Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation

3 

Comprehensive 

Management of 

Type 2 Diabetes 

Diabetes Care Guidelines/Flow Sheet 

Achieving Glycemic Control 

• A1c Recommendations 

• Blood Glucose Level Goals 

• Recommended Blood Glucose Treatment Goals 

• Monitoring Blood Glucose Levels 

• Proper Disposal of Syringes and Needles 

• Patient Logs and Worksheets 

• Pharmacotherapy for Diabetes 

• Hypoglycemia 

Clinical Management of Hypertension 

• Target Blood Pressures and Self Measurement 

• Hypertension Treatment Algorithm, Initial Drug Choices 

• Pharmacotherapy for Hypertension 

• JNC 7 Reference Card 

Clinical Management of Dyslipidemia 

• Target Adult Cholesterol Levels 

• Classification of Lipid Profile 

• Pharmacotherapy for Dyslipidemia 

• ATP III At-A-Glance: Quick Desk Reference 

Lifestyle Interventions and Modifications 

• Recommended Lifestyle Modifications 

• Weight Loss/Maintenance 

• Medical Nutrition Therapy (MNT) 

• General Nutritional Recommendations for Diabetes 

o Nutritional Recommendations for Weight Loss In Diabetes 

o Physical Activity and Exercise In Diabetes 

CMA FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 19

Comprehensive Management 

While achieving glycemic control early in the course of the disease is critical to reducing serious 

long term complications, so is having good control of lipids and blood pressure. Unfortunately, 

many people with diabetes struggle with achieving target control levels of this clinical triad. 

Comprehensive management of diabetes means addressing the management of blood glucose, 

blood pressure and lipids for all patients with diabetes to reduce the risk of common comorbidities 

such as heart attack, congestive heart failure and chronic kidney disease. 8 

This approach is supported by recently released guidelines of the American Association of Clinical 

Endocrinology, which also emphasize a personalized approach to care that includes consideration 

of patient risk factors, comorbid conditions, expected life span, and psychological, social and 

economic status. 

Diabetes Care Guidelines/Flow Sheet 2,9 

Individuals with diabetes should receive regular office visit exams and tests according to the 

following schedule: 

20 CMA FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011

TAbLe 13 Diabetes Care Guidelines/Flow Sheet 

Clinical 

Priorities 

History, 

Physical 

and 

Emotional 

General 

Care 

Parameters Frequency Goal/ Recommendation Date/ 

Results: 

Blood Pressure Every Visit

Achieving Glycemic Control 

A1c Recommendations 

Studies have demonstrated that A1c is a strong predictor of future diabetes complications. 

Recent studies confirm that the A1c closely represents the average glucose over the last 3 

months. The table below correlates A1c with estimated average glucose. A calculator can 

be used to covert A1c results into estimated average glucose (eAG) at http://professional. 

diabetes.org/GlucoseCalculator.aspx. 

Note that the A1c can be affected by conditions that affect red blood cell turnover (such 

as anemia and hemoglobinopathies like sickle cell disease), which needs to taken into 

consideration especially when the A1c result does not correlate with the patient’s clinical 

situation or home monitored glucose levels. 

TAbLe 14 Correlation of A1c to Mean blood Glucose Values 

Table 14: Correlation of A1c to mean Blood Glucose Values 

A1c % estimated Average Glucose (eAG) 

mg/dL 

6 126 

7 154 

8 183 

9 212 

10 240 

11 269 

12 298 

The American Diabetes Association recommends that patients have A1c done at least every 6 

months if they have stable glucose levels that are at goal, and every 3 months in patients who are 

not at goal or who are changing therapy. 

Blood Glucose Level Goals 

The A1c goal for most adult patients with diabetes should be < 7.0%, in order to decrease the long 

term risk of complications. 

Some patients with long life expectancy, and no significant CVD may benefit from an even lower 

A1c goal (such as < 6.5%) due to evidence of a small incremental 

improvement of microvascular outcomes. 8 


TAbLe 15 Recommended blood Glucose Treatment Goals 

Table 15: Recommended Blood Glucose Treatment Goals 

HgA1c < 7 7% 

% 

Monitoring Blood Glucose Levels 

FPG/Preprandial (before meals) 70-130 mg/dl 

Peak postprandial (1-2 hours 

after meals) 

Difference between preprandial 

and 1-2 hour postprandial 

Keeping blood glucose levels within a normal range is the principal goal of having patients check 

their blood sugar levels on a daily basis using a home meter. Patients who benefit should be 

encouraged to use their home glucose meters as a self-management tool to help them keep 

adequate control over sugar levels and minimize the risk of disease-related complications. 

There are many different types of blood glucose monitoring devices available on the market today. 

Consider the following tips when discussing glucometer options. 

• In most cases, the meter options and decision about what meter to use will be affected by 

insurance coverage. Patients should be advised to contact their health plan to find out what 

materials and supplies are covered. 

• Patients need to understand how to use their meter. They should be trained before leaving the 

office or referred to a certified diabetes educator for full instruction. They should also be referred 

to the glucometer’s website for further information. In addition, some pharmacists are able to 

provide point of service training on how to use personal blood glucose meters 

• Recommend keeping logs or a diary of blood glucose results to be reviewed at the next visit. 

• Patients should bring their personal meters and log books with them to every office visit. 

While regular monitoring of blood glucose values takes commitment on the patient’s part and is 

expensive, testing can help patients identify patterns, respond quickly to high or low blood sugar 

levels, learn how food and exercise affects sugar levels, and make appropriate lifestyle adjustments 

to achieve better control. 

Examples of common blood glucose testing times: 

• Immediately after waking up 

• Before meals 

• 1 to 2 hours after meals 

• Before and after exercising 

• Before driving a vehicle 

• At bedtime 

• As necessary during the night 

• More frequently during illness or stress (4-6 hours) 

< 180 mg/dl 

< 30-50 mg/dl 

* Note: higher or lower goals may be appropriate for individual 

patients. Goals should be individualized based on duration of 

diabetes, age/life expectancy, comorbid conditions, known CVD or 

advanced microvascular complications, hypoglycemia unawareness, 

individual patient considerations. 

CMA FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 23 

Comprehensive 

management of 

type 2 diabetes

Notes: 

• Patients on multiple daily doses of insulin should generally check at least 3-4 times per day. 

• Patients who are not on insulin may consider choosing an occasional meal and check both 

before and 1-2 hours after that meal, to see how the content of the meal affects the glucose 

levels. 

