Outpatient Diabetes

Matthew Lu

Background

  • Type I Diabetes - insulin deficiency (GAD65, IA2, ZnT8 antibodies positive, Insulin and C-peptide inappropriately low).
  • Type II Diabetes - insulin resistance (generally associated with obesity).
  • Classification by HgA1c: Pre-diabetes: 5.7 to 6.4%; Diabetes: >= 6.5.

Management

  • Lifestyle changes:
    • Exercise 175 minutes weekly.
    • Caloric restriction for weight loss of 10%.
    • Low carb or Mediterranean diet, reduce normal portions by 10-20%, limit sugary drinks, drink large glass of water before meals.
    • BP Goal generally <130/80: ACE-inhibitor is first-line anti-hypertensive.
  • Manage complications of diabetes:
    • Retinopathy – annual retinal exams.
    • Peripheral Neuropathy – annual foot exams, can use gabapentin if present.
    • Autonomic Neuropathy – ED, orthostatic hypotension, gastroparesis.
    • Nephropathy – annual creatinine and urine microalbumin (albumin/creatinine ratio) - need repeat measurements 3mo apart to confirm albuminuria.
      • Normal: < 30mg/g.
      • Moderate albuminuria: 30-300 mg/g (consider starting ACE-I).
      • Severe albuminuria: > 300 mg/g i(should be on ACE-I).
    • If persistent despite ACE-I, start SGLT2 inhibitor (if GFR allows).
    • If persistent despite SLGT2 inhibitor, start finerenone.
    • Consider involving nephrology.
    • Increased cardiovascular risk (2-4x risk of MI, CVA or death).
    • High intensity statin if clinical ASCVD present.
    • Moderate intensity statin if age > 40 or with ASCVD risk factors (LDL >100, HTN, smoking, FHx of CVD, CKD).
    • Consider aspirin if ASCVD > 10% (balanced against bleeding risk)
      Smoking cessation.
    • Baseline ECG at diagnosis.
  • Glycemic goals:
    • Fasting glucose 80-130 mg/dL, postprandial (90-120 min after meal) < 180mg/dL.
    • A1c goal: generally < 7%, < 7.5% for 65 yrs, < 8% for poor health or life expectancy < 10 yrs.
  • Medications for glycemic control:
    • If pre-diabetic
      • Encourage lifestyle management and consider starting metformin.
    • If initial HgA1c < 9%
      • 1st agent: metformin (usually decreases HgA1c by 1-2%) – start at 500mg daily and increase by 500mg every 1-2 weeks if no GI side effects up to goal 2000mg daily.
        • If eGFR < 45, then half dose.
        • If eGFR < 30, then discontinue.
      • 2nd agent (if HgA1c still not at goal within 3 months):
        • GLP-1 agonist generally preferred (best weight loss benefit, usually decreases HgA1c by 1%).
        • SGLT2 inhibitor preferred if pt has HF or DM nephropathy (usually decreases HgA1c by 1%).
        • Consider sulfonylurea if pt on HD.
      • 3rd agent (if HgA1c still not at goal after additional 3 months).
        • GLP-1 agonist or SGLT2 inhibitor (whichever was not started as second agent.
    • If initial HgA1c > 9%
      • Start metformin AND GLP-1/DDP4-I OR insulin.
  • How to initiate insulin:
    • Start with long-acting insulin nightly (10 units or 0.1 units/kg/d).
    • Check fasting glucose daily and increase insulin by 2 units q 2-3 days until
      fasting glucose within goal (80-130mg/dL).
    • If hypoglycemia occurs, decrease insulin by 4 units or 10% (whichever is greater).
    • If A1c > 7% after 3mo, add mealtime insulin.
    • Check post-prandial glucose and start with 4 units short acting insulin at meals where post-prandial glucose > 180. Adjust by 2 units q 3 days until post-prandial glucose < 180.
    • When HgA1c < 6.5% consider de-escalating medications.
    • Other medication class options: sulfonylureas, DDP4-I, thiazolidinediones.

Tip: Search “Adult Diabetes Smartset” in Epic for a one-stop shop for ordering insulin and supplies (glucometer, lancets, test strips, etc.).

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