetes; move
to Type 2: Master DecisionPath
FASTING
> 126 mg/dL
110-125 mg/dL
< 126 mg/dL
75 gram Oral Glucose Tolerance Test
2 HOURS
DIAGNOSIS
> 200 mg/dL
Diabetes mellitus
< 140 mg/dL
Impaired fasting glucose (IFG)
140-199 mg/dL
Impaired glucose tolerance (IFG)
Type 2: < Age 18: Screening and Diagnosis
1-4
Fasting plasma glucose (FPG): No
caloric intake for at least 8 hours
or
Casual plasma glucose (CPG): Any
time of day without regard to time
of last meal
FPG < 110
mg/dL
or
CPG < 140
mg/dL
No diabetes
With risk
factors:
Screen
annually
No risk factors: Screen
every 3 years
*If obese and type 1
diabetes suspected,
measure insulin
level by C-peptide
FPG 110-125
mg/dL
(if CPG is
140-199 mg/dL,
consider OGTT)
FPG >
126
mg/dL
CPG >or
200
mg/dL
Urine
ketones
present
and
nonobese?*
Diagnosis of
impaired
glucose
homeostasis;
move to
Impaired
Glucose
Homeostasis
/Start
NO
YES
See
Type 1:
Screening
and
Diagnosis
Repeat FPG
in 7 days
NO
FPG > 126
mg/dL?
YES
Diagnosis of type 2 diabetes; move to Type 2
< Age 18: Master DecisionPath
FASTING
> 126 mg/dL
110-125 mg/dL
< 126 mg/dL
75 gram Oral Glucose Tolerance Test
2 HOURS
DIAGNOSIS
> 200 mg/dL
Diabetes mellitus
< 140 mg/dL
Impaired fasting glucose (IFG)
140-199 mg/dL
Impaired glucose tolerance (IFG)
Type 2: Master DecisionPath
At Diagnosis*
Fasting PG
Casual PG
Food Plan and Exercise Stage
At Diagnosis*
Fasting PG
Casual PG
Oral Agent Stage
Acarbose, Metformin,
Sulfonylurea or
Troglitazone; see Oral Agent
Selection, 1-13
1-5
Combination Therapy
Oral Agents or SulfonylureaInsulin; see Combination
Therapy Selection, 1-25
At Diagnosis*
Fasting PG
Casual PG
Medications
• Continue with food plan
and exercise program
throughout all stages of
therapy
• Acarbose may be used in
combination with insulin
or sulfonylurea
• The Master DecisionPath
is bi-directional; patients
may move in either direction between therapies
• Human Ultralente insulin
may be used in place of
human NPH insulin
• Insulin sensitizers may be
added when total daily
insulin dose > 0.7 U/kg
* Place the customized
criteria for starting
each therapy in the
space provided
Insulin Stage 3A
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Insulin Stage 3A
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Insulin Stage 3 A-Mid
R - R - R/N - 0
LP - LP - LP/N - 0
Insulin Stage 4A
R-R-R-N
LP - LP - LP - N
Medications
R = Regular Insulin
0 = None
LP = Lispro Insulin
( ) = Optional
N = NPH Insulin
Dose schedule: AM - MIDDAY - PM - BEDTIME
Type 2 < Age : Master DecisionPath
At Diagnosis*
Fasting PG
Food Plan and Exercise Stage
At Diagnosis*
Fasting PG
Insulin Stage 2
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Medications
R = Regular Insulin
LP = Lispro Insulin
N = NPH Insulin
0 = None
Insulin Stage 3A
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Insulin Stage 3A-Mid
R-R-R-N
LP - LP - LP - N
Dose Schedule:
BEDTIME
AM-MIDDAY-PM-
Comments
• Oral agents
(Acarbose,
Metformin,
Sulfonylureas,
Troglitazone) have
not been tested in
children and adolescents
