Start with bedtime intermediateacting insulin or bedtime or morning long-acting insulin (can initiate with 10 units or 0.2 units per kg) Initiation and Adjustment of Insulin Regimens Insulin regimens should be designed taking lifestyle and meal schedule into account. The algorithm can only provide basic guidelines for initiation and adjustment of insulin. Check fasting glucose (fingerstick) usually daily and increase dose, typically by 2 units every 3 days until fasting levels are consistently in target range (3.9-7.2 mmol/l [70-130 mg/dl]). Can increase dose in larger increments e.g.., by 4 units every 3 days, if fasting glucose is > 10 mmol/l (180mg/dl) If hypoglycemia occurs, or fasting glucose level <3.9 mmol/l (70mg/dl), reduce bedtime dose by 4 units or 10%--- whichever is greater A1C 7% after 2-3 months No Pre-lunch bg out of range, add rapidacting insulin at breakfastª Yes If fasting bg is in range (3.9-7.2 mmol/l [70-130 mg/dl]), check bg before lunch, dinner, and bed. Depending on bg results, add second injection as below. Can usually begin with ~4 units and adjust by 2 units every 3 days until bg is in range Pre-dinner bg out of range, add NPH insulin at breakfast, or rapid-acting at lunch Pre-bed bg out of range, add rapid-acting insulin at dinnerª Continue regimen, check A1C every 3 mo No Recheck pre-meal bg levels and if out of range, may need to add another injection. If A1C continues to be out of range, check 2 h postprandial levels and adjust preprandial rapid-acting insulin Yes A1C 7% after3 months Adapted from the Diabetes Care Consensus Statement, Diabetes Care, Volume 32, Number 1, January 2009
Algorithm for Type 2 Tier 1: Well Validated At dx: Lifestyle Metformin Basal Insulin Sulfonylurea STEP 1 STEP 2 STEP 3 Intensive insulin Tier 2: Less wellvalidated Pioglitazone GLP-1 agonist Pioglitazone Sulfonylurea basal insulin Adapted from the Diabetes Care Consensus Statement, Diabetes Care, Volume 32, Number 1, January 2009
Lipid Algorithm For Type 1 and Type 2 Diabetes Mellitus in Adults FLP Goals: LDL-C <100 mg/dl (<70 with CVD, CVA, or PVD) HDL-C > 40 mg/dl TG <150 mg/dl Determine Fasting Lipid Profile (FLP) yearly Abnormal fasting lipids: Initial therapy with TLC & Intensive Glucose Control (with A1c goal < 6%) Evaluate and treat secondary causes of dyslipidemia: alcohol, estrogen, anabolic steroids, corticosteroids, hypothyroidism, hepatic disease, nephrotic syndrome, chronic renal failure. LDL-C is the primary target of therapy unless TG > 400 mg/dl, at which point TG then becomes the primary treatment target Elevated LDL-C or LDL-C at goal with at least one additional CV risk factor present Start statin, titrate to goal, reinforce TLC Goal: LDL-C <100 (<70 if history of CVD, CVA, or PVD) Elevated TG 150-199 200-399 > 400 Isolated low HDL-C (with LDL-C & TG at target) Optimize TLC Optimize TLC, smoking cessation, Optimize TLC, smoking cessation, When TG < 400, reassess LDL-C Optimize TLC, smoking cessation, fibrate, niacin, fish oil or statin¹ LDL-C not at goal, follow elevated LDL-C guideline¹ If LDL-C remains above goal and/or patient does not tolerate statin, then add bile acid resin, ezetimibe, niacin or Orlistat If not at goal Refer to Lipid Specialist Definitions: TLC = Therapeutic Lifestyle Changes Statin = HMG Co-A Reductase Inhibitor TG = Triglycerides Footnotes: ¹ If a fibrate is combined with a statin, then fenofibrate is preferred rather than gemfibrozil due to risk of myositis and rhabdomyolysis. Adapted from the Texas Diabetes Council and the Texas Department of State Health Services
