Diabetes Mellitus Type 2
Criteria for diagnosis of Pre-Diabetes:
HbA1C 5.7-6.5%
Fasting glucose 100-125mg/dL
2-hour plasma glucose >140-199mg/dL
Criteria for diagnosis of Diabetes Mellitus Type 2:
HbA1C >= 6.5%
Hyperglycemia crisis plus random plasma glucose >= 200mg/dL
Fasting plasma glucose >= 126 mg/dL on 2 occasions or 2-hour plasma glucose >= 200mg/dL during oral glucose tolerance test with a 75 gram glucose load.
Targets:
- A1C <7.0% for recently diagnosed without other co-morbidities (aim for 6.5% if low risk for hypoglycemia)
- A1C <8.0% for older patients or patients with comorbidities and established diabetic end organ disease
- LDL goal <70mg/dL in patients with existing cardiovascular disease. If the patient is >= 40 years of age, with >= 1 cardiovascular risk factor and LDL greater than 70mg/dL, the patient should start on a statin
- Blood pressure <140/80 mm Hg (if tolerated, <130 preferable) [ACE-I/ARB is 1st line. If contraindicated consider a Calcium Channel Blocker]
Visit Considerations:
Every Visit:
Diabetic foot exam at every visit
Lifestyle interventions should be discussed
Every 3 months:
A1C
Yearly
Nephropathy: urine microalbumin-to-creatinine ratio
Retinopathy:diabetic eye exam
Management:
Low-dose aspirin for all adults with CVD
ACE-I/ARB 1st line for increased blood pressure
Statin therapy for elevated LDL
Update the patient’s Hepatitis B vaccine
Lifestyle modifications including weight loss
Medication:
1st Line:
Biguanides:
- Metformin: Promotes weight loss and improves insulin resistance. Average A1C decrease when used as monotherapy is 1.0-2.0 points
- Start metformin and titrate up to 850mg BID for 3 months
- Avoid in renal insufficiency, prior to radiocontrast agent use, surgery and severe acute illnesses
- Caution with CHF, alcohol abuse, elderly or if combined with tetracycline
- ADE’s: GI side effects, vitamin B12 deficiency
2nd Line/Alternatives:
Sulfonylureas: Consider in patients who cannot tolerate Metformin. Lowers A1C by 1-2%. However, their effectiveness decreases over time
- Glipizide: short acting. 2.4-40mg/day. Dosage 5 or 10 mg/d given bid 30 minutes before meals
- Other examples: Glyburide, Glimepriride, Chlorpropamide
- Caution with renal or liver disease, sulfa allergy, creatinine clearance < 50mL/min, pregnancy
Thiazolidenediones: lower blood glucose concentrations by increasing insulin sensitivity. Lowers A1C by 0.5 – 1.4%.
- Used more for their synergistic effects as a second line treatment adjunct to other diabetic medications
- Examples: Pioglitazone (Actos):15-45mg/d. Dosages: 15, 30, 45mg
- Monitor serum transaminases every 2 months for the 1st year
- Also associated with weight gain, fluid retention, CHF, bone loss and are expensive. Liver disease and symptomatic heart failure.
Dipeptidyl peptidase-4 inhibitors: More commonly used as a second to third line agent.
- May be a good choice as first line agent in patients with chronic kidney disease
- Examples: Sitagliptin (Januvia): Start 100mg/d. Dosages: 25,50,100mg
- Sitagliption/Simvastatin (Juvisync):
- Sitagliptin/Metformin (Janumet)
- Saxagliptin (Onglyza): Start 2.5-5mg/d. Dosages: 2.5, 5mg
- Linagliptin (Tradjenta)
Alpha Glucosidase inhibitors: Have an additive hypoglycemic effect and are therefore used as an adjunct agent. Only decrease A1C by 0.5-0.8%. Taken pre-prandially to decrease post-prandial hyperglycemia.
- Examples include Acarbose (Precose): Start 75-300mg divided into 3 doses. 50, 100mg
- Miglitol (Glyset): 25,50, 100mg
- Avoid in renal insufficiency, inflammatory bowel disease, colonic ulceration or partial bowel obstruction
- Adverse reactions include increased flatulence and diarrhea.
Meglitinides: Useful in patients with a sulfa allergy or renal impairment. They are short-acting glucose lowering drugs.
- Repaglinide (Prandin): 0.5-4mg TID. Dosages: 0.5,1,2mg
Insulin:
Initiate insulin therapy for for patients
- Who cannot achieve a target A1C on 2 or more oral hypoglycemic agents,
- Have severe fasting plasma glucose > 250mg/dL
- Hgb A1C >10%

Diagram adapted from: Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325
Initiating Insulin

Diagram adapted from: Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325



References:
American College of Clinical Endocrinologists. Comprehensive Diabetes Management Algorithm 2013.
Rao S, Krishnasamy S. Diabetes Mellitus, Type 2. 5-The 5-Minute Clinical Consult Standard 2015, 23rd Edition. Accessed 11/26/2014.
Wallia A, Molitch M. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315-2325
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