Diabetes Planned Visit Notebook

Diabetes planned visits address several health topics of concern to the diabetic patient, including glycemic control. This document is a decision support aid for controlling blood glucose levels.

Glycemic Control

• Effects of HgbA1c changes on health:
  • ↑ 1% → ↑ cardiovascular disease 28%.
  • ↓ 1% → ↓ heart attack rate 14%.
  • ↓ 1% → ↓ diabetes related deaths 25%.
  • ↓ 1% → ↓ kidney, eye or nerve damage 30%.
• Each oral agent lowers HgbA1c about 1%.
• Most patients eventually require insulin.
• 50% by 6 years; 80% by 9 years.

Steps to control Blood Glucose

1. Find out patient's understanding and priorities.
2. If diet questions or High BMI: Summa dietitian, Summa DM Center, or U of A diet study.
3. Optimize oral agents and follow Q2-4 weeks.
4. Prepare patient for insulin treatment: FMC nurse visit for DM education, Summa DM Center.
5. Start insulin.

Medication selection

HgbA1c >7%, but <8%

• Most patients will require two agents for long-term control.
• Choosing sulfonylurea or metformin initially is not particularly important.
  • Sulfonylurea—more rapid onset than metformin.
    • Hypoglycemia with glipizide (Glucotrol) than glyburide (Diabeta, Micronase).
  • Metformin (Glucophage)—lower risk of hypoglycemia, less weight gain.

HgbA1C > 8%

• Start sulfonylurea (glipizide, glyburide), rather than metformin, for more rapid onset.

HgbA1c >9.0%

• Combination therapy will likely be required, may not reach AIC <7.
  • Consider metformin + glyburide (Glucovance) or glipizide + metformin (Metaglip).

Hemoglobin A1C >10% 

• Start insulin.

Oral agents

• If HgbAIC ≥9, unlikely to reach goal with oral agents.
• Sulfonylureas show full effect within 1 to 2 weeks.
• Metformin shows full effect in 4 weeks.
• TZDs may not reach full effect for several months.

Metformin (Glucophage)

Avoid metformin in patients who are at risk for lactic acidosis.

• Females serum creatinine >1.4, males creatinine >1.5.
• Estimated creatinine clearance <60 cc/min.
• Congestive heart failure.
• Hypoxia.

• Take with food to avoid GI symptoms of diarrhea, nausea, vomiting.
• Start 500mg-850mg in the morning with meals
  • Increase by 500-850 mg every 2 weeks.
  • Split the dose to b.i.d.
  • Usual maintenance is 850 mg b.i.d.
  • Max benefit at 2,000 mg daily.
• If iHgbA1C >7 after 4 weeks at maximal doses, add a second agent.
• If HgbA1c >7 after 4-12 weeks of max metformin plus a second agent, switch to different agent
  • i.e, substitute TZD for sulfonylurea, or vice versa.

Thiazolidinediones (TZDs) (pioglitazone, rosiglitazone)

Contraindications:

• NYHA class 3 or 4 CHF.
• ALT >1.5 the upper limit of normal.
• Monitor ALT, AST and bilirubin periodically.
  • If ALT is greater than 1.5 to 2 times higher than the upper limit of normal during therapy, retest in a week, then weekly until it returns to normal.
  • If ALT ≥3 X ULN discontinue TZD.
• Not recommended as monotherapy.
• May be used with sulfonylurea or metformin.
• Monitor hemoglobin A1C at three and at six months.
• Discontinue TZD if HgbA1c >7.

Starting Insulin 

• Glargine (Lantus) in the morning (or at bedtime).
• Initial glargine dose: 10 units daily or 2 units for each 20 mg above 100mg.
• Titrate weekly based on last 2 FPG values:
  • 2 units for each 20mg above 100mg
    i.e., FPG 140 → increase 4 units; FPG 200 → Increase 10 units.
  • No increase in dose if BG <72 or documented severe hypoglycemia.
• Avg doses to achieve a FPG of 100 mg = 0.45-0.5 units/kg.