Recommend immediate checking of blood sugar levels using a personal meter if the patient thinks 

their blood sugar is low or they experience any of the following signs: 

• Weakness 

• Fatigue 

• Dizziness or shakiness 

• Excessive sweating 

• Fast heart rate 

• Headache 

• Hunger 

• Nervousness or irritability 

• Blurred vision 

Common patient barriers to using personal blood glucose meters and routine monitoring include: 

• Test strips can be expensive. Some insurance providers limit the number of strips patients can 

purchase each month. 

• Need to have testing supplies on hand. 

• Testing can be inconvenient and interrupt daily activities. 

• Fingersticks can cause pain and discomfort. (Many meters can be used painlessly in alternate 

sites. Patients should check their glucometer instruction manual.) 

• Monitoring is a constant reminder of the diagnosis. 

• Fear that elevated results mean their diabetes is worse or insulin is needed. 

• Belief that results place judgment on self-management efforts. 


Proper Disposal of Syringes and Needles 

On September 1, 2008 a new California law went into effect prohibiting the disposal of home 

generated sharps waste in California residents’ trash or recycling containers and requiring that all 

such waste be transported to a collection center in an approved sharps container. This includes 

needles, pen needles, intravenous needles, lancets and other devices that are used to penetrate 

the skin for medication administration. 27 

Table 16: Household Sharps Waste Disposal Options 

TAbLe 16 Household Sharps Waste Disposal Options 

Pharmacies 

Hospitals 

Local Household 

Hazardous Waste 

Programs 

Mail-Back Service 

You can also look for 

this information here 

Local jurisdictions’ 

sharps collection 

programs 

Collection programs 

Some drug stores take back their customers’ needles, especially in small 

quantities 

Hospitals may take back sharps from patients using regular outpatient 

services 

Call your local household hazardous waste agency and ask if they collect 

needles (sharps) at their collection facilities or on household hazardous 

waste days 

A list of sharps waste mail-back services authorized for use in California is 

available from the California Department Of Public Health (CDPH) at 

http://www.cdph.ca.gov/certlic/medicalwaste/Pages/MailBackSharps.aspx 

Your local white pages’ government section may list your city’s or county’s 

household hazardous waste department 

Visit the Earth 911.org at http://earth911.com/website or call 1-800- 

CLEANUP (1-800-253-2687), a service of Earth 911 

Visit the Local Enforcement Agency Directory at 

http://www.calrecycle.ca.gov/LEA/Directory/default.asp 

Sharps and Medication Disposal Directory at 

http://www.calrecycle.ca.gov/HomeHazWaste/HealthCare/Collection 

Local Jurisdiction Sharps Collection Programs at 

http://www.calrecycle.ca.gov/HomeHazWaste/Sharps/LocatorProgrm.pdf 

This spreadsheet could help jurisdictions that don’t currently have 

collection programs to set up their own sharps collection program 

Needle Destruction Devices. The U.S. Food and Drug Administration (FDA) currently only lists the 

“Disintegrator” as a needle destruction device approved for use by self-injectors. 

Sharps Containers. The California Department of Public Health Medical Waste Management Program is 

recommending the use of sharps containers approved by the FDA. After accessing the FDA website, type 

“sharps” in the search box. The container names will display alphabetically. 

Listserv: To receive periodic information about sharps, subscribe to the Sharps and Medication Disposal 

Listserv. 

Contact: Please contact pharmasharps@calrecycle.ca.gov for questions or more information. 


Comprehensive 

management of 

type 2 diabetes

Patient Logs and Worksheets 

Patient blood glucose daily logs, diabetes health records and healthy goal worksheets are helpful 

tools that promote better self-management and increase medication adherence by reminding 

patients to check their blood glucose levels and track daily activities. Many logs and worksheets 

also contain simple tools and tips to help patients adhere to recommended therapies and promote 

making lifestyle changes necessary to manage their type 2 diabetes. Such logs and worksheets 

can help guide health care providers by patient discussions, support adjustments to prescribed 

therapies and educate patients about type 2 diabetes and the importance of effective selfmanagement. 

See the Patient Resources section Chapter 6, page 95 of this reference guide for a selection of 

sample logs, goal worksheets and more. 

Pharmacotherapy for Diabetes 28,29 

The clinical approach to managing diabetes starts with lifestyle/behavior modification, weight loss, 

physical activity promotion, and dietary control (see page 56). However, most patients with type 

2 diabetes will also need oral or insulin medications to help achieve glycemic control. Healthcare 

providers should take into consideration any individual patient cardiovascular risk factors and the 

potential impact of side effects including fluid retention and weight gain when prescribing oral and 

injectable diabetes medications. Of note, diabetes progresses over time, requiring adjustments to 

the medication regimen. 

Often using multiple drugs is necessary to achieve adequate glycemic control and reduce the risk of 

co-morbid cardiovascular disease and complications. In some cases, the use of combination drugs 

can help to simplify patient drug regimens and hopefully lead to better compliance or fewer copays. 

The following tables highlight common oral and injectable medications used to treat and manage 

diabetes. 


TAbLe 17 Oral Medications 

Drug class Generic name brand name(s) Mechanism of 

action 

biguanides Metformin Fortamet 

Glucophage 

Glucophage XR 

Glumetza 

Riomet 

Inhibits liver 

glucose 

production, 

q muscle glucose 

uptake 

Sulfonylureas Glimepiride Amaryl q pancreatic 

insulin 

production 

Glipizide Glipezide ER 

Glipezide XL 

Glucotrol 

Glucotrol XL 

Glyburide Diabeta 

Glynase 

Micronase 

Glycron 

Meglitinides Repaglinide Prandin q insulin released 

from pancreas 

Thiazolidinediones 

(TZDs) 

Alpha-glucosidase 

inhibitors 

bile acid 

sequestrant 

Nateglinide Starlix 

Pioglitazone Actos q skeletal muscles 

Avandia 

glucose uptake 

Rosiglitazone** 

**Restricted use by 

FDA due to possible 

increased CV risk 

(only use if unable to 

use other options.) 

Acarbose Precose Inhibits 

carbohydrate 

absorption by 

the small intestine 

Colesevelam 

hydocloride 

Welchol Lipid t polymer 

that binds bile 

acids in the 

intestine, t 

reabsorption. 

The exact A1c t 

action is currently 

unknown. 

Potential side 

effects 

Cramping, nausea, 

diarrhea, vomiting, 

gas, loss of appetite, 

metallic taste 

Hypoglycemia, GI 

upset, weight gain 

(note: avoid 

glyburide in elderly 

and those with renal 

insufficiency due 

to increased risk of 

hypoglycemia in this 

population.) 

