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Care Process Model

AUGUST 2017

O U T PAT I E N T M A N A G E M E N T O F

Adult Diabetes Mellitus


2017 Update

This care process model (CPM) was created by the Diabetes Prevention and Management Development Team, a committee of the
Primary Care Clinical Program at Intermountain Healthcare. It summarizes current medical literature and, where clear evidence
is lacking, provides expert advice on diagnosing and treating diabetes. It provides clinicians with treatment goals and interventions
that are known or believed to favorably affect health outcomes for adult patients with diabetes.

This CPM is part of Intermountain’s comprehensive, team-based care approach WHAT’S INSIDE
for adults with diabetes in the outpatient setting. Other components of this ALGORITHMS:
system include:
1. Screening and diagnosis. . . . . . . . . . . 4
• Education materials and programs for providers and patients
2. Monitoring HbA1C. . . . . . . . . . . . . . . . 6
• Data systems that allow for population health management of patients
3. Antihyperglycemic treatment in
with diabetes
type 2 diabetes (two algorithms) . . . 12
• Enhancements to the electronic medical record and other tools to make it easier
4. Initial physiologic insulin regimen. . . 19
for clinicians to provide quality care
5. Risk assessment and screening
• Multidisciplinary coordination of diabetes care for CVD . . . . . . . . . . . . . . . . . . . . . . . 20
6. Assessing and managing
What’s New IN THIS UPDATE? cholesterol levels and ASCVD risk. . . 22
The primary changes to this CPM involve recommendations for: 7. Management of hypertension. . . . . . 24
• Strategic post-prandial walking to reduce blood glucose. New studies 8. Nephropathy screening. . . . . . . . . . . 26
recommend walking after meals, particularly after the evening meal when 9. Patient visit. . . . . . . . . . . . . . . . . . . . 32
carbohydrate intake is higher.REY See page 9.
WHY FOCUS ON DIABETES? . . . . . . . 2
• Metabolic and bariatric surgery (MBS). Evidence supports MBS as a
TREATMENT GOALS & MEASURES . . 2
treatment for type 2 diabetes in appropriate surgical candidates. A study by
LDS Hospital researchers, published in the Journal of the American Medical SCREENING & DIAGNOSIS. . . . . . . . . 3
Association showed that MBS may produce remission.ADA,ADM See page 11. MANAGEMENT OVERVIEW. . . . . . . . 6
• Weight-loss medications. The addition of three, new weight-loss medications LIFESTYLE MANAGEMENT. . . . . . . . . 8
to the market gives providers and patients more options for achieving
GLUCOSE CONTROL WITH
weight loss through lifestyle modification, which can lead to better HbA1c
MEDICATION. . . . . . . . . . . . . . . . . . 12
control in patients with type 2 diabetes. See page 10 for a list of medications,
contraindications, and recommendations from the ADA and AACE regarding PREVENTION AND MANAGEMENT
their use. OF RELATED CONDITIONS. . . . . . . . 20

• New insulins. Insulin deglutec (Tresiba) has been added to the insulin DATA AND REPORTS. . . . . . . . . . . . 31
medication information table. Basiglar is an FDA-approved biosimilar of CARE TEAM ROLES. . . . . . . . . . . . . 32
glargine insulin, which is now a recommended therapy. Two, new insulin
PROVIDER RESOURCES. . . . . . . . . . 33
combinations were also approved: Glargine/lixisenatide (soliqua) and
deglutec/liraglutide (xultophy). See page 16. DIABETES EDUCATION RESOURCES. . . 34

• Cardiovascular risk reduction. New information on three medications that


have proven beneficial in reducing cardiovascular events are reviewed in a new
section on page 21.
O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

Why Focus ON DIABETES?


• Diabetes is a growing problem. The estimated number of Americans with diabetes
increased from 12.1 million in 2002 to 29.1 million in 2017.CDC1 The CDC projects

that by 2050, as many as 33 % of U.S. adults could have diabetes.CDC2  

• The healthcare cost burden is high and increasing. The American Diabetes
Association estimated the economic burden of diabetes in 2012 at $245 billion.
This is a 41 % increase over 2007.It’s estimated that within the next decade,

spending will rise to almost $500 billion — 10 % of total health spending. ADAE
• Late diagnosis negatively affects outcomes. Better screening and early diagnosis
of diabetes is crucial to improving patient outcomes. Many patients with type
2 diabetes develop complications just before or immediately after diagnosis.
Approximately 25 % of type 2 diabetes cases may be currently undiagnosed.ADA  

• Good management can preserve and improve quality of life. Uncontrolled


diabetes can result in catastrophic health problems, including heart disease, stroke,
blindness, kidney disease, nervous system disease, amputations, dental disease, and
pregnancy complications. Following the diabetes management recommendations
set forth in this CPM can help delay or prevent these complications.

TREATMENT GOALS & MEASURES


TABLE 1: Treatment Goals

Measure GOAL
HbA1c (test at least every 6 months) < 7.0 %*
THE ADA NO LONGER Blood pressure (check at each office visit) < 140 / 90 mm Hg* (lower in some)
RECOMMENDS SPECIFIC
Foot exam (perform at least every year — Normal
LIPID TARGETS
every visit if abnormal)
Treatment goals have been modified to reflect
the fact that the ADA Standards no longer Statin medication Taking statin medication at appropriate
recommend specific lipid targets. Treatment is level of intensity
now driven primarily by risk status rather than Urine albumin/creatinine ratio < 30 mg albumin / g of creatinine
LDL cholesterol level. See page 22 for detail. (test at least every year )
Serum creatinine Normal
(every year, estimate GFR)
Retinal or dilated eye exam Normal
(check every year or every 2 years if diabetes
is well controlled)
*Although these blood glucose and blood pressure goals are recommended generally for most people
with diabetes, we also recommend individualizing these goals. See the sidebar discussion on page 6
(HbA1c goal) and pages 24-25 mangement of hypertension algorithm and notes).

Throughout this CPM the icon indicates places where data is collected about
each patient.

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

SCREENING AND DIAGNOSIS PROFILES: TYPE 2,


Timely, accurate screening and diagnosis is important because it can prevent or delay TYPE 1, LADA
diabetes complications. The length of time between the onset of hyperglycemia
Most new diabetes patients over the age of
and appropriate treatment can be a significant factor in complication development 30 will have type 2 diabetes. Nevertheless,
and severity. Type 2 diabetes is often asymptomatic, and at the time of diagnosis, a when the type of diabetes is uncertain by
significant number of type 2 patients already have complications, such as neuropathy, clinical presentation, antibody testing is
nephropathy, or retinopathy. recommended. Key considerations:

Screening Type 2:
• Onset is usually slow.
This CPM recommends:
• Occurs mainly in older adults, but can
• Routine screening for type 2 diabetes. Note that in addition to testing the patients occur in children.
specified in the algorithm on page 4, physicians should consider testing adults older • Common features at diagnosis are obesity,
than age 30 every three to five years. This is a cost-effective strategy; the benefits insulin resistance, and neuropathy.
of early detection of type 2 diabetes include a reduced incidence of myocardial • Family history usually includes a
infarction and microvascular complications. K AH first‑degree relative with type 2 diabetes.
• Condition usually responds to oral
• No routine screening for type 1 diabetes. People with type 1 typically present with medications for years.
acute symptoms and markedly elevated blood glucose, and most cases are diagnosed
soon after the onset of hyperglycemia. Type 1:
• Onset is usually rapid (over the course of
For pregnant patients, routine screening for gestational diabetes is recommended per days or weeks).
the Intermountain care process model Management of Gestational Diabetes. • Occurs primarily in children and
younger adults.
Diagnosis • Common features at diagnosis are DKA,
Recommended diagnostic tools for type 2 diabetes include: recent weight loss, and insulin deficiency.
• Family history including a first‑degree
• Hemoglobin A1c (HbA1c). ADA HbA1c measurement does not require the patient to relative with diabetes is less common.
fast or undergo a glucose tolerance test, and required specimens are stable at room • Condition requires insulin from onset.
temperature. Venipuncture is preferred to point-of-care testing. Further, HbA1c
LADA
testing can be done even during illness. Limitations of this test are that an HbA1c’s (latent autoimmune diabetes in adults):
normal range is modestly higher in certain ethnic groups (e.g., African-Americans, • Onset is slow.
Asian-Indian descent), and increases with age. HbA1c is elevated in patients with • Occurs in adults age 30 and older
untreated hypothyroidism, and among U.S. adults with diabetes, it tends to be (does not occur in children).
slightly higher in winter. TSE False low values can occur in patients with rapid red cell • Prevalence among patients with
turnover, some anemias, and recent onset of diabetes. adult‑onset diabetes is about 10 %.HAW  

• In LADA patients, glutamic acid


• Fasting plasma glucose (FPG). The FPG is more reproducible, less costly, and easier to decarboxylase (GAD) antibodies are
administer than the two-hour oral glucose tolerance test (OGTT). present close to 90 % of the time, with
only a small additional fraction of patients
• Other acceptable diagnostic tests include a two-hour, 75-gram oral glucose having other autoantibodies.HAW  

tolerance test (OGTT). This test may be required when evaluating patients with • In comparison to diabetic patients without
impaired fasting glucose (IFG) or if diabetes is still suspected despite a normal FPG autoantibodies, LADA patients are more
or HbA1c result. often female, younger at diagnosis,
have a smaller waist circumference (are
Diagnostic criteria for diabetes are listed in algorithm note (d) on page 5. Note overweight but not obese), and do not
that in the absence of unequivocal hyperglycemia, repeat testing is required to exhibit DKA.
• Family or personal history often includes
make a diagnosis of diabetes. ADA In an outpatient setting, if a patient has new onset
autoimmune disorder.
hyperglycemia, causes other than diabetes should be considered. The differential • Condition may initially respond to oral
diagnosis of hyperglycemia includes type 1 and type 2 diabetes, Cushing’s syndrome, medications and other therapies but will
electrolyte abnormalities, acromegaly, pheochromocytoma, and pancreatic cancer. eventually require insulin.
To order antibody testing:
• GAD antibody: ARUP # 2001771
• If GAD is negative, then order
insulinoma \ associated-2 antibodies
and /3 or zinc transporter 8 antibodies.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

ALGORITHM 1: SCREENING AND DIAGNOSIS

Patient appropriate for SCREENING or with symptoms (a)

TEST by measuring one of the following:


•• Plasma glucose (not capillary
glucose): FPG or 2-hour OGTT
•• HbA1c

ABNORMAL (b) ABNORMAL (b)


NORMAL but below diagnostic meets criteria
threshold for diagnosis
•• HbA1c < 5.7 % •• HbA1c 5.7 % – 6.4 % •• HbA1c ≥ 6.5 %
•• FPG < 100 mg / dL •• FPG 100 – 125 mg / dL •• FPG ≥ 126 mg / dL
•• 2-hour OGTT < 140 mg / dL •• 2-hour OGTT 140 – 199 mg / dL •• 2-hour OGTT ≥ 200 mg / dL

In the absence of unequivocal elevated


•• EDUCATE on lifestyle blood glucose, REPEAT same or alternative
management
test using a new blood sample
•• REPEAT TESTING every
3 years for: (a)
–– All adults age ≥ 45 OR
–– Adults of any age if
overweight and ≥ 1 Meets criteria for
no
other risk factors DIAGNOSIS (d)?

yes

P R E D I A B E T E S (c) DIABETES MELLITUS

If suspected type 1 or LADA


(see profiles page 3),
CONSIDER ANTIBODY TESTS (e)

REFER to Prediabetes See ALGORITHM:


Care Process Model Antihyperglycemic Therapy in
for follow-up plan Type 2 Diabetes on page 12

Indicates an Intermountain measure

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ALGORITHM NOTES
(a) Diabetes screening (c) Prediabetes
Screen these patients at least every 3 years Prediabetes is not a clinical entity of itself. It is the term used for individuals
or more frequently depending on initial results and risk status: with impaired fasting glucose (IFG) and / or impaired glucose tolerance (IGT),
which are risk factors for developing diabetes and cardiovascular disease.
•• Adults ≥ 45 years
The Prediabetes Care Process Model provides system-wide support for
•• Adults of any age who are overweight or obese (BMI ≥ 25 kg / m2 helping patients prevent these conditions. Criteria for prediabetes include:
or ≥ 23 kg / m2 in Asian Americans) and have any of these additional
•• HbA1c < 5.7 % – 6.4 %
risk factors:*
–– Hypertension > 140 / 90 mm Hg or on therapy for hypertension
OR
•• FPG < 100 – 125 mg / dL
–– Family history: first-degree relative with diabetes
OR
–– Habitual physical inactivity
•• 2-hour OGTT < 140 – 199 mg / dL
–– High-risk ethnicity (African American, Latino, Native American,
Asian American, Pacific Islander)
–– Previous gestational diabetes mellitus (GDM)
(d) Criteria for diabetes diagnosis
–– Dyslipidemia (HDL cholesterol < 35 mg / dL and / or triglycerides
> 250 mg / dL) Criteria for diabetes diagnosis:
–– Polycystic ovary syndrome (PCOS) •• TWO HbA1c values ≥ 6.5 %
–– History of vascular disease OR
–– Other clinical conditions associated with insulin resistance (e.g., acanthosis •• TWO FPG values ≥ 126 mg / dL
nigricans, sleep apnea, multiple skin tags, peripheral neuropathy, and gout) OR
*For SelectHealth patients, obesity must be listed in the first position for billing. •• TWO, 2-hour OGTT values > 200 mg / dL
Remember: Plasma glucose values must NOT come from a finger stick.
Screen these patients annually
•• History of elevated HbA1c ≥ 5.7 %, impaired fasting glucose (≥ 100 mg / dL), or
impaired glucose tolerance (≥ 140 mg / dL) (e) Antibody testing
•• Glutamic acid decarboxylase (GAD) antibodies account for 90 % of
diabetes‑associated autoantibodies.
(b) Investigating abnormal values •• Insulinoma associated-2 antibodies and zinc transporter 8 antibodies
account for only the remaining 10 %.
•• Ensure the integrity of plasma glucose values: must be obtained
from a correctly collected/stored specimen, NOT from finger stick. •• See sidebar on page 3 for more further discussion of LADA and
information on ordering tests.
•• If repeat testing is indicated by an abnormal value, use ICD-10
code R79.89 “other specified abnormal findings of blood chemistry” to
order follow-up test.
•• If patient has hemoglobinopathy and diabetes is suspected
based on blood glucose or symptoms, measure two FPG values
for confirmation.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

HbA1c: INDIVIDUALIZED GOALS MANAGEMENT OVERVIEW


Current ADA standards stress individualizing
management goals for specific circumstances Diabetes care is complex, requiring regular medical care and follow up. Patients with
including duration of diabetes, life expectancy, well-controlled diabetes should be seen at least every six months; those who are not
comorbid conditions, CVD, hypoglycemia, and meeting treatment goals should be seen even more frequently.
patient self-care capacity.INZ,ADA
Good diabetes care focuses on comprehensive management of blood glucose,
   

• For most nonpregnant adults, aim blood pressure, and lipids and includes regular screening for eye, nerve, and kidney
for HbA1c less than 7.0 %. complications. This section of the CPM focuses on some important elements of diabetes
• Consider more stringent goals care and self-management, namely blood glucose monitoring, medical nutrition therapy
(e.g., 6.0 % to 6.5 %) for selected individual (MNT), physical activity, and medication. It emphasizes individualization of treatment
patients such as those with short duration
to address the patient's needs, preferences, and values.
of diabetes, long life expectancy, and no
significant CVD. For pregnant patients
aim for less than 6.0 %. Monitoring blood glucose
• Consider less-stringent goals The role of HbA1c
(e.g., 7.5 % to 8.0 %) for patients with HbA1c testing is an indication of the overall trend of blood glucose levels for the previous
a history of severe hypoglycemia, long
two to three months and usually reflects overall diabetes control during that period.
disease duration, limited life expectancy,
advanced complications, or extensive HbA1c measurement can validate or call into question a patient’s home record of
comorbid conditions. glucose testing or glucose testing performed in the office. In situations where higher
Results of the ACCORD,GER ADVANCE,CHA
   
home glucose readings do not match in-office HbA1c, consider conditions causing rapid
and VADTDUC studies did not show increased

RBC turnover.BRU
cardiovascular benefits from tight control
of diabetes. However, tight control has
consistently been shown to reduce the risk of
microvascular and neuropathic complications. ALGORITHM 2: MONITORING H b A 1 c
Office visit for patient with
confirmed diabetes mellitus

Draw HbA1c

Good control Inadequate control


In most patients: In most patients:
HbA1c less than 7 % HbA1c more than 7 %
(see sidebar at left on (see sidebar at left on
individualized goals) individualized goals)
Indicates an Intermountain measure

•• MAINTAIN treatment. No changes •• INITIATE or ADJUST medications


Approximate comparison of HbA1c indicated (unless significant •• REFER to diabetes educator*
hypoglycemia)
and plasma glucose valuesADA
•• REINFORCE previous diabetes

HbA1c Plasma Glucose education; REFER as indicated*


FOLLOW UP HbA1c every 3 months
6 % 126 mg / dL
7 % 154 mg / dL FOLLOW UP HbA1c:
8 % 183 mg / dL •• If on oral or no medication, at least
every 6 – 12 months If HbA1c more than 8 % for 6 – 9 months,
9 % 212 mg / dL CONSIDER referral to endocrinologist or
•• If on insulin, every 3 – 6 months other diabetes specialist
10 % 240 mg / dL
11 % 269 mg / dL
*At least annually, reinforce / update a patient's diabetes knowledge and skills. Certified diabetes educators (CDEs),
12 % 298 mg / dL RNs, and registered dietitian nutritionists (RDNs) can provide individualized medical nutrition therapy (MNT).

