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

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1 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 00) >.5% (preferably using the same test for confirmation) Guidelines for Type Diabetes - Treatment Step Treatment for ALL Diabetics and Impaired Glucose Tolerance 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 R. Brower: Nov. 0; R.Chan & R.Batra: 08/0 R.Chan & R.Brower: Aug. 03

5% (preferably using the same test for confirmation) Guidelines for Type Diabetes - Treatment Step Treatment for ALL Diabetics and Impaired Glucose Tolerance Education Nutritional counseling

2 Step (if HbAC 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 HbAc >8.5% Step 3 (if HbAC goals not achieved) Add: nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbAc goals not achieved with the above Step 4 (if HbAC goals not achieved) Add: TZD (if not already on and no contraindications) or nd generation sulfonylurea or DPP-4 inhibitor or GLP- agonist or Consider adding or adjusting insulin R. Brower: Nov. 0; R.Chan & R.Batra: 08/0 R.Chan & R.Brower: Aug. 03

5% Step 3 (if HbAC goals not achieved) Add: nd generation sulfonylurea or glinide or Add DPP-4 inhibitor Start or intensify insulin therapy if HbAc goals not achieved with

3 Pharmacologic Agents for Treatment of Type Diabetes 03 SCAN Formulary Drugs Medication Tier Level & Notes Dosing & Administration Biguanides Risk for Drug-Drug Interactions* Adverse Drug Reactions metformin metformin er Sulfonylureas mg BID TID daily Nausea/ vomiting, GI upset, metallic taste, diarrhea, flatulence, lactic acidosis (rare) Nausea/ vomiting, GI upset, diarrhea, flatulence, lactic acidosis glimepiride glipizide - 8 mg daily.5-0 mg daily Moderate Dizziness, headache, hypoglycemia, nausea, weight gain Rash, diarrhea, dizziness, headache, diarrhea, hypoglycemia, nausea, weight gain Updated: 08/03 3

taste, diarrhea, flatulence, lactic acidosis (rare) Nausea/ vomiting, GI upset, diarrhea, flatulence, lactic acidosis glimepiride glipizide - 8 mg daily.

4 glipizide er/ xl 5-0 mg daily Asthenia, headache, dizziness, rash, nausea, hypoglycemia, weight gain glipizide / metformin.5 / 500 mg bid Moderate Rash, diarrhea, dizziness, headache, nausea, flatulence, hypoglycemia, lactic acidosis, glyburide**.5-0 mg daily Rash, heartburn, hypoglycemia, nausea, hypoglycemia, weight gain glyburide** / metformin.5/50 mg QD- BID Rash, heartburn, hypoglycemia, nausea, vomiting, lactic acidosis, flatulence Thiazolidinediones & Thiazolidinedione Combination Agents pioglitazone 5-45 mg QD Anemia, edema, weight gain, headache, myalgia, bone fracture, heart failure pioglitazone/ metformin 5 / 500 mg - 45 / 500mg daily Anemia, edema, weight gain, headache, myalgia, lactic acidosis, flatulence, bone fracture, heart failure Updated: 08/03 4

5-0 mg daily Rash, heartburn, hypoglycemia, nausea, hypoglycemia, weight gain glyburide** / metformin.

5 pioglitazone/ glimepiride [QL] 30 / mg 30 / 4 mg daily Anemia, edema, weight gain, headache, myalgia, dizziness, hypoglycemia, nausea Alpha-Glucosidase Inhibitor acarbose 5-00 mg TID Administered at the start of each meal to decrease postprandial glucose peaks Meglitinides Abdominal pain, diarrhea, flatulence, elevated serum transaminases nateglinide 0-0 mg TID before meals Dizziness, arthralgia, diarrhea, hypoglycemia, weight gain, increase uric acid PRANDIN (repaglinide) 3 [ST] mg TID before meals Moderate Hypoglycemia, arthralgia, diarrhea, weight gain Updated: 08/03 5