Lipid Algorithm For Type 1 and Type 2 Diabetes Mellitus in Adults Revised 1-24-08 FLP Goals: LDL-C <100 mg/dl (<70 with CVD, CVA, or PVD) HDL-C > 40 mg/dl TG <150 mg/dl Determine Fasting Lipid Profile (FLP) yearly Abnormal fasting lipids: Initial therapy with TLC & Intensive Glucose Control (with A1c goal < 6%) Evaluate and treat secondary causes of dyslipidemia: alcohol, estrogen, anabolic steroids, corticosteroids, hypothyroidism, hepatic disease, nephrotic syndrome, chronic renal failure. LDL-C is the primary target of therapy unless TG > 400 mg/dl, at which point TG then becomes the primary treatment target. Elevated LDL-C or LDL-C at goal with at least one additional CV risk factor present Start statin, titrate to goal, reinforce TLC Goal: LDL-C <100 (<70 if history of CVD, CVA, or PVD) If LDL-C remains above goal and/or patient does not tolerate statin, then add bile acid resin, ezetimibe, niacin or Orlistat Elevated TG 150-199 200-399 > 400 If not at goal Isolated low HDL-C (with LDL-C & TG at target) Optimize TLC Optimize TLC, smoking cessation, Optimize TLC, smoking cessation, When TG < 400, reassess LDL-C Optimize TLC, smoking cessation, fibrate, niacin, fish oil or statin¹ LDL-C not at goal, follow elevated LDL-C guideline¹ Refer to Lipid Specialist Footnotes: ¹ If a fibrate is combined with a statin, then fenofibrate is preferred rather than gemfibrozil due to risk of myositis and rhabdomyolysis. Definitions: TLC = Therapeutic Lifestyle Changes (refer to TDC Medical Nutrition, Weight Loss, and Exercise Algorithms) Statin = HMG Co-A Reductase Inhibitor TG = Triglycerides Publication # 45-10777 (Page 1 of 3) See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer.
Revised 1-24-08 Lipid Algorithm For Type 1 and Type 2 Diabetes Mellitus in Adults HMG Co-A Reductase Inhibitors LDL-C Equivalency in Patients with Hypercholesterolemia* Fluvastatin Pravastatin Lovastatin Simvastatin Atorvastatin Rosuvastatin Ezetimbe/ Simvastatin Approximate %LDL 20 mg 10 mg 10 mg 15-20 40 mg 20 mg 20 mg 5-10 mg 21-29 80-XL 40-80 mg 40 mg 20 mg 10 mg 30-38 80 mg 40 mg 20 mg 5-10 mg 10/10 mg 39-47 80 mg 40 mg 20 mg 10/20 mg 48-54 80 mg 40 mg 10/40 mg 55-59 10/80 mg >59 Footnote: *this information is not based on head to head comparison (Page 2 of 3)
Revised 1-24-08 References: Collins R, Armitage J, Parish S, Sleigh P, Peto R; Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003 Jun 14;361(9374):2005-16. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6;360(9326):7-22. Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.lancet. 2004 Aug 21-27;364(9435):685-96. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association.Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13; 110(2):227-39. Jones P, Kafonek S, Laurora I, Hunninghake D.Comparative dose efficacy study of atorvastatin versus simvastatin, pravastatin, lovastatin, and fluvastatin in patients with hypercholesterolemia (the CURVES study) Am J Cardiol. 1998 Mar 1;81(5):582-7. Jones PH, Davidson MH. Reporting rate of rhabdomyolysis with fenofibrate statin versus gemfibrozil any statin.am J Cardiol. 2005 Jan 1;95(1):120-2. Maeda K, Noguchi Y, Fukui T.The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a metaanalysis. Prev Med. 2003 Oct;37(4):283-90. Keech A, Simes RJ, Barter P, Best J, Scott R, Taskinen MR, Forder P, Pillai A, Davis T, Glasziou P, Drury P, Kesäniemi YA, Sullivan D, Hunt D, Colman P, d'emden M, Whiting M, Ehnholm C, Laakso M; FIELD study investigators. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial. Lancet. 2005 Nov 26;366(9500):1849-61. Rubins HB, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas FH, Linares E, Schaefer EJ, Schectman G, Wilt TJ, Wittes J.Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med. 1999 Aug 5; 341(6):410-8. Cholesterol Treatment Trialists' (CTT) Collaborators, Kearney PM, Blackwell L, Collins R, Keech A, Simes J, Peto R, Armitage J, Baigent C.Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a metaanalysis. Lancet. 2008 Jan 12;371(9607):117-25. (Page 3 of 3)