• While insulin theerapies may be combined with some
oral agents intrating adults, this
should only be considered in consultation with a Diabetes
with a Diabetes
Specialist when
treating individuals
< age 18
Insulin Stage 4A
R-R-R-N
LP - LP - LP - N
* Place the customized criteria for
starting each therapy in the
space provided
1-6
Type 2 : Food Plan and Exercise/Start
At Diagnosis*
Mild or no symptoms
Start Food Plan and Exercise
Assessment
• HbA1c, SMBG, lipid
profile, albuminuria
• Food history or 3-day food
record (meals and snacks
with times and portions)
• Nutrition adequacy
• Height/weight/BMI
• Weight goals/eating
disorders
• Fitness level (strength,
flexibility, endurance)
• Exercise times, duration,
and type
Goals
• SMBG and HbA1cin
target range
• Serum cholesterol
< 200 mg/dL;
LDL < 130 mg/dL; triglycerides < 200 mg/dL
• BP < 130/85 mm Hg
• Urine albumin < 30 mg/24
hour or < 30 mg/g creatinine
• BMI < 27 kg/m2
• Regular exercise
Plan
• Set meal and snack times
• Set consistent carbohydrate
intake at meals and snacks
to meet BG targets (see
sample food plan)
• Exercise regimen based on
fitness level
Follow-up
Medical: Within 1 month
Nutrition: Within 2 weeks
1-8
Medical; Nutrition
Therapy Guidelines
• Total fat = 30% total
calories; less if 0bese
and elevated LDL
• Saturated fat < 10%
total calories; < 7%
with elevated LDL
• Cholesterol < 300
mg/kg/day
• Sodium < 2400 mg/day
• Protein reduced to 0.8
gm/kg/day (~10% total
calories) if
macroalbuminuria
• Calories decreased by
10-20%
if BMI > 27
kg/m2
Sample Food Plan
MEAL CHO MEAT/SUB FAT
Bkfst.
Snack
Lunch
Snack
Dinner
Snack
3-4
1-2
3-4
1-2
3-4
1-2
0-1
0
2-3
0
2-3
0
0-1
0-1
1-2
0-1
1-2
0-1
• 1 CHO =1 carbohydrate
serving, = 15 gm = 60-90
calories
• 1 Meat/Sub = 1 oz serving
(28 gm) = 7 gm protein;
5 gm fat; 50-100 calories
• 1 Added Fat = 1 serving
= 5 gm fat; 45 calories
• Vegetables = 1-2
servings/day with each
meal; not counted in plan
Type 2 : Oral Agent Selection
Serum creatinine
> 2.0 mg/dL?
YES
NO
Serum creatinine
1.4-2.0 mg/dL?
YES
NO
Serum creatinine < 1.4m
mg/dL
If no hepatic disease, consider Metformin,
Sulfonylurea,
Troglitazone, or Acarbose
If hepatic disease, consider insulin therapy; see
Insulin Stage 2, Insulin
3A. Or Insulin 4A
If no hepatic disease,
move to
Troglitazone/Start
If hepatic disease, move
to Insulin Stage 2, 3A,
or 4A/Start
Metformin contraindicated
If no hepatic disease,
consider Sulfonylurea,
Troglitazone or Acarbose
If hepatic disease, consider insulin therapy; see
Insulin Stage 2, Insulin
3A, or Insulin 4A
Indicators for Use of Oral Agents
SULFONYLUREA
FPG > 250 mg/dL
CPG > 300 mg/dL
Negative
Hypoglycemia
Weight gain
Sulfa allergy
ACARBOSE
TROGLITAZONE
Positive
Post-meal
Obesity
hyperglycemia
Dyslipidemia
(with failure on Metformin)
Negative
Gastro-intestinal Cardiovascular disease
disturbances
Liver disease
Altered metabolism of
oral contraceptives
Note: Oral agents are not approved for use in pregnancy and have
not been tested for use in adolescents and children.