Abdominal pain, diarrhea, flatulence, elevated serum transaminases nateglinide 0-0 mg TID before meals Dizziness, arthralgia, diarrhea,

6 DPPIs (Dipeptidyl Peptidase-4 Inhibitors) JANUVIA (sitagliptin) 3 00 mg daily Abdominal pain, diarrhea, headache, nasopharyngitis, nausea, URI, pancreatitis JANUMET, JANUMET XR (sitagliptin/ metformin) KOMBIGLYZE XR (saxagliptin/ metformin) / 000mg daily Individualize dose; 5/000mg daily max Abdominal pain, diarrhea, headache, nasopharyngitis, nausea, flatulence, lactic acidosis, pancreatitis Nausea/ vomiting, GI upset, asthenia, diarrhea, flatulence, lactic acidosis, pancreatitis ONGLYZA (saxagliptin) Insulins 3.5 5mg daily Abdominal pain, diarrhea, URI, pancreatitis, nausea, hypoglycemia HUMALOG HUMALOG mix 50/50,75/5 Patient specific dosing applies Hypoglycemia, injection site reaction, lipodystrophy, hypokalemia HUMULIN N, R HUMULIN 70/30 LANTUS, LANTUS SOLOSTAR (insulin glargine) Updated: 08/03

pancreatitis Nausea/ vomiting, GI upset, asthenia, diarrhea, flatulence, lactic acidosis, pancreatitis ONGLYZA (saxagliptin) Insulins 3.

7 LEVEMIR (insulin detemir) NOVOLIN N, R NOVOLIN 70/30 NOVOLOG NOVOLOG mix 70/30 GLP- Agonist (Glucagon-Like-Peptide-) BYETTA (exenatide) 4 [PA] 0 mcg SC BID Diarrhea, nausea, vomiting, dizziness, headache, pancreatitis VICTOZA (liraglutide) Amylinomimetic 4 [PA].-.8 mg SC QD Headache, nausea, diarrhea, pancreatitis SYMLIN, SYMPLINPEN (pramlintide) 4 [PA] 0 mcg 0 mcg SC prior to main meals Nausea, anorexia, dizziness, fatigue 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 * 009 AACE/ACE Consensus Statement ** High Risk Medication Updated: 08/03 7

8 mg SC QD Headache, nausea, diarrhea, pancreatitis SYMLIN, SYMPLINPEN (pramlintide) 4 [PA] 0 mcg 0 mcg SC prior to main meals Nausea, anorexia, dizziness, fatigue

8 Diabetes Guidelines References Diabetes Guidelines adapted from: AACE Comprehensive Diabetes Management Algorithm 03. Endocrine Practice (03, March/April) 9(), Standards of Medical Care in Diabetes-0: Diabetes Care January 0 vol. 35 no. Supplement S-S3 AACE/ACE Consensus Statement: Consensus Panel on Type Diabetes Mellitus: An Algorithm for Glycemic Control. Endocrine Practice. (009, Sept-Oct). 5() Executive Summary: Standards of Medical Care in Diabetes 00. Diabetes Care, Vol 33, Sup, (00, Jan). Drug Facts & Comparisons. (00, Feb). Retrieved from Wolters Kluwer Health: Deventer, The Netherlands. Epocrates Online. (03). Retrieved from: Epocrates, Inc.: San Mateo, California. R. Brower: Nov. 0; R.Chan & R.Batra: 08/0 R.Chan, R.Brower: Aug. 03 8

full AACE/ACE Consensus Statement: Consensus Panel on Type Diabetes Mellitus: An Algorithm for Glycemic Control. Endocrine Practice. (009, Sept-Oct). 5(). 540-559.

Guidelines for Type 2 Diabetes Diagnosis

Guidelines for Type 2 Diabetes Diagnosis Fasting Plasma Glucose (in asymptomatic individuals, repeat measurement to confirm the test) Normal FPG < 100 2-hr OGTT < 140 HbA1C < 5.5% Impaired Fasting Glucose