Guidelines for Type 2 Diabetes Diagnosis

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1 Guidelines for Type 2 Diabetes Diagnosis Fasting Plasma Glucose (in asymptomatic individuals, repeat measurement to confirm the test) Normal FPG < hr OGTT < 140 HbA1C < 5.5% Impaired Fasting Glucose (IFG) 100 to < % - 6.4% Diabetes Mellitus hr plasma glucose > 200 Random glucose > 200 with symptoms of hyperglycemia 6.5% (performed in a lab using a method that is NGSP certified & standardized to DCCT assay) OGTT Oral Glucose Tolerance Test NGSP National Glycohemoglobin Standardization Program DCCT Diabetes Control and Complications Trial Goals of treatment for older patients with DM Patient Health A1c Goal FPG or PPG Bed time glucose BP goal Lipid Tx Healthy % <140/80 statin Complex/ % <140/80 statin Intermediate* Very complex/ % <150/90 consider statin Poor health** *Some IADL dependent, co morbidities MCI **ADL dependent, Dementia, co morbidities Pg 1 R.Chan & R.Brower 8/2013; R.Batra 08/2014; D. Osterweil 10/2015

5% (performed in a lab using a method that is NGSP certified & standardized to DCCT assay) OGTT Oral Glucose Tolerance Test NGSP National Glycohemoglobin Standardization Program DCCT Diabetes Control

2 Diabetes Treatment Algorithm Pg 2 R.Chan & R.Brower 8/2013; R.Batra 08/2014; D. Osterweil 10/2015

3 Guidelines for Type 2 Diabetes Treatment Treatment for ALL Diabetics and Impaired Glucose Tolerance Step 1: Education Nutritional counseling Weight loss if obese Regular exercise Daily self- foot exam Low dose ASA Folate ARB or ACEI for HTN or if urine is positive for microalbumin (or increase in urine albumin/creatinine) Statin for hyperlipidemia Minimize alcohol use Vaccinations Psychosocial screening Smoking cessation counseling Check HbA1C two times per year in those meeting glycemic goal Check HbA1C quarterly in patients whose therapy has changed and those not meeting glycemic goals HbA1C goal is < 7%, however, less stringent treatment goals of < 8% may be appropriate for older patients and individuals with comorbid condition Step 2, if HbA1C goals not achieved: Metformin preferred, with or without acarbose Pioglitazone (Actos) if metformin contraindicated Go to Step 3 if both metformin and pioglitazone are contraindicated May initiate QHS basal insulin for those with HbA1c > 8.5% Step 3, if HbA1C goals not achieved, add: 2 nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbA1c goals not achieved with above steps Step 4, if HbA1C goals not achieved, add: TZD (if not already on and no contraindications) or 2nd generation sulfonylurea or DPP-4 inhibitor or GLP-1 agonist or Consider adding or adjusting insulin Reference: American Diabetes Association. Standard of Medical Care in Diabetes 2015 Pg 3 R.Chan & R.Brower 8/2013; R.Batra 08/2014; D. Osterweil 10/2015

Psychosocial screening Smoking cessation counseling Check HbA1C two times per year in those meeting glycemic goal Check HbA1C quarterly in patients whose therapy has changed and those not meeting

4 Pharmacologic Agents for Treatment of Type 2 Diabetes SCAN Formulary Drugs Medication Biguanides Tier Level & Notes Dosing & Administration metformin mg BID metformin er tabs 500 mg & 750 mg Sulfonylureas daily glimepiride mg daily glipizide mg daily Risk for Drug- Drug Interactions* Moderate Adverse Drug Reactions Nausea/ vomiting, GI upset, metallic taste, diarrhea, flatulence, lactic acidosis (rare) Nausea/ vomiting, GI upset, diarrhea, flatulence, lactic acidosis Dizziness, headache, hypoglycemia, nausea, weight gain Rash, diarrhea, dizziness, headache, diarrhea, hypoglycemia, nausea, weight gain glipizide er / xl mg daily Asthenia, headache, dizziness, rash, nausea, hypoglycemia, weight gain 4

