Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation

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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% Upper respiratory apoB ↓15-16% infections TG ↓ 7-9% Diarrhea Arthralgia LDL apoB TG ↓ 46-58% ↓35-47% ↓ 26-31% Headache Increased ALT Myalgia Upper respiratory 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). 52 CMA FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
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). CMA FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 53 Comprehensive management of type 2 diabetes
Page 1 and 2: 3 Comprehensive Management of Type
Page 3 and 4: TAbLe 13 Diabetes Care Guidelines/F
Page 5 and 6: TAbLe 15 Recommended blood Glucose
Page 7 and 8: Proper Disposal of Syringes and Nee
Page 9 and 10: TAbLe 17 Oral Medications Drug clas
Page 11 and 12: TABLe 18 Non-Insulin Injectables Dr
Page 13 and 14: Diabetes Coalition of California Ty
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Page 17 and 18: TABLe 20 Insulin Injectables Drug c
Page 19 and 20: separate prescriptions or in fixed-
Page 21 and 22: TABLe 22 Oral Blood Pressure Loweri
Page 23 and 24: TABLe 22 Oral Blood Pressure Loweri
Page 25 and 26: Reference Card From the Seventh Rep
Page 27 and 28: Clinical Management of Dyslipidemia
Page 29 and 30: Pharmacotherapy for Dyslipidemia 23
Page 31 and 32: TABLe 24 Lipid combinations Fibric
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Page 37 and 38: Hard Coronary Heart Disease (10-Yea
Page 39 and 40: Weight Loss/Maintenance Even a mode

Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation

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