type 2: management during pregnancy 1-44 maternal monitoring baseline: thyroid functions, if not...

Type 2: Management During Pregnancy

1-44

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 DiabetesSpecialist and other specialists as necessaryNutrition• 300Increase calories /day in the seeeee eee eeeee eeeeeeeeee• eeeeeeee e eeeee eeee eeeeeeeee e eeeee eeeee

% DBW BMI GAIN 9 0 % < 19.8

28-40 1bs 90-120 19.8-26 20-35 1bs > 120 > 26 15-25 1bsDBW = Desirable Body WeightBMI = Body Mass Index (wt/ht2= kg/m2)Self-management Education• Emphasize hypoglycemia prevention/treatment• Instruct family member on gluca

gon administration• Instruct on self adjustment of ins

ulin as administration• Importance of not skipping meals

Type 2: Management During Pregnancy

1-43(continued on next

page)Patient is pregnantPatient is pregnant

SMBG and/or HbA1cwithin target rangefor 1 month prior to

conception?

SMBG and/or HbA1cwithin target rangefor 1 month prior to

conception?

• eeeeeeee e( e -e 3 4

ee eeeeee)ee eeeeeeeeee ee

d speci al i st i neeee eeee eeeeeeeee• Assess diabetes

control and makeeeeeeee eeee ee eeeeeeeee

(SMBG, urine keto nes, HbA 1c )

• Det er mi ne gesteeeeeee eee• Hospitalization

may be necessary

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 anddiabetes education

YES

Follow-upMedical: Phone 1-2

times/week;

office visit at least every 2 weeksEducation: One visit each trimester (minimum)

SMBG Targets• - 6095Fasting:/• - -601Pre meal: 05mg/dL• - 12Post meal: < 0 2mg/dL hours af ter start ofmeal• -100Bedtime: 140mg/dL• eeeeee eeeeeeeee( ee eeeeeeeee eeeeee)ycemia

1HbA c Target• e eeeee eeee ee eeeeeU UUUU UUUUUUU UUUUUU• NegativeUU U U UUUUUUUUU• - eee eeeee4 7 /y; eee e eeeee2 after start of meals and at bedtime• e ee ee ee3eeee

Urine KetonesMonitoring• Test if ill

NO

Type 2: Preconception Planning

1-42Patient planing pregnancyPatient planing pregnancy

SMBG and/or HbA1cwithin target range?SMBG and/or HbA1cwithin target range?

eeeeeeee e, eee eeeeeeee, ry evaluation by cleeeeeee• History: Diabetee eeeeeee eee control, miscarria ges, fetal anomalies, macr osomia, LGA• ee e: , ee eeee ee e eeeeeeeee ee Hydralazine; ACEinhibitors and beta blockere eeeeee-eeeeeeeee ee eeeeeeeee• Complications:Hypoglycemia unawareness; retinopathy; nephropathy; neeeeeeeee • e eeeeee eeeeeeeee-eeeeeee eeeee eeeeeeeee eeeeeee -tion of hyper glycemia with meeeeeee eee fetal complicatioee• Physical exam: I -nclude fundus copic eye exam with dilation by e eeeeeee eeeeeee• eeee eeeeeeeeeee, Sulfonylurea, Met formin, Acarbose; start ieeeeee• Consult Diabete s Specialist if eeeeeeeeeee eeeeee• Laboratory: CBC ; UA/UC; thyroid studies;- 24 hour urine for creatinine cleeeeeee eee albumin; HbA

1c;EKG

SMBG Targets

•

50More than ee ee ee% eeeeee e eeeee eeeee

•

- e: 7- 0100mg/dL

•

- Post meal: < 140mg/dL1 eeee eeeee eee rt of meal; e e< 1 2 0 /dL 2 hours afeee st ar t of meae

•

eeeeee ee( ssisted) or eeeeeeeee eepogl ycemi a Goals may beeeeeeee eee hypogl ycemi aeeeeeeeeeee UUU

1c UUUUUU

•

At ;east 2 val 1ues month apar t wi t hi n nor mal r angeMonitoring

•

SMBG: Up to7 times/day; be eee e2 eeeee eeeee st ar t of meale eee ee eeeeeme

•

HbA1c:At lea 2st values 1month apaee

Work with patient to establish BG controe• eeeeeeee eeeeeee eeeeeee• Strt or adjust intensified regimen as ne eded; see 3Insulin Stage A ee 4A• Continue with birth control• - Consider co management with a Diabe tes Secialist

