DIABETES MANAGEMENT

TreatmentGuide

DIABETES MANAGEMENTDon’t leave

High blood sugar may cause complications such as heart and kidney diseases, blindness, and sexual dysfunction, but living with diabetes can be manageable.

SHOOT FOR LUCKY NUMBER A1C reflects the average glucose in your blood over the last few months. An A1C

number of 7 or above means there has been too much glucose in your blood.

SET YOUR GOAL FOR:Getting an A1C lab test at least every six months.

An A1C level less than 7 percent.

Following your treatment plan can help you stay healthy and keep your diabetes under control.

up to luck.

your health

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If your A1C is 7 or above, talk to your doctor about a treatment plan today!

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HMSA recognizes the effort involved in managing care for patients with a chronic disease. This booklet contains useful information to support your efforts in helping patients obtain diabetes control.

This booklet includes: • An ADA algorithm for treatment of hyperglycemia for type 2 diabetes. • A medication reference chart for insulin and non-insulin drugs.

In addition, HMSA is including the following items: • A poster for your office. • Patient handouts with important diabetes information.

With these resources, we aim to support you in helping those with diabetes manage their disease, control their blood glucose, and live happy, healthy lives.

MemberHandout

Poster

When it comes to diabetes,

shoot for lucky number

Every step you take to reach your blood sugar goal can reduce your risk of compli-cations from diabetes. Maintaining healthy blood sugar, a nutritious diet, an active lifestyle and taking medications properly will help keep you healthy and feeling great.

Don’t leaveyour healthup to luck.

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D I A B E T E S M A N A G E M E N T

TRACK YOUR HbA1C LEVELS

Values Goal for Diabetics

Where I am Now

Whole Blood Values

Average Prepran-dial Glucose (mg/dL)

Average Bedtime Glucose (mg/dL)

80-120

100-140

_________

_________

HbA1c (%)Less

than 7 _________

Algorithm Notes:~ Check A1C every three months until <7 percent, and then at least every six

months.

* Associated with increased risk of fluid retention, CHF and fractures. Rosigli-tazone, but probably not pioglitazone, may be associated with an increased risk of myocardial infarction.

° Although three oral agents can be used, initiation and intensification of insu-lin therapy is preferred based on effectiveness and lower expense.

^ David M. Nathan, et al. Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: Update regarding thiazolidinediones: A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 31: 173-175.

Management of Hyperglycemia in Type 2 Diabetes^

Diagnosis

Lifestyle intervention

+ metformin

No

Add basal insulin - most effective

Add sulfonylurea

- least expensiveAdd glitazone*

- no hypoglycemia

No

Yes~

No

Yes~

No

Yes~

Intensify insulin Add glitazone*˚ Add basal insulin Add sulfonylurea˚

No Yes~No Yes~

Intensive insulin + metformin +/- glitazone*

Yes~

Add or intensify basal insulin

>HbA1C 7%

>HbA1C 7% >HbA1C 7% >HbA1C 7%

>HbA1C 7% >HbA1C 7%

Support programs for HMSA members with diabetes:

HMSA’s Care Connection supports members with diabetes, heart, respiratory and chronic kidney disease across the entire health care continuum. Our programs focus on prevention, education, behavior change and evidence-based medicine to drive member’s adherence to proven standards of care, medications and their physician’s care plan. Members can speak to a Care Connection team member by calling 1 (800) 499-5036.

Diabetes Education Provider Network is a network of trained diabe-tes educators who conduct education classes in the community on subjects including Diabetes Overview, Basic Diet and Self Monitor-ing of Blood Glucose, Prevention of Long-Term Complications and Self Management, Medication Management, and Insulin Training. This service is available to Care Connection participants. Enroll by contacting Care Connection at 1 (800) 499-5036.

Medco By Mail is the mail order prescription drug program that offers your patients an easier way to get a 90-day supply of mainte-nance medication, insulin, and diabetic supplies. For more informa-tion about Medco By Mail, please contact Medco toll-free at 1 (888) 327-9791 and provide your fax number for a mail order form to be sent directly to you.