Positive
METFORMIN
Obesity
Dyslipidemia
Lactic acidosis
Hypoxia
1-13
Type 2: Acarbose/Start
At Diagnosis or from Food
Plan and Exercise Stage,
another Oral Agent Stage, or
Insulin Stages
Start Acarbose
Assess food plan and exercise
See Food Plan and Exercise
Dose (take before each meal)
Acarbose: 25 mg before the
largest meal of the day and
titrate up weekly to 3
times/day to improve tolerability
Educate patient about using
glucose tablets instead of
sucrose to treat hypoglycemia
Refer patient for nutrition and
diabetes education
Follow-up
Medical:
Within 1 week
Move to Acarbose/Adjust
Precautions and
Contraindications
• Pregnancy and lactation
• Renal disease (serum
creatinine > 2.0
mg/dL)
• Inflammatory
bowel disease
• Colonic ulceration
• Partial intestinal blockage
• Any chronic intestinal
disease
• Liver dysfunction
(cirrhosis)
• Diabetic ketoacidosis
Side Effects
• Flatulence, abdominal
pain, and diarrhea
• Tend to decrease in
frequency and intensity
with time
1-14
Type 2 : Acarbose/Adjust
Patient treated with
Acarbose and not
at target
Patient on maximum
tolerated dose of
Acarbose for 4-8 weeks?
Consider alternative
oral agent or move to
YES
NO
Combination Therapy
Selection or Insulin
Therapy
Consider stopping
Acarbose if used as
adjunct therapy with
insulin
Acarbose Dose Adjustments (in mg)
START
NEXT
NEXT
UP TO MAX
Acarbose
25 mg/day
25 mg bid 25 mg tid
100 mg tid
May be increased by 25 mg/day/week if tolerating dos; maximum dose is 100 mg
tid or 50 mg tid for people who weigh < 60 kg (132 Ibs)
Follow-up
Medical:
Monthly; use this DecisionPath for
follow-up
Determine serum transaminase levels every 3 months for first year and periodically
thereafter; if elevated, discontinue Acarbose
Discontinue Acarbose if side effects do not
diminish within 1 month of starting therapy;
see Oral Agent Selection, 1-13
1-15
Type 2: Metformin/Start
At Diagnosis or from Food
Plan and Exercise Stage
or another
Oral Agent Stage
Start Metformin
Assess food plan and exercise
See Food Plan and Exercise
Dose (take in the PM)
Metformin: 500 or 850
mg/day
Refer patient for nutrition and
diabetes education
Follow-up
Medical: Within 1 week
Move to Metformin/Adjust
Precautions and
Contraindications
• Pregnancy and lactation
• Risk of lactic acidosis
in patients with:
Renal disease (serum
creatinine >1.4 mg/dL)
Liver dysfunction
Alcohol abuse, binge
drinking
Acute cardiovascular
or pulmonary disease
In patients > 80 years
old unless creatinine
clearance demon
strates renal function
not impaired
Patients with CHF
who require pharmacologic treatment
• Intravenous radiographic contrast
agents
Side Effects
• Usually dose related
and self-limited
• Common: Diarrhea,
nausea, and abdominal
discomfort
• Occasional: Metallic
taste
1-16
Type 2 : Metformin/Adjust
1-17
Patient treated with
Metformin and not
at target
Patient on maximum
dose of
Metformin for
2-4 weeks?
YES
Consider alternative
oral agent or move to
Combination Therapy
Selection or
Insulin Therapy
NO
Metformin Dose Adjustments (in mg)
Metformin
500 mg
Metformin
850 mg
PM
500
START
AM/PM
500/500
850
850/850
NEXT
NEXT
NEXT
MAX
AM/PM AM/PM AM/MID/PM
500/1000 1000/1000 1000/500/1000
-
-
850/850/850
May be increased by weekly when suing 500 mg
biweekly when using 850 mg tablets
Follow-up
Medical:
Monthly; use this DecisionPath for follow-up
If persistent gastro-intestinal discomfort, consider discontinuing Metformin and
starting Troglitazone
Type 2: Sulfonylurea/Start
At Diagnosis or from Food
Plan and Exercise Stage
or another
Oral Agent Stage
Start Sulfonylurea
Assess food plan and exercise
See Food Plan and Exercise
Dose (take with first meal
of the day)
Glyburide:
2.5 mg/day
Micro.Glyburide: 1.5 mg/day
Glipizide :
5.0 mg/day
Glipizide XL:
5.0 mg/day
Glimepiride:
1 mg/day
Refer patient for nutrition and
diabetes education
Follow-up
Medical: Within 1 week
Move to Sulfonylurea/Adjust
Precautions and
Contraindications
• Pregnancy and lactation
• Significant renal disease
ease (serum creatinine >
2.0 mg/dL
• Allergy tosulfa drugs
Side Effects
• Hypoglycemia
• Weight gain
1-18
Type 2 : Sulfonylurea/Adjust
1-19
Patient treated with
Sulfonylurea and not
at target
Patient on maximum
dose of
Sulfonylurea for 2-4
weeks?