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

The role of self-monitoring blood glucose systems (SMBG) SMBG GUIDELINES


SMBG helps patients evaluate their individual response to therapy, avoid hypoglycemia, Although we recommend tailoring the
and make necessary adjustments to insulin therapy, medication, medical nutrition frequency and timing of SMBG to individual
therapy (MNT), and physical activity. However, the accuracy of SMBG depends on the patients and circumstances, some general
user and the instrument. Physicians or diabetes educators should teach patients how to guidelines appear below.
do SMBG accurately and routinely evaluate patients’ technique and ability to use the Test once a day, or less often:
data to adjust their therapy.ADA  

Patients who are controlling their


diabetes with oral agents or with diet
Providers who manage insulin-treated patients — especially patients using multiple daily and exercise alone
injection therapy or insulin pumps — must be able to appropriately analyze patients'
SMBG data including control over specific time intervals, control by time of day (modal Test 3 or fewer times a day:
day), testing frequency, and glucose variability. Software for this purpose is provided by Patients using less-frequent insulin injections
device manufacturers at no cost. See sidebar at right for testing guidelines. Test 3 to 4 times a day:
Patients using multiple insulin doses
The role of continuous glucose monitoring systems (CGM)
Continuous glucose monitoring (CGM) devices provide continuous feedback to the Test 4 or more times a day:
patients about their glycemic control. When used consistently and in combination • Pregnant women or patients
with an intensive insulin regimen, they can help lower HbA1c in adults age 25 and with hypoglycemic unawareness
(4 to 8 times per day)
older. (Though there is less evidence supporting benefit in children, teens, and young
• Patients having sick days
adults, success correlates with consistent use.) In addition, CGM devices can be a
• Patients modifying therapy
valuable supplemental tools for patients with frequent hypoglycemic episodes and / or
hypoglycemic unawareness — and can significantly reduce the burden of diabetes by • Patients having hypoglycemia

reducing fear of hypoglycemia and the pain of frequent testing. • Any patient motivated to test this often
to achieve best control possible
A CGM device consists of a sensor electrode that is inserted into the subcutaneous
tissue, a small radiofrequency transmitter, and a monitoring device that stores and Coverage for SMBG test strips
displays the data. There are two types of CGM devices: • For all patients: Sometimes a durable
medical equipment benefit is a better
1. Personal CGM devices belong to the patient and display subcutaneous glucose values alternative than a pharmacy benefit to
to the patient in real time. An alarm feature alerts patients when their subcutaneous obtain test strips. Patients should compare
glucose values cross a prespecified threshold. In addition, these monitors have both options.
alarms that warn patients when glucose values are changing rapidly, potentially • For Medicare patients: Medicare
averting hypoglycemia. Several short-term studies have demonstrated their efficacy allows three test strips daily for patients
in lowering HbA1c levels and reducing frequency of hypoglycemia.BEC, TAM Most

with type 1 or type 2 diabetes on any
commercial insurance carriers cover CGM; however, the majority of Medicaid plans form of insulin therapy. To obtain approval
for four or more tests per day, Medicare
do not. requires proof of higher testing frequency
2. Professional CGM devices belong to the clinic or hospital and are used for short (download from glucose monitor), a
periods to give providers detailed information on a patient's glucose control. These statement attesting to the need for
added tests, and often a record from
devices can help identify patterns leading to hypoglycemia, hyperglycemia, and
office notes demonstrating the provider's
significant glucose variability. In addition, they can provide quick information on recommendation for high‑frequency testing.
glucose patterns during pregnancy.
• For patients without insurance
coverage: Simple meters (usually with
The role of continuous subcutaneous insulin infusion (CSII) no memory or download capability) with
CSII (also called insulin pump therapy) is recommended for selected patients with names like ReliOn and Truetrack can be
type 1 diabetes and for some patients with insulin-treated type 2 diabetes. These significantly less expensive for patients
should only be prescribed by experienced clinicians who have the knowledge, skills, lacking insurance coverage for products
with added features.
and resources to monitor for failure. Adequate pump programs should involve a
multidisciplinary team of providers, not just the services of industry-employed trainers
and salespersons. Most insurance carriers, including SelectHealth, have liberal criteria
for approval of CSII and rely on physician discretion to identify patients who are likely
to benefit. Identifying patients appropriate for this technology is complex and beyond
the scope of this discussion.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

FREQUENT LIFESTYLE LIFESTYLE MANAGEMENT


COUNSELING HELPS PATIENTS All patients with diabetes and prediabetes should be counseled on lifestyle measures.
ACHIEVE TARGETS FASTER Lifestyle counseling is associated with better control of HbA1c, blood pressure, LDL
Lifestyle counseling in the primary care cholesterol, and weight as well as improved overall well-being.MOR 

setting is strongly associated with faster


achievement of HbA1c, blood pressure, and The two, principal goals of lifestyle intervention are to achieve a mean loss of ≥ 7 % of
LDL cholesterol control. A large retrospective initial body weight in overweight patients and to increase patient physical activity to
study found that with a face‑to‑face
counseling rate of at least one time per ≥ 175 minutes of moderate intensity a week. Key components of lifestyle management
month, patients reached goals much faster are medical nutrition therapy, physical activity, behavior modification and accountability,
than with less‑frequent rates.MOR  

and intensive lifestyle interventions.


Average face-to-face lifestyle
counseling rate Nutrition counseling
(unique patients / combined periods)
All patients with diabetes should be referred for nutrition education.
100
 % of Patients with A1c ≥ 7.0 % SBP / DBP ≥

≥ 1 per month Medical Nutrition Therapy (MNT) is an integral component of diabetes management

(2, 154 / 3, 434)


130 / 85 mmHg, or LDL ≥ 100 mg / dL

and is covered by most commercial insurance providers and by Medicare. It includes


80 between 1 per month
and 1 per 6 months an individualized meal plan that accommodates the patient’s medications and metabolic
(13, 455 / 29, 546)
needs as well as their eating habits, lifestyle, and readiness to change. Meal plans are
60 < 1 per 6 months
(24, 687 / 52, 807) adjusted as needed to help patients comply with needed changes and meet goals. At a
minimum, a meal plan includes the following:
40
• Amount and type of carbohydrates consumed. Both quality and quantity of
20 carbohydrate in foods influence blood glucose levels and glycemic response. However,
there is no standard regarding the ideal amount of carbohydrate intake for people
0
0 1000 2000 3000 4000 with diabetes. ADA Individualized recommendations should address the total amount
Time from first elevated of carbohydrate that should be distributed through the day. Consistency in method
A1c, BP, or LDL days of carbohydrate monitoring should be encouraged. A number of dietary interventions
exist. This CPM recommends referral to a registered dietitian nutritionist (RDN) is
SUPPORT FOR recommended for implementation as well as patient guidance and support.
LIFESTYLE MANAGEMENT • Timing of meals and snacks. Monitoring and maintaining a consistent pattern of
The 2015 Lifestyle and Weight Management carbohydrate intake is key to achieving glycemic control. Meals should include a mix
CPM provides detailed strategies and
tools to help build a team process around of macronutrients (carbohydrate, protein, and fat) individualized to meet the patient's
evidence‑based guidelines metabolic goals and personal preferences.
for behavior change, physical
activity, nutrition, weight • Caloric restriction combined with physical activity to support any needed
management, and other
lifestyle factors. weight loss. Weight loss should be gradual and slow. Aim for a rate of one to two
Click the image to open the pounds per week. Mediterranean, low-fat, calorie-restricted, or low-carbohydrate
document, or see page 34 diets may be effective for weight loss. ADA Until an RDN can provide an individualized
for ordering information.
meal plan, counsel overweight patients to reduce calories.
THE LOOK AHEAD TRIAL –– As a temporary guideline, an initial goal is to reduce dietary intake by 500 total
The Look AHEAD trial was a large clinical trial  

calories per day from their current intake until a plan can be individualized by an
designed to examine the long‑term effects
of an intensive lifestyle intervention (ILI) in RDN.
overweight volunteers with type 2 diabetes.DEL –– Additional recommendations could include limiting fat to < 30 % of calories (with
Although the trial showed no difference in CVD
endpoints compared to the control group, study < 7 % from saturated fat) and limiting carbohydrates per meal (or split between
participants who received ILI experienced: meal and snack) to 45 to 60 grams for women and 60 to 75 grams for men.
• Average weight loss of 8.6 %
–– Resources, such as CalorieCount.com, can provide nutrition content of foods.
• Significant reduction of HbA1c
• Reduction in several CVD risk factors
Assistance with healthy food choices is available at ChooseMyPlate.gov. Smart
The Look AHEAD findings suggest that ILI is phone apps, such as MyFitnessPal, can also help patients track nutrients and

associated with partial diabetes remission in physical activity.


patients with type 2 diabetes, particularly in
those whose diabetes is of short duration, who
have lower HbA1c levels, and who do not yet
require insulin therapy.

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Physical activity RECOMMENDATIONS


Regular physical activity improves blood glucose control and can prevent or delay • Increase activity to ≥ 175 minutes
type 2 diabetes.COLB Regular activity also positively affects cholesterol, blood pressure,

per week of moderate-to-vigorous
cardiovascular risk, mortality rates, and quality of life. intensity aerobic activity (heart beating
faster than normal and breathing
Preexercise evaluation. Sedentary patients should be encouraged to engage in regular harder than normal, such as a brisk
physical activity. Preexercise health screening should be based on the following three walk). Spread activity over at least
factors: three days per week, with no more
than two consecutive days between
1. The individual’s current level of physical activity bouts of aerobic activity. While the ADA
2. The presence of signs or symptoms and / or known cardiovascular, metabolic, or guidelines recommend ≥ 150 minutes
renal disease per week, Intermountain endorses
the target of ≥ 1 75 minutes used
3. Desired exercise intensity. The table below outlines recommendations from the
in the Look AHEAD trial (see sidebar on
American College of Sports Medicine regarding recommendations for pre-exercise page 8) based on findings that higher
evaluation.REI levels of physical activity significantly
Refer to appropriate specialists, or provide suggestions for adapting exercise based on improve weight-loss maintenance and
individual needs. Note: Even patients with known coronary artery disease and stable other health outcomes. DEL Record patient
activity in the Physical Activity Vital
angina benefit from regular physical activity. BOD
Sign in iCentra. Casual walking below
moderate intensity does not count
toward the weekly goal.
TABLE 2. Recommendations based on pre-exercise evaluationREI,  USDH, PES • Gradually increase activity.
Current Medical Medical Exercise recommendations Patients who are currently sedentary
exercise status status clearance? (discontinue or level of intensity) should start with 10 minutes of walking
at moderate intensity three days per
Light1-to-moderate2 intensity exercise recommended. Progress week, gradually increasing to five days
A No
to vigorous-intensity per ACSM guidelines.3
Does NOT per week. Once they are walking on
participate B Yes Moderate-intensity exercise recommended. Progress gradually most days, patients should add minutes
per ACSM guidelines. to achieve 20 minutes on most days
C Yes
and build toward the goal of 30 to 60
Continue moderate- or vigorous-intensity exercise. May minutes on most days of the week.
A No
gradually progress following ACSM guidelines.
• Unless contraindicated, undertake
Continue moderate-intensity exercise. Medical clearance resistance training two days per
(with NO change in signs of symptoms in the preceeding
Participates B No
12 months) recommended before participating in vigorous- week, focusing on major muscle groups
intensity exercise. and core body conditioning.
Discontinue. May return to exercise after obtaining medical • Decrease time sitting and
C Yes
clearance. Progress gradually per ACSM guidelines. increase daily movement. All
B. Known CV, metabolic, or renal disease AND individuals should be encouraged to
Medical status: break up extended amounts of time
asymptomatic
A. No cardiovascular (CV), metabolic (e.g., diabetes), or renal sitting (> 90 minutes). ADA Taking a two-
C. Any signs or symptoms of CV, metabolic,
disease AND no signs or symptoms suggestive of CV, metabolic or renal disease (regardless of whether or not to three-minute walk every 20 minutes
disease or renal disease disease is known)
has been demonstrated to reduce
1 Light-intensity exercise, 35–50% of age-predicted maximal heart rate, an intensity that causes slight increases in postprandial glucose and insulin levels
HR and breathing
in overweight and obese adults. DUN
2 Moderate-intensity exercise, 50–70% of age-predicted maximal heart rate, an intensity that causes noticeable
increases in HR and breathing Individuals can increase daily movement
3 Vigorous-intensity exercise, 70–85% of age-predicted maximal heart rate, an intensity that causes substantial through activities, such as taking the
increases in HR and breathing stairs, walking rather than riding in a
Age-predicted maximal heart rate: 220-age = HR (max) car, etc. A brisk walk for 30 minutes
after meals is associated with clinically
meaningful decreases in blood glucose
levels.REY
• Patients taking insulin or
sulfonylureas should monitor
blood glucose before, during,
and after physical activity. Once
patients have a sense of how exercise
works with their medication, food
choices, and other factors that affect
blood glucose, they won't need to check
levels as often.

©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 9


O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

Behavior modification and accountability


THE WEIGH TO HEALTH®
Diabetes self-care requires modification to daily behaviors that most patients find
PROGRAM challenging. For detailed, evidence-based support of this process, see the "Behavior
Intermountain Healthcare’s The Weigh Change Techniques and Tools" section of the Lifestyle and Weight Management CPM.
to Health® program is an example of an
intensive lifestyle intervention. Beginning Patients experiencing difficulty adhering to diet and exercise recommendations, or
in 2018, the program will have pending who lose < 1 % of weight per month, may require additional assistance. Referral to an
recognition as a CDC "lifestyle change intensive lifestyle intervention program (such as The Weigh to Health®) or additional
program" as part of the National Diabetes
contact with a clinician may help. See sidebar at left for more information.
Prevention Program. It will consist of:
• Seven individual sessions with an RDN Intensive lifestyle intervention (ILI)
• Regular group sessions (an orientation An intensive lifestyle intervention (also referred to as behavioral intervention)
and 17 additional sessions over 12 months)
can provide the support and follow up necessary for behavior modification. The
covering nutrition, exercise, behavior
change, and more. Affordable Care Act (ACA) requires commercial payers to cover an intensive lifestyle
There is no cost for SelectHealth
intervention at no cost to patients with BMI ≥ 30 or with BMI ≥ 25 and one or more
members who: cardiovascular disease risk factors. Intermountain's The Weigh to Health® program
• Have a BMI over 30
(see sidebar) is an example of an intensive lifestyle intervention that may be covered by
a plan. Medicare and Medicare Advantage do not cover The Weigh to Health® but may
OR
cover medical nutrition therapy for select patients.
• Have a comorbidity
for a diet-related Weight-loss medications HAN, ADA
chronic condition
Weight-loss medications (see table 2 below) may be used in conjunction with lifestyle
(such as diabetes)
modification to support weight-loss goals. This CPM recommends that a patient should
AND either see a loss of at least 5 % in three months or the medication should be stopped.
• Complete the Check the patient’s insurance coverage before ordering medications as they are costly and
program rarely covered. The ADA and AACE recommend:
Patients who do not
• ADA: Weight-loss medications may be effective as adjuncts to diet, physical
complete the program
pay for the sessions activity, and behavioral counseling for selected patients with type 2 diabetes and
they attended. BMI ≥ 27. Potential benefits must be weighed against the potential risks of the
medications. (Grade A)
Click the image to open
the brochure, or refer to • AACE: Weight-loss medications should be considered as an adjunct to lifestyle therapy
page 34 for ordering information. in all patients with type 2 diabetes as needed for weight loss sufficient to improve
glycemic control, lipids, and BP. (Grade A)

TABLE 2. Weight-loss medications used in the treatment of type 2 diabetes


Medication name — ∆ ∆ DM Risk of
∆ A1c ∆ SBP ∆ LDL Drug interactions Contraindications
generic (Brand) Weight medications hypoglycemia
Pregnancy
No
locaserin (Belviq) - 3 kg - 0.5 % No difference
difference
No difference Increased Antidepressants Severe hepatic disease
CrCl < 30 ml / min
Pregnancy
liraglutide (Saxenda) - 4 kg - 0.9 % Decreased - 2.4 mmHg No difference Increased N / A
Severe hepatic disease
Pregnancy
naltrexone / buproprion - 3 kg - 0.5 % Decreased
No
No difference No difference
Antidepressants
Severe hepatic disease
(Contrave) difference Opioids
CrCl < 30 ml / min
Pregnancy
phentermine / topiramate - 6 kg - 4.0 % Decreased - 4.8 mm Hg No difference Increased Antidepressants Severe hepatic disease
(Qsymia)
CrCl < 30 ml / min
Vitamins A, D, E, K
No Warfarin Pregnancy
orlistat (Xenical or Alli) - 3 kg - 0.4 % Decreased
difference
- 4.9 mg / dL Increased
Levothyroxine Severe hepatic disease
Anticonvulsants
∆ = change in measure

10 ©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .


A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

Metabolic and bariatric surgery (MBS)


Lifestyle modifications are often not enough to help people who are severely overweight. ADM
Metabolic surgery should be recommended to treat type 2 diabetes in appropriate adult KEY RECOMMENDATION
surgical candidates as follows:ADA More detailed information on MBS can
be found in the CPM Metabolic and
• BMI > 40 regardless of the level of glycemic control or complexity of glucose-lowering Bariatric Surgery for the Treatment
regimens of Obesity and
the patient fact
• BMI of 35 – 39.9 when hyperglycemia is inadequately controlled despite lifestyle and
sheet Weight
optimal medical therapy Loss Surgery: A
• "Type 2 diabetes and a BMI of 30 – 34.9 if hyperglycemia is inadequately controlled decision tool as
a means to guide
despite optimal medical control by either oral or injectable medications including
patients through
insulin the decision-making
process.
Clinical efficacy. Studies show that MBS can produce a remission in type 2 diabetes
(normal or near-normal glycemia in approximately 55 % to 95 % of patients with
type 2, depending on the surgery). ADA Rates of remission tend to be greater with DIABETES IN REMISSION
malabsorptive (bypass) procedures versus restrictive procedures. Additionally, patients
In patients who have had gastric bypass
with type 2 diabetes of less than two years' duration tend to have the best response to surgery or banding or who have implemented
bariatric surgery, while those who have had type 2 diabetes for more than 10 years or lifestyle and weight management changes,
require insulin therapy may be less responsive. VET For further discussion of diabetes in glycemia measures may fall below diagnostic
thresholds. Because chronic conditions,
remission. See the sidebar at right. such as diabetes, are never considered to
be completely cured, these patients are
A study by LDS Hospital researchers, published in the Journal of the American Medical considered to be in remission. An ADA
Association showed the following benefits for patients who underwent gastric bypass consensus statement defines remission as the
(Roux-en-Y):ADM following: ADA
• Partial remission. Hyperglycemia below
• Diabetes benefits are enduring. Among diabetes patients who had diabetes before diagnostic thresholds for at least one year
surgery, 62 % were in remission after six years and 52 % at 12 years. That compares with no active pharmacologic intervention
to 8 % and 6 % for the nonsurgical groups. Gastric bypass patients who did not have • Complete remission. Normal glycemia
diabetes before the surgery were five to nine times less likely to develop the disease than measures for at least one year with no active
nonsurgical participants. pharmacologic therapy
• Prolonged remission. Complete remission
• Weight loss benefits are enduring. Surgical patients lost an average of 34.9 % for at least five years
of their initial weight by two years after gastric bypass surgery, maintaining a loss
of 27.7 % of the weight at 6 years and 26.9 % at 12 years. Of these patients, 96 % Follow up for patients
maintained more than 10 % weight loss from baseline, and 76 % maintained more in remission
than a 20 % loss. By contrast, patients who did not have bariatric surgery either lost no The science is limited regarding patient risk for
weight or gained weight over the next six years. macrovascular and microvascular complications
in remission. The ADA currently recommends
• Other health risks: Surgical patients also showed improvements in hypertension, the following care: ADA
cholesterol, and triglyceride levels — three factors associated with an increased risk of • Until the patient is in prolonged remission,
heart disease and stroke. continue the same follow-up practices as for
a patient with diabetes.
Primary care recommendations. This CPM recommends: • Once the patient is in prolonged remission,
make a shared decision with the patient
• Considering bariatric surgery for patients ≥ 18 with type 2 diabetes who on how to monitor based on personal risk
have a BMI ≥ 35, particularly when diabetes or its comorbidities are present. This factors. At a minimum, this should include
recommendation follows national guidelines.ADA HbA1c monitoring every three years, which
matches the preventive care guidelines.
• Refer patient candidates to an accredited Intermountain bariatric surgery
This Diabetes in Remission fact sheet
center. These centers provide a board‑certified physician with a practice devoted to (see ordering information
bariatric medicine, presurgical consultation with RDNs, social workers, and other
FACT SHEET FOR PATIENTS AND FAMILIES

on page 34) is a shared


Diabetes in Remission

staff who can help patients with nutritional, psychological, and logistical (insurance) decision-making tool that
Great news!
Your blood glucose has gone down
Congratulations! You’ve
been taking care of yourself Normal blood glucose
and your blood glucose has HbA1c less than 5.7%
gone down. Your blood and
tests show that your blood Fasting blood glucose

can help providers and


glucose has been in the less than 100 mg/dL

issues as well as robust postoperative processes. A list of accredited Intermountain


“normal” range for a number
of months. This means your diabetes may be in remission.

What is remission?
Being in remission means you no longer have the signs of Great job making choices that brought your blood glucose
diabetes. Technically, diabetes never goes away. You are in down! You and your doctor can decide whether to make

patients decide together


remission when your blood glucose has been normal for changes to the way you manage and monitor your health.
at least a year. When your blood glucose has been normal
for at least 5 years, you are in prolonged remission.

centers is available in the Metabolic and Bariatric Surgery for the Treatment of Obesity CPM.
You’ll remain in remission or prolonged remission as long How long do I need to keep doing
as your blood glucose remains in the normal range. diabetes tests and measures?
When your blood glucose was high, your doctor
recommended a regular schedule of monitoring your

on an appropriate
PROLONGED
REMISSION REMISSION blood glucose, cholesterol, blood pressure, kidney
function, and eyes.
Normal blood glucose Normal blood glucose How long do you need to keep doing these things? Not
for at least 1 year for at least 5 years
enough research has been done yet to clearly answer this
What does this mean for my health? question. In the future we will likely know for sure.
Now that you’re in remission, your health risks have gone Currently experts at the American Diabetes Association

follow-up plan.
down. Compared to when your blood glucose was high, recommend that you continue to do the same monitoring
you did before until you are in prolonged remission

• Offer and refer for ongoing lifestyle support. This is critical for long-term
you now have a lower risk of stroke, heart problems,
kidney problems, foot problems, and vision problems. — when your glucose has been normal for 5 years.
Because you have had diabetes, however, your risk of You and your doctor should consider your personal
these problems is still higher than someone who never health risks and decide on the best plan for you. Review
had diabetes. the list of tests on page 2 of this handout and consider
each one.

weight-loss success.

©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 11


O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

GLUCOSE CONTROL WITH MEDICATION


Medication therapy includes oral and injectable antidiabetic agents as well as several classes of insulin.
• For type 2 diabetes, oral medication is required for glycemic control if lifestyle modifications don’t achieve glycemic control within
two to three months (see page 13). Prescribing considerations include the patient’s age, weight, any renal or hepatic impairment, and
cardiopulmonary comorbidities. Insulin may be used initially (often temporarily) for significant hyperglycemia and is a long-term
option for patients on oral agents who still have HbA1c values more than 1 % above goal.
• For type 1 diabetes, insulin therapy is essential. A regimen that combines peakless insulin (also called long‑acting or basal insulin)
and rapid-acting insulin (bolus) most closely mimics normal physiologic insulin production (see page 17).
• For LADA , insulin therapy will be required eventually, if not immediately. Frequent follow up is required to assess the patient’s blood
glucose control and the timing of insulin initiation.

A B R I D G E D S TA N D A R D S O FADA
ALGORITHM 3: ANTIHYPERGLYCEMIC THERAPY IN TYPE 2 DIABETES C A R E
Clinical Diabetes Papers In Press, published online December 15, 2016
GENERAL RECOMMENDATIONS
Start with Monotherapy unless:
A1C is greater than or equal to 9%, consider Dual Therapy.

A1C is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dl,
or patient is markedly symptomatic, consider Combination Injectable Therapy (See Figure 8.2).

Monotherapy Metformin Lifestyle Management


EFFICACY* high
HYPO RISK low risk
WEIGHT neutral/loss
SIDE EFFECTS GI/lactic acidosis
COSTS* low
If A1C target not achieved after approximately 3 months of monotherapy, proceed to 2-drug combination (order not
meant to denote any specific preference — choice dependent on a variety of patient- & disease-specific factors):

Dual Therapy Metformin + Lifestyle Management


Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (basal)

EFFICACY* high high intermediate intermediate high highest


HYPO RISK moderate risk low risk low risk low risk low risk high risk
WEIGHT gain gain neutral loss loss gain
SIDE EFFECTS hypoglycemia edema, HF, fxs rare GU, dehydration, fxs GI hypoglycemia
COSTS* low low high high high high

If A1C target not achieved after approximately 3 months of dual therapy, proceed to 3-drug combination (order not
meant to denote any specific preference — choice dependent on a variety of patient- & disease-specific factors):

Triple Therapy Metformin + Lifestyle Management


Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (basal) +

TZD SU SU SU SU TZD

or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i

or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or SGLT2-i or SGLT2-i

or GLP-1-RA or GLP-1-RA or Insulin §


or GLP-1-RA or Insulin §
or GLP-1-RA

or Insulin§ or Insulin§ or Insulin§

If A1C target not achieved after approximately 3 months of triple therapy and patient (1) on oral combination, move to
basal insulin or GLP-1 RA, (2) on GLP-1 RA, add basal insulin or (3) on optimally titrated basal insulin, add GLP-1 RA or
mealtime insulin. Metformin therapy should be maintained, while other oral agents may be discontinued on an individual
basis to avoid unnecessarily complex or costly regimens (i.e. adding a fourth antihyperglycemic agent).

Combination Injectable Therapy See Algorithm


(See Notes below
Figure 3)
2. Antihyperglycemic
Antihyperglycemic
■ FIGURE therapy in Typetherapy
2 Diabetes:in type 2 diabetes:
general general recommendations.
recommendations. The order in the chart wasThe orderbyin
determined the chart
historical wasand
availability determined
the route
of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type
by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific
2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending
pref-
erence. Potential
on the sequences
circumstances). of antihyperglycemic
*See original source for description of therapy for patients
efficacy categorization. witha basal
§Usually typeinsulin
2 diabetes are displayed,
(NPH, glargine, with Adapted
detemir, degludec). the usual withtransition
permission
fromvertically
moving Diabetes
Inzucchi et al.from topCare
to2015;38:140–149.
bottom (although horizontal movement within therapy stages is also possible, depending on the
circumstances).
12 DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, GLP-1 ©2001–2017 receptor
INTERMOUNTAINagonist; GU,
HEALTHCARE. ALL geni-
RIGHTS RESERVED .

tourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. *See
A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

P O S I T I O N S TAT E M E N T
ALGORITHM 3, CONTINUED: ANTIHYPERGLYCEMIC THERAPY
Clinical Diabetes
IN TYPE 2 DIABETES: ADA
PapersINJECTABLE
COMBINATION In Press, published
THERAPY online De
Abbreviations:
DPP-4-i = DPP-4 inhibitor Initiate Basal Insulin
FBG = fasting blood glucose Usually with metformin +/- other noninsulin agent
fxs = fractures
GI = gastrointestinal
Start: 10 U/day or 0.1–0.2 U/kg/day
GLP-1 RA = GLP-1 receptor agonist
GU = genitourinary Adjust: 10–15% or 2–4 units once or twice weekly to reach FBG target
t
HF = heart failure For hypo: Determine & address cause; if no clear reason for hypo,
Hypo = hypoglycemia Ð dose by 4 units or 10–20%
SGLT2-i = SGLT2 inhibitor
SU = sulfonylurea
TZD = thiazolidinedione If A1C not controlled, consider
U = units combination injectable therapy

Add 1 rapid-acting Change to premixed


insulin injection before Add GLP-1 RA insulin twice daily (before
largest meal breakfast and supper)
Start: 4 units, 0.1 U/kg, or 10% If not tolerated or A1C Start: Divide current basal dose
basal dose. If A1C <8%, consider target not reached, into Ҁ AM, ѿ PM or ½ AM, ½ PM
Ð basal by same amount change to 2 injection
Adjust: Ï dose by 1–2 units or insulin regimen
Adjust: Ï dose by 1–2 units or
10–15% once or twice weekly t
10–15% once or twice weekly until SMBG target reached
until SMBG target reached For hypo: Determine and
If goals not met, consider
For hypo: Determine and changing to alternative address cause; if no clear reason
address cause; if no clear reason insulin regimen for hypo, Ð corresponding dose
for hypo, Ð corresponding dose by 2–4 units or 10–20%
by 2–4 units or 10–20%

If A1C not controlled, If A1C not controlled,


advance to basal-bolus advance to 3rd injection

Add ≥2 rapid-acting Change to premixed


insulin injections before analog insulin 3 times daily t
meals (‘basal-bolus’) (breakfast, lunch, supper)
Start: 4 units, 0.1 U/kg, or 10% Start: Add additional injection
basal dose/meal. If A1C <8%, before lunch
consider Ð basal by same amount Adjust: Ï doses by 1–2 units or
If goals not met, consider
Adjust: Ï dose(s) by 1–2 units or changing to alternative 10–15% once or twice weekly to
10–15% once or twice weekly to insulin regimen achieve SMBG target
achieve SMBG target For hypo: Determine and
For hypo: Determine and address cause; if no clear reason
address cause; if no clear reason
for hypo, Ð corresponding dose
for hypo, Ð corresponding dose
by 2–4 units or 10–20% t
by 2–4 units or 10–20%

■ Combination 3. Combination
FIGUREinjectable injectable therapy for type 2 diabetes. FBG, fasting
therapy for type 2 diabetes. Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.

blood glucose; GLP-1 RA, GLP-1 receptor agonist; hypo, hypoglycemia; U, units.
Adapted with permission

from Inzucchi et al. Diabetes Care 2015;38:140–149. 13
©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

Medication details
The tables on pages 14 – 16 give detailed information on oral agents and non-insulin injectables. Insulin for the treatment of adult
diabetes is covered on (page 17). Providers should be aware that SelectHealth requires a step-therapy approach or preauthorization
for many medications that might be used for diabetes management as a cost-reduction measure. In general, there must be evidence of
lack of adequate effect, adverse side effects, or contraindications to at least two medications in the class of sulfonylurea, metformin, or
pioglitazone before other non-generic medications may be prescribed. Keep in mind that the choice of non-generic medication is also
influenced by the specific SelectHealth plan (SelectMed, SelectMed Advantage, SelectMed Community Health, etc.).
Access SelectHealth’s preauthorization and step-therapy information.
If the patient has chronic kidney disease beyond Stage G2, refer to the Chronic Kidney Disease CPM for necessary dose
adjustments.