5 20 mg daily Risk for Drug- Drug Interactions* Moderate Adverse Drug Reactions Nausea/ vomiting, GI upset, metallic taste, diarrhea, flatulence, lactic acidosis (rare) Nausea/ vomiting, GI

5 Sulfonylureas, cont. glipizide / metformin / 500 mg BID glyburide** [NF] [NF] mg daily glyburide** / metformin [NF] [NF] 1.25 / 250 mg QD BID Thiazolidinediones & Thiazolidinedione Combination Agents pioglitazone mg daily Moderate Rash, diarrhea, dizziness, headache, nausea, flatulence, hypoglycemia, lactic acidosis Rash, heartburn, hypoglycemia, nausea, hypoglycemia, weight gain Rash, heartburn, hypoglycemia, nausea, vomiting, lactic acidosis, flatulence Anemia, edema, weight gain, headache, myalgia, bone fracture, heart failure pioglitazone / metformin / 500 mg 45 / 1500mg daily Rash, diarrhea, dizziness, headache, nausea, flatulence, hypoglycemia, lactic acidosis pioglitazone / glimepiride 2 [QL] 2 [QL] 15 / 500 mg 45 / 1500mg daily Anemia, edema, weight gain, headache, myalgia, dizziness, hypoglycemia, nausea Alpha-Glucosidase Inhibitor acarbose mg TID Administered at the start of each meal to decrease postprandial glucose peaks Abdominal pain, diarrhea, flatulence, elevated serum transaminases 5

$bone fracture, heart failure pioglitazone / metformin 2 2 15 / 500 mg 45 / 1500mg daily Rash, diarrhea, dizziness, headache, nausea, flatulence, hypoglycemia, lactic acidosis pioglitazone /$

6 Meglitinides nateglinide 2 2 repaglinide 2 [ST] 2 DPPIs (Dipeptidyl Peptidase-4 Inhibitors) JANUVIA (sitagliptin) mg TID before meals mg TID before meals mg daily Moderate Dizziness, arthralgia, diarrhea, hypoglycemia, weight gain, increased uric acid Hypoglycemia, arthralgia, diarrhea, weight gain Abdominal pain, diarrhea, headache, nasopharyngitis, nausea, URI, pancreatitis JANUMET, JANUMET XR (sitagliptin / metformin) / 2000 mg daily Abdominal pain, diarrhea, headache, nasopharyngitis, nausea, flatulence, lactic acidosis, pancreatitis KOMBIGLYZE XR (saxagliptin / metformin) 3 3 Individualize dose; 5 / 2000 mg daily max Nausea/ vomiting, GI upset, asthenia, diarrhea, flatulence, lactic acidosis, pancreatitis ONGLYZA (saxagliptin) mg daily Abdominal pain, diarrhea, URI, pancreatitis, nausea, hypoglycemia TRADJENTA (linagliptin) Insulins [NF] [NF] 5 mg daily Vial Pen Vial Pen HUMALOG Patient specific dosing applies Nasopharyngitis, diarrhea, cough, back pain, arthralgia, URI, headache Hypoglycemia, injection site reaction, lipodystrophy, hypokalemia 6

diarrhea, headache, nasopharyngitis, nausea, URI, pancreatitis JANUMET, JANUMET XR (sitagliptin / metformin) 3 3 100 / 2000 mg daily Abdominal pain, diarrhea, headache, nasopharyngitis, nausea,

7 Insulins, cont. HUMALOG MIX 50/50, 75/ HUMULIN N, R HUMULIN 70/ LANTUS (insulin glargine) Patient specific dosing applies Hypoglycemia, injection site reaction, lipodystrophy, hypokalemia LEVEMIR (insulin detemir) 6 3 [NF] [NF] NOVOLIN & NOVOLOG products [NF] [NF] BYDUREON (exenatide er) 3 [PA] 3 [PA] 2 mg SC weekly Diarrhea, nausea, vomiting, constipation, headache, pancreatitis 7