NO

YES

Stop birth control andcontinue current insulinstage; maintain SMBG

and HbA1C within targetrange until pregnancyconfirmedMove to Management During Pregnancy

Type 2: SMBG and HbA1c

Targets1-2

SMBG Targets• More than 5 0 % of values wi

thin target range• - - Pre meal: 8 0 1 4 0 mg/dL• - 2Post meal ( hours after start

e e e e eeee16 0

• - Bedtime: 100 160 mg/dL• No severe (assisted) or noctur

nal hypoglycemia Adjust target upward if frail elde rly, decreased lifeeeeeeeeeeee eeeeeeeee eeeeeeeee , or other medical concerns

HbA 1c Target• Within 1.5 percentage points

of upper limit of normal SMBG Frequency• - eeeeee 2 4 / ; and 2 hours after start of meals and at bedtime

Lispro Insulin (LP) Considerations• 1 1unit of LP = unit of Regu

lar insulin• Administer within 15 minut

es before the meal due to rapid action• May need to increase basal

insulin dose• - -Use both pre meal and poste eee ee ee eeee ee e eee LP dose adjustments• May have reduced need for

snacks between meals

Type 2: Screening and Diagnosis

1-3

FPG > 126mg/dL?

FPG > 126mg/dL?

YES

NO

FASTING 2 HOURS U UU U U U UUU> 126mg/dL > 200mg/dL Diabetes mellitus- 110125mg/dL 140< mg/dL Impaired fasting glucose (IFG) 126< mg/dL- 140199mg/dL Impaired glucose tolerance (IFG)

Diagnosis of impairedglucose

homeostasis; move to

ImpairedGlucoseHomeostasis

/Start

Casual plasma glucose (CPG): Anytime of day without regard to timeof last meal

Urineketonespresent?

Urineketonespresent?

Fasting plasma glucose (FPG): Nocaloric intake for at least 8 hours

or

CPG > 200mg/dL

FPG > 126mg/dL ee

FPG 1 1-012 5mg/dL

(if CPG is-140 199m/,eeeeeeee OGTT)

CPG <140mg/dL

FPG < 110mg/dL ee

SeeType 1:ScreeningandDiagnosis

No diabetes With riee

factors:Screeneeeeeeee

No risk-fac tors: Sceeee

eeeee eeee3 e

Repeat FPGin 7 days

NO

YES

Diagnosis of type 2 diabetes; moveto Type 2: Master DecisionPath

Diagnosis of type 2 diabetes; moveto Type 2: Master DecisionPath

75 gram Oral Glucose Tolerance Test

Type 2: < Age 18: Screening and Diagnosis

1-4

FPG > 126mg/dL?

FPG > 126mg/dL?

YES

NO

FASTING 2 HOURS U UU U U U UUU> 126mg/dL > 200mg/dL Diabetes mellitus- 110125mg/dL 140< mg/dL Impaired fasting glucose (IFG) 126< mg/dL- 140199mg/dL Impaired glucose tolerance (IFG)

Diagnosis of impairedglucose

homeostasis; move to

ImpairedGlucoseHomeostasis

/Start

Casual plasma glucose (CPG): Anytime of day without regard to timeof last meal

Urineketonespresent

andnon-

obese?*

Urineketonespresent

andnon-

obese?*

Fasting plasma glucose (FPG): Nocaloric intake for at least 8 hours

or

CPG > 200mg/dL

FPG > 126mg/dL ee

FPG 1 1-012 5mg/dL

(if CPG is-140 199m/,eeeeeeee OGTT)

CPG <140mg/dL

FPG < 110mg/dL ee

SeeType 1:ScreeningandDiagnosis

No diabetes With riee

factors:Screeneeeeeeee

No risk-fac tors: Sceeee

eeeee eeee3e

Repeat FPGin 7 days

NO

YES

Diagnosis of type 2 diabetes; move to Type 2< Age 18: Master DecisionPathDiagnosis of type 2 diabetes; move to Type 2< Age 18: Master DecisionPath