Hypoglycemia, 

weight gain, joint 

pain 

Hypoglycemia, 

edema, headache, 

mild anemia, weight 

gain, muscle pain, 

URI, sinusitis 

Cramping, diarrhea, 

gas, GI upset/pain, 

weight loss. 

Need to treat 

hypoglycemia with 

glucose 

Constipation, 

nasopharyngitis, 

dyspepsia, 

hypoglycemia, 

nausea, hypertension 


Comprehensive 

management of 

type 2 diabetes

TABLe 17 Oral Medications 

Drug class Generic name brand name(s) Mechanism of 

action 

Dipeptidyl 

peptidase-4 

(DPP-4) inhibitor 

Combination 

drugs 

Sitagliptin Januvia Enzyme inhibitor, 

suppresses 

release of 

glucagon by 

pancreas 


effects 

Runny/stuffy 

nose, sore throat, 

headache, stomach 

pain, diarrhea 

Saxagliptin Onglyza Upper respiratory 

tract infection, 

urinary tract 

infection, headache 

Linagiptin Tradjenta t blood sugar by 

q incretin levels 

Metformin HCL/ 

glyburid, Micro 

Glyburide, 

Micronized 

Metformin/ 

glipizide 

Metformin HCL 

/Pioglitazone 

HCL 

Metformin/ 

Sitagliptin 

Glimepiride / 

Pioglitazone 

Glimepiride/ 

Rosiglitazone 

Rosiglitazone/ 

Metformin HCL 

Repaglinide/ 

Metformin HCL 

Saxagliptin/ 

Metformin 

Glucovance See mechanism 

of action for 

Glycron 

Glynase 

Metaglip 

Actopuls Met 

Janumet 

Duetact 

Avadaryl 

Avandamet 

Prandimet 

Kombiglyze XR 

each drug in the 

combination, 

listed separately 

above. 

Upper respiratory 

infection, stuffy or 

runny nose, sore 

throat, muscle pain, 

headache 

See side effects for 

each drug in the 

combination, listed 

separately above. 


TABLe 18 Non-Insulin Injectables 

Drug class Generic name brand name Mechanism of 

action 

Amylin analog 

emptying sugar 

Incretin 

mimetics 

Insulin Guidelines 

Pramlintide Symlin Synthetic amyin 

which aids in 

the absorption 

of glucose by 

slowing stomach 

emptying, 

promoting fullness, 

and preventing 

secretion of 

glucagon from the 

liver. 

Exenatide Byetta q insulin secretion 

in the presence of 

elevated plasma 

glucose levels 

Liraglutide Victoza 

q insulin secretion 

in the presence of 

elevated plasma 

glucose levels, 

and delays gastric 

emptying. 


effects 

Nausea; decrease 

appetit, vomiting, 

dizziness, indigestion 

and stomach pain. 

Hypoglycemia when 

used with insulin 

Headache, nausea 

and vomiting, 

(titration dependent) 

diarrhea, dizziness, 

possible increased 

risk of pancreatitis 

(Victoza: watch for 

thyroid cancer due 

to increased risk in 

animal models) 

Consider using the Diabetes Coalition of California (DCC) insulin guidelines when starting and 

titrating insulin in patients with type 2 diabetes. For additional information, please visit the DCC’s 

website at www.diabetescoalitionofcalifornia.org. 


Comprehensive 

management of 

type 2 diabetes

TAbLe 19 DDC Insulin Guidelines 

Diabetes Coalition of California 

Type 2 Diabetes Adult Outpatient Insulin Guidelines 

This product may be reproduced with the citation: “Developed by the Diabetes Coalition of California, October 2010” 

See Web site (www.diabetescoalitionofcalifornia.org) for the latest version and disclaimer. Page 1 of 5 







Comprehensive 

management of 

type 2 diabetes







Comprehensive 

management of 

type 2 diabetes


TABLe 20 Insulin Injectables 

Drug class Generic name brand 

name 

Rapid-acting Lispro Humalog 5-15 min 30-90 

min 

Aspart Novolog 5-15 min 30-90 

min 

Glulisine Apidra 5-15 min 30-90 

min 

Onset Peak Duration Comments 

< 5 hr Clear 

< 5 hr 

< 5 hr 

Short acting Regular (R) Human 30-60 min 2-3 hr 5-8 hr Clear 

Intermediate 

acting 

NPH (N) Human 2-4 hr 4-10 hr 10-16 hr Cloudy 

Long acting Detemir Levemir 3-8 hr 3-4 hr 

(50%) 

No peak 

Premixed – 

human 

6-24 hr, 

dose 

dependent 

Glargine Lantus 2-4 hr No peak 20-24 hr 

75% insulin 

lispro protamine 

suspension/ 

25% insulin 

lispro 

50% insulin 

lispro protamine 

suspension/ 

50% insulin 

lispro 

70% insulin 

aspart protamine 

suspension/ 30% 

insulin aspart 

70% NPH/ 30% 

regular 

Humalog 

Mix 75/25 

Humalog 

Mix 50/50 

NovoLog 

Mix 70/30 

70% NPH/ 

30% 

regular 

Note: Nausea and vomiting can be lessened or avoided with dose titration. 

Clear, 

typically 

taken once 

daily (example 

before evening 

meals or at 

bedtime). Helps 

prevent high 

morning blood 

glucose values. 

5-15 min Dual 10-16 hr Cloudy 

5-15 min Dual 10-16 hr 

5-15 min Dual 10-16 hr 

30-60 min Dual 10-16 hr 


Comprehensive 

management of 

type 2 diabetes

Hypoglycemia 

There are many drugs including oral diabetes medication and insulin that can decrease blood 

sugar levels, resulting in increased risk for hypoglycemic events. The risk of experiencing drug 

interactions and negative side effects relative to the expected benefits should be discussed with the 

patient when deciding medication regimens to treat and control diabetes. 

In particular, beta blockers are known to have adverse interactions with insulin by masking the signs 

and symptoms of hypoglycemia. In some cases beta blockers can also increase overall chances of 

developing high blood sugar. 

Clinical Management of Hypertension 23 

The National Heart Lung and Blood Institute (NHLBI), JNC-7 guidelines recommend that 

patients with hypertension receive interventional therapies that include a combination of lifestyle 

modifications (see Chapter 5, page 79) and pharmacologic therapies to reach target blood pressure 

values and decrease long term cardiovascular risk. JNC-7 emphasizes that adoption of healthy 

lifestyles by individuals with high blood pressure is critical to preventing and lowering blood 

pressure and overall body weight. See JNC-7 Reference Cards, pages 43-44. 