3 6 3 Patient specific dosing applies Hypoglycemia, injection site reaction, lipodystrophy, hypokalemia

8 GLP-1 Agonist (Glucagon-Like-Peptide-1) cont. BYETTA (exenatide) VICTOZA (liraglutide) 3 [PA] 3 [PA] 5 10 mcg SC BID 3 [PA] 3 [PA] 0.6 mg 1.8mg SC daily Diarrhea, nausea, vomiting, dizziness, headache, pancreatitis Diarrhea, nausea, vomiting, dizziness, headache, pancreatitis Amylinomimetic SYMLINPEN (pramlintide) 3 [PA] 3 [PA] SGLT2 Inhibitor (Sodium-Glucose Cotransporter 2) FARXIGA (dapagliflozin) 60 mcg 120 mcg SC prior to main meals 3 [ST] 3 [ST] 5 10 mg daily Nausea, anorexia, dizziness, fatigue Genital mycotic infections, nasopharyngitis, UTI, back pain, increased urination, nausea XIGDUO XR (dapagliflozin/ metformin) 3 [ST] 3 [ST] 5 / / 2000 mg daily Low vitb12, diarrhea, headache, UTI, genital mycotic infection, nasopharyngitis INVOKANA (canagliflozin) 3 [ST] 3 [ST] mg daily Genital mycotic infections, UTI, thirst, increased urination, nausea INVOKAMET (canagliflozin/ metformin) 3 [ST] 3 [ST] 50 / / 1000mg BID Abdominal discomfort, constipation, diarrhea, flatulence, increased thirst, indigestion, N/V, asthenia, headache, UTI, polyuria pruritis 8

Inhibitor (Sodium-Glucose Cotransporter 2) FARXIGA (dapagliflozin) 60 mcg 120 mcg SC prior to main meals 3 [ST] 3 [ST] 5 10 mg daily Nausea, anorexia, dizziness, fatigue Genital mycotic infections,

9 Brand-name drugs are capitalized and generic drugs are listed in the lower-case italics. [NF] = Non-formulary [PA] = Prior Authorization [QL] = Quantity Limit [ST] = Step Therapy * 2009 AACE/ACE Consensus Statement ** High Risk Medication 9

10 Diabetes Guidelines References SCAN Health Plan Diabetes Guidelines adapted from: AACE Comprehensive Diabetes Management Algorithm Endocrine Practice, Volume 21, Issue 4 (April 2015) American Diabetes Association; Standards of Medical Care in Diabetes-2015: Diabetes Care January 2015 vol. 38 no. Supplement 1 S1-S94 %20Sean/Documents/January%20Supplement%20Combined_Final.pdf AACE/ACE Consensus Statement: Consensus Panel on Type 2 Diabetes Mellitus: An Algorithm for Glycemic Control. Endocrine Practice. (2009, Sept- Oct). 15(6) Executive Summary: Standards of Medical Care in Diabetes Diabetes Care, Vol 33, Sup 1, (2010, Jan). Drug Facts & Comparisons. (2015, Oct). Retrieved from Wolters Kluwer Health: Deventer, The Netherlands. Epocrates Online (2015). Retrieved from: Epocrates, Inc.: San Mateo, California. Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2015). Geriatrics at your fingertips. 17th ed. (Based on AGS Guidelines.) Pg 10

Supplement 1 S1-S94 http://professional.diabetes.org/admin/userfiles/0%20- %20Sean/Documents/January%20Supplement%20Combined_Final.

Add: 2 nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbA1c goals not achieved with the above

Add: 2 nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbA1c goals not achieved with the above Guidelines for Type Diabetes - Diagnosis Fasting Plasma Glucose (confirm results if borderline) HbAIC Normal FPG < 00 < 5.5 Impaired Fasting Glucose (IFG) 00 to < 5.7%-.5% Diabetes Mellitus (or random