75 gram Oral Glucose Tolerance Test

*If obese and type 1diabetes suspected,measure insulinlevel by C-peptide

YES

Type 2: Master DecisionPath

1-5

R = Regular Insulin 0 =None

LP = Lispro Insulin ( ) = Optional N = NPH Insulin

- - - Doseschedul e: AM MI DDAY PMBEDTIME

At Diagnosis*Fasting PGCasual PG

Food Plan and Exercise Stage

Oral Agent Stage

Acarbose, Metformin,Sulfonylurea orTroglitazone; see Oral AgentSelection, 1-13

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 4AR - R - R - N

LP - LP - LP - N

Insulin Stage 4AR - R - R - N

LP - LP - LP - N

Medications* Place the customized criteria for starting each therapy in the space provided


Combination TherapyOral Agents or Sulfonylurea-Insulin; see CombinationTherapy Selection, 1-25

Insulin Stage 3A

R/N - 0 - R/N - 0

LP/N - 0 - LP/N - 0

Medications• Continue with food plan and exercise program eeeeeeeeee eee

stages of eeeeeee• Acarbose may

be used in combination

with insulin or sulfonyluree• The Master Deeeeeeeeeee -is bi direction

al; patients may move ineeeeee eeeee- tion between teeeeeeee• Human Ultraleeee eeeeeee may be used i

n place of human NPH ineeeee• Insulin sensiti zers may be added when teeee eeeee insulin dose >

07. U/kg


At Diagnosis*

Fasting PG

Type 2 < Age : Master DecisionPath

1-6Food Plan and Exercise Stage

Insulin Stage 2

R/N - 0 - R/N - 0

LP/N - 0 - LP/N - 0

* Place the customized criteria for starting each therapy in the space provided

At Diagnosis*Fasting PG

Insulin Stage 3A

R/N - 0 - R/N - 0

LP/N - 0 - LP/N - 0

Insulin Stage 3A-MidR - R - R - N LP - LP - LP -

NInsulin Stage

4AR - R - R - N LP - LP - LP -

NComments

• Oral agents (Acarbose, Metformin, Sulfonylurea, Troglitazone ) have not been teseee ee eeeeeeee eee eeeeeeeeeee• While insulie eeeeee- pies may be-com bined with some eeee eeeeee eeeeee- eeeeeee e,eee eeeeee eeee -be con eeeeeee ee eeeeeeee- tion with a Diabetes with a Diabeeee Specialist weee eeeeeeee eeeeeeeeeee e e18

R = Regular Insulin LP = Lispro Insulin N = NPH Insulin 0 = None

Dose Schedule:

AM-MIDDAY-PM-BEDTIME

Medications

At Diagnosis*

Mild or no symptoms

Type 2 : Food Plan and Exercise/Start

1-8

UUUUUUU UUU• HbA

1c , SMBG, lieee profile, albumineeee• eeee eeeeeee ee - 3 day food record (meals aee eeeeee with times and portions)• Nutrition adequeee• Height/weight/BMI• Weight goals/eaeeee eeeeeeeee• eeeee eeee( , flexibility, endurance)• eee eee , , eee eeeeGoals• SMBG and HbA

1

eee eeeeee eeeee• Serum cholesteree 200< mg/dL; LDL < 130 mg/dL -; triglyc 2 00

mg/dL• 1308BP < / 5mm Hg• Urine albumin < 30 24mg/ e e e 3 0 mg/g creatinine• BMI < 2 7 kg/m2• Regular exercise

U UUU• Set meal and sn ack times• Set consistent carbohydrate intake at mealseee eeeeee to meet BG targ eeee( sample food plan)• Exercise regime n based on fitness level

Sample Food Plan MEAL CHO MEA T/SUB FAT - 34Bkfst.

