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Diabetes Mellitus: Outpatient Treatment
Diagnostic Criteria for Diabetes and Pre-Diabetes
Diabetes
Any of the followingconfirm by repeat testing on a
different day:
Symptoms of hyperglycemia, plus random
plasma glucose > 200 mg/dl or
Fasting blood sugar (FBS) (no caloric intake for
at least 8 hours prior to laboratory
determination) > 126 mg/dl or
Two-hour post-prandial plasma glucose
> 200 mg/dl during a fasting 75-gram Oral Glucose
Tolerance Test (OGTT).
HbA1c >6.5%
Pre-Diabetes
Impaired Fasting Glucose (IFG) - FBS
100-125 mg/dl
Impaired Glucose Tolerance (IGT) - 2-h. plasma
glucose 140 -199 mg/dl
Hgb A1c 5.7-6.4%
Screening for Pre-Diabetes and Diabetes in
Asymptomatic, Undiagnosed Individuals
Testing presumably healthy individuals for type 1
diabetes is not recommended.
Routine testing for individuals 45 years of age
for type 2 diabetes with FBS or OGTT. If normal,
repeat every 3 years.
Consider testing in all adults, and retest yearly,
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with BMI > 25 kg/m , and/or:
o Physical inactivity
o First-degree relative with diabetes
o High-risk ethnic population (African
American, Latino, Native American,
Asian American, Pacific Islander)
o Delivered a baby weighing > 9 lb or
gestational diabetes
o Hypertension (> 140/90 mmHg or on
treatment for hypertension)
o HDL cholesterol < 35 mg/dl and/or
triglycerides > 250 mg/dl
o Previously at risk for DM (IFG, IGT, or
A1c > 5.7%)
o Women with PCOS
o Other risk factors (severe obesity,
acanthosis nigricans, history of CVD)
Outpatient Visit for Known Diabetes
Medical History
Review:
History of diagnosis (age, characteristics, initial
treatment, diabetic education etc.)
History of acute complications (DKA,
hypoglycemia)
Current treatment, level of adherence
Lifestyle assessment
History of glycemic control
History of hypoglycemia, hypoglycemia
unawareness, or severe events requiring
emergency care
History of chronic complications
Smoking status
Physical Examination
Height, weight, BP, pulses
Eye, oral, thyroid, cardiac, abdominal
(hepatomegaly), hand / finger, bare foot, neuro,
skin exam
Indications for secondary diabetes
(hemochromatosis, pancreatic disease, and
endocrine disorders such as acromegaly,
pheochromocytoma, Cushings syndrome)
Management Plan
Consider age; daily schedule; physical activity;
eating patterns; health, social, personality, and
cultural factors; capacity to understand and carry
out treatment plan.
Establish short- and long-term goals.
All patients should be referred to general diabetes
education classes at diagnosis and periodically
thereafter.
Recommend medical nutrition therapy (MNT);
lifestyle changes (exercise, smoking cessation);
self-management and problem-solving training;
annual dilated eye exam; dental hygiene; mental
health professional.
Advise to exercise 150 min / week moderate
intensity aerobic activity; consider resistance
training 3 times/week.
Instruct on glucose monitoring (at least 3 or 4
times/day for patients on insulin, individualized
otherwise) and recording or downloading
measurements.
Measure Target*
HbA1c 7%
Pre-meal glucose 70-130 mg/dl
Peak Post-meal glucose 180 mg/dl
*Glucose targets should be individualized according
to risk of hypoglycemia, comorbidities and life
expectancy.
Family planning.
Prescribe medications (see Appendix).
Glucose monitoring may be used to guide therapy
in patients with less frequent injections, on non-
insulin therapies, or medical nutrition therapy
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Type 1 Diabetes
Basic treatment plan to consist of: Class % HbA1C Primary Cautions
o multiple-dose insulin injections or insulin Reduction Effect
pump therapy Metformin 1.1-3.0 Reduce Renal, CHF,
o matching pre-meal insulin to hepatic liver disease
carbohydrate intake, pre-meal glucose, glucose
and anticipated activity production
Patients not meeting treatment goals on injections TZD 1.5-1.6 Sensitizer Liver disease,
CHF, osteo-
should be considered for Endocrinology referral
porosis,
and continuous subcutaneous insulin infusion edema
and/or real-time continuous glucose monitoring. Sulfonylurea 0.9-2.5 Secretagogue Renal, liver
Start with 0.5-0.6 units/kg/d, with 50% of insulin disease
as basal and 50% as bolus. Repaglinide 1.0-2.0 Secretagogue Renal, liver
Advise patients on urinary ketone testing and disease
use of glucagon. Nateglinide 0.5 Secretagogue Renal, liver
disease
Alpha- 0.6-1.3 Block Renal, liver,
Preparation Action Peak Action glucosidase glucose malabsorption
Onset Duration inhibitor absorption syndromes