Consider alternative
oral agent or move to
YES
Combination Therapy
Selection
or Insulin Therapy
NO
Sulfonylurea Dose Adjustments (in mg)
MAX
START
AM
AM
NEXT
AM/PM
NEXT
AM/PM
NEXT
AM/PM
Glyburide
2.5
5
5/5
10 / 5
10 / 10
Micro.Glyburide 1.5
3
6/9/12 / Glipizide
5
10
15 / 10 / 10
20 / 20
GlipizideX L
5
10
15 / -/20 / May be increased every
Glimepiride
1 1-2 weeks2
3/4/8/Follow-up
Medical: Monthly; use this DecisionPath for follow-up
If significant hypoglycemia, consider Acarbose, Acarbose, Metformin, or
Troglitazone; see Oral Agent Selection, 1-13, and Hypoglycemia/Treatment, 4-9
Type 2 : Combination Therapy Selection
Metformin
Maximum
Dose
Add
Sulfonylurea
at minimum
dose
Sulfonylurea
Maximum
Dose
Add
Metformin
at minimum
dose
If Metformin and
Sulfonylurea at maximum
dose, discontinue Metformin,
and add bedtime insulin; see
Sulfonylurea-Insulin or discontinue both oral agents and
start insulin; see Insulin Stage
2, 3A, or 4A
Troglitazone
Maximum
Dose
Acarbose
Maximum
Dose
Add
Sulfonylurea
at minimum
dose
Add
Sulfonylurea
at minimum
dose
If combination fails, start
insulin therapy; see Insulin
Stage 2, 3A or 4A
Indicators for Use of Oral Agents Combinations
Positive
Negative
Positive
Negative
METFORMIN/
SULFONYLUREA
Obesity
Dyslipidemia
FPG > 250 mg/dL
CPG > 300 mg/dL
Lactic acidosis
Hypoxia
Hypoglycemia
Weight gain
Sulfa allergy
ACARBOSE/
SULFONYLUREA
FPG > 250 mg/dL
CPG > 300 mg/dL
Primarily post-meal
excursions
GI disturbances
Hypoglycemia
Sulfa allergy
1-25
TROGLITAZONE/
SULFONYLUREA
Obesity
Dyslipidemia
Metformin not tolerted
CPG > 300 mg/dL
Liver disease
Cardiovascular disease
Altered metabolism of
oral contraceptives
SULFONYLUREA/
INSULIN
FPG > 250 mg/dL
CPG > 300 mg/dL
Primarily high fasting
Hypoglycemia
Sulfa allergy
Type 2: Combination Oral Agent/Start
From any Oral Agent Stage
Unable to achieve targets
on current oral agent therapy
Start Combination Oral Agent
T/S - 0 - (S) - 0
M/S - (M) - (M)/(S) - 0
A/S - A - A/(S) - 0
• Maintain current oral agent dose
• Add starting dose of second
oral agent with first meal
unless otherwise noted
Metformin(M)
Glyburide (S)
Micro.glyburide
Glipizide (S)
GlipizideXL(S)
Glimepiride (S)
Acarbose (A)
Troglitazone
500 or 850
mg/day
2.5 mg/day
1.5 mg/day
5.0 mg/day
5.0 mg/day
1 mg/day
25 mg/day*
200 mg/day
*before largest meal of the day
Refer patient for nutrition and
diabetes education
Follow-up
Medical: Within 1-2 week
Move to Combination
Oral Agent/Adjust
Precautions and
Contraindications for
All Combinations
• Pregnancy and lactation
• Renal disease
• Liver dysfunction
• Alcohol abuse; binge
drinking
See specific
DecisiondPaths for
precautions,
contraindications and side
effects
1-26
Type 2: Insulin Stage 3 A-Mid/Start
At Diagnosis
Start insulin within 1 week; hospitalize if outpatient education
not available; if acute illness, hospitalize and start insulin
immediately or from Oral Agent Stage,
Combination Therapy, or Insulin Stage 2 or 3A
Start Insulin Stage 3A-Mid
R - R - R/N - 0
LP - LP - LP/N - 0
At Diagnosis
• Calculate total dose at 0.3 U/kg based on current weight