TABLE 3. Oral agents and non-insulin injectable medications

SelectHealth commerical 2017 AWP cost for


formulary status 30-day supply*
Class Usual dosing Pros Cons
generic Brand (MAC Cost for generics)

metformin Glucophage 500 mg twice daily (once Generic: •• Extensive experience •• GI distress
(Tier 1) (Tier 3) daily to start) to 1,000 mg 500 mg twice daily: $6 •• No hypoglycemia (nausea / diarrhea)
twice daily (max) •• B12 deficiency — suggest
850 mg twice daily: $7 ••  weight (preferred for
Most benefit 1000 mg twice daily: $7 obese patients — most periodic testing
obtained between type 2 diabetics) •• CHF patients should
1,500 – 1,700 mg / day Brand name:
•• Favorable lipid effects be stable
500 mg twice daily: $68
biguanides

850 mg twice daily: $102 •• Maximum PG effect •• Risk of acidosis:


1000 mg twice daily: $126 at 3 – 4 weeks. STOP with acute illness,
dehydration, or IV
••  insulin resistance contrast dyes
metformin Glucophage 500 mg to 1,500 mg once Generic:
ER (Tier 1) XR (Tier 3) daily at dinner 500 mg twice daily: $9 •• Consensus first-line •• Multiple
agent
750 mg twice daily: $17 contraindications:
2,000 mg (4 × 500 mg): $27 •• Very cost-effective Do not use for patients
Brand name: with chronic liver disease,
alcoholism, or chronic
500 mg twice daily: $64 kidney disease
750 mg twice daily: $98 (eGFR < 30)

glipizide XL Glucotrol XL 5 mg to 20 mg daily (max) Generic: •• Extensive experience ••  hypoglycemia,


(Tier 1) (Tier 3) May give dose once or 5 mg once daily: $5 especially with reduced
sulfonylureas

•• Well tolerated
twice daily GFR
10 mg once daily: $8 •• Maximum PG effect at
5 to 7 days ••  weight
glimepiride Amaryl (Tier 3) 1 mg to 8 mg (max) daily Generic:
•• Do not use with
(Tier 1) May give dose once or 1 mg once daily: $7
twice daily Prandin, Starlix, or other
4 mg once daily: $11 sulfonylureas
•• Limited duration of effect
pioglitazone Actos (Tier 3) 15 mg to 45 mg once daily Generic: •• Option for patients •• Edema, especially if given
(Tier 1) (dosing at bedtime may 15 mg once daily: $11 intolerant of metformin with insulin; adding
spironolactone can help
thiazolidinediones

decrease edema) 30 mg once daily: $13 •• No hypoglycemia


•• Fluid retention may lead
45 mg once daily: $14 ••  serum insulin to or exacerbate heart
•• Durability failure or macular edema
••  triglycerides (if so, discontinue)
•• Possible  CVD events •• Bone fractures
•• May change metabolism
of birth control pills
•• Slow onset: max effect in
6 – 12 weeks
*AWP = Average Wholesale Pricing; MAC = Maximum Allowable Cost. Many patients may benefit from manufacturers' discounts or patient assistance programs.
Tier: Tier 1: generic; Tier 2: preferred brand; Tier 3: non-preferred brand

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

TABLE 3. Oral agents and non-insulin injectable medications (continued)


SelectHealth commerical 2017 AWP cost for
formulary status Usual 30‑day supply*
Class Pros Cons
dosing
generic Brand (MAC Cost for generics)

sitagliptin Januvia 100 mg once daily (as 25 mg, 50 mg, or 100 mg once •• Can be taken with or •• Increased cost
phosphate (Not covered) monotherapy or as daily: $405 without food •• Can be used only for
combination therapy with
metformin or glitazones) •• No hypoglycemia type 2 diabetes
•• No weight gain •• Reduce dose with
DPP-4 inhibitors

saxagliptin Onglyza 2.5 mg or 5 mg once daily 2.5 mg or 5 mg once daily: $405 •• Most PG effect decreasing creatinine
(Not covered) within 1 – 2 weeks clearance < 50 
of initiation — except linagliptin
•• Possible acute pancreatitis
linagliptin Tradjenta 5 mg once daily 5 mg once daily: $397
(Tier 2, •• Possible  heart failure
step edit) hospitalizations

alogliptin Nesina 6.25 mg to 25 mg orally All generic strengths: $205


(Tier 1, step edit) (Not covered) once daily

canagliflozin Invokana 100 mg or 300 mg All strengths: $437 •• Non-insulin ••


 female genital mycotic
(Tier 2, once daily dependent; infections, UTIs, and
step edit) novel MOA increased urination
•• Low incidence of •• Volume depletion; use
SGLT2 inhibitors

dapagliflozin Farxiga 5 mg or 10 mg All strengths: $441 hypoglycemia cautiously in elderly and
(Tier 3, prior once daily patients already on diuretic
authorization) ••
 weight
•• Possible  risk of bladder
cancer (dapagliflozin)
empagliflozin Jardiance 10 mg or 25 mg All strengths: $441
(Tier 2, once daily •• Requires normal renal
step edit) function (> 45 ml / min
for empagliflozin
and canagliflozin
and > 60 ml / min for
dapagliflozin)

exenatide Byetta 5 mcg twice daily (within 5 mcg twice daily: $588 •• No hypoglycemia •• Exenatide: Use caution
(Not covered) 60 minutes before when initiating or when
••
 Weight
breakfast and dinner) increasing dose from 5 mcg
May be increased to ••  Postprandial to 10 mcg in CKD Stage G3
10 mcg twice daily glycemia
•• All in this class:
after 1 month •• Exhibits many
–– Gastrointestinal side
GLP-1 receptor agonists

of the same
exenatide ER Bydureon 2 mg once every 7 days 2 mg once every 7 days: $570 glucoregulatory effects (nausea,
(Not covered) actions of naturally vomiting, diarrhea)
occurring hormones –– Training requirements
liraglutide Victoza 1.2 mg or 1.8 mg 1.2 mg once daily:
(Tier 2, once daily (18 mg / 3 mL pen): $564 ––  Heart rate
step edit) –– Possible acute
1.8 mg once daily:
(18 mg / 3 mL pen): $798 pancreatitis

albiglutide Tanzeum 30 mg or 50 mg 30 mg or 50 mg


(Tier 3, once every 7 days once every 7 days: $448
step edit)
dulaglutide Trulicity 0.75 mg or 1.5 mg 0.75 mg or 1.5 mg
(Tier 2, once every 7 days once every 7 days: $647
step edit)

*AWP = Average Wholesale Pricing; MAC = Maximum Allowable Cost. Many patients may benefit from manufacturers' discounts or patient assistance programs.
Tier: Tier 1: Generic; Tier 2: Preferred brand; Tier 3: Non-preferred brand

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

TABLE 3. Oral agents and non-insulin injectable medications (continued)


SelectHealth commerical
formulary status 2017 AWP cost for
Class Usual dosing 30‑day supply* Pros Cons
generic Brand (MAC Cost for generics)

pramlintide Symlin (Prior **See inset 60 injection pen (1.5 mL): Very positive effect on Symlin should only be
acetate authorization) $708 weight loss used by providers with
amylin mimetic

significant knowledge of
**Dosing instructions for Symlin: its properties.
•• Type 1: 15 mcg immediately prior to major meals; increase at 15 -mcg increments to a maintenance dose of 60 mcg or as tolerated. Three injections per day
•• Type 2: 60 mcg immediately prior to major meals; increase to 120 mcg as tolerated. bring significant risk
•• When initiating Symlin, reduce insulin dosages including premixed insulins (70 / 30). of severe nausea and
hypoglycemia.
sitagliptin + Janumet XR Once daily: All strengths: $397 See notes for individual components (page 13)
metformin XR (Not covered) 100 mg / 1,000 mg
50 mg / 500 mg
Two 50 mg / 1,000 mg
combinations (examples only)

saxagliptin + Kombiglyze XR Once daily: All strengths: $390


metformin XR (Not covered) 5 mg / 500 mg
5 mg / 1,000 mg
2.5 mg / 1,000 mg
linagliptin + Jentadueto Twice daily: All strengths: $397
metformin (Tier 3, step edit) 2.5 mg / 500 mg
2.5 mg / 1,000 mg
Alogliptin + Kazano Twice daily: All strengths: $397
metformin (Not covered) 2.5 mg / 500 mg
(Tier 1, step edit) 2.5 mg / 1,000 mg

Alogliptin + Oseni Once a day: $200


pioglitazone (Not covered) 25 mg / 45 mg
(Tier 1, step edit)

Insulin Xultophy Initial: insulin degludec $1,144 •• Single injection of two •• Fixed dose
degludec + (Not covered) 16 units + liraglutide medications combination
liraglutide 0.58 mg once daily •• Limited to 50 units
•• Consistent coverage of
Maximum: glycemic control of insulin degludec
50 units (insulin degludec per day
50 units + liraglutide •• Large potential for
•• Must be inadequately
1.8 mg) once daily HbA1c reduction through
controlled on insulin
combination therapy
Insulin combinations

or liraglutide prior to
initiation
•• High expense
Insulin glargine Soliqua Initial: 15 units (insulin $762 •• Single injection of two •• Fixed dose
+ lixisenatide (Not covered) glargine 15 units + medications combination
lixisenatide 5 mcg) •• Limited to 60 units
•• Consistent coverage of
once daily. of insulin glargine
glycemic control
Maximum: per day
60 units (insulin glargine •• Large potential for
•• Must be inadequately
60 units + lixisenatide HbA1c reduction through
controlled on insulin
20 mcg) once daily combination therapy or liraglutide prior to
initiation
•• High expense
*AWP = Average Wholesale Pricing; MAC = Maximum Allowable Cost. Many patients may benefit from manufacturers' discounts or patient assistance programs.
Tier: Tier 1: generic; Tier 2: preferred brand; Tier 3: non-preferred brand

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

TABLE 4. Insulin profiles


Usual
Onset Peak effective SelectHealth commercial
Insulin type Generic (Brand) name
(min. or hrs.) (hours)
2017 30-Day AWP
duration formulary status**
(hours)
Rapid acting (clear, aspart (NovoLog) 10 mL: $244 Tier 2
10 to 20 min. 1 to 2 3 to 5
except Afrezza) FlexPen 15 mL: $471
glulisine (Apidra) 10 mL: $243 Not covered
10 to 20 min. 1 to 2 3 to 5
SoloSTAR pen 15 mL: $471
lispro (Humalog) 10 mL: $243 Not covered
10 to 20 min. 1 to 2 3 to 5
KwikPen 15 mL: $470
human (Afrezza)* 10 to 15 min. 1 2 to 3
equivalent to 1000 units: $630 Not covered
(inhalation powder)
Regular (rapid Novolin R 10 mL: $132 Novolin R: Tier 2
acting) (clear) Humulin R 30 to 60 min. 2 to 4 4 to 8 Humulin R: Not covered
ReliOn R ReliOn R 10 mL: $28 ReliOn R: Not covered†
Intermediate NPH (Novolin N) 10 mL: $132 Novolin N: Tier 2
acting (cloudy) NPH (Humulin N) 1 to 3 hrs 4 to 10 10 to 18 Humulin N: not covered
ReliOn N ReliOn N 10 mL: $28 ReliOn N: Not covered†
Peakless (clear) detemir (Levemir)‡ 10 mL: $333 Tier 2
1 hr 18 to 24 FlexTouch 15 mL: $485
glargine U-100 (Lantus)‡ 10 mL: $298 Tier 2
2 to 3 hrs 24 + SoloSTAR pen 15 mL: $447
glargine U-100 (Basaglar) 2 to 3 hrs
Kwikpen 15 mL: $380 Not covered
24 +
glargine U-300 (Toujeo) develops over SoloSTAR pen 14.5 mL: $403 Tier 2
6 hrs 24 +

deglutec U-100, U-200 FlexTouch 15 mL: $533 Not covered


(Tresiba) ~ 1 hr 24 to 48

Insulin mixes 70 / 30 (NovoLog Mix) 10 mL: $253; pen: $471 70/30 NovoLog mix: Tier 2
75 / 25 (Humalog Mix) 10 mL: $252; pen: $470 Humalog mixes: Not covered
50 / 50 (Humalog Mix) 10 mL: $252; pen: $470
70 / 30 (ReliOn Mix) 10 mL: $28 ReliOn mix: Not covered†

* Afrezza contraindications: Asthma, COPD, smoking. Requires PFT monitoring ‡ Peakless insulin (detemir, glargine, and deglutec). Administer as follows:
at baseline, 6 months, and then yearly. Supplied in 4‑unit and 8‑unit, single‑dose •• Detemir insulin twice a day for type 1 diabetes and at bedtime for type 2
cartridges. Dose adjustments are made in 4‑unit increments. diabetes.
** Tier: Tier 1: generic; Tier 2: preferred brand; Tier 3: non-preferred brand •• Glargine insulin once a day at the same time for type 1 and type 2 diabetics who
require long‑acting insulin for control of hyperglycemia.
† ReliOn is available at Walmart and is a possible option for cash-paying patients.
Cash price is about $25–$30 per vial.
•• Degludec for type 1 and type 2 diabetics who require long-acting insulin once a
day at any time.
•• Peakless insulin cannot be diluted or mixed with other types of insulin or solutions.
•• Administer peakless insulin subcutaneously only — DO NOT give it intravenously.

GLUCOSE MANAGEMENT IN SPECIAL CIRCUMSTANCES


Some circumstances — such as when a patient is preparing for a test or procedure, has had a cortisone injection, etc. — may require temporary adjustment
to diabetes treatment. We advise the following:
• Before surgery: Optimize glycemic control, and temporarily stop metformin and sulfonylureas if appropriate.

• When patient receives a steroid (injection or oral): Patients often experience a elevation of plasma glucose. Advise more frequent SMBG, and
either increase medication doses or initiate low-dose insulin as needed.
• When patient is fasting prior to a test or procedure. Temporarily stop metformin and sulfonylureas if appropriate.

• Illness. Consider increasing frequency of blood glucose monitoring. Metformin may need to be held if the patient is at risk for dehydration.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

Insulin therapy for type 2 diabetes


To treat patients with type 2 diabetes, keep these general principles in mind when
METFORMIN WITH INSULIN using oral agents with insulin:
FOR PEOPLE WITH TYPE 2
• Use starting dose for patients with type 2. A total daily dose (TDD) is
DIABETES KOO
approximately 0.5 U/kg to 0.7 U/kg. See table 4 on page 17 for insulin profiles.
A metformin and insulin
combination may: • Follow basal insulin regimen (bedtime dose of peakless insulin) as the
• Prevent weight gain
recommended first choice when adding insulin to treatment with oral agents.
• Improve glycemic control • Consider the timing of the patient’s hyperglycemia when adding or
• Reduce insulin requirements adjusting insulin.
–– Control morning FPG with peakless insulin at bedtime.
–– Control daytime PPG with sulfonylureas, DPP-4 inhibitors, and GLP-1 agonists.
HIGHER DIETARY FAT AND When morning FPG is controlled with peakless insulin, daytime PPG readings
frequently come under control with an oral agent and dietary modification.
POSTMEAL HYPERGLYCEMIA
–– Consider physiologic insulin regimen generally while continuing metformin if
Higher dietary fat intake can cause late
postprandial hyperglycemia. This
two-hour postprandial PG is still above goal with FBG > 100 mg / dL.
can be addressed either by reducing fat
intake (especially for type 2 patients on Example of a weekly titration schedule
nonphysiologic regimens) and / or by (Treat-to-Target Trial)RID Forced weekly insulin
adjusting premeal insulin doses (for type 1 titration schedule
patients on rapid-acting insulin). A large, randomized controlled trial showed
(for treat-to-target FBG of <120 mg / dL)
that systematically titrating bedtime basal
Practical ways to compensate for a high-fat Mean of FBG values Increase of insulin
meal include splitting premeal insulin into insulin added to oral therapy can safely achieve
over 3 days dosage (IU / day)
two injections from one to three hours 7 % HbA1c in overweight patients with type 2
apart or using an extended bolus. diabetes as compared to 7.5 % to 10 % HbA1c > 180 mg / dL + 8
The total amount of insulin provided may in patients on oral agents alone. To titrate: 160 – 180 mg / dL + 6
need to be increased from the usual dose
• Start with 10 IU at bedtime. 140 – 159 mg / dL + 4
as well. The response to dietary fat will vary
according to the individual and the specific • Titrate weekly based on FBG values over
foods, so defining insulin adjustments may 120 – 139 mg / dL + 2
three days as shown in the table at right.
require multiple attempts.
Use a peakless insulin with this titration schedule to significantly reduce nocturnal
hypoglycemia. This can help achieve recommended standards of diabetes care
more quickly.