INSULIN PRODUCTS Type Form Onset Peak Duration Cost*

Rapid Acting

Insulin aspart - Novolog 10 ml vial 3 ml Flex-pen

10 - 20 minutes 1 - 3 hours 3 - 5 hours $94.25 $191.89

Insulin lispro - Humalog 10 ml vial 3 ml - cartridge 3 ml- KwikPen

15 - 30 minutes 30 minutes - 2.5 hours 3 - 6.5 hours $89.99 $173.28 $169.98

Insulin glulisine - Apidra** 10 ml vial 3 ml cartridge

10 - 15 minutes 1 - 1.5 hours 3 - 5 hours $90.68 $174.25

Regular Insulin

Humulin R 10 ml vial 30 - 60 minutes 1 1/2 - 2 hours 5 - 8 hours $46.99

Novolin R 10 ml vial 3 ml PenFill cartridge 3 ml Innolet

$45.99 $115.28 $85.04

Intermediate-Acting

NPH (Isophane insulin suspension; contains zinc and protamine)

1 - 2 hours 4 - 8 hours 10 - 20 hours

Humulin N 10 ml vial 3 ml cartridge

$49.99 $134.49

Novolin N 10 ml vial 3 ml PenFill Cartridge 3 ml Innolet

$46.99 $115.28 $87.23

Long-Acting (basal insulin)

Insulin detemir - Levemir 10 ml vial 3 ml FlexPen

0.8 - 2 hours (dose dependent)

Relatively flat Dose dependent: 12 hours for 0.2 units/kg, 20 hours for 0.4 units/kg, up to 24 hours. Binds to albumin.

$89.21 $168.12

Insulin glargine - Lantus 10 ml vial 3 ml cartridge 3 ml SoloStar disposable device

1- 2 hours No significant peak 24 hours $92.26 $179.95 $176.99

Pre-Mixed

Novolin 70/30 (70% NPH, 30% regular human insulin)

10 ml vial 3 ml PenFill Cartridge 3 ml Innolet

30 - 60 minutes 2 - 12 hours Effective: 10 - 16 hours Max: Up to 18 - 24 hours

$46.26 $125.59 $87.23

Novolog Mix 70/30 (70% insulin aspart, 30% insulin aspart protamine)

10 ml vial 3 ml FlexPen

10 - 20 minutes Mean: 2.4 hours Range: 1 - 4 hours

Effective: 15 - 18 hours Max: Up to 24 hours

$101.36 $176.20

Humalog Mix 75/25 (75% insulin lispro protamine susp, 25% insulin lispro)

10 ml vial 3 ml Pen 3 ml KwikPen

Faster than Humulin 70/30

Mean: 2.6 hours Range: 1 - 6.5 hours

Up to 24 hours (similar to Humulin 70/30)

$96.89 $164.99

Humulin 70/30 (70% NPH, 30% regular) 10 ml vial 3 ml cartridge

30 - 60 minutes Mean: 4.4 hours Range: 1.5 - 16 hours

Effective: 10 - 16 hours Max: Up to 18 - 24 hours

$54.00 $274.36

Humulin 50/50 (50% NPH, 50% regular) 10 ml vial 30 - 60 minutes Mean 3.3 hours Range: 2 - 5.5 hours

Effective: 10 - 16 hours Max: Up to 18 - 24 hours

$54.00

Reference: Medical Letter Vol. 6 (71), July 2008: Pharmacists Letter Vol. 22, March 2006.* Per Drugstore.com; cost per one 1,000U vial or 5 cart/syringes.**Average copayment due to different drug plans for all insulin = $5/30 days, except Apidra = $55/30 days.

TyPe 2 DIAbeTeS MeLLITUS MeDICATION CHART Drug Dosage Forms Usual Daily Dosage ↓ in HbA1C Advantages/Disadvantage Member

CopaymentCost per 30 day supply*

Biguanides 1 - 2 % Weight neutral, inexpensive GI side effects

Metformin - Generic (Glucophage)

500, 850, 1,000 mg tablets 1,500 - 2,550 mg divided with meals Generic $55.80 (generic)** $91.80 (brand)

Extended release - Generic (Glucophage XR)

500, 750 mg tablets 1,500 - 2,000 mg once with meals Generic $60.00 (generic) $92.40 (brand)

Fortamet (Extended release)

500, 1,000 mg tablets 1,500 - 2,500 mg once with meals Other Brand $162.00

Riomet - liquid 500 mg/5 ml 4, 16 oz

1,500 - 2,550 mg divided with meals Other Brand $87.98 (16 oz bottle)

Second Generation Sulfonylureas

1 - 2 % Inexpensive Weight gain, hypoglycemia

Glimepiride - Generic (Amaryl)

1, 2, 4 mg tablets 1 - 4 mg once with breakfast or first meal

Generic Other Brand

$10.20 (generic) $16.20 (brand)

Glipizide - Generic (Glucotrol)

5, 10 mg tablets 10 - 20 mg once or divided (>15 mg/day dose BID)

GenericOther Brand

$15.90 (generic) $32.70 (brand)

Extended release - Generic (Glucotrol XL - sustained release tablets)

5 - 20 mg tablets 5 - 20 mg once Generic Other Brand

$10.20 (generic) $17.70 (brand)