Target Blood Pressures and Self Measurement 

By treating hypertension to reach target blood pressure values, the risk of developing 

cardiovascular complications and mortality is greatly reduced. The NHLBI recommends the 

following target blood pressures for individuals with and without related complications: 

Table 21: Target Blood Pressure 

TAbLe 21 Target blood Pressure 

With hypertension, no additional compelling 

conditions 

For patients with diabetes or chronic kidney 

disease 

Optimal (Normal) 

Less Than 140/90 mm Hg 



Patients with high blood pressure should be advised to self monitor at home and work, as a 

practical approach to understanding and managing this chronic disease. Self measurements are 

also useful in assessing the difference between home and in medical office values commonly 

associated with white coat hypertension, also referred to as white coat syndrome. Monitoring 

through self measurement will help patients reach target blood pressure values by offering further 

insight into the effect of medically supervised management strategies on blood pressure control. 

Hypertension Treatment Algorithm, Initial Drug Choices 

In addition to lifestyle modifications highlighted in the JNC-7 guidelines, initial hypertensive 

therapies may require the use of medications to reach goal. Most patients frequently require a 

combination of medications from different antihypertensive drug classes when a single medication 

fails to achieve adequate control of blood pressures. 


separate prescriptions or in fixed-dose combinations. (See figure 1.) The initiation 

of drug therapy with more than one agent may increase the likelihood of 

achieving the BP goal in a more timely fashion, but particular caution is 

advised in those at risk for orthostatic hypotension, such as patients with diabetes, 

autonomic dysfunction, and some older persons. Use of generic drugs 

or combination drugs should be considered to reduce prescription costs. 

FIGuRe 3 Algorithm for Treatment of Hypertension 

Figure 1. Algorithm for treatment of hypertension 

Stage 1 

Hypertension 

(SBP 140–159 or DBP 

90–99 mmHg) 

Thiazide-type diuretics 

for most. May consider 

ACEI, ARB, BB, CCB, 

or combination. 

Lifestyle Modifications 

Not at Goal Blood Pressure (

Pharmacotherapy for Hypertension 23 

Today there are number of commonly used antihypertensive medications in different drug classes. 

Many patients with hypertension may require two or more antihypertensive medications from 

different drug classes and in combination to reach goal. 

Thiazide diuretics are considered the initial therapy for hypertension in most patients and can be 

useful in helping to achieve control of elevated blood pressure levels. Thiazide may be used as a 

stand-alone agent or in combination with other drug classes 

Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) 

are also considered ideal medications for the treatment of patients with diabetes and hypertension. 

Both ACE and ARBs inhibitors provide positive effects on renal function and may result in improved 

insulin sensitivity. 30 

A patient receiving drug therapy for hypertension should receive regular and routine follow-up to 

adjustment medications as necessary to reach target blood pressure measurements and prevent 

cardiovascular complications. Patients with related co-morbidities including heart failure and 

diabetes may require more frequent office visits and lab testing to reach goal. 

The following tables list commonly used antihypertension medications. There are currently six 

commonly used classes of medications used to treat hypertension: 

• ACE Inhibitors 

• ARBs (angiotensin II receptor antagonists) 

• Calcium channel blockers 

• Thiazide diuretics 

• Beta blockers 

• Alpha blockers or alpha-adrenergic blockers 


TABLe 22 Oral Blood Pressure Lowering Medications 

Drug class/ 

category 

Angiotensin- 

Converting 

enzyme (ACe) 

Inhibitors 

Angiotensin II 

Receptor blockers 

(ARbs) 