- -01 0

1

- 12Snack -0 01

- 34Lunch - -23 1

2

- e 120

-01 - 34Dinner

- -23 1

2

- e 120

-01

Start Food Plan and Exercise

Medical; NutUUUUUUUUUUUUU U UUUU lines• Total fat = 30% total calories; less if 0 bese eee eeeeeeee LDL• Saturated fa e e e10

eeeee eeeeeeee ;<7 % with elevate d LDL• Cholesterol 300 mg/kg/day• Sodium < 24 00mg/day• eeeeeee eeee e ee0 8

gm/kg/day ( eeeee~1 0 % calories) if macroalbumieeeee• Calories decr eased by - 1020 i f BMI > 27 kg/m2

• 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

Follow-upMedical: Within 1 monthNutrition: Within 2 weeks

Type 2 : Oral Agent Selection

1-13

Metformin coUUUUUUUUUUUUU If no hepatic d isease, consider Sulfo

nylurea, Troglitazone oU U UUUUUUU If hepatic dise -ase, con sider insulin t herapy; see 2Insulin Stage , UUUUUUU 3A , or 4InsulinU

Indicators for Use of Oral AgentsMETFORMIN

SULFONYLUREAPositive Obesity

FPG > 250 mg/dLDyslipidemia CPG

> 300 mg/dLNegative Lactic acidosisHypoglycemia

Hypoxia Weight gain Sulfa allergy

ACARBOSETROGLITAZONEPositive -Post meal Obesity

hyperglycemiaDyslipidemia

(with failure on Metformin)Negative -Gastro intestinal

Cardiovascular diseasedisturbances

Liver disease

Altered metabolism of oral contraceptives

Note: Oral agents are not approved fo r use in pregnancy and have not been tested for use in adolescent s and children.

If no hepatic disease, move to Troglitazone/Start

If hepatic disease, move

to Insulin Stage 2, 3A,or 4A/Start

Serum creatiniee

> 2.0 mg/dL?

Serum creatiniee

- 1420. . mg/dL?NO

NO

YES

YES

mg/dL If no hepatic di eee -, sider Metformi,

Sulfonylurea, Troglitazone, o r Acarbose If hepatic dise eeeeee -,ee eeeeeee eeee apy; see ee eeeeeee2, 3A. Or Insulin4A

Type 2: Acarbose/Start 1-14

Follow-upMedical: Within 1 week

At Diagnosis or from Food

Plan and Exercise Stage,another Oral Agent Stage, or

Insulin Stages

Assess food plan a nd exercise

See Food Pl an andeeeeeeeeDose (take before each meal)

25Acarbose: m g before the largest meal of theeee eee

titrate up weekly t e3 times/day to improee eeeeee-

bility

Educate patient abeee eeeee

glucose tablets ins tead ofeeeeeee ee eeeee eepoglycemia

Refer patient for neeeeeeee eee diabetes education

PrecautionsUUUU UUUUUUUUUUUUUUUU• eeeeeeeee eee eeeeeeeee• Renal disea se (serum creatinine >20

mg/dL)• Inflammatoee bowel diseaee• Colonic ulceeeeeee• eeeeeee eeeee -tinal block eee• eee eeeeeee eeeeeeeeee eeeeeee• Liver dysfueeeeee (cirrhosis)• Diabetic keteeeeeeeeeUUUU UUUUUUU• ,abdominal eee ee,eeeeee• Tend to deceeeee ee frequency aee eeeeeeeee with time

Move to Acarbose/Adjust

Start Acarbose

Type 2 : Acarbose/Adjust 1-15

Acarbose Dose Adjustments (in mg)

Patient treated withAcarbose and not

at target

Patient on maximumtolerated dose ofAcarbose for 4-8 weeks?

NO

YES

Consider alternativeoral agent or move to

Combination TherapySelection or Insulin

Therapy

Consider stoppingAcarbose if used as

adjunct therapy withinsulin

UUU U U U UU U NEXT UP TO MAX

U 25 25carbose mg/day mg bid 2 5 mg tid 1 0 0 mg tid

25May be increased by mg/day/week if tol erating dos; maximum dose is 1 0 0 mg

50 6tid or mg tid for people who weigh < 0 132kg ( Ibs)

-Follow up: Monthly; use this DecisionPath for

-follow up

Determine serum transaminase levels every 3 months for first year and periodically there

after; if elevated, discontinue Acarbose

Discontinue Acarbose if side effects do not diminish within 1 month of starting therapy;

eee Oral Agent Selection - 113,

Type 2: Metformin/Start 1-16At Diagnosis or from Food

Plan and Exercise Stageor another

Oral Agent Stage

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 anddiabetes education

PrecautionsUUUContraindicaUUUUU• eeeeeeeee eee eeeeeeeee• Risk of lacticeeeeeeee in patients wi: Renal disea se (serum eeeeeeeeee >1.4 mg/dL) Liver dysfueeeeee Alcohol abu se, binge eeeeeeee eeeee eeeeeeeeeeeeee or pulmonaee eeeeeee In patients > 80 years eee eeeeee eeeeeeeeee eeeeeeeee eemon eeeeeee eee al function not impairee Patients wit h CHF who requir -e pharma eeeeeee eeeetment• Intravenouseeee- eeeeeeee eeeeeeee eeeeeeUUUU UUUUUUU• Usually doseeeeeeee -and self limitee• Common: Di, eee ,abdominal discomfort• Occasional:e eeeeeee eeeee

