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Joslin Diabetes Center & Joslin Clinic Clinical Guideline for ...

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SELECTING ANTIHYPERGLYCEMIC THERAPY*Consider Met<strong>for</strong>min• Obesity present• Renal/liver function normalContraindicated:• Creatinine > 1.4 (women)• Creatinine > 1.5 (men)• IV contrast• CHF• Dehydration• Alcohol excess• > 80 years age (unlesscreatinine clearance isnormal)Consider Thiazolidinediones(TZDs)• Obese, signs of insulinresistance• Liver function normal; needto follow LFT monitoringschedule**• Can be used in renalimpairment but mayincrease fluid retentionNote: Full effect of initiation ortitration of therapy may take 2-4months to be seenContraindicated:• Class III or IV CHF• LFT > 2.5 times upper limitof normalConsider Insulin Secretagogue(sulfonylurea or short-actingsecretagogue)• Non-obese/mild obesity• Repaglinide or nateglinideare useful <strong>for</strong> patients withpostprandial hyperglycemiaor hypoglycemia onsulfonylureaContraindicated:• Sulfonylureas in severeliver or renal diseaseConsidera-Glucosidase Inhibitor• Milder presentation• Use if postprandialhyperglycemia is thepredominant hyperglycemicpattern.• No GI symptomsContraindicated:• Chronic intestinal disorders• Acarbose in cirrhosis• Acarbose and miglitol inrenal impairment(creatinine > 2.0)Titrate Dose over 2 – 4 MonthsRein<strong>for</strong>ce MNT and Physical ActivityFasting Plasma Glucose > 140 ORPostprandial Glucose > 180 ORA1C ‡ 7.0%Add Drug of Another ClassAcceptable Choices<strong>for</strong> Combination Therapy(Suggested well-studied combinationsbased on results of clinical studies;these do not preclude other combinations)• Insulin secretagogue and met<strong>for</strong>min(met<strong>for</strong>min and glyburide, met<strong>for</strong>min and glipizide available in fixed combinations)• Sulfonylurea and α-glucosidase inhibitor• Thiazolidinediones and sulfonylurea• Thiazolidinediones and met<strong>for</strong>min(met<strong>for</strong>min and rosiglitazone available in fixed combination)• Thiazolidinediones and repaglinide* A combination of two drugs of different classes may be used as initial pharmacotherapy when there is marked hyperglycemiaor when MNT and physical activity alone have not resulted in an A1C of < 8.0%.**FDA Requirements <strong>for</strong> LFT monitoring:For pioglitazone (Actos) and rosiglitazone (Avandia):• If initial ALT is 2.5 times > normal, do not start this Rx.• If ALT is 2.5 times > normal during treatment, check weekly. If rise persists or becomes 3 times > normal, discontinue Rx.• For Actos, monitor ALT periodically thereafter according to clinical judgement.• For Avandia, monitor ALT every 2 months <strong>for</strong> the first 12 months and then periodically thereafter.Copyright © 2004 by <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>. All rights reserved. These <strong>Guideline</strong>s are the property of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong> and are protected by copyright. Any reproduction of thisdocument, which omits <strong>Joslin</strong>’s name or copyright notice is prohibited. This document may be reproduced <strong>for</strong> personal use only. It may not be distributed or sold. It may not bepublished in any other <strong>for</strong>mat (e.g., book, article, Web site) without the prior, written permission of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>, 617-732-2695.


ANTIHYPERGLYCEMIC THERAPY continuedFasting Plasma Glucose > 140 OR2 Postprandial Plasma Glucose > 180 ORA1C ‡ 7.0%Add Third Oral Medication OR Add InsulinAdd Third OralAntihyperglycemic Agentof Different Class(No proven benefit of adding two differentinsulin secretagogues in combination)Add Insulin (*) (**)• Several options available:•Intermediate acting insulin q hs (e.g. NPH or lente)•Long-acting or basal insulin (e.g. glargine once daily at any timeor ultralente pre-supper or hs)•Pre-supper insulin mixture (e.g. 75/25 lispro, 70/30 insulin,or 70/30 aspart)• Suggested starting dose: 0.1-0.2u/kg ideal body weight• Titrate/adjust insulin dosage until glucose goals metIf target glucose not met, consider:• Changing to multidose therapy using combination of rapid or very rapidacting,intermediate, or long -acting insulin• Pre-meal rapid or very rapid-acting insulin (e.g. aspart, lispro, or regular)added to hs intermediate or long-acting/basal insulin• Adding oral medication to reduce insulin resistance or improve glycemiccontrol if already on insulin(Met<strong>for</strong>min, TZDs, sulfonylureas, and a-glucosidase inhibitors are approved<strong>for</strong> use in combination with insulin)• Refer to endocrinologist if goals not met* May need to taper and discontinue some or all oral agents as insulin is initiated and adjusted, particularly if using rapid-actingand basal insulins.**Pre- and postprandial blood glucose should be checked. Frequency may vary 1-4 times/day depending on individual patientand status of glycemic control.Oral Agents Available in the USABiguanides• met<strong>for</strong>min(Glucophage)• met<strong>for</strong>minextended release(Glucophage XR)(met<strong>for</strong>min andmet<strong>for</strong>min ERavailable asgenericmedication)TZDs(Thiazolidinediones)• pioglitazone(Actos)• rosiglitazone(Avandia)a-GlucosidaseInhibitors• acarb ose(Precose)• miglitol(Glyset)Insulin SecretagoguesSulfonylureas Non-sulfonylurea2 nd generation SecretagoguesD-phenylalanineDerivatives• nateglinide(Starlix)• glimepiride (Amaryl)• glipizide (Glucotrol)• glipizide extendedrelease (Glucotrol XL)• glyburide(Micronase, Diabeta)• micronized glyburide(Glynase)(glipizide and glyburide areavailable as genericmedications)Meglitinides• repaglinide(Prandin)FixedCombinations• met<strong>for</strong>min andglipizide(Metaglip)• met<strong>for</strong>min andglyburide(Glucovance)• met<strong>for</strong>min androsiglitazone(Avandamet)Copyright © 2004 by <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>. All rights reserved. These <strong>Guideline</strong>s are the property of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong> and are protected by copyright. Any reproduction of thisdocument, which omits <strong>Joslin</strong>’s name or copyright notice is prohibited. This document may be reproduced <strong>for</strong> personal use only. It may not be distributed or sold. It may not bepublished in any other <strong>for</strong>mat (e.g., book, article, Web site) without the prior, written permission of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>, 617-732-2695.