Calcium Channel 

blockers, 

Dihydropyridines 

Generic name brand name(s) Mechanism of 

action 

Benazepril Lotensin Prevents the 

formation of 

Captopril Capoten 

angiotensin II 

Enalapril Vasotec 

Vasotec IV 

Fosinopril Monopril 

Lisinopril Prinivil 

Zestril 

Moexipril Univasc 

Perindopril Aceon 

Quinapril Accupril 

Ramipril Altace 

Trandolapril Mavik 

Candesartan Atacand Prevents the 

interaction of 

Eprosartan Teveten angiotensin 

Irbesartan Avapro 

II with tissue 

receptors 

Losartan Cozaar 

Olmesartan Benicar 

Telmisartan Micardis 

Valsartan Diovan 

Amlodipine Norvasc Blocks calcium 

Felodipine Plendil 

Isradipine DynaCirc 

DynaCirc CR 

Nicardipine Cardene 

Cardene SR 

Cardene IV 

Nifedipine Adalat 

Adalat CC 

Afeditab CR 

Nifedical XL 

Procardia 

Procardia XL 

Nisoldipine Sular 

channels in 

muscle cells of 

the heart and 

blood vessels 

Common side 

effects 

Cough, elevated 

potassium 

levels, low 

blood pressure, 

dizziness, 

headache, 

drowsiness, 

weakness, 

abnormal taste, 

rash 

Cough, elevated 

blood potassium 

levels, low 


dizziness, 

headache, 

drowsiness, 

diarrhea, 

abnormal taste, 

rash 

Constipation, 

nausea, 

headache, rash, 

edema, low 


drowsiness, 

dizziness, 

difficulty 

breathing, 

wheezing 


Comprehensive 

management of 

type 2 diabetes


Drug class/ 

category 

Calcium Channel 

blockers, Non- 

Dihydropyridines 


action 

Diltiazem Cardizem 

Cardizem CD 

Cardizem LA 

Cardizem SR 

Cartia XT 

Dilacor XR 

Diltia XT 

Nu-Diltiaz 

Taztia XT 

Tiazac 

Verapamil Apo-Verap 

Calan 

Calan SR 

Covera-HS 

Isoptin 

Isoptin SR 

Verelan 

Verelan PM 

Blocks calcium 

channels in 

muscle cells of 

the heart and 

blood vessels 

Thiazide diuretics Chlorothiazide Diuril Inhibits sodium 

Chlorthalidone Hygroton 

Thalitone 

Hydrochlorothiazide Esedrix 

HCTZ 

Hydro-chlor 

Hydro-D 

HydroDIURIL 

Microzide 

Novo- 

Hydrazide 

Oretic 

Polythiazide Renese 

Indapamide Lozol 

Metolazone Zaroxolyn 

and chloride 

reabsorption 

from the distal 

convoluted 

tubules in the 

kidneys 

Loop diuretics Bumetanide Bumex Inhibits sodium 

Furosemide Lasix 

and chloride 

reabsorption 

Torsemide Demadex from the loop 

Ethacrynic Acid Edecrin 

of Henle in the 

kidneys 

Potassium sparing 

diuretics 

Amiloride Midamor Prevents sodium 

reabsorption 

without lower 

Triamterene Dyrenium potassium levels 

Common side 

effects 

Constipation, 

nausea, 

headache, rash, 

edema, low 


drowsiness, 

dizziness, 

difficulty 

breathing, 

wheezing 

Dizziness, 

lightheadedness, 

blurred vision, 

loss of appetite, 

itching, stomach 

upset, headache, 

weakness, rash, 

gout, muscle 

pain, 



Drug class/ 

category 

Aldosterone 

receptor blockers 


action 

Eplerenone Inspra Blocks the action 

Spironolactone Aldactone 

of aldosterone 

beta blockers Atenolol Tenormin Blocks the 

beta blockers 

w/ intrinsic 

sympathomimetic 

activity 

Betaxolol Kerlone 

Bisoprolol Monocor Zibeta 

Metoprolol 

Extended 

Lopressor 

Toprol-XL 

Nadolol Corgard 

Propranolol Inderal 

Inderal LA 

InnoPran XL 

Timolol Blocadren 

action of 

epinephrine and 

norepinephrine 

on B-adrenergic 

receptors 

Acebutolol Sectral Exerts low level 

agonist activity 

Penbutolol Levatol 

at B-adrenergic 

receptors site 

while acting as 

Pindolol Visken a receptor site 

antagonist 

Alpha-blockers Doxazosin Cardura Inhibits the alpha 

1 adrenergic 

nervous system, 

Prazosin Minipress causing muscle 

relaxation and 

dilation of blood 

vessels 

Terazosin Hytrin 

Common side 

effects 

Cough, 

diarrhea, flu 

like symptoms, 

headache, 

stomach pain 

Dizziness, 


drowsiness, 

blurred vision, 

rash, itching, 

swelling 

Dizziness, 


drowsiness, 

headache, 

constipation, 

loss of appetite, 

dry mouth, stuffy 

nose, blurred 

vision, trouble 

sleeping 


Comprehensive 

management of 

type 2 diabetes


Drug class/ 

category 

Combined Alpha & 

beta blockers 

Direct 

vasodilators 

Central alpha 

agonists 


action 

Carvedilol Coreg 

Coreg CR 

Labetalol Normodyne 

Trandate 

Blocks alpha-, 

beta1-, and 

beta2-adrenergic 

receptor sites 

Hydralazine Apresoline Smooth muscle 

relaxant, causing 

Minoxidil Loniten 

arterial dilation 

Clonidine 

Clonidine patch 

Catapres 

Catapres-TTS 

Duracion 

Methyldopa Aldomet 

Reserpine Novoreserpine 

Reserfia 

Guanfacine Tenex 

Centrally acting 

alpha-adrenergic 

agonist 

Common side 

effects 

Dizziness, fatigue, 

headache, 

diarrhea, edema, 

dry eyes, scalp/ 

skin tingling 

Dizziness, fatigue, 

headache, 

diarrhea, edema, 

Skin Irritation, 

itching, contact 

dermatitis, hives, 

swelling and 

sensitivity 

Dizziness, 


drowsiness, 

dry mouth, 

constipation 


Reference Card From the 

Seventh Report of the Joint National Committee on Prevention, 

Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 

T R E A T M E N T 

Principles of Hypertension Treatment 

• Treat to BP

Principles of Lifestyle Modification 

• Encourage healthy lifestyles for all individuals. 

• Prescribe lifestyle modifications for all patients with prehypertension 

and hypertension. 

• Components of lifestyle modifications include weight reduction, DASH 

eating plan, dietary sodium reduction, aerobic physical activity, and 

moderation of alcohol consumption. 

Blood Pressure Measurement Techniques 

Method Notes 

Two readings, 5 minutes apart, sitting in chair. 

Confirm elevated reading in contralateral arm. 

In-office 

Indicated for evaluation of “white coat hypertension.” 

Absence of 10–20 percent BP 

decrease during sleep may indicate increased 

CVD risk. 

Ambulatory BP monitoring 

Lifestyle Modification Recommendations 

Modification Recommendation Avg. SBP Reduction Range † 

Provides information on response to therapy. 

May help improve adherence to therapy and is 

useful for evaluating “white coat hypertension.” 

Patient self-check 

5–20 mmHg/10 kg 

Maintain normal body weight 

(body mass index 18.5–24.9 

kg/m2 ). 

Weight 

reduction 

8–14 mmHg 

Adopt a diet rich in fruits, 

vegetables, and lowfat dairy 

products with reduced content 

of saturated and total fat. 

DASH eating 

plan 

2–8 mmHg 

Reduce dietary sodium intake to 

Clinical Management of Dyslipidemia 9,31,32,33 

Addressing dyslipidemia is a key component in preventing long term cardiovascular disease in 

individuals with type 2 diabetes. Many patients with diabetes have elevated cholesterol values, 

which can lead to greater risk of developing cardiovascular disease or acute cardiovascular events. 

Diabetic dyslipidemia is a recognizable and modifiable patient risk factor that should be identified 

and treated early to prevent complications. 

Published by the National Heart Lung and Blood Institute (NHLBI), the ATP III guidelines are an 

evidence-based set of recommendations that focus on intensive cholesterol-lowering therapy. The 

guidelines address the primary prevention of coronary heart disease (CHD) in persons with multiple 

risk factors by managing elevated patient cholesterol levels to reach goal. The ATP III Guidelines 

At-a-Glance Quick Desk Reference which outlines the step by step sequence of cholesterol 

management has been provided. The NHLBI and the American Diabetes Association recommend 

prescribing lifestyle modifications and cholesterol lowering medications to reach the following 

target (optimal) adult cholesterol levels: 

Targeting Adult Cholesterol Levels 

Table TABLe 23: Classification 23 Classification of Lipid of Lipid Profile Risk 

LDL Cholesterol – Primary Target of Therapy (mg/dL) 

In addition to recommending primary preventive strategies that include therapeutic lifestyle 

modifications and lipid modifying medications, healthcare providers should evaluate patients for 

preventable secondary causes of dyslipidemia that include: 

• Chronic renal failure 

• Diabetes 

• Hypothyroidism 

• Obstructive liver disease 

• Medications that affect LDL and HDL cholesterol levels, including: 

o Progestins 

o Corticosteroids 

o Anabolic steroids 

There have been a number of recent clinical trials demonstrating that lowering LDL cholesterol 

levels using secondary prevention strategies can also help reduce the risk of developing major 

cardiovascular disease. Secondary prevention of dyslipidemia focuses on decreasing the 

overall risk of developing cardiovascular disease, acute coronary events, stroke, and mortality in 

people identified with chronic heart disease by lowering LDL cholesterol to a level less than 100 

mg/dL by: 34 

• Increase or intensify lifestyle modifications 

• Recommend weight loss and increased physical activity for people with risk factors 

• Delay use or intensification of LDL lowering medication and institute treatment of other lipid 

or non-lipid risk factors 

• Consider use of other lipid modifying drugs to treat elevated triglyceride or low HDL 

cholesterol 

Most lipid problems associated with a chronic illness are hereditary, and early consideration of 

lifelong medication management is important. Although lifestyle modification, diet and exercise 

are effective in combination with the use of pharmacotherapy, diet and exercise alone do not 

correct the underlying genetic disorder. Lowering LDL cholesterol levels through the use of 

secondary prevention strategies in combination with appropriate lifestyle modifications can 

greatly reduce an individual’s risk of developing diabetes related complications, experience 

cardiovascular events and premature mortality. 