Move to Metformin/Adjust

Start Metformin


Type 2 : Metformin/Adjust

1-17

Metformin Dose Adjustments (in mg)

Patient treated withMetformin and not

at target

Patient on maximum dose of

Metformin for2-4 weeks?

NO

YES


Combination TherapySelection or

Insulin Therapy

START NEXT NEXT NEXT MAX

PM AM/PM AM/PM AM/PM AM/MID/PM

500 500500Metformin / 5001000 10001000 10005001000/ /

e e500

850 850850Metformin / - - 850850850/ / 850mgMay be increased by weekly when suing 500 mgbiweekly when using 850 mg tabletsFollow-upMedical: Monthly; use this DecisionPath for follow-up

- If persistent gastro intestinal discomfort, con sider discontinuing Metformin and starting Tr

eeeeeeeeee

Type 2: Sulfonylurea/Start

1-18At Diagnosis or from Food

Plan and Exercise Stageor another

Oral Agent Stage

Assess food plan a nd exercise

See Food Pl an andeeeeeeeeDose (take with fir st meal of the day) Glyburide: 25. mg/day Micro.Glyburide: 15. mg/day Glipizide : 50. mg/day Gl i pi zi de XL : 50. mg/day

Glimepiride: 1 mg/day

Refer patient for neeeeeeee eee diabetes education

PrecautionsUUUContraindicaUUUUU• eeeeeeeee eee eeeeeeeee• Significant reeee eeeeeee ease (serum creatinine >

20. mg/dL

• Allergy tosulfe eeeee

UUUU UUUUUUU

• Hypoglycemie• Weight gain

Move to Sulfonylurea/Adjust

Start Sulfonylurea


Type 2 : Sulfonylurea/Adjust

1-19

Sulfonylurea Dose Adjustments (in mg)

Patient treated withSulfonylurea and not

at target

Patient on maximum dose of

Sulfonylurea for 2-4 weeks?

NO

YES


Combination TherapySelection or Insulin Therapy

START NEXT NEXT NEXT MAX

AM AM AM/P M AM/PM AM/PM

Glyburide 2 .5 5 5 5 10 5 10 10/ / / 15 3Micro.Glyburide . - - -6 9 12/ / /

Glipizide 5 1 0 - 15 10 10 20 20/ / /Gl i pi zi de X L 5 10 - - - -15 20/ / /

Glimepiride 1 2 3 - - -4 8/ / /

May be increased every 1-2 weeksFollow-upMedical: 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

1-25

Indicators for Use of Oral Agents CombinationsMETFORMIN/

TROGLITAZONE/SULFONYLUREA

SULFONYLUREAObesity ObesityDyslipidemia Dyslipidemia

Positive FPG > 2 5 0 mg/dL Metformin not t

eeeeeee 300CPG > mg/dL CPG > 300 mg/dLeeeeee eeeeeeee

eeeee eeeeeeeHypoxia

Cardiovascular diseaseNegative Hypoglycemia

Altered metabolism of Weight gain

eeee eeeeeeeeeeeeee Sulfa allergy

ACARBOSE// SULFONYLUREAINSULIN

FPG > 2 5 0 mg/dL FPG > 2 5 0 mg/dL 300CPG > mg/dL CPG > 300 mg/dLPositive -Primarily post meal Primarily high fastingexcursions

GI disturbancesHypoglycemiaNegative Hypoglycemia Sulfa allergy Sulfa allergy

AcarboseMaximumDose

Metformin

MaximumDose

TroglitazoneMaximumDose

SulfonylureaMaximumDose

If Metformin andSulfonylurea at maximumdose, discontinue Metformin,and add bedtime insulin; seeSulfonylurea-Insulin or discon-tinue both oral agents andstart insulin; see Insulin Stage2, 3A, or 4A