INSULIN CHART*Insulin Type Product Onset Peak DurationVery Rapid ActingInsulin aspart analogNovoLogInsulin lispro analogHumalog10 – 30 minutes 0.5 – 3 hours 3 – 5 hoursRapid ActingRegular insulinIntermediate ActingLente insulinNPH insulinLong ActingInsulin glargineHumulin RNovolin RHumulin LHumulin NNovolin NLantus30 minutes 1 - 5 hours 8 hours1 – 4 hours 4 - 15 hours 16 – 26 hours1 – 4 hours 4 - 12 hours 14 –26 hours1 – 2 hoursWithoutUltralente insulinHumulin U4 - 6 hours8 - 30 hoursPremixed CombinationsInsulin TypeProduct50% NPH; 50% Regular Humulin 50/5070% NPH; 30% Regular Humulin 70/3070% NPH; 30% Regular Novolin 70/3075% lispro protamine suspension, 25% lispro Humalog Mix 75/2570% aspart protamine suspension, 30% aspart NovoLog Mix 70/3024 hours24 - 36 hours*The onset, peak and duration of any insulin type depend on many factors. Patients may experience variations in timing and/or intensity of insulinactivity due to dose, site of injection, temperature, level of physical activity, in addition to other factors. There<strong>for</strong>e, TAP should be considered as onlyreasonable estimates of the action of an insulin.Insulins listed alphabetically by generic name; TAP derived from in<strong>for</strong>mation provided by manufacturers.<strong>Guideline</strong> Authors: Martin Abrahamson, MD, Richard Beaser, MD, Elizabeth Blair, CS-ANP, Om Ganda, MD, James Rosenzweig, MDApproved by <strong>Joslin</strong> <strong>Clinic</strong>al Oversight Committee 2/20/04GlossaryA1C: Glycohemoglobin (Hemoglobin A 1c)Casual plasma glucose: a random plasma glucoseCHF: congestive heart failureFDA: Food and Drug AdministrationFPG: fasting plasma glucoseHS: bedtimeMNT (Medical Nutrition Therapy): Begins with assessment of overall nutrition status, followed by individualized prescription <strong>for</strong> treatment. Registered dietitianconsiders food intake, physical activity, course of any medical therapy, individual preferences and other factors.Rx: treatmentTAP: time action profilesTZDs: thiazolidinedionesReferencesAmerican <strong>Diabetes</strong> Association. Screening <strong>for</strong> type 2 diabetes. <strong>Diabetes</strong> Care. 27:S11-S14, 2004.Beaser, RS and Staff of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>. <strong>Joslin</strong>’s <strong>Diabetes</strong> Deskbook For Primary Care Providers. Revised edition. <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>, Boston; 2003.Inzucchi SE. Oral antihyperglycemic therapy <strong>for</strong> type 2 diabetes: scientific review. JAMA. 287(3):360-72, 2002.Nesto RW et al. Thiazolidinedione use, fluid retention, and congestive heart failure: A consensus statement from the American Heart Association and American <strong>Diabetes</strong>Association. Circulation. 108:2941-2948, 2003.James Rosenzweig, MD - ChairpersonMartin Abrahamson, MDRichard Beaser, MDElizabeth Blair, MS, CS-ANP, CDEPatty Bonsignore, MS, RN, CDEAmy Campbell, MS, RD, CDECathy Carver, ANP, CDEJerry Cavallerano, ODSonya Celeste-Harris, RN, MSNOm Ganda, MDJohn Hare, MDJoan Hill, RD, CDE<strong>Joslin</strong> <strong>Clinic</strong>al Oversight CommitteeLori Laffel, MD, MPHLuAnn Kimker, MS, RNWilliam Petit, MDEvan Rosen, MDKristi Silver, MDSusan Sjostrom, JDKenneth Snow, MDRobert Stanton, MDWilliam Sullivan, MDHoward Wolpert, MDAlan Moses, MD, ex officioCopyright © 2004 by <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>. All rights reserved. These <strong>Guideline</strong>s are the property of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong> and are protected by copyright. Any reproduction of thisdocument, which omits <strong>Joslin</strong>’s name or copyright notice is prohibited. This document may be reproduced <strong>for</strong> personal use only. It may not be distributed or sold. It may not bepublished in any other <strong>for</strong>mat (e.g., book, article, Web site) without the prior, written permission of <strong>Joslin</strong> <strong>Diabetes</strong> <strong>Center</strong>, 617-732-2695.

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