Glyburide - Generic (DiaBeta) (Micronase)

1.25, 2.5, 5 mg tablets 5 - 20 mg once or divided with breakfast or first meal

Generic Other Brand Other Brand

$18.00 (generic) $31.80 (brand) $39.30 (brand)

Mirconized tablets - Generic (Glynase Prestab)

1.5, 3, 6 mg tablets 1.5 - 12 mg once or divided with breakfast or first meal

Generic Other Brand

$9.30 (generic) $22.50 (brand)

Non-sulfonylurea secretagogues

1 - 1.5% Short duration TID dosing, expensive, hypoglycemia

Nateglinide - Starlix 60, 120 mg tablets 60 - 120 mg TID AC Preferred $138.60

Repaglinide - Prandin 0.5, 1, 2 mg tablets 1 - 4 mg TID AC Preferred $143.10

Thiazolidinediones 0.5 - 1.4% Improved lipid profile, decreased risk of MI (rosiglitazone) Fluid retention, increased risk of CHF, potential increased risk of MI (pioglitzone), atherogenic lipid profile, weight gain, expensive

Pioglitazone - Actos 15, 30, 45 mg tablets 15 - 45 mg once Other Brand $132.30

Rosiglitazone - Avandia 2, 4, 8 mg tablets 4 - 8 mg once or divided Other Brand $110.70

Reference: Medical Letter, Vol. 6 (71), July 2008; 47-54.* Avg retail cost for lowest usual daily dosage from Wolter Kluwers Health

and/or Drugstore.com.**Some generics available for $4 at select retailers.

TyPe 2 DIAbeTeS MeLLITUS MeDICATION CHART Drug Dosage Forms Usual Daily Dosage ↓ in HbA1C Advantages/Disadvantage Member

Copayment Tier***

Cost per 30 day supply*

a-glucosidase inhibitors 0.5 - 0.8% Weight neutral Frequent GI side effects, TID dosing, expensive

Acarbose - generic Precose

25, 50, 100 mg tablets 50 - 100 mg TID with meals Generic Other Brand

$86.65 (generic)** $92.70 (brand)

Miglitol - Glyset 25, 50, 100 mg tablets 50 - 100 mg TID with meals Preferred $89.10

Incretin Mimetics 0.5 - 1.0% Weight loss Injections, frequent GI side effects, expensive, little experience

Exanatide (Byetta) 250 mcg/ml (1.2, 2.4 ml prefilled pen)

10 mcg SC bid AC breakfast and dinner

Preferred $213.03 (2.4 ml pen)

Amylin analogs 0.5 - 1.0% Weight loss Injections, TID dosing, frequent GI side effects, expensive, little experience

Pramlintide (Symlin) 0.6 mg/ml (5 ml vial); 1,000 mcg/ml (1.5, 2.7 ml prefilled pen)

Other Brand $213.60 (1 box of 2 X 2.7 ml pens)

DPP-4 Inhibitors 0.5 - 0.8% Weight neutral Little experience, expensive

Sitagliptin (Januvia) 25, 50, 100 mg tablets 100 mg once Preferred $180.60

Combination Products N/A

Metformin/glipizide - Metaglip 250/2.5, 500/2.5, 500/5 mg tablets

500 mg/2.5 mg BID with meals Preferred $72.60

Metformin/glyburide - Generic Glucovance

250/1.25, 500/2.5, 500/5 mg tablets

500 mg/5 mg BID with meals GenericOther Brand

$51.60 (generic) $80.40 (brand)

Metformin/pioglitazone - Actoplus Met

500/15, 850/15 mg tablets

500 mg/15 mg po BID with meals Preferred $201.60

Metformin/rosiglitazone - Avandamet

500/1, 400/2, 500/4, 1000/2, 1000/4 mg tablets

500 mg/2 mg BID with meals Preferred $130.80

Metformin/sitagliptin - Janumet 500/50, 1000/50 mg tablets 500 mg/50 mg BID with meals Preferred $181.80

Glimepiride/rosiglitazone - Avandaryl

1/4, 2/4, 4/4, 2/8, 4/8 mg tablets

4 mg/4mg BID Preferred $249.00

Glimiepiride/pioglitazone - Duetact

2/30, 4/30 mg tablets 4 mg/30 mg once Preferred $204.00

Reference: Medical Letter, Vol. 6 (71), July 2008; 47-54.* Avg retail cost for lowest usual daily dosage from Wolter Kluwers

Health and/or Drugstore.com.** Some generics available for $4 at select retailers.***Refer to Guide to Benefit for applicable copayment amount.

DIABETES MANAGEMENT

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