Pharmacotherapy for Dyslipidemia 23 

To reach optimal lipid levels, most patients will require lipid modifying medications combined 

with Therapeutic Lifestyle Changes (TLC). While reducing serum LDL cholesterol is the primary 

target of treatment in clinical lipid management, some people may also benefit from therapies 

to lower triglycerides and/ or increase HDL cholesterol levels. Some individuals will require 

combined drug therapies to reach target treatment goals that result in a reduction of LDL 

cholesterol levels and, when advisable, raise HDL cholesterol levels. 

Statins, also known as HMG-CoA reductase inhibitors, are currently considered the most 

effective, practical, and commonly prescribed class of drugs that target reducing LDL 

cholesterol levels. The statins are generally well tolerated by most people and have a lower risk 

of adverse side effects and/or risk of drug to drug interactions. 

In some cases, drug therapies may need to be tailored to address specific dyslipidemias, 

including very high LDL cholesterol, elevated serum triglycerides, low HDL cholesterol and 

atherogenic dyslipidemia in persons with type 2 diabetes. Consideration should also be given 

to prescribing drug therapies that target both lipid and non-lipid causes of metabolic syndrome 

and insulin resistance. 

There are several classes of lipid modifying and LDL lowering medications available to treat 

dyslipidemia, including: 

• Statins (HMG-CoA reductase inhibitors) 

• Cholesterol absorption inhibitors 

• Niacin (nicotinic acid) 

• Fibric acid derivatives 

• Bile acid sequestrants 

• Combination drugs 

Currently only nicotinic acid (niacin) has been approved for over the counter (OTC) use. The 

following table lists commonly used dyslipidemia treatment medications. 


Comprehensive 

management of 

type 2 diabetes

TABLe 24 Dyslipidemia Treatment Medications 69 

Drug class/ 

category 

Statins 

(HMG-CoA 

Reductase 

Inhibitors) 

Cholesterol 

Absorption 

inhibitors 

Niacin 

(Nicotinic 

Acid) 


action 

Atorvastatin Calcium Lipitor Inhibits HMG- 

CoA reductase, 

causing a slow 

Fluvastatin Sodium Lescol 

Lescol XL 

Lovastatin Alctocor 

Altoprev 

Mevacor 

Pravastatin Sodium Pravachol 

Rosuvastatin Sodium Crestor 

Simvastatin Zocor 

Pitavastatin Livalo 

down in the 

production of 

cholesterol and 

q the removal of 

LDL-cholesterol 

by the liver 

Ezetimibe Zetia Inhibits intestinal 

cholesterol 

absorption and 

reduces liver 

cholesterol stores 

Nicotinic acid Endur-Acin 

Nia-Bid 

Niac 

Nacels 

Niacor 

Niaspan 

Nicobid 

Nico-400 

Nicolar 

Nicotinex 

Nicotinic Acid 

Slo-Niacin 

Vitamin B 

Inhibits fatty acid 

release from 

adipose tissue 

and inhibits liver 

production of 

fatty acids and 

triglycerides; 

q HDL levels, 

t triglycerides and 

LDL cholesterol 


effects 

Headache, 

nausea, vomiting, 

constipation, 

diarrhea, rash, 

weakness, 

muscle pain, 

rhabdomyolysis 

Diarrhea, 

abdominal pain, 

back pain, joint 

pain, sinusitis, 

allergic reactions 

Stomach 

upset, flushing, 

headache, allergic 

reactions 


TABLe 24 

Lipid 

combinations 

Fibric acid 

derivatives 

bile acid 

sequestrants 

Dyslipidemia Treatment Medications 69 

Lovastatin/Niacin, Advicor t LDL cholesterol, 

triglyceride, and 

total cholesterol 

levels, q HDL 

cholesterol 

Simvastatin/Niacin Simcor tTotal cholesterol 

– LDL and 

triglycerides. 

Slightly q HDL 

Simvastatin 

Ezetimibe 

Amlodipine 

Atorvastatin 

Fenofibrate Antara, 

Lipofen 

Lofibra 

Tricor 

Triglide 

Trilipix 

Gemifibrozil Lopid 

Cholestyramine, 

Cholestyramine light 

See statin and 

niacin side effects 

Warmth, redness, 

dizziness, 

sweating or 

chills, headache, 

stomach or back 

ache, runny 

nose or other 

symptoms 

Vytorin t LDL cholesterol Headache, 

nausea, vomiting, 

diarrhea, muscle 

pain, abnormal 

liver tests 

Caduet t LDL cholesterol 

and triglycerides 

in the blood, while 

q levels of HDL 

cholesterol 

LoCHOLEST 

LoCHOLEST 

Light 

Prevalite 

Questran 

Questran Light 

Cholestipol Cholestid 

Colesevelam WeChol 

t Liver production 

of VLDL and 

q triglyceride 

blood 

t LDL cholesterol 

by binding with 

cholesterol 

containing 

bile acids in 

the intestines, 

eliminated in the 

stool 

Headache, 

dizziness, 

drowsiness, 

flushing, diarrhea, 

abdominal pain, 

weakness, joint 

pain 

Nausea, stomach 

upset, diarrhea, 

liver inflammation, 

formation of 

gallstones 

Constipation, 

abdominal 

pain, bloating, 

vomiting, 

diarrhea, 

weight loss and 

flatulence 


Comprehensive 

management of 

type 2 diabetes

National Cholesterol Education Program High 

ATP III Guidelines At-A-Glance 

Quick Desk Reference 

(NHLBI 2001 including updates from the NCEP Report 2004) 

1 

Step 1 

2 

Step 2 

3 

Step 3 

Determine lipoprotein levels–obtain complete lipoprotein profile after 

9- to 12-hour fast. 

ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL) 

LDL Cholesterol – Primary Target of Therapy 

< 100 

(optional goal: < 70)* Optimal 

100-12 

9 

Near 

optimal/ 

above 

optimal 

130-15 

9 

Borderline 

high 

160-18 

9 

High 

> 190 

Very 

high 

Total Cholesterol 

< 200 

200-23 

9 

> 240 

HDL Cholesterol 

< 40 

> 60 

Identify presence of clinical atherosclerotic disease that confers high risk 

for coronary heart disease (CHD) events (CHD risk equivalent): 

■ Clinical CHD 

■ Symptomatic carotid artery disease 

■ Peripheral arterial disease 

■ 

■ 

Desirable 

Borderline 

High 

Low 

High 

Abdominal aortic aneurysm 

Diabetes 

high 

*An LDL-C goal of =200 mg/dL plus non-HDL-C >=130 mg/dL 

with low HDL-C [140/90 mmHg or on antihypertensive medication) 

Low HDL cholesterol (60 mg/dL counts as a “negative” risk factor; its presence removes one 

risk factor from the total count. 

N A T I O N A L I N S T I T U T E S O F H E A L T H 

N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E 

Blood Cholesterol 


4 

Step 4 

5 

Step 5 

6 

Step 6 

If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 

10-year (short-term) CHD risk (see Framingham tables). 

Three levels of 10-year risk: 

■ >20% — CHD risk equivalent 

■ 10-20% 

■

7 

Step 7 

Consider adding drug therapy if LDL exceeds levels shown in Step 5 table: 

■ Consider drug simultaneously with TLC for CHD and CHD equivalents 

■ Consider adding drug to TLC after 3 months for other risk categories. 

Drugs Affecting Lipoprotein Metabolism 

Drug Class Agents and Lipid/Lipoprotein Side Effects Contraindications 

Daily Doses Effects 

HMG CoA reductase 

inhibitors (statins) 

Bile acid sequestrants 

Nicotinic acid 

Fibric acids 

Lovastatin (20-80 mg) 

Pravastatin (20-40 mg) 

Simvastatin (20-80 mg) 

Fluvastatin (20-80 mg) 

Atorvastatin (10-80 mg) 

Rosuvastatin (5-40 mg) 

Pitavastatin (1-4 mg) 

Cholestyramine (4-16 g) 

Colestipol (5-20 g) 

Colesevelam (2.6-3.8 g) 

Immediate release 

(crystalline) nicotinic acid 

(1.5-3 gm), extended 

release nicotinic acid 

(Niaspan ® ) (1-2 g), 

sustained release 

nicotinic acid (1-2 g) 

Gemfibrozil 

(600 mg BID) 

Fenofibrate 

(48 mg,145 mg,200 mg) 

Clofibrate 

(1000 mg BID) 

Fenofibric Acid 

(45mg, 135 mg) 

Cholesterol adsorption Ezetimibe (10 mg) 

inhibitors 

Lipid combination Ezetimibe/simvastatin 

(10/10 mg to 

10/80 mg) 

LDL ↓18-55% 

HDL ↑5-15% 

TG ↓7-30% 

LDL ↓15-30% 

HDL ↑3-5% 

TG No change 

or increase 

LDL ↓5-25% 

HDL ↑15-35% 

TG ↓20-50% 

LDL ↓5-20% 

(may be increased in 

patients with high TG) 

HDL ↑10-20% 

TG ↓20-50% 

Myopathy 

Increased liver 

enzymes 

Gastrointestinal 

distress 

Constipation 

Decreased absorption 

of other drugs 

Flushing 

Hyperglycemia 

Hyperuricemia 

(or gout) 

Upper GI distress 

Hepatotoxicity 

Dyspepsia 

Gallstones 

Myopathy 

LDL ↓18% 


apoB ↓15-16% 

infections 

TG ↓ 7-9% Diarrhea 

Arthralgia 

LDL 

apoB 

TG 

↓ 46-58% 

↓35-47% 

↓ 26-31% 

Headache 

Increased ALT 

Myalgia 


tract infection 

Diarrhea 

Absolute: 

• Active or chronic 

liver disease 

Relative: 

• Concomitant use of 

certain drugs* 

Absolute: 

• dysbetalipoproteinemia 

• TG >400 mg/dL 

Relative: 

• TG >200 mg/dL 

Absolute: 

• Chronic liver disease 

• Severe gout 

Relative: 

• Diabetes 

• Hyperuricemia 

• Peptic ulcer disease 

Absolute: 

• Severe renal disease 

• Severe hepatic 

disease 

Statin contraindications 

apply when used with a 

statin. 

Active liver disease or 

unexplained persistent 

elevation of hepatic 

transminase levels 

Women who are pregnant 

or who may become 

pregnant 

Nursing mothers 

* Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (�brates and niacin should be used with 

appropriate caution). 


8 

Step 8 

Identify metabolic syndrome and treat, if present, after 3 months of TLC. 

Criteria for Clinical Diagnosis of Metabolic Syndrome 

Measure (any 3 of 5 constitute 

diagnosis of metabolic syndrome 

Elevated waist circumference*† 

Elevated triglycerides 

Reduced HDL-C 

Elevated blood pressure 

Elevated fasting glucose 

Treatment of the Metabolic Syndrome 

Categorical Cutpoints 

>102 cm (>40 in) in men 

>88 cm (>35 in) in women 

>150 mg/dL (1.7 mmol/L) 

or 

On drug treatment for elevated triglycerides‡ 

85 mmHg diastolic blood pressure 

or 

On antihypertensive drug treatment in a 

patient with a history of hypertension 

>100 mg/dL 

or 

On drug treatment for elevated glucose 

*To measure waist circumference, locate top of right iliac crest. Place a measuring tape in a horizontal plane around abdomen at 

level of iliac crest. Before reading tape measure, ensure that tape is snug but does not compress the skin and is parallel to floor. 

Measurement is made at the end of a normal expiration. 

†Some US adults of non-Asian origin (eg, white, black, Hispanic) with marginally increased waist circumference (eg. 94-101 cm 

[37-39 inches] in men and 80-87 cm [31-34 inches] in women) may have strong genetic contribution to insulin resistance and 

should benefit from changes in lifestyle habits, similar to men with categorical increases in waist circumference. Lower waist 

circumference cutpoint (eg, >90 cm [35 inches] in men and >80 cm [31 inches] in women) appears to be appropriate for Asian 

Americans. 

‡Fibrates and nicotinic acid are the most commonly used drugs for elevated TG and reduced HDL-C. Patients taking one of these 

drugs are presumed to have high TG and low HDL. 

Reference: Grundy, et al. (2005). Diagnosis & Mgmt of the Metabolic Syndrome. Table 2. AHA/NHLBI Scientific Statement. Circulation. 112: 2735-2752. 