If combination fails, startinsulin therapy; see Insulin Stage 2, 3A or 4A

AddSulfonylureaat minimumdose

Add

Metformin

at minimumdose



Type 2: Combination Oral Agent/Start

1-26From any Oral Agent Stage

Unable to achieve targetson current oral agent therapy

PrecautionsUUUContraindica tions for

All CombinatUUUU• eeeeeeeee eee eeeeeeeee• Renal disease• Liver dysfuneeeee• Alcohol abus e; binge eeeeeeee

See specificDecisiondPath s for precautio,eeeeeeeeeeeeeeeee eee eeee effects

Move to CombinationOral Agent/Adjust

Start Combination Oral Agent

Follow-upMedical: Within 1-2 week

- - - 0 0T/S (S) - - M/S (M) (M)/(S)- 0

- U - UUUUU - U 0

• e eeeeeee eeeeeee eeee eeeee eeee• eee eeeeeeee eeee of second oral agent with firs t meal unless otherwise neeeeMetformin(M) 500 850or

mg/day Glyburide (S) 25. mg/day

Micro.glyburide 15. mg/day Glipizide (S) 50. mg/day

Gl i pi zi deXL(S) 50. mg/day Glimepiride (S) 1 mg/day

Acarbose (A) 25 *mg/day Troglitazone 200mg/day

eeeeeee e e* al of the day

Refer patient for nut rition and diabeteseeeeeeeee

Type 2: Insulin Stage 3 A-Mid/Start

1-36At Diagnosis

Start insulin within 1 week; hospitalize if outpatient educationnot available; if acute illness, hospitalize and start insulinimmediately or from Oral Agent Stage,

Combination Therapy, or Insulin Stage 2 or 3A

Move to Insulin Stage 3A/Adjust

Start Insulin Stage 3A-Mid

Follow-upMedical: 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

- - - R R R/N 0 - - - LP LP LP/N 0

At Diagnosis

• 03Calculate total dose at . U/kg based o n current weight AM MIDDAY PM BTDistribution 14 14/ / 12 0/

- - R/N or LP/N ratio 1:1 -

From Insulin Stage 2

• If current total dose is > 1 .5 U/kg, consi 10der decreasing dose to . U/kg, otherwise use current total dose• Add MIDDAY R or LP at 5 0 % of current A M N• Discontinue AM N• Increase AM R or LP by 1 0 %

Refer patient for nutrition and diabetes educeeeee

Type 2: Insulin Stage 4 A/Start

1-38At Diagnosis

Start insulin within 1 week; hospitalize if outpatient educationnot available; if acute illness, hospitalize and start insulinimmediately or from Oral Agent Stage,

Combination Therapy, or Insulin Stage

Move to Insulin Stage 4A-Mid/Adjust

Start Insulin Stage 3A-Mid

Follow-upMedical: 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

R - R - R/N - 0LP - 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 BTDistribution 20% 25% 25% 30%

Refer patient for nutrition and diabetes education

Type 2 : Insulin Stage 4A/Adjust

1-39

Am ฏ BT N ฏ BT N ฏBT N - - 3 12 12or AM U(a,b) - 24U(a) U(a)

Insulin Stage 4A Patter AdjustmentsR - R - R - N or LP - LP - N

Patient in Insulin 4Stage A

If persistent hyp-er glycemia after u sing 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?

YES

In no significantimprovement in 6

months,refer patient to a

Diabetes Specialist

See Insulin Adjustment Guidelines, 1-40, for consideration designated by each letter.

NO

-80 140< mg/dL 250 250mg/dL > mg/dL

MIDDAY ฏ AM R or LP ฏAM R or LP ฏAM R or LP - - 3 12 12or AM U(c,e) - 24U(f,g) U(f,g,i)

ee ฏ MID R or LP ฏ MID R or LP ฏMID R or LP - - 12 12U(d,e) U - (f,h) 2 4 U(f,h,j,k) 100 1 6- 0250 250mg/dL > mg/dLBEDTIME ฏ PM R or LP ฏ PM R or LP ฏ PM R or LP ( BT - - ) 1 2 U(e) 1 2 - 24U(f) U(f)eeeeee eeeeeee eeeee ee ee eeeeeeee