AM
MIDDAY
PM
BT
Distribution
1/4
1/4
1/2
0
R/N or LP/N ratio
1:1
From Insulin Stage 2
• If current total dose is > 1.5 U/kg, consider decreasing dose to 1.0 U/kg,
otherwise use current total dose
• Add MIDDAY R or LP at 50% of current AM N
• Discontinue AM N
• Increase AM R or LP by 10%
Refer patient for nutrition and diabetes education
Follow-up
Medical: If new insulin start, daily phone contact for 3 days, then office visit
within 2 week; 24-hour emergency phone support needed
If changing therapies, phone or office visit within 1 week, then office
visit within 1 month
Education: If new insulin start, within 24 hours, otherwise within 2 weeks
Move to Insulin Stage 3A/Adjust
1-36
Type 2: Insulin Stage 4 A/Start
At Diagnosis
Start insulin within 1 week; hospitalize if outpatient education
not available; if acute illness, hospitalize and start insulin
immediately or from Oral Agent Stage,
Combination Therapy, or Insulin Stage
Start Insulin Stage 3A-Mid
R - R - R/N - 0
LP - LP - LP/N - 0
At Diagnosis
• Calculate total dose at 0.3 U/kg based on current weight
• Start BT N at 30% of total dose
• Start R or LP before each meal and distribute as needed b
From Insulin Stage 2
• If current total dose is > 1.5 U/kg, consider decreasing dose to 1.0 U/kg,
otherwise use current total dose
• Add MIDDAY R or LP at 50% of current AM N
• Discontinue AM N
• Increase AM R or LP by 10%
AM
MIDDAY
PM
BT
Distribution
20%
25%
25%
30%
Refer patient for nutrition and diabetes education
Follow-up
Medical: If new insulin start, daily phone contact for 3 days, then office visit
within 2 week; 24-hour emergency phone support needed
If changing therapies, phone or office visit within 1 week, then office
visit within 1 month
Education: If new insulin start, within 24 hours, otherwise within 2 weeks
Move to Insulin Stage 4A-Mid/Adjust
1-38
Type 2 : Insulin Stage 4A/Adjust
1-39
Patient in Insulin
Stage 4A
If persistent hyperglycemia after using both
insulin and Troglitazone,
consider referral to
Diabetes Specialist
Is current insulin dose:
< 1.5 U/kg
for age >
18?
< 1.0 U/kg for age < 18?
NO
In no significant
improvement in 6
months,
refer patient to a
Diabetes Specialist
YES
Insulin Stage 4A Patter Adjustments
R - R - R - N or LP - LP - N
Am
Am
or
AM
or 3
33 AM
or
AM
MIDDAY
MIDDAY
or 3
AM
3 AM
or
AM
PM
PM
mg/dL
BEDTIMD
BEDTIME
BEDTIMD
(BT)
(BT)
< 80 mg/dL
ฏ
ฏ
ฏ
BT N
1-2 U(a,b)
140-250 mg/dL
ญ
BT N
1-2 U(a)
AM R or LP
ญ AM
MID R or LP
ญ MID R or LP
1-2 U(c,e)
R or LP
1-2 U(f,g)
> 250 mg/dL
ญ BT N
2-4 U(a)
ญ AM
R or LP
2-4 U(f,g,i)
ญ MID R or LP
1-2 U(d,e)
1-2 U(f,h)
2-4 U(f,h,j,k)
< 100 mg/dL
160-250 mg/dL
> 250
ฏ
PM R or LP
ญ
PM R or LP
ญ
PM R or LP
1-2 U(e)
1-2 U(f)
2-4 U(f)
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit within 1-2 months;
use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 1-40, for consideration designated by each letter.
Type 2 : Insulin Stage 3A/Adjust
Patient in Insulin
Stage 3A-Mid
If persistent hypoglycemia or fasting hyperglycemia, consider Insulin
Stage 4A
Is current insulin dose:
< 1.5 U/kg
for age >
18?