■ Treat underlying causes (overweight/obesity and physical inactivity): 

– Intensify weight management 

– Increase physical activity. 

■ Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies: 

– Treat hypertension 

– Use aspirin for CHD patients to reduce prothrombotic state 

– Treat elevated triglycerides and/or low HDL (as shown in Step 9). 


Comprehensive 

management of 

type 2 diabetes

9 

Step 9 

Treat elevated triglycerides. 

ATP III Classification of Serum Triglycerides (mg/dL) 

200 mg/dL after LDL goal is reached, set 

secondary goal for non-HDL cholesterol (total – HDL) 

30 mg/dL higher than LDL goal. 

Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories 

Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL) 

CHD and CHD Risk Equivalent

Hard Coronary Heart Disease (10-Year Risk) 

Men Women 

Estimate of 10-Year Risk for Men 

(Framingham Point Scores) 

Age Points 

20-34 -9 

35-39 -4 

40-44 0 

45-49 3 

50-54 6 

55-59 8 

60-64 10 

65-69 11 

70-74 12 

75-79 13 

Total 

Cholesterol 

Points 

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 

Lifestyle Interventions and Modifications 36,37,38,39 

Therapies focused on modification of patient lifestyle (Therapeutic Lifestyle Changes or TLC), 

including medical nutrition therapy (MNT) and exercise programs, are essential to achieving 

glycemic, lipid and blood pressure control, moderate weight loss and reduction of cardiovascular 

risk factors. 

Tips for Supporting Lifestyle Change 

• Encourage lifestyle modifications that reduce total caloric intake, saturated and trans fat 

consumption and cholesterol and sodium intake such as: 

o Consume carbohydrates from fruits, vegetables whole grains, legumes and low-fat milk 

o Monitor carbohydrate intake 

o Consume a variety of fiber-rich foods like beans, berries and greens 

o Limit sodium intake 

• Encourage moderate to vigorous physical activity to improve glucose, lipid and blood pressure 

values 

• Refer patients to registered dietician and/or to Medical Nutrition Therapy for additional support 

• Encourage patients to quit smoking 

TABLe 25 Recommended Lifestyle Modifications 

Target Therapy Goal Recommendations 

Overweight and obesity Healthy weight and BMI Advise weight reduction to optimize BMI 

≥18.5 and

Weight Loss/Maintenance 

Even a moderate loss of 5-10% of overall body weight in patients with diabetes will result in 

improvement of blood glucose, blood pressure and lipids profile. 

Nearly 80% of patients who lose weight will gradually regain it if they are not supported by a 

weight maintenance program. The keys to a successful weight maintenance program are patient 

motivation and team support from health care providers. Effective management of overweight 

and obesity can be delivered by a variety of healthcare providers including primary care providers, 

registered dietitians, nutritionists, exercise physiologists, nurses, and psychologists. 

Achieving and maintaining an appropriate body weight requires daily effort, good dietary/ 

nutritional behaviors and adequate physical activity. Combined management approaches (diet, 

exercise and behavior modification) are likely to produce better results than any single approach. 

Healthcare providers should encourage patients to consult their health plan for weight loss/ 

maintenance programs that may be covered by their policy. 

Medical Nutrition Therapy (MNT) 9,36,40,41 

Medical Nutrition Therapy (MNT) services involve a nutritional assessment, specific diet planning, 

and counseling services to prevent or treat an illness or medical condition. MNT counseling 

services are typically provided by a registered dietitian (RD) focusing on behavior and lifestyle 

changes with the goal of addressing nutrition problems and associated medical conditions, 

such as diabetes. MNT goals for the treatment of diabetes focus on interventions to maintain 

blood glucose, lipids, and blood pressure within a normal range in order to prevent or slow the 

rate of development of the chronic complications of the disease. In addition, MNT can be useful 

in helping patients with diabetes to achieve and maintain a healthy body weight. During each 

counseling session, the RD works with patients to assess individual needs, determine goals, 

develop a care plan, and monitor overall progress towards treatment goals. 

Coverage for and access to MNT services vary by health insurance program or carrier. Patients 

should consult with their health insurance evidence of coverage booklet or call their health plan 

regarding coverage for MNT services. Medicare currently covers MNT services for people with 

diabetes or renal disease as a means of helping to manage the condition covering. Medicare 

covers 3 hours of one-on-one counseling the first year, and 2 hours each subsequent year. 

Beneficiaries may be able to receive more hours of treatment with a physician’s referral if the 

condition, course of treatment or diagnosis changes. Physicians must prescribe MNT services for 

Medicare recipients and renew the referral annually as necessary. 41 

For a list of CPT codes for MNT, please go to chapter 7, page 139. 


Comprehensive 

management of 

type 2 diabetes

General Nutritional Recommendations for Diabetes 36 

• Regular and individualized meal planning advice. 

• Total carbohydrate (in grams) monitoring to help control glycemia. 

• Balance calories from foods and beverages with calories used. 

• Consume varieties of nutrient and vitamin rich foods and beverages. 

• Limit saturated fat intake to < 7% of total calories. 

• Limit intake of trans fats. 

• Limit cholesterol intake to < 200 mg/day. 

• Limit sodium intake to < 1,500 mg/day (in patients with hypertension) with a diet high in fruits, 

vegetables, and low-fat dairy products to lower blood pressure. 

• Daily alcohol intake should be limited to < 1 drink/day for women and < 2 drinks/day for men) 

Table 26: Modifiable Nutrients and Fats 

TABLe 26 Modifiable Nutrients and Fats 

Saturated fat < 7% of total calories 

Polyunsaturated 

fat 

Up to 10% of total calories 

Monounsaturated 

fat 

Up to 20% of total calories 

Total fat 25-35% of total calories 

Cholesterol < 200 mg/day 

Carbohydrates 50-60% of total calories 

Protein Approx. 15% of total calories 

Soluble fiber 10-25 g/day 

Plant 

stanols/sterols 

2 g/day 

Total calories Balance energy intake with expenditure 

Nutritional Recommendations for Weight Loss In Diabetes 9 

• Moderate decreases in calories (500-1000 kcal/day) can result in progressive weight loss of 

1-2 lbs/week. 

• Low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 

year) for weight loss. 

• Physical activity and behavior modification are important components of weight loss 

programs and are most helpful in maintenance of weight loss. 

Physical Activity and exercise In Diabetes 9 

• At least 150 minutes of moderate/intense aerobic activity per week (30 minutes, five days a 

week) 

• In the absence of contraindications, people with type 2 diabetes should be encouraged to 

perform resistance training 3 days/week

Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation

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