Basic (nonphysiologic) regimen: NPH + rapid-acting insulin


Basic insulin therapy is not designed to mimic normal insulin physiology. Although
a basic regimen is not recommended for type 1 patients, it may provide adequate
control for type 2 patients who either have been unsuccessful with oral medication
combinations or are unable to manage a multiple daily dose regimen as required in
physiologic insulin therapy.
For a basic insulin therapy regimen to be successful, a patient must be consistent
with meals and adhere to a MNT plan. The following are examples of basic
insulin regimens:
Premixed insulins. These insulins are given twice a day (before breakfast and before the
evening meal):
• 70 % aspart protamine suspension / 30 % aspart injection (NovoLog Mix 70 / 30)
• 70 % NPH / 30 % regular (Novolin 70 / 30)
Split-mixed insulins. NPH is given twice a day (either morning and before the evening
meal, or morning and bedtime) with regular or rapid-acting insulin before breakfast
and before the evening meal.

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

Insulin therapy for type 1 diabetes USING THE 1,700 RULE


The 1,700 Rule can be used to calculate
ALGORITHM 4: INITIAL PHYSIOLOGIC INSULIN REGIMEN* a correction dose of rapid-acting insulin for
either a high plasma glucose (PG) reading or
•• USE recommended starting doses: For patients with type 1, the total daily dose (TDD) of insulin is an insulin-to-carb ratio to approximate the
approximately 0.5 U / kg. rapid‑acting insulin needed to cover a meal's
•• TEACH injection technique. carbohydrate content.
•• DIVIDE dose as follows: One-half of total daily dose as peakless "basal" insulin dose and one-half as • Determine the current total daily
rapid-acting, "bolus" insulin (The rapid-acting insulin dose is divided through the day). Use carbohydrate
ratio and correction factor to calculate premeal and bedtime rapid-acting insulin doses. See table 4 on dose (TDD). Add up ALL the insulin
page 17 for insulin profiles. (rapid and long‑acting) the patient takes in
a 24‑hour period. If the patient is not yet on
•• INSTRUCT patient to carefully record SMBG (before meals, at bedtime).
a stable insulin dose, then use 0.5 U / kg to
calculate a TDD.
FOLLOW UP in 2 to 5 days
• Divide 1,700 by the TDD. This is the
predicted amount (mg / dL) the PG will
Morning FPG = no •• If morning FPG is > bedtime PG, increase peakless insulin by 10 %. decrease for each unit of rapid‑acting
bedtime PG? •• If morning FPG is < bedtime PG, decrease peakless insulin by 10 %. insulin added (correction factor).
yes To calculate a correction dose: Increase
rapid-acting insulin by the number of units
Premeal PG •• If 3- to 4-hour postmeal PG is > premeal PG, increase rapid‑acting insulin by 10 %.
= 3 – 4 hour no needed to reduce the PG to the desired goal.
postmeal PG? •• If 3- to 4-hour postmeal PG is < premeal PG, decrease rapid-acting insulin by 10 %. Encourage patient to keep careful records
yes
of resulting PG readings, especially morning
FPG, premeal 2‑hour PPG, and bedtime PG.
Consistent •• If hypoglycemia, decrease all doses 10%.
hypoglycemia or yes
hyperglycemia? •• If hyperglycemia, increase all doses by 10 %. Correction dose example:
• Patient takes 50 units of insulin per day:
no TDD = 50.
• 1,700 ÷ 50 = 34 (Round to 35, which
Initial return visit in 2 weeks, then means that one unit of insulin will lower
every 3 months: Continued consistent REFER for
no hypoglycemia or yes endocrine PG by 35 points — a correction factor
REVIEW patient’s blood glucose record. hyperglycemia? consult of 35).
REPEAT HbA1c.
• If the goal is 130, and PG is 165, use
one extra unit of insulin to drop PG to
*Insulin requirements vary considerably from patient to patient depending on the degree of insulin deficiency and resistance.
about 130. If PG is 200, use two extra
These formulas are guidelines for estimating insulin doses. Providers will likely need to adjust these estimates.
units, and so on.

Physiologic insulin regimen: Peakless + rapid-acting insulins To calculate an insulin-to-carb ratio:


Using multiple daily injections (MDI), a physiologic insulin regimen most closely Multiply predicted PG lowering (mg / dL)
mimics normal insulin physiology. This intensive regimen uses peakless insulin as the basal by 0.33. This is the number of grams of
dose and rapid-acting insulin for control with meals. Almost all type 1 patients require this carbohydrate covered by one unit of insulin.
physiologic (basal / bolus) regimen. For most people, a starting dose would be
one unit of rapid-acting insulin for every 10 to
• Use peakless insulin to control blood glucose when not eating. The period between
15 grams of carbohydrate to be eaten.
bedtime and breakfast is the best reflection of how this method is working; prebreakfast
blood glucose should approximate bedtime blood glucose. A bedtime snack is not required; if
desirable, match the carb content of the snack with a rapid‑acting insulin dose. Insulin-to-carb ratio example:
• Patient takes 50 units of insulin per day:
• Add rapid-acting insulin prior to each meal and planned snack.
TDD = 50.
–– Adjust to prevent post-meal hyperglycemia or hypoglycemia. Blood glucose levels four • 1,700 ÷ 50 = 34 (Round to 35, which
hours after a meal should approximate premeal levels. means that one unit of insulin will lower
–– Determine premeal rapid-insulin doses by counting carbohydrates and using an PG by 35 points).
insulin‑carbohydrate ratio. Alternatively, base premeal insulin dose on a fixed-meal plan • 35 × 0.33 = 12, which means that one
(budgeted carbohydrates). unit of insulin is needed for every 12
grams of carbohydrate anticipated in
–– Train patients in MNT and insulin use; refer to diabetes educator / RDN. a meal.
–– Train patients in use of correction dose to treat hyperglycemia. (At bedtime, the correction
dose may be reduced to as much as 50 % of the usual correction dose.)
• Teach patients how to modify insulin doses when exercising, on sick days, to combat
significant premeal hypoglycemia, or to prevent delayed postmeal hyperglycemia due to
higher-fat meals (see sidebar on page 18). Support with referral to diabetes educator / RDN.

©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 19


O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

PREVENTION AND MANAGEMENT OF


RELATED CONDITIONS
Patients with diabetes are likely to have
RELATED CONDITIONS
related conditions that often accompany or
result from diabetes, such as: Cardiovascular disease
• Cardiovascular disease (page 20) Diabetes is considered a cardiovascular disease equivalent, and patients with diabetes
• High cholesterol (page 22) have a two to eight times higher prevalence of, incidence of, and mortality from all
• High blood pressure (page 24)
forms of cardiovascular disease than those without diabetes. GRU All patients with
diabetes should be assessed annually for cardiovascular risk. Treat all risk factors
• Kidney disease (page 26)
aggressively, and perform further screening and diagnostic testing as suggested in the
• Retinopathy (page 27)
algorithm below.
• Diabetic nephropathy (page 27)
• Foot problems (page 28)
• Obstructive sleep apnea (page 30) ALGORITHM 5: RISK ASSESSMENT &
• Low testosterone in men (page 30) SCREENING FOR CARDIOVASCULAR DISEASE
• Conditions associated with
type 1 diabetes (page30)
PERFORM cardiovascular risk assessment with any
The pages that follow highlight the risks, cardiovascular symptoms and at least annually
goals, and management options for these
related conditions. MONITOR for symptoms at ever y clinic visit

Asymptomatic Asymptomatic Typical or atypical


with no history of with history of symptoms suggestive
CAD or PVD CAD or PVD of CAD

REDUCE REDUCE risk factors aggressively, PERFORM


risk factors following guidelines on page 21 and these noninvasive
aggressively, additional recommendations for secondary testing and / or
following guidelines prevention: REFER to a
on page 21. • USE a beta blocker if previous MI cardiologist
• PRESCRIBE antiplatelet therapy for
CAD = coronary secondary prevention
• CONSIDER ACE inhibitor, especially for
artery disease
PVD = peripheral patients older than 55 years
vascular disease

CONDUCT surveillance and RESCREEN


Examine and watch for progression of new
symptoms, and repeat CV risk assessment annually

Multifactorial risk reduction for cardiovascular disease


In patients with diabetes, risk factors for cardiovascular disease and cardiovascular events
are similar to those in patients without diabetes. However, the magnitude of risk may be
greater. Research suggests that long-term control of blood glucose, blood pressure, and lipids
can substantially reduce these risks in all patients, but patients with diabetes may benefit to
an even greater extent. ADA
This CPM recommends helping patients lower their cardiovascular risk by promoting
lifestyle modifications as needed (smoking cessation, weight loss, etc.) and following the
guidelines for good management of glucose, lipids, and blood pressure. Also consider
using proven medications in appropriate patients; see discussion on page 21.

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

Medications for CV risk reduction BEYOND CVD


Empagliflozin and liraglutide. With the findings of recent cardiovascular outcomes In addition to heart disease, many
trials, there is support for using liraglutide and empagliflozin for diabetic patients with complex factors contribute to reduced
cardiovascular disease: cardiopulmonary function in patients with
diabetes, including:
• Empagliflozin: The EMPA-REG OUTCOME trial demonstrated a reduction
• Obstructive sleep apnea
in overall cardiovascular mortality that started within three months of taking
empagliflozin, which continued to strengthen over a three-year period. The final • Diastolic dysfunction
outcome revealed a 14% reduction in nonfatal myocardial infarction, nonfatal stroke, • Reduced pulmonary diffusing capacity
and cardiovascular death. Hospitalizations for congestive heart failure also decreased • Functional restrictive lung disease
with use of this medication.ZIN
These conditions are commonly
• Liraglutide: The LEADER Trial found liraglutide extended the first occurrence of underdiagnosed in patients with
cardiovascular death (as compared to a placebo). While nonfatal myocardial infarction, diabetes. However, they can aggravate
nonfatal stroke, and hospitalization for congestive heart failure were not statistically hypertension, cause fatigue, and reduce
significant, the death rate was significantly less.MAR exercise capacity. The cornerstones of
therapy are:
• Canagliflozin: The CANVAS study proved that the composite of cardiovascular death,
• Tight blood pressure control
nonfatal MI, and nonfatal stroke was reduced with canagliflozin therapy. Heart failure
• Blood glucose control
hospitalizations also decreased significantly. The study also reports an increased risk of
toe and foot amputation.NEA • Weight loss

There is no consensus currently as to when and for which patients these three medications
should be considered, but their impact on cardiovascular outcomes is a welcome finding
and should be considered by individual physicians. Calculate 10-year CVD risk
The American Heart Association
ACE inhibitors. Several studies have shown ACE inhibitors can reduce cardiovascular and American College of Cardiology
complications even more than can be explained by blood pressure reduction alone. For recommend the new Risk Calculator to
example, the HOPE trial showed a reduction in cardiovascular events in diabetes patients evaluate 10-year risk and lifetime risk of
ASCVD.GOF This calulator is available at:
over 55 years of age with normal blood pressure. If not contraindicated, consider an ACE
tools.acc.org/ascvd-risk-estimator/
inhibitor in all patients over 55 years of age, with or without hypertension, with any
additional risk factor such as history of cardiovascular disease, dyslipidemia, increased
urinary albumin, or smoking.DAG  

Beta blockers. Patients with diabetes and significant coronary artery disease may benefit from
beta blockers, especially those who have had a coronary event within the previous two years.

Aspirin therapy. ADA For secondary prevention in people with


atherosclerotic vascular disease, low‑dose aspirin provides a substantial TABLE 5. Aspririn guidelines
20 % relative risk reduction (RRR) and 1.5 % per year absolute risk Recommended for: May be NOT
reduction (ARR) in recurrent cardiovascular disease (CVD) events. considered for: recommended for:
However, for primary prevention the relative and absolute benefits of • Adults with > 10 % • Adults with • Adults with < 5 %
aspirin are much lower — just 12 % RRR and 0.06 % per year ARR in 10-year CVD risk* 5 – 10 % 10-year 10-year CVD risk*
OR FOR CVD risk* OR FOR
CVD events. For primary prevention in people with diabetes, recent
• Most men > 50 years OR FOR • Men < 50 years and
randomized trials and meta-analyses of available trials have found a
and women > 60 • Men > 50 years or women < 60 years
similar 10 % RRR in CVD events. Given the uncertain efficacy of aspirin years with any of women > 60 years with none of the
for primary CVD prevention in adults with diabetes and its recognized these risk factors: with none of the risk factors noted in
risk for upper gastrointestinal bleeds and hemorrhagic stroke, a 2010  Smoking risk factors noted the first column
expert consensus document suggested that for primary prevention, in the first column
 High blood
aspirin therapy should be guided by a combined assessment of either OR FOR
pressure
• Men ≤ 50 years or
age, sex, and other CVD risk factors or by an estimate of absolute,  Albuminuria women ≤ 60 years
10-year CVD risk. Risk can be calculated via the resource noted in the  High cholesterol with one or more
sidebar at right.  Family history of risk factors noted
in the first column
For patients with no history of CVD who are not at increased risk for premature CVD
bleeding (no history of prior gastrointestinal bleeding, no prior peptic ulcer
disease, no concurrent warfarin or NSAID therapy), we recommend aspirin
at a dose of 75 to 162 mg / day following the guidelines in table 5 at right.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

CARDIOVASCULAR RISK AND High cholesterol


CHOLESTEROL CPM Diabetes mellitus is associated with multiple lipid abnormalities, most typically
The 2017 Cardiovascular Risk and Cholesterol hypertriglyceridemia, low HDL cholesterol, and increased numbers of small, dense
CPM provides LDL cholesterol particles. Insulin resistance, insulin deficiency, hyperglycemia, and
further guidance obesity are common contributing factors for dyslipidemia in people with diabetes.
on treating Multiple studies have demonstrated that treating dyslipidemia can improve cardiovascular
dyslipidemia.
disease outcomes in people with diabetes. HEA, SEV  

Click the image to


open the document, Recommendations on cholesterol management have recently changed. In 2013,
or see page 31 the American Heart Association and American College of Cardiology revised their
for ordering cholesterol treatment guidelines to recommend that treatment initiation and initial
information. statin dose be driven primarily by risk status, not by LDL cholesterol level. The
2017 ADA Standards recommend following this guideline for diabetes treatment.ADA  

DIABETES AND AGE 20 – 39 The algorithm below is taken directly from Intermountain's Cardiovascular Risk and
OR OVER 75: INTERMOUNTAIN Cholesterol CPM.
RECOMMENDATIONS Some controversy exists around the new recommendations. The National Lipid
Association (NLA) continues to recommend initiation of statin therapy based on lipid
For patients with diabetes who are outside
the 40 – 75 age range, the AHA / ACC targets. For a detailed comparison of AHA and NLA recommendations, visit
did not have enough data to make clear www.lipid.org/recommendations.
recommendations.GOF Intermountain experts
in cardiology and primary care recommend
shared decision making with patients in
these categories, considering the patient's ALGORITHM 6: ASSESSING AND MANAGING
cumulative risk factors for atheroscleotic
cardiovascular disease (ASCVD), and patient
CHOLESTEROL LEVELS AND ASCVD RISK
preference in making the final decision:
PROMOTE heart-healthy lifestyle habits as the foundation
• For nonpregnant patients, ages 20 – 39
of ASCVD risk reduction (See page 8)
–– If lifetime ASCVD risk is 30 % to 40 %,
consider a low-intensity statin. Screen at diabetes
–– If lifetime ASCVD risk is > 40 %, SCREEN adults age ≥ 20 years diagnosis, at initial
consider a moderate-intensity statin medical evaluation,
with full lipoprotein panel (fasting preferred) once every 5 years
and / or at age 40
• For younger patients who have had type 1
diabetes for ≥ 15 years, consider a shared- •• PRESCRIBE high-
decision discussion regarding statin use. intensity statin (b)
Clinical yes Age ≤ 75? yes Baseline LDL yes •• CONSIDER additional
• For patients > 75, consider a ASCVD? (a) > 190?
treatment to achieve
moderate-intensity statin. no 50 %LDL reduction or
no if LDL remains > 70
PRESCRIBE no
STATIN INTOLERANCE moderate-intensity statin (b)
Statin intolerance may occur in LDL-C ≥ 190 yes
5 % to 15 % of patients. Symptoms: mg / dL? •• PRESCRIBE high-intensity statin (b)
• Include myalgias, proximal and symmetrical, •• CONSIDER additional treatment for patients with:
PRESCRIBE high-
often in the thighs. no –– NO comorbidities: < 50 % LDL reduction OR LDL remains
intensity statin (b) > 100 m / dL
• Typically occur one month after statin start –– Cormorbidities: < 50 % reduction OR LDL remains > 70 m / dL
or change Diabetes? yes
• Are often dose‑dependent. (Confirmation of no •• ESTIMATE 10-year ASCVD risk every 5 years beginning at
intolerance may require a two- to six-week age 20, using Pooled Cohort Equation
trial off statin.) Age 40 to 75? yes •• SUPPORT primary prevention
Treatment: For diabetes patients
age 20 – 39 or > 75, 10-year ASCVD risk < 7.5% 10-year ASCVD risk ≥ 7.5 %
• Includes lowering statin dose by 50 % no see sidebar at left
• Reducing frequency to every other day or
less often
REFER to Cardiovascular •• CONSIDER moderate-intensity statin OR high-intensity statin
• Trials of other statins (e.g., pravastatin or if higher % or additional risk factors.
Risk and Cholesterol
rosuvastatin). CPM •• REFER to Cardiovascular Risk and Cholesterol CPM