< 1.0 U/kg for age < 18?
NO
Consider adding insulin
sensitizer or move to
Insulin Stage 4A/Start
YES
Insulin Stage 3A Patter Adjustments
R - R - R/N - 0 or LP - LP - LP/N - 0
Am
Am
or
AM
or 3
33AM
or
AM
MIDDAY
MIDDAY
(MID)
3 AM
or
3
AM
PM
PM
< 80 mg/dL
> 250 mg/dL
ญ PM N
1-2 U(a)
2-4 U(a)
ฏ AM R or LP
ญ AM R or LP
ญ AM R or LP
1-2 U(c,e)
1-2 U(f,g)
2-4 U(f,g,i)
ฏ MID R or LP
ญ AM R or LP
ญ MID R or LP
1-2 U(d,e)
1-2 U(f,h)
2-4 U(f,h,j,k)
< 100 mg/dL
160-250 mg/dL
> 250
mg/dL
BEDTIMD
BEDTIME
BEDTIMD
ฏ PM R or LP
ญ PM R or LP
ญ PM R or LP
(BT)
1-2 U(e)
1-2 U(f)
2-4 U(f)
(BT)
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit within 1-2 months;
use this DecisionPath for follow-up
ฏ
PM N
1-2 U(a,b)
140-250 mg/dL
ญ
PM N
See Insulin Adjustment Guidelines, 1-40, for consideration designated by each letter.
1-37
Type 2 : Insulin Stage 2A/Adjust
1-33
Patient in Insulin Stage 2
If nocturnal hyperglycemia
or morning hyperglycemia,
consider Insulin Stage 3 A
Is current insulin dose:
< 1.5 U/kg
for age >
18?
< 1.0 U/kg for age < 18?
NO
YES
Insulin Stage 2 Patter Adjustments
R/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0
Am
Am
or
AM
or 3
33AM
or
AM
MIDDAY
MIDDAY
(MID)
3 AM
or
3
AM
PM
PM
< 80 mg/dL
ฏ
ฏ
PM N
1-2 U(a,b)
AM R or LP
140-250 mg/dL
ญ
PM N
1-2 U(a)
ญ AM
R or LP
Consider adding insulin
sensitizer or, if persistent fasting hyperglycemia or nocturnal
hypoglycemia, move to
Insulin Stage 3A; if
midday hyperglycemia,
move to Insulin Stage
4A; if more flexibility
required, move to
Insulin Stage 3 A-Mid
> 250 mg/dL
ญ PM N
2-4 U(a)
ญ AM
R or LP
1-2 U(c,e)
1-2 U(f,g)
2-4 U(f,g,i)
ฏ AM N
ญ AM N
ญ AM N
1-2 U(d,e)
1-2 U(f,h)
2-4 U(f,h,j,k)
< 100 mg/dL
160-250 mg/dL
> 250
mg/dL
BEDTIMD
BEDTIME
BEDTIMD
ฏ PM R or LP
ญ PM R or LP
ญ PM R or LP
(BT)
1-2 U(e)
1-2 U(f)
2-4 U(f)
(BT)
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit within 1-2 months;
use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 1-40, for consideration designated by each letter.
V
Diabetes Classification
If patient is pregnant and diabetes is suspected,
see Gestational: Screening and Diagnosis
Patient with classic symptoms
of type 1 diabetes:
Sudden weight loss;
frequent urination, thirst, and hunger
or
Patient with classic symptoms of type 2
diabetes or asymptomatic:
Blurred vision; urinary tract infection; dry/itchy skin; numbness/tingling in extremities; unexplained weight loss
Any risk factors
for type 2 diabetes?
Risk factors: Family history;
age > 45; obesity
27 (BMI >
kg/m2); hypertension; dyslipidemia; previous impaired fasting glucose, impaired glucose
tolerance or gestational diabetes; American Indian;
Hispanic/Mexican American;
African American;
Pacific Islander
YES
NO
Urine ketones present?
YES
See Type 1: Screening and
Diagnosis,2-3
NO
See Type 2:
Screening and
Diagnosis, 1-3