DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
• Have psychosocial problems (including alcohol or substance abuse) that complicate management
• Have HbA 1 c > 9.0 percent and are considered for aggressive management on an expedited basis.
• Are not achieving glycemic control despite comprehensive treatment with complex regimen of
combination pharmacotherapy including insulin
• Require evaluation or management beyond the level of expertise and resource level of the primary
team.
G. Does Patient Require Insulin?
OBJECTIVE
Identify the patient for whom insulin treatment is necessary.
RECOMMENDATIONS
1. The patient with type 1 diabetes mellitus (DM) must receive insulin replacement therapy.
2. Patients with type 2 diabetes, or diabetes of undetermined cause who exhibit significant or rapid weight
loss and/or persistent non-fasting ketonuria, have at least severe relative insulin deficiency and will require
insulin therapy on an indefinite basis.
DISCUSSION
Weight loss and ketonuria are indications of a catabolic state for which insulin is the preferred therapy in type 2 DM.
Insulin is an anabolic hormone, and is often beneficial in such circumstances, especially if there is a concurrent
illness. Some patients with ketosis prone diabetes can eventually be weaned from insulin.
H. Institute/Adjust Insulin; Consider Referral
OBJECTIVE
Achieve glycemic control using insulin.
RECOMMENDATIONS
1. All patients with type 1 DM should be managed by a provider experienced in managing type 1 DM in a
multidisciplinary approach or by a clinic team with multidisciplinary resources (e.g., diabetologist, diabetes
nurse, educator/manager, and registered dietitian) for institution and adjustment of insulin therapy.
2. When expeditious referral is not possible, the primary care provider should institute “survival” insulin
therapy comprised of total daily insulin (TDI) 0.5 units/kg/day; half as basal insulin and half as meal time
insulin.
DISCUSSION
Because type 1 DM is caused by absolute insulin deficiency, insulin replacement therapy is the only viable treatment
option. Insulin therapy for patients with type 1 DM must be individualized and customized according to multiple
lifestyle factors. Institution and adjustment of insulin therapy is most efficiently accomplished by referral to a
Diabetes clinic with multidisciplinary resources including diabetologists, diabetes nurses, educator/managers, and
registered dietitians. If expedient referral cannot be accomplished, the healthcare provider should institute "survival"
insulin therapy. This can be initiated at a calculated TDI of 0.5 Units/kg body weight/day. (See Annotation J-3,
Insulin Therapy)
Module G: Glycemic Control Page 51