-Follow up Medical: Weekly while adjusting insulin, t - hen office visit within 1 2 months;

-use this DecisionPath for follow ue

Amor 3 AMMIDDAYor 3 AMPM

BEDTIMD(BT)

Amor 3 AMMIDDAY

or 3 AM

PM

BEDTIMD(BT)


1-37

Am ฏ PM N ฏ PM N ฏPM N - - 3 12 12or AM U(a,b) - 24U(a) U(a)

Insulin Stage 3A Patter AdjustmentsR - R - R/N - 0 or LP - LP - LP/N - 0

Patient in Insulin -Stage 3A Mid

If persistent hyp-o glycemia or fasti -ng hyper

glycemia, consi der Insulin Stage 4A


YES

Consider adding insulinsensitizer or move to

Insulin Stage 4A/Start


NO

-80 140< mg/dL 250 250mg/dL > mg/dL

MIDDAY ฏ AM R or LP ฏ AM R or LP ฏ AM R or LP - - 3 12 12or AM U(c,e) - 24U(f,g) U(f,g,i)

ee ฏ MID R or LP ฏ AM R or LP ฏ MID R or LP - - 12 12U(d,e) U - (f,h) 2 4 U(f,h,j,k) 100 1 6- 0250 250mg/dL > mg/dLBEDTIME ฏ PM R or LP ฏ PM R or LP ฏ PM R or LP( BT - - ) 1 2 U(e) 1 2 - 24U(f) U(f)eeeeee eeeeeee eeeee ee ee eeeeeeee




BEDTIMD(BT)

Amor 3 AMMIDDAY

(MID)

PM

BEDTIMD(BT)


1-33

Am ฏ PM N ฏ PM N ฏPM N - - 3 12 12or AM U(a,b) - 24U(a) U(a)

Insulin Stage 2 Patter AdjustmentsR/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0

Patient in Insul UUUUU U2 If nocturnal hyperglycemia or morning hyp-erglycemia,

consider Insulin Stage 3 A


YES

sensitizer or, -if persist

ent fasting hy-per

glycemia or nocturnalhypoglycemi a, move to Insulin Stag 3e A ; if midday hyperglycemia, move to Insu lin Stage4A ; if more flexibility required, mo ve to Insulin Stag U U -U UU3


NO

-80 140< mg/dL 250 250mg/dL > mg/dL

MIDDAY ฏ AM R or LP ฏAM R or LP ฏAM R or LP - - 3 12 12or AM U(c,e) - 24U(f,g) U(f,g,i)

ee ฏ AM N ฏ AM N ฏ AM N - - 12 12U(d,e) U - (f,h) 2 4 U(f,h,j,k) 100 1 6- 0250 250mg/dL > mg/dLBEDTIME ฏ PM R or LP ฏ PM R or LP ฏPM R or LP ( BT - - ) 1 2 U(e) 1 2 - 24U(f) U(f)eeeeee eeeeeee eeeee ee ee eeeeeeee




BEDTIMD(BT)

Amor 3 AMMIDDAY

(MID)

PM

BEDTIMD(BT)

Diabetes Classification VIf patient is pregnant and

diabetes is suspected,

see Gestational: Screening and Diagnosis

YES

See Type 2:Screening andDiagnosis, 1-3

See Type 2:Screening andDiagnosis, 1-3

See Type 1: Screening andDiagnosis,2-3

Patient with classic symptomsof type 1 diabetes:Sudden weight loss;

frequent urination, thirst, and hungeror

Patient with classic symptoms of type 2diabetes or asymptomatic:

Blurred vision; urinary tract infection; dry/itchy skin; numb-ness/tingling in extremities; unexplained weight loss

Any risk factore for type 2 diabetes?

Risk factors: Fa mily history; age > 4 5 ; obe si t y ( BMI > 27

kg/m2 ); hyperte -nsion; dyslipi demia; previous -impaired fast

ing glucose, impeeeee eeeeeeeeeeeeeeee ee eeeeeeeeeee eee-

betes; AmericanIndian;Hispanic/Mexica n American;

African American; Pacific Islander

Urine ketones present?

YES

NO

NO

type 2: management during pregnancy 1-44 maternal monitoring baseline: thyroid functions, if not...

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