Indicates an Intermountain measure


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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

ALGORITHM NOTES
(a) Clinical ASCVD
Clinical ASCVD is defined as one or more of the following: Treatment fundamentals for patients with clinical ASCVD:
• Acute coronary syndromes • Atherosclerotic stroke A — Aspirin / antiplatelet therapy
• History of MI • Atherosclerotic TIA B — Blood pressure control
• Stable or unstable angina • Atherosclerotic peripheral artery
C — Cholesterol control and cigarette smoking cessation
• Coronary or other arterial disease
revascularization • Abdominal aortic aneurysm D — Diet and weight management and diabetes and blood glucose control
E — Exercise

(b) Statin therapyGOF (Do not prescribe if patient is pregnant or lactating)


The results of statin interventions in patients with diabetes have demonstrated that the observed benefits are independent of baseline LDL-C and other lipid
values. Subsequently, the American College of Cardiology and the American Heart Association indicate that there is strong evidence that moderate-intensity
statin therapy should be initiated or continued for all adults with diabetes who are 40 to 75 years of age, or a high-intensity statin should be started if the
individual calculated risk is high (≥ 7.5% 10-year ASCVD risk).
High-intensity statin therapy Moderate-intensity statin therapy Low-intensity statin therapy
(For patients with clinical ASCVD and age (For patients with clinical ASCVD and age > 75, diabetes and age (For patients with < 5 % 10-year ASCVD risk and
< 75, LDL-C > 190, diabetes and age 40 to 40 to 75 without other risk factors, or 5 %–7.5 % 10-year ASCVD other risk factors)
75 with other risk factors, or > 7.5 % 10-year risk)
ASCVD risk)
Daily dose lowers LDL-C on average Daily dose lowers LDL-C on average Daily dose lowers LDL-C on average
by approximately 50 % or more •• atorvastatin
by approximately10
30% 50%1 •• fluvastatin XL 80 mg
(20)tomg by up to 30 %1
•• simvastatin 20 – 40 mg3 •• fluvastatin 40 mg bid
•• atorvastatin (402)–80 mg •• pravastatin 10 – 20 mg
•• pravastatin 40 (80) mg •• pitavastatin 2 – 4 mg
•• rosuvastatin 20 (40) mg •• lovastatin 20 mg
•• lovastatin 40 mg •• rosuvastatin (5) 10 mg
•• simvastatin 10 mg
•• fluvastatin 20 – 40 mg
•• pitavastatin 1 mg

NOTES: Beware of drug interactions with atorvastatin (80 mg) and simvastatin (40 mg), including clarithromycin, erythromycin, amiodarone, calcium channel blockers, or
fluconazole.
1 Individual responses to statin therapy should be expected to vary in clinical practice. There may be a biologic basis for less-than-average response.
2 Evidence from 1 RCT only: Down-titrate if unable to tolerate atorvastatin 80 mg in IDEALPED.
3 Although simvastatin 80 mg was evaluated in RCTs, initiation of simvastatin 80 mg or titration to 80 mg is not recommended by the FDA due to the increased risk of myopathy,
including rhabdomyolysis.

(c) New pooled-cohort risk calculator


The American Heart Association and American College of Cardiology  recommend the new Risk Calculator available at tools.acc.org/ascvd-risk-estimator/ to evaluate
10-year and lifetime risk of ASCVD and more accurately identify higher-risk patients who may benefit from statin therapy.GOF

OTHER ISSUES
Triglycerides: If triglycerides are over 500 mg / dL, treat to reduce risk of pancreatitis. There is no evidence of cardiovascular risk reduction from treatment.
Blood glucose: The impact of statins on blood glucose is small and should not influence the decision to prescribe.

Other classes of lipid-lowering medications:


• Fibrates. Gemfibrozil should not be initiated in patients on statin therapy because of an increased risk for muscle symptoms and rhabdomyolysis.
Fenofibrates may be considered concurrent with low- or moderate-intensity statin only if benefits are judged to outweigh risks.
• Ezetimibe. May show some benefit. Make shared decision with patient.
• Omega-3 fatty acids (fish oil supplements). Not recommended.
• Bile-acid sequestrants. Consider using colesevelam for statin-intolerant patients.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

HIGH BLOOD PRESSURE CPM High blood pressure


The 2014 High Blood Pressure CPM High blood pressure affects most patients with diabetes. Aggressive treatment of
provides further guidance on treating high high blood pressure has been convincingly shown to reduce cardiovascular risk in
blood pressure. It recommends a standardized these patients to an extent equal to or greater than the effect of glucose control. JAM
medication cascade

The 2015 ADA Standards of Medical Care in Diabetes changed the recommended
for most patients.
goal for diastolic blood pressure in most patients with diabetes from 80 mm Hg to
Click the image to 90 mm Hg, reflecting the clearest evidence from randomized clinical trials.
open the document,
or see page 34 for The algorithm below is a shortened version of the algorithm in the High Blood
ordering information. Pressure CPM and is consistent with the recommendations in the ADA standards.
Using the same treatment protocol across the system has been shown to facilitate
consistent team‑based care.

ALGORITHM 7: MANAGEMENT OF HYPERTENSION


General approach for most patients under 80 years old

CHECK BP at each office visit (a)

Systolic ≥ 140 or diastolic ≥ 90? No


Yes

RECHECK to confirm high BP (b)


•• Follow-up office visit
•• Home BP readings

High BP confirmed? No

Yes

•• Consider individualized target,


TREAT high BP to INITIATE therapeutic lifestyle changes (TLC) (d) as needed, based on patient's
clinical circumstances.
management target: •• Start meds concurrently with TLC
•• Consider secondary causes of
< 140 / < 90 (c) •• Maintain TLC throughout course of treatment high BP (e)

Treatment process:
Special populations:
•• Evaluate BP every 2 weeks ACEI (or ARB): Lisinopril (or losartan) (f)
while titrating or switching Lisinopril titration: 10 mg daily  20 mg daily See note (g) for options in
treating high blood pressure in
medications. (d)
patients who have:
•• Order BMP 2 – 3 weeks ••Prediabetes
after initiation or dose changes ••Coronary artery disease
For patients who require additional medications
of lisinopril or HCTZ. ••Heart failure
to manage high blood pressure, refer to the
•• Consider divided dosing ••Chronic kidney disease
High Blood Pressure CPM.
(AM / PM) when patient is on ••Black patients (African ancestry)
more than 1 medication. ••Age > 80 years
••Confirmed pregnancy
•• When BP is at target,
maintain current therapy and
evaluate BP every 6 months. Indicates an Intermountain measure

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

ALGORITHM NOTES
(a) Check BP at each office visit (f) Medication notes
Best practices for consistent BP readings: •• Consider nonadherence. Ask how many doses were missed
•• Patient should be seated with feet on the floor, back supported, since the last visit.
and arm supported at heart level. •• Consider interfering agents, such as NSAIDs.
•• Allow patient to rest for 5 minutes. Empty air bladder if necessary.
Ensure reading is at least 30 minutes after last heavy meal, heavy Medications in the algorithm
exercise, or intake of caffeine, alcohol, or nicotine. lisinopril/ •• Either drug class is acceptable as a first-line choice.
•• Use appropriate-size cuff (not too small). losartan
•• If dry cough with lisinopril, switch to losartan.
•• Avoid talking with the patient or asking questions while taking BP.
•• Avoid all ACEI or ARB medications in pregnancy.
See the High Blood Pressure CPM for more detail.
•• Do NOT combine an ACEI or an ARB.
•• Avoid the direct renin inhibitor aliskiren.
(b) Confirming high BP
Methods Other preferred blood pressure medications
Follow-up High BP can be confirmed through two office visits amlodipine •• Monitor for peripheral edema.
office visit total, with two BP checks in each visit. •• If patient is on simvastatin > 20 mg daily, consider
alternative statin due to drug interaction.
Home BP •• Train patient on checking BP at home, and make sure
monitoring patient has appropriate home BP monitor. •• Consider starting with 2.5 mg daily in elderly
patients. Maximum therapeutic effect can take up
•• Patient takes at least 6 – 10 home BP readings over
to three weeks.
two weeks or more. Make sure patient brings monitor
to office visit to verify consistency of readings. HCTZ •• Prescribe as single combination with an ACEI / ARB.

carvedilol •• Monitor for bradycardia (keep HR > 55 BPM).


(c) Blood pressure targets
Most The 2015 ADA standards recommend management to
patients < 140 / < 90 for most patients with diabetes, but allow (g) Special populations
for individualized targets for patients with chronic Prediabetes Consider avoiding thiazides and beta blockers as
kidney disease or other risk factors. they can increase blood glucose. However, if a beta
Younger or
blocker is used, carvedilol is preferred as it may help
Consider a target of < 130 / < 80 for some patients,
at risk for with insulin resistance.
including younger patients, if the burden of more
stroke aggressive therapy is not excessive. The recommendations below are for patients with both
diabetes and the condition listed:
Elderly In elderly patients, avoid reducing diastolic BP
below an average of 60. Lower diastolic BP may Coronary Consider adding carvedilol (preferred) or metoprolol
cause symptoms of hypotension and increase risk of artery succinate to ACEI / ARB. As needed, add amlodipine
myocardial infarction and stroke. disease and then a diuretic.

Heart failure If ejection fraction ≤ 40 %, ACEI / ARB, plus


carvedilol (preferred) or metoprolol succinate, plus
(d) Therapeutic lifestyle changes (TLC)
spironolactone (if not contraindicated). If needed
TLC elements include weight reduction, the DASH eating plan, for BP, add amlodipine.
sodium reduction, regular physical activity, limiting alcohol, and
smoking cessation. For more information on the effects of TLC on Chronic Treat to < 140 / <90; consider < 130 / 80 if ACR
kidney > 300. Monitor K+ and creatinine with ACEI / ARBs.
blood pressure, see page 10 of the High Blood Pressure CPM. disease

African Consider starting with CCB or thiazide; then, add


(e) Secondary causes of uncontrolled BP ancestry thiazide or CCB as 2nd line.
If a patient is on multiple medications and still not meeting BP goals,
Age > 80 Consider target of < 150 / < 90 and individualized
explore these possible secondary causes: Primary aldosteronism, years approach; consider starting with CCB or thiazide.
sleep apnea, chronic kidney disease, coarctation of aorta,
Cushing's syndrome or steroid therapy, drug-induced hypertension, Confirmed Avoid ACEI / ARB medications. Consider labetalol,
pheochromocytoma, renovascular disease, thyroid/parathyroid pregnancy CCB (nifedipine preferred), hydralazine, or
disease, alcohol use. methyldopa.

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Kidney Disease
COMBINATION RENIN-SYSTEM
Diabetic nephropathy occurs in 20 % to 40 % of patients with diabetes and is the
THERAPY FOR ALBUMINURIA leading cause of end-stage renal disease. Increased urinary albumin excretion, a marker
A combination of drugs that block the for development of nephropathy in type 2 diabetics, is also a well-established marker for
renin-angiotensin-aldosterone system increased cardiovascular disease risk.ADA  

(e.g., ACEI plus an ARB, or a mineral


Screening and management recommendationsADA, HAN, NKF
corticoid antagonist [SARA]) has been

shown to provide additional lowering Detect the onset of diabetic kidney disease at its earliest stage with an annual albumin-
of albuminuria. However, long-term creatinine ratio. (Morning spot urine specimens are preferred.) In addition, this CPM
cardiovascular or renal benefit has not recommends measuring serum creatinine with calculation of estimated Glomerular
been proven and may lead to increased Filtration Rate (eGFR) at least every year. Some patients with diabetic kidney disease will
adverse effects.PIC have normal albumin excretion in the presence of reduced renal function. GFR is also used
to monitor for improvement or progression of preexisting nephropathy and to establish
ALGORITHM NOTES stages of chronic kidney disease (as defined by the National Kidney Foundation).
To reduce the risk of progression of diabetic nephropathy:
(a) Modification of diet
• Optimize blood glucose control (HbA1c less than 7 %).
The Modification of Diet in Renal
Disease (MDRD) equation may • Optimize blood pressure control. In patients with increased urinary albumin excretion
significantly underestimate the filtration or nephropathy, treat to a blood pressure goal of 130 / 80 or lower.
rate in patients with increased urinary • Use ACE inhibitors or ARBs in nonpregnant patients, even in patients with normal
albumin excretion or obesity and in blood pressure. If one class of medication is not tolerated, substitute the other class.
the elderly. The calculations have been
validated only to age 70. When eGFR • Restrict dietary protein. Reducing protein to 0.8 to 1 g / kg / day for patients in earlier-
< 60 ml / min / 1.73 m2 body surface stage CKD and to 0.8 g / kg / day for patients in later stages of CKD may improve
area, evaluate further. measures of renal function, including eGFR. 
For patients with increased urinary albumin excretion, nonsteroidal inflammatory
(b) Urine testing medications are discouraged. Note also that in this population, intravenous contrast
dyes may precipitate renal failure.
Two specimens — collected three
months apart — should be positive
before considering a patient to have
increased urinary albumin excretion. ALGORITHM 8: NEPHROPATHY SCREENING
Vigorous exercise within 24 hours
of the test, infection, fever, CHF,
marked hyperglycemia, and marked TEST ANNUALLY: urine albumin/creatinine ratio (ACR)
hypertension all may elevate urinary AND serum creatinine + eGFR
albumin excretion.
Note that a 24-hour urine test ACR < 30? yes
for albumin is no longer typically (a)
recommended.
no

REPEAT ACR, and DO urinalysis (b)


(c) Causes of nephropathy
Consider other causes of chronic kidney yes
ACR < 30?
disease when patients have:
•• No diabetic retinopathy no

•• No albuminuria
CONSIDER secondary causes of nephropathy (c)
•• Low or rapidly decreasing eGFR
•• Rapidly increasing proteinuria or
nephrotic syndrome CONFIRM diabetic nephropathy
•• Refractory hypertension
•• Active urinary sediment present
REFER to Chronic
•• Signs or symptoms of other
Kidney Disease
systemic disease
CPM
•• Greater than 30 % reduction in eGFR
within two to three months after initiation
of an ACEI or ARB Indicates an Intermountain measure

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A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

Retinopathy
RETINAL PHOTOGRAPHY
In the U.S., diabetes is the leading cause of new cases of blindness for adults ages 20
Retinal photography is
to 74 years. ANT Good glycemic and blood pressure control can help prevent or slow the
recommended as an alternative
progression of diabetic retinopathy; early treatment of retinopathy can be the key to to traditional ophthalmologic
preventing blindness. This CPM recommends the following practices:ADA screening examinations. It is a valid
method for performing a diabetes eye
• Screening. Early signs of retinopathy frequently go unnoticed by patients, but can be
exam and can be done in the primary
seen with retinal photography (on a dilated fundus exam), or with optical coherence
care office.
tomography. These tests, with remote reading by an ophthalmologist or optometrist, are
acceptable for screening but do not replace comprehensive, in-person exams. Equipment and proper training of
staff are required for this test to be
Follow the screening schedule below: performed. The digital images are sent
–– For type 2 diabetes, initial screening should occur at diagnosis. Repeat dilated eye to a designated ophthalmologist for
exam every one to two years if under good control and no retinopathy; every two formal reading and diagnosis.
years in those with good blood pressure, blood glucose, and lipid levels. When this procedure is complete,
–– For type 1, initial screening should occur within five years of diagnosis. Repeat CPT code 92250 is reported to the
dilated eye exam every year or every one to two years following one or more normal insurance company. SelectHealth and
many other insurers are now covering
eye exams. If retinopathy is progressing, more frequent exams are required.
this billing code.
–– For women with diabetes who are pregnant or considering pregnancy, dilated eye
Limitations include a lack of evaluation
exams should occur before conception, during the first trimester of pregnancy, and
of other non-retinal disease processes
every three months thereafter or as recommended by the ophthalmologist.
such as glaucoma and cataracts. In
• Referral. Refer to an ophthalmologist experienced in managing diabetic retinopathy addition, treatment is not performed
those patients with: based on this image alone. Any
identified abnormality must be
–– Diabetes who become pregnant. (Women who develop gestational diabetes are not
fully evaluated in the office of an
at increased risk.)
ophthalmologist / retinologist.
–– Macular edema or any retinopathy.

