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Diabetes Mellitus Type 2

Criteria for diagnosis of Pre-Diabetes:  

HbA1C 5.7-6.5%

Fasting glucose 100-125mg/dL

2-hour plasma glucose >140-199mg/dL

Criteria for diagnosis of Diabetes Mellitus Type 2:

HbA1C >= 6.5%

Hyperglycemia crisis plus random plasma glucose >= 200mg/dL

Fasting plasma glucose >= 126 mg/dL on 2 occasions or 2-hour plasma glucose >= 200mg/dL during oral glucose tolerance test with a 75 gram glucose load.

Targets:

 

  • A1C <7.0% for recently diagnosed without other co-morbidities (aim for 6.5% if low risk for hypoglycemia)
  • A1C <8.0% for older patients or patients with comorbidities and established diabetic end organ disease
  • LDL goal <70mg/dL in patients with existing cardiovascular disease.  If the patient is >= 40 years of age, with >= 1 cardiovascular risk factor and LDL greater than 70mg/dL, the patient should start on a statin
  • Blood pressure <140/80 mm Hg (if tolerated, <130 preferable) [ACE-I/ARB is 1st line. If contraindicated consider a Calcium Channel Blocker]

Visit Considerations:

Every Visit:

Diabetic foot exam at every visit

Lifestyle interventions should be discussed

Every 3 months:

A1C

Yearly

Nephropathy: urine microalbumin-to-creatinine ratio

Retinopathy:diabetic eye exam

Management:

Low-dose aspirin for all adults with CVD

ACE-I/ARB 1st line for increased blood pressure

Statin therapy for elevated LDL

Update the patient’s Hepatitis B vaccine

Lifestyle modifications including weight loss

 

Medication:

1st Line:

Biguanides:

  • Metformin: Promotes weight loss and improves insulin resistance. Average A1C decrease when used as monotherapy is 1.0-2.0 points
    • Start metformin and titrate up to 850mg BID for 3 months
    • Avoid in renal insufficiency, prior to radiocontrast agent use, surgery and severe acute illnesses
    • Caution with CHF, alcohol abuse, elderly or if combined with tetracycline
    • ADE’s: GI side effects, vitamin B12 deficiency

2nd Line/Alternatives:

Sulfonylureas: Consider in patients who cannot tolerate Metformin. Lowers A1C by 1-2%. However, their effectiveness decreases over time

  • Glipizide: short acting. 2.4-40mg/day. Dosage 5 or 10 mg/d given bid 30 minutes before meals
  • Other examples: Glyburide, Glimepriride, Chlorpropamide
  • Caution with renal or liver disease, sulfa allergy, creatinine clearance < 50mL/min, pregnancy

Thiazolidenediones:  lower blood glucose concentrations by increasing insulin sensitivity. Lowers A1C by 0.5 – 1.4%.

  • Used more for their synergistic effects as a second line treatment adjunct to other diabetic medications
  • Examples: Pioglitazone (Actos):15-45mg/d. Dosages: 15, 30, 45mg
  • Monitor serum transaminases every 2 months for the 1st year
  • Also associated with weight gain, fluid retention, CHF, bone loss and are expensive. Liver disease and symptomatic heart failure.

Dipeptidyl peptidase-4 inhibitors: More commonly used as a second to third line agent.

  • May be a good choice as first line agent in patients with chronic kidney disease
  • Examples: Sitagliptin (Januvia): Start 100mg/d. Dosages: 25,50,100mg
  • Sitagliption/Simvastatin (Juvisync):
  • Sitagliptin/Metformin (Janumet)
  • Saxagliptin (Onglyza): Start 2.5-5mg/d. Dosages: 2.5, 5mg
  • Linagliptin  (Tradjenta)

Alpha Glucosidase inhibitors: Have an additive hypoglycemic effect and are therefore used as an adjunct agent.  Only decrease A1C by 0.5-0.8%. Taken pre-prandially to decrease post-prandial hyperglycemia.

  • Examples include Acarbose (Precose): Start 75-300mg divided into 3 doses. 50, 100mg
  • Miglitol (Glyset): 25,50, 100mg
  • Avoid in renal insufficiency, inflammatory bowel disease, colonic ulceration or partial bowel obstruction
  • Adverse reactions include increased flatulence and diarrhea.

Meglitinides: Useful in patients with a sulfa allergy or renal impairment. They are short-acting glucose lowering drugs.

  • Repaglinide (Prandin): 0.5-4mg TID. Dosages: 0.5,1,2mg

 

Insulin:

Initiate insulin therapy for for patients

  • Who cannot achieve a target A1C on 2 or more oral hypoglycemic agents,
  • Have severe fasting plasma glucose > 250mg/dL
  • Hgb A1C >10%

DM1

Diagram adapted from: Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325

 

Initiating Insulin

DM2

Diagram adapted from: Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325

DM3

DM4

DM5

 

References:

American College of Clinical Endocrinologists. Comprehensive Diabetes Management Algorithm 2013.

Rao S, Krishnasamy S. Diabetes Mellitus, Type 2. 5-The 5-Minute Clinical Consult Standard 2015, 23rd Edition. Accessed 11/26/2014.  

Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325

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