Diabetic neuropathy
Neuropathies are among the most-common chronic complications of both type 1 and
type 2 diabetes. They are asymptomatic up to 50 % of the time, and early recognition
is important. Early control of glucose may help to prevent or delay the development of
peripheral neuropathy in both type 1 and type 2 diabetes and development of autonomic
neuropathy in type 1 diabetes.
Peripheral polyneuropathy is generally symmetrical
and is felt first in the lower extremities, but it may affect TABLE 6: Medication options for peripheral polyneuropathy
the upper extremities as well. It can cause pain, numbness,
or both. It can also affect position sense and increase the Class Examples Typical Doses
risk of falls. The pain associated with neuropathy can be Tricyclic drugs Amitriptyline 10 – 75 mg at bedtime
treated with medication. Peripheral neuropathy is generally
Nortriptyline 25 – 75 mg at bedtime
a clinical diagnosis, and nerve conduction tests are usually
not needed except in complicated cases. Once the diagnosis Imipramine 25 – 75 mg at bedtime
is made, it may be worth considering other causes for
Anticonvulsants Gabapentin 300 – 1,200 mg 3 times a day
neuropathy, such as vitamin B12 deficiency, liver, kidney, or
thyroid disease, in selected patients. Carbamazepine 200 – 400 mg 3 times a day

Autonomic neuropathy is also common and may cause Pregabalin 100 mg 3 times a day
symptoms in multiple organ systems, such as tachycardia, 5-hydroxytryptamine Duloxetine 60 – 120 mg a day
orthostatic hypotension, gastroparesis, sexual dysfunction, and norepinephrine
and bladder dysfunction. uptake inhibitor
Although loss of sensation from neuropathy cannot Substance P inhibitor Capsaicin cream 0.025 – 0.075 % applied
be reversed, the medications listed in table 6 at right 3 to 4 times a day
could be considered for treatment of discomfort due to Note: Peripheral polyneuropathy has been associated with vitamin B12 deficiency, a
peripheral polyneuropathy. potential side-effect of metformin use.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

Foot problems
DIABETIC FOOTWEARCMS
Foot problems are a frequent cause of morbidity and mortality in patients with diabetes.
Diabetes shoes can be helpful for patients In the U.S., diabetes patients account for over 60 % of non-traumatic, lower‑limb
who have or are at high risk of developing amputations.CDC1 Foot problems derive from a combination of factors:
foot problems. They are constructed with

extra depth to accommodate custom made • Peripheral vascular disease causes changes in skin tone, impaired wound healing,
shoe inserts that prevent friction that leads to and greater susceptibility to infection.
callus formation and ulceration. They can also
be made to accommodate foot deformities. • Peripheral neuropathy allows for nonpainful rubbing and callus formation, which
Medicare pays for one pair of diabetic shoes often result in asymptomatic diabetic foot ulcers over time.
per year for patients who meet one or more • Impaired wound healing is a result of glycosylation of proteins and of peripheral
of the following criteria: vascular disease.
• Peripheral neuropathy with evidence of
Ulceration and failure of wounds to heal frequently lead to lower extremity
callus formation
amputation. Once the amputation of one limb occurs, the prognosis for the contralateral
• History of pre-ulcerative calluses limb is poor.
• History of previous ulceration
Prevention is key. Neglect is by far the most common reason for severe diabetic foot
• Foot deformity
problems. Patients with diabetes often have decreased sensation and proprioception. They
• Previous amputationof all or part of develop calluses over areas of friction, which can lead to ulcers. Often they don’t seek
the foot care until a serious infection has been established — one that may have already reached
• Poor circulation a bone. The CDC estimates that comprehensive foot care programs can have a positive
The physician who treats the patient must impact for those with diabetes, reducing amputations by 45 % to 85 %.CDC2  

certify that the patient has diabetes and Refer patients with any open ulcers or wounds to a podiatrist. Most of these wounds
that they need diabetic shoes as part of a
will require debridement and off-weighting techniques to heal. Diabetic patients with
comprehensive treatment plan. This need
must be documented in the medical
neuropathy or peripheral vascular disease qualify for routine nail care every 61 days. This
record. The prescription for diabetic shoes allows regular follow-up and prevention of problems.
can be written by a podiatrist or a physician
who in knowledgeable in the fitting of Preventive foot care: Three major components
diabetic shoes. 1. Perform routine foot exams. For patients with insensate feet, foot deformities, or a
history of foot ulcers, examine feet every visit.
See page 29 for foot exam guidelines. Note that no single test of sensation is 100 %
sensitive in detecting sensory deficits. Testing should include a combination of
monofilament fiber plus any one of the following:
• Vibratory sensation testing using a 128-Hz tuning fork (see page 29 for instructions)
• Pinprick sensation testing
• Ankle reflex testing
Vibratory sensation testing may be the most sensitive test. An abnormal monofilament
fiber test result most accurately predicts ulcer risk.
2. Educate patients on daily foot care, which includes the following:
• Check feet daily for problems.
• Wear white socks to help identify drainage from an unknown ulcer.
• Use a hand, rather than a foot, to check bathtub and other water temperatures.
• Avoid going barefoot.
• Avoid medicated corn pads, as well as cutting corns and calluses with a blade. Use a
pumice stone or nail file.
• Trim nails straight across.
3. Emphasize the importance of appropriate footwear.
Patients should select soft-fitting, extra‑depth shoes. They should not expect shoes to
stretch out and should break in new shoes slowly.
Medicare covers diabetic shoes for patients with previous ulcers, foot deformities,
or neuropathy. Diabetic shoes are easier to put on and have softer insoles (to
accommodate foot deformities) and higher toe boxes (to avoid rubbing).

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IMMUNIZATIONS
TABLE 7: Routine foot exams
Influenza and pneumonia are common
Exam Action Document and preventable infectious diseases. These
diseases are associated with high mortality
•• Edema Whether pulses are palpable and the
Vascular and morbidity in people with chronic
•• Dorsalis pedis and posterior tibial pulses degree of edema
diseases, such as diabetes. This CPM
recommends the following vaccinations for
•• Sensory exam using monofilament test
Protective threshold present or absent patients with diabetes:
(see description below)
Neurologic • Annual influenza vaccination for
•• Vibratory exam using 128-Hz tuning fork Number of seconds until the patient no all patients over six months of age.
(see description below) longer feels the vibration Patients with diabetes show an increased
rate of hospitalization for influenza. The
•• Open lesions influenza vaccine can reduce hospital
•• Thickened or deformed nails admissions for these patients by as much at
•• Callus formation on bony prominences 79 % during flu epidemics.COLQ

and the ball of the foot • Pneumococcal vaccine for all adult
Dermatological Any positive findings
•• Hyperkeratosis or corns, including patients with diabetes. Patients
between the toes with diabetes may be at increased risk
•• Dry skin and cracks on heels of bacterial pneumonia and have a high
•• Evidence of venous stasis reported risk of nosocomial bacteremia,
which has a mortality rate as high as
Musculoskeletal abnormalities, such as 50 %.SMI Patients with diabetes need the
Skeletal Any positive findings  

bunions, hammer toes, etc. following pneumococcal vaccines:


–– Age 19 to 64: One dose PPSV23.

–– Age 65 or older: One dose PPSV23.


HOW TO PERFORM A SENSORY EXAM If patient has not previously received
Using a Semmes-Weinstein 5.07 monofilament, test several toes PCV13 as an adult, give also one dose
on each foot, being careful not to test directly over a callus, ulcer, PCV13 (preferably before PPSV23). Doses
need to be separated by one year.
scar, or necrotic tissue. LEW, ADAM
Apply the monofilament perpendicular to the skin’s surface Note: CMS-Medicare Part B now
forcefully enough to bend the filament. Do not let it slide or make
covers both PCV13 and PPSV23 when
given at least one year apart.
repetitive contact.
• Hepatitis B vaccination for
unvaccinated adults with diabetes
under 60. In 2013, the Advisory
Committee on Immunization Practices of
the CDC recommended the following: ADA
–– Age 19 – 59: Vaccinate with three doses
of hepatitis B vaccine.
HOW TO PERFORM A VIBRATORY SENSATION EXAM
–– Aged ≥ 60 years: Consider vaccination
Patients with low vibratory sensation are at increased risk of falls. Use after assessing risk and likelihood of an
a 128-Hz tuning fork to test vibratory sensation. One suggested adequate immune response. 
method of testing is as follows:LEW, ADAM
: 

This acknowledges increased risk of


1. Explain the test to patient; mention that fork vibration may feel like hepatitis B in institutionalized (e.g., nursing
“buzzing.” (Consider demonstrating feel of vibrating/nonvibrating home, prison) patients.
fork on patient’s forehead or wrist.)
2. Have the patient close eyes.
3. Strike the fork forcefully (on a desk or other hard surface) to set
off a strong vibration. Instruct the patient: "Tell me when you no longer feel the buzzing.”
4. Holding the fork by the stem, place the base of the fork on the patient’s large toe.
5. Record the number of seconds the patient can feel the vibration. Ten or more seconds
is normal.
6. Repeat the test on the other side.

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USING THE STOP-BANG Obstructive sleep apnea (OSA)


SCREENING TOOL Individuals with diabetes or insulin resistance have a two- to four-fold higher prevalence
There is some concern that the STOP-BANG of OSA compared with the general population. Prevalence in obese patients is
screen may be too sensitive for the primary
significantly higher.
care setting, since such a large percentage of
the general population may be overweight, While no study has shown that having OSA causes diabetes, there is mounting
over 50, male, and/or hypertensive. In evidence that OSA, along with sleep deprivation in general, is associated with insulin
addition, other literature defines a large
resistance, increased insulin secretion, and impaired glucose metabolism.VAN Follow
neck size as over 16 inches for women and

over 17 inches for men (compared to the these guidelines:


15.75 inches used in STOP-BANG). KAP • Screening. All patients with diabetes should be screened for OSA, particularly those
Of greater concern, however, is that OSA patients with waist circumference above normal. Intermountain
is under-diagnosed and under-treated in
recommends using the OSA STOP-BANG Screening Questionnaire
the primary care setting. Therefore, using
a sensitive screen helps alert providers to because it is concise, easy to use, and has been validated in a
the possibility of OSA. Providers should presurgical setting. In general, the more of these symptoms a patient
weigh all these factors, along with specific has and the more severe the symptoms are, the greater the pretest
patient characteristics, when determining probability a patient will have moderate or severe OSA.
next steps for referral and sleep testing.
• Referral. For patients with three or more STOP-BANG risk factors
(see below), consider referral to a sleep specialist.
LOW TESTOSTERONE IN MEN
Type 2 diabetes is a known risk factor for Evaluate Patient and Administer STOP-BANG OSA
low testosterone levels in men. Consider screening questionnaire
evaluating male patients who have diabetes
o Snoring: Do you snore loudly (louder than talking o Body mass index (BMI) greater
and symptoms of hypogonadism. Refer to the or loud enough to be heard through closed doors)? than 35?
Intermountain clinical o Tired: Do you often feel tired, fatigued, or sleepy o Age older than 50 years?
guideline Testosterone during the daytime, even after a “good” night’s sleep? o Neck circumference greater
Therapy for Men for o Observed: Has anyone observed you stop breathing than 16 inches (41 cm) for
guidance on diagnosis during your sleep? females or 17 inches (43 cm)
for males?
and treatment. The o Pressure: Do you have or are you being treated for
guideline can be high blood pressure? o Gender = male?
accessed from within
the Intermountain
Healthcare firewall at • Treatment. Treatment of sleep apnea significantly improves quality of life and blood
Intermountain.net. pressure control. Evidence for an effect on glycemic control is mixed, and preliminary
evidence is hopeful that treatment can improve visual acuity in
those struggling with diabetic retinopathy.ADA, ANT, MAS  

CONDITIONS ASSOCIATED Treating OSA should be done according to standard guidelines


for OSA, as outlined in the Intermountain care process model
WITH TYPE 1 DIABETES
Management of Obstructive Sleep Apnea. Extra effort toward weight
• Thyroid disease. Perform thyroid-
loss, however, will likely be of great benefit to patients who suffer
stimulating hormone (TSH) testing as part
of an initial evaluation. If the diagnosis of from diabetes and its comorbidities.
diabetes is confirmed, repeat this testing
periodically.
• Celiac disease (sprue). This disease is
common in patients with type 1 diabetes
(1 % to 16 % of individuals compared with
0.3 % to 1 % in the general population).
Perform a tissue transglutaminase test as
the initial screening for this disease in all
patients with type 1 diabetes. Repeat testing
may be appropriate. Symptoms of celiac
disease may be subtle and include diarrhea,
abdominal pain, and chronic fatigue.

30 ©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .


A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

DATA AND REPORTS THE DIABETES LIST


Patients are included on the list if they have:
The Intermountain Primary Care Clinical Program maintains a database of 130,000
patients with diabetes who have been seen within the Intermountain system • One abnormal HbA1c

(see sidebar at right for inclusion criteria). The purpose of the database is to improve • Two outpatient visits with diabetes
as the diagnosis
clinical care. It includes information on HbA1c, lipids, blood pressure, urinary
albumin excretion, eye exams, foot exams, and ACEI or ARB use. Using this • One acute inpatient or ED visit with diabetes
as the diagnosis
information, reports are developed for primary care physicians and endocrinologists
• Filled a prescription for insulin or an oral
to identify patients who either may not have had testing done or who have test hypoglycemic/antihyperglycemic agent other
results outside standards of good diabetes management. than metformin
Data for the reports is obtained from insurance claims, billing records, lab results,
and the electronic medical record (EMR). Physicians can review their data and THE DIABETES REPORT
submit corrections if needed (see sidebar at right). Throughout this CPM, the icon indicates
places where data is collected about each
The diabetes bundle patient. Reports are updated monthly and
are available to Intermountain-employed
Good management of diabetes is key to delaying and preventing complications,
providers through the report portal. Affiliated
which improves patient satisfaction, medical outcomes, and appropriate healthcare providers receive their reports through
resource utilization. The "diabetes bundle" is a set of four elements that together SelectHealth. If you have questions about
represent a measure of an individual's diabetes control. This set allows for comparison your report, please contact Stephen Smith,
of management within the Medical Group and with other groups nationally and leads Primary Care Clinical Program Data Manager.
to more coordinated and accountable, team-based care. One of the quality measures 801-442-5269
Stephen.C.Smith@imail.org.
for the Primary Care Clinical Program is to increase the percentage of diabetes
patients ages 18 to 75 who meet the targets indicated in the bundle. How to submit corrections
The diabetes bundle targets are set to allow for appropriate individualization of care. If you have corrections to the report (e.g.,
not your patient, does not have diabetes, in
The diabetes bundle consists of the following targets: remission, deceased, moved away, etc.):
• Intermountain-employed providers can
1. Hemoglobin A1c less than 8 %
access the corrections tool directly and
2. Blood pressure less than 140 / 90 mm Hg indicate the changes on the form.
3. Nephropathy evaluation and care (one of the following): –– Go to the Primary Care Clinical Program
• Spot urine or 24-hour urine microalbumin-to-creatinine ratio in the measurement period home page, and download the Diabetes
• Nephropathy care as determined by ICD-10 diagnosis or patient visit with nephrologist Data Management Tool.
• Patient on an ACEI or ARB OR
4. Eye exam: A retinal or dilated eye exam by an ophthalmologist or optometrist within the –– When within the Intermountain firewall,
last two years click on the links or enter either PCCPCT
or CorrectionTool in your browser to
go directly to the correction tool.
For most patients with diabetes, recommended treatment goals for HbA1c are lower
than those in the diabetes bundle. For some patients with diabetes, recommended • Affiliated providers can fax their corrections
along with documentation to SelectHealth
treatment goals for blood pressure goals are lower as well. The bundle targets were
Quality Improvement (801-442-0920).
selected so care plans could be individualized for each patient as clinically indicated.
Most patients with diabetes should be treated to at least the levels indicated in the
diabetes bundle.

SelectHealth support
SelectHealth is actively partnering with healthcare providers to care for patients
with diabetes. SelectHealthuses interactive voice response telephone calls, diabetes
care managers, and newsletters to reach out to members with diabetes, actively
promoting good self-management, proper medical follow up, and continued education.

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O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

COLLABORATIVE PHARMACY
CARE TEAM ROLES
MANAGEMENT A clinic visit for a patient with diabetes requires the support of the entire team to
assure comprehensive care. Algorithm 9 below suggests general responsibilities to help
The collaborative pharmacy model of disease
management is an emerging program to help a clinic team share accountability for diabetes management.
providers achieve clinical goals and improve
satisfaction for patients with dyslipidemia,
diabetes, and / or hypertension.
This program allows providers to partner
ALGORITHM 9: PATIENT VISIT
with a pharmacist for support in selecting,
titrating, and monitoring medications. For
Prior to visit
more information on this program, contact •• PSR prints worksheet for diabetes appointments, and PATIENT completes in waiting room
jeff.olson@imail.org. •• CMT scrubs schedule to identify patient needs

PROPOSED ORDERS
The medical assistant should propose orders
for the following tests as the appropriate
Patient check in
advisories fire in iCentra:*
• HbA1c (every six months, or every three
months if HbA1c is > 9). Patient rooming (MA)
• eGFR and serum potassium if patient is Data Orders and tests
taking an ACE / ARB or diuretic (yearly, or •• ENTER responses from patient worksheet •• PROPOSE orders as prompted by iCentra
as needed).ADA (see sidebar at left)
•• RECORD vital signs, including height, weight,
• Creatinine blood test (yearly). BP, and PAVS •• PERFORM A1c test as needed
• Urine ACR (yearly). •• DOWNLOAD data from glucose meter, •• ADMINISTER PHQ-2 to patients who have
if applicable not had one in the last 12 months
• B12 (yearly for patients taking metformin).
•• ADMINISTER PHQ-9 if PHQ-2 is positive
•• DOCUMENT problems as directed by provider
• Two-year exam scheduled with
Patient preparation
ophthalmologist, or date of last Medications and allergies
•• HAVE patient remove shoes and socks in
eye exam entered. •• RECONCILE medications preparation for foot exam
Consider prescribing: •• VERIFY and document allergies •• ASK patient if they need additional
• ACE / ARB •• PROVIDE any additional education education and notify care manager
if requested
• Statin (if not on allergy list)
*It's important that visits be scheduled
with the appropriate diagnosis.
Patient visit (PCP)
ADDITIONAL SUPPORT Data Management
FROM THE CARE •• REVIEW responses to diabetes questionnaire •• MANAGE diabetes based on CPM guidelines
MANAGEMENT TEAM •• DOCUMENT diabetes in the problem list •• COLLABORATE with pharmacist as needed
(if not already done) including date of (see sidebar at left)
The role of the care management team is to onset, if possible
provide support by: •• IDENTIFY patients whose comorbid
Orders and tests conditions or age may be a contraindication
• Collaborating with providers on: to pursing treatment goals
•• REVIEW and sign all proposed orders
–– Managing patients and •• DETERMINE compliance with diet and
providing education •• CONSIDER preordering labs for next visit
exercise recommendations
•• PERFORM foot exam and record results
–– Identifying and referring patients who •• DETERMINE need for vaccinations
need specialty care
Follow-up
–– Utilizing the diabetes bundle reports
•• SCHEDULE quarterly follow-up appointment
• Counseling patients via face-to-face visits for patients who are not at goal per CPM
or phone calls to help them achieve their Abbreviations: •• ENCOURAGE patients to work with care
lifestyle management goals CMT = care management team manager or health advocate as needed
MA = medical assistant (see sidebar at left)
PCP = primary care provider
PSR = patient service representative

32 ©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .


A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

TRANSITIONS OF CARE
To ensure the coordination and continuity of care as patients transfer between locations
or levels of care, the team recommends the following:
• Review the problem list, and look for diabetes diagnosis.

• Review the provider note for most current dosing of medications.

–– Changes in insulin dosing may appear in the comments rather than in the
medication list on the order information.
–– The most up-to-date information is likely to be located in the notes from the
primary care provider (PCP), endicrinologist, or Certified Diabetes Educator
(CDE).
• If admission or evaluation at a hospital is caused by or related to a diabetes diagnosis,
message the PCP and schedule a follow-up appointment within an appropriate
time frame.
• Ensure admissions and discharge information is sent to the PCP with
each hospitalization.

PROVIDER RESOURCES
Go to: IntermountainPhysician.org/ClinicalPrograms, and select “Diabetes” from the
topic list. See the tab titled "Clinical Guidelines & CPMs" for the following:

Outpatient Prediabetes CPM Gestational Diabetes Lifestyle and Weight Living Well PowerPoint
Management of Adult CPM Management CPM Teaching Slides
Diabetes Mellitus
(this care process
model)

Related condition care process models and clinical guidelines include the following:

Metabolic and Chronic Kidney Cardiovascular Risk High Blood Obstructive Sleep Testosterone Therapy
Bariatric Surgery Disease CPM and Cholesterol CPM Pressure CPM Apnea CPM for Men Clinical
for the Treatment of Guideline
Obesity CPM

©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 33


O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

LOCATING PATIENT DIABETES EDUCATION RESOURCES


EDUCATION MATERIALS The Intermountain Diabetes Workgroup, diabetes educators, and Patient and Provider
Intermountain education materials are Publications team have developed patient education materials to directly support
designed to support your efforts to treatment recommendations in this care process model. Education for patients and
educate and engage patients and families. families increases patient compliance with a treatment plan.
They complement and reinforce diabetes
team interventions by providing a means
for patients to reflect and learn in another Intermountain-approved patient education materials
mode and at their own pace. To access The following Intermountain-approved patient education resources can be accessed and
these materials: ordered online at minimal cost. See access and ordering information at left.
• As the iCentra EMR system
is implemented. search for Living Well: A Diabetes Carb Counselor:
Intermountain items in the patient Care Handbook Advice and Tools
education module. Intermountain’s for Counting Carbs
• Log in to Intermountain comprehensive guide to
diabetes and diabetes Available in English
physician.org, and search for the
self-management and Spanish
patient education library under A – Z.
Then, search item number and title in Available in English
the appropriate atrea. and Spanish
• Use Intermountain’s Online
Library and iPrint Store for Food Finder Patient Education
intermountainhealthcare.org/diabetes
BG Tracker
one-stop access and ordering for all Available in Available in English and Spanish
Intermountain-approved education, such English and
as fact sheets, booklets, and trackers. Spanish
BG Tracker
for people with diabetes
MONITORING BLOOD GLUCOSE

Programa de alimentación
O B J e t i V O S
Total en
gramos
D i a r i O S
Porcentaje Porciones
diario de calorías diarias

Meal Plan Diabetes Care Card


Available in English and
carbohidratos
Nombre: _________________________ Fecha: __________
proteínas
grasas

Available in
calorías
Nutricionista:______________________ Teléfono: _________
otros
o sodio (sal): _______ o fibras: _______
o alcohol: _______ o cafeína: _______
o grasas saturadas: _______ o calcio: _______
Si esta contabilizando los carbohidratos, recuerde:
o cholesterol: _______ o agua: _______
1 opción = equivale a 15 gramos de carbohidratos

Spanish
Horas Opciones Propuestas alimenticias D a i L y t a r g e t S

Meal Plan
Mantenga horarios fijos Elija sus alimentos en forma inteligente y tenga en cuenta la cantidad Disfrute sus alimentos grams percent servings

English and
total daily calories per day
Desayuno o Carbohidratos: _____ gramos
o Almidones _____
carbohydrates
o Frutas _____ Name: _________________________ Date: __________ protein
o Leche _____
fat
o Verduras sin almidon _____
o Proteínas: carnes/reemplazo de las carnes _____ porciones calories:
o Grasas: aceites y grasas Dietitian: _____
_______________________
porciones Phone: _________ other

Spanish
Bocadillo (Snack) o Carbohidratos: _____ gramos o sodium (salt): _______ o fiber: _______
o Proteínas: carnes/reemplazo de las carnes _____ porciones o alcohol: _______ o caffeine: _______
o Grasas: aceites y grasas _____ porciones o saturated fat: _______ o calcium: _______
If you’re counting carbohydrates, remember:
almuerzo o Carbohidratos: o cholesterol: _______ o water: _______
1 choice_____
= 15gramos
grams of carbohydrate
o Almidones _____
o Frutas _____
o Leche _____ Time Choices Menu Ideas
o Verduras sin almidon _____ Stick to regular patterns Choose foods wisely — and watch your portions Enjoy your food
o Proteínas: carnes/reemplazo de las carnes _____ porciones
o Grasas: aceites y grasas _____ porciones
Breakfast o Carbohydrate: _____ grams
Bocadillo (Snack) o Carbohidratos: _____ gramos
o Starches _____
o Proteínas: carnes/reemplazo de las carnes _____ porciones
o Grasas: aceites y grasas _____ porciones o Fruits _____
Cena o Carbohidratos: _____ gramos o Milk _____
o Almidones _____ o Non-starchy vegetables _____
o Frutas _____
o Protein: meat/meat substitutes _____ servings
o Leche _____
o Verduras sin almidon _____ o Fat: oils and fats _____ servings
o Proteínas: carnes/reemplazo de las carnes _____ porciones
o Grasas: aceites y grasas Snack_____ porciones o Carbohydrate: _____ grams
Bocadillo (Snack) o Carbohidratos: _____ gramos o Protein: meat/meat substitutes _____ servings
o Proteínas: carnes/reemplazo de las carnes _____ porciones
o Fat: oils and fats _____ servings
o Grasas: aceites y grasas _____ porciones

©2006-2009 Intermountain Healthcare, Inc. Todos los derechos reservados Lunch o Carbohydrate:
TEl contenido de la presente guía es solamente para su información. No sustituye los consejos profesionales de un médico, tampoco debe utilizarse para diagnosticar o tratar un problema de salud o enfermedad. Por favor, consulte a su proveedor de _____ grams
cuidados de salud en caso de preguntas o inquietudes. Si desea obtener más información acerca de la salud, ingrese al sitio: intermountainhealthcare.org Clinical Education Services (801) 442-2963 IHCEDDB034 – 11/09
o Starches _____
o Fruits _____
o Milk _____
o Non-starchy vegetables _____
o Protein: meat/meat substitutes _____ servings
o Fat: oils and fats _____ servings

Snack o Carbohydrate: _____ grams


o Protein: meat/meat substitutes _____ servings
o Fat: oils and fats _____ servings

Dinner o Carbohydrate: _____ grams


o Starches _____
o Fruits _____
o Milk _____
o Non-starchy vegetables _____
o Protein: meat/meat substitutes _____ servings
o Fat: oils and fats _____ servings

Bedtime snack o Carbohydrate: _____ grams


o Protein: meat/meat substitutes _____ servings
o Fat: oils and fats _____ servings

©2006-2009 Intermountain Healthcare, Inc. All rights reserved.


The content presented here is for your information only. It is not a substitute for professional medical advice, and it should not be used to diagnose or treat a health problem or disease. Please consult your healthcare provider if you have any questions
or concerns. More health information is available at intermountainhealthcare.org. Clinical Education Services (801) 442-2963 IHCEDDB034 – 11/09

FACT SHEETS from Intermountain (All available in English and Spanish):

Diabetes Medications: Diabetes Medications: Diabetes Medications: Weight-loss Surgery: Diabetes in Remission
Glitazones Metformin Meglitinides A Decision Tool

34 ©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .


A U G U S T 2 0 17 O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S

Diabetes educators and diabetes education programs


Diabetes education and medical nutrition therapy are covered by most commercial insurance providers and by Medicare. For help
locating diabetes educators in the area of your practice, call Intermountain’s Primary Care Program at 801-442-2990.

Salt Lake Valley Area Central Utah Southern Utah


Salt Lake City, UT Heber, UT Panguitch, UT
Salt Lake Clinic Heber Valley Medical Center Garfield Memorial Hospital
389 South 900 East 1485 South Highway 40 200 North 400 East
385-282-2600, option 2 435-657-4311 435-676-8811

Murray, UT American Fork, UT Cedar City, UT


Intermountain Medical Center American Fork Hospital Cedar City Hospital
5121 Cottonwood Street 98 North 1100 East, Suite 302 110 West 1325 North, Suite 100
801-507-3366 801-492-2200 435-868-5576

Intermountain Medical Group St. George, UT


Provo, UT
Comprehensive Care Clinic Dixie Regional Diabetes Clinic
Utah Valley Regional Hospital
5171 Cottonwood Street 348 East 600 South
801-507-9369 1034 North 500 West
435-251-2888
801-357-7546
Cottonwood Endocrine and
Diabetes Center Mt. Pleasant, UT Southern Idaho and
181 Medical Tower Drive Sanpete Valley Hospital
801-314-4500
Northern Utah
1100 South Medical Drive
Internal Medicine Associates 435-462-2441 Burley, ID
9844 South 1300 East, Suite 200 Cassia Regional Hospital
(Alta View Hospital Campus) Fillmore, UT
1501 Hiland Avenue
801-572-1472 Fillmore Community Hospital 208-677-6035
674 South Highway 99
Bountiful, UT 435-743-5591 Tremonton, UT
Bountiful Health Center Bear River Valley Diabetes Education
Richfield, UT
390 North Main Street 440 West 600 North
801-294-1000 Sevier Valley Hospital
435-716-5310
1000 North Main
Taylorsville, UT 435-893-0371 Logan, UT
Taylorsville Health Center Logan Regional Hospital
3845 West 4700 South 500 East 1400 North
801-840-2000 435-716-5310
Budge Diabetes Clinic
1350 North 500 East
435-792-1710

Ogden, UT
McKay-Dee Hospital
4401 Harrison Blvd
801-387-7520

McKay-Dee Endocrine and


Diabetes Clinic
4403 Harrison Blvd, #3630
801-387-7900
North Ogden Clinic
2400 North 400 East (Washington Blvd)
801-786-7500


©2001–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 35
O U T PAT I E N T M A N A G E M E N T O F A D U LT D I A B E T E S M E L L I T U S A U G U S T 2 0 17

REFERENCES
CPM DEVELOPMENT TEAM
For a list of the references used to prepare this care process model, see the
Mark R. Greenwood, MD
Diabetes topic page on intermountainphysician.org
(Medical Director)
Sharon Hamilton, RN, MS, APRN-BC
(Clinical Operations Director)
Christopher W. Jones, MD (Facilitator)
Kim Brunisholz, PhD, MST
Robert Day, MD
Roy Gandolphi, MD
Timothy Graham, MD
Emily Hayes, PharmD, BCPS
Karla Howe, RN, BSN, CDE
Doug Jones, MD
Liz Joy, MD, MPH
David Larsen, RN, MHA
Brett Muse, MD
Tonya Schaffer, RN, MBA
Jessica Shields, MS, RD, CD
Jane Sims, BA (Medical Writer)
Dane Stewart, MBA
Steven Towner, MD
Curtis Wander, PharmD, BCPS
David Winmill, APRN

This CPM presents a model of best care based on the best evidence available at the time
of publication. It is not a prescription for every patient, and it is not meant to replace
clinical judgment. Although physicians are encouraged to follow the CPM to help focus
on and measure quality, deviations are a means for discovering improvements in patient
care and expanding the knowledge base. Send feedback to Mark R. Greenwood, MD,
Intermountain Healthcare, Primary Care Medical Director (Mark.Greenwood@imail.org).

36 ©2001– 2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications CPM013 - 08/17