Bolus Insulin DPP-IV 0.8 Increase Pancreatitis,

inhibitors Incretin activity c-cell tumors
Regular q.a.c. 30 min 2-4 hr 6-10 hr GLP-1 0.8-1.5 Incretin Renal disease,
Aspart q.a.c. 5-15 min 1-2 hr 4-6 hr agonists replacement c-cell tumors,
pancreatitis,
Glulisine q.a.c. 5-15 min 1-2 hr 4-6 hr gastro-
Lispro q.a.c. 5-15 min 1-2 hr paresis
4-6 hr Pramlintide 0.3-0.6 Amylin Gastro-paresis
Basal Insulin replacement
SGLT-2 0.5-1.0 Block renal Renal/liver
NPH daily or bid 1-2 hr 4-8 hr 10-20 hr Inhibitors glucose disease,
reabsorption candidiasis
Detemir daily or 3-4 hr Flat Approx
bid 24 hr
NOTE: For detailed information about prescribing
Glargine daily 3-4 hr Flat Approx medications, see the Appendix.
24 hr
Other
Continuing Care for Known Diabetes
70/30, 75/25, 5-15 min 1-2 hr 10-20 hr
50/50 bid Quarterly Exam (until treatment goals are achieved)
Height, weight, BP.
Type 2 Diabetes Eye and bare foot exam.
Glucose resultshyperglycemia / hypoglycemia.
Lifestyle interventions in patients with pre- Other illnesses, current meds and adherence,
diabetes or diabetes include MNT, and psychosocial issues / screening, lifestyle changes,
exercise for goal weight loss of 7% and smoking cessation.
attention to cardiovascular risk factors. Adjustments / problems with therapeutic regimen.
Consider Metformin in patients with pre-diabetes Symptoms suggesting development of
or an A1c 5.7-6.4% if: complications.
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o BMI >35 kg/m and/or HbA1c if treatment changes / patient not meeting
o age <60 years of age and/or goals (or twice a year if stable).
o history of gestational diabetes
Initiate metformin at diagnosis, unless Annual Exam
contraindicated; begin combination therapy if
A1C 8-10% and initiate insulin if A1C > 10% or Comprehensive visual exam.
in patients that are overtly symptomatic with Dental exam biannually
A1C < 10%. TSH if type 1 diabetes, dyslipidemia or females
Individualize therapy based upon cost, risk for >50 years of age
severe hypoglycemia, and cautions and Microalbumin measurement and creatinine
contraindications (listed in the following table). Liver panel and Lipid profile, with follow-up tests
as needed.

Special Considerations
Intercurrent Illness
If erratic glycemic control, obtain more frequent
monitoring of blood glucose and urine ketones.
If marked hyperglycemia, temporarily adjust
treatment.
If accompanied by ketosis, involve diabetes care
team.
If treated with oral glucose-lowering agents or
MNT alone, consider insulin temporarily.
Assure adequate fluid and caloric intake.
Consider hospitalization for ketosis, infection, or
dehydration.
Severe or Frequent Hypoglycemia
May be due to defective counter-regulation,
hypoglycemic unawareness, insulin dose errors,
excessive alcohol intake.
If due to therapeutic regimen of patient who
uses insulin, evaluate management plan,
readjust as needed, and provide patient / family
re-education.
Cardiovascular Disease (CVD)
Correction of obesity, smoking, hypertension,
sedentary lifestyle, dyslipidemia, poorly
regulated diabetes in addition to specific
treatment of the cardiovascular problem.
Recommend low dose (75-162mg) daily aspirin as
primary prevention for men > 50 and women > 60
years old who have one or more of the following
risk factors:
o current smoker
o hypertension
o hyperlipidemia
o family history of early CVD or albuminuria
(10 year CVD risk of > 10%)
Consider daily low dose aspirin for primary
prevention in younger patients with one or more
risk factors, or older patients without additional risk
factors. (10 year CVD risk 5-10%)
Recommend daily aspirin as secondary
prevention.
Dyslipidemia
Fasting lipid profile annually in adults unless
low-risk lipid profiles, then every 2 years.
Advise weight loss if indicated; a meal plan
designed to lower glucose levels and to alter
lipid patterns; and increased physical activity as
appropriate.
High intensity statin should be started in patients
with overt CVD or in patients 40 years of age
with 10 year CVD risk of > 7.5%.
Moderate intensity statin should be started as
primary prevention in patients 40 to 75 years of
age with an LDL 70-189.
In patients <40 years of age, estimate 10 year
CVD risk to determine if statin beneficial.
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Hypertension
Goal for adults > 18 years of age: BP
<140/90 mmHg.
ACE inhibitor or ARB preferred first line therapy.
especially in patients with kidney disease. If one
class is not tolerated, the other should be
substituted.
In African American patients, thiazide or calcium
channel blocker is preferred first line therapy.
Second line therapy is otherwise a thiazide
diuretic.
Two or more drugs at maximal dose are usually
required to achieve BP target.
Retinopathy
Screening with dilated retinal exam annually.
For type 2 diabetes, begin shortly after
diagnosis; for type 1, within 5 years of diagnosis.
Risks for retinopathy include duration of diabetes,
chronic hyperglycemia, presence of nephropathy,
hypertension.
NOTE: For retinopathy and nephropathy: Optimization
of blood sugar and blood pressure control is key to
prevention of development / progression
Nephropathy
Screening with microalbumin/creatinine ratio
annually. For type 2 diabetes, to begin shortly
after diagnosis; for type 1, within 5 years of
diagnosis.
Assess annual creatinine clearance with serum
creatinine.
In hypertensive patients, lower BP to < 140/90 to
decrease progression of diabetic nephropathy
(see hypertension section for treatment).
Institute protein-restricted meal plans designed
by a registered dietitian (0.8-1.0 gm/kg/d for
early stages and 1.0 gm/kg/d for later stages of
nephropathy).
When using ACE-I / ARB, or diuretic, monitor
creatinine and potassium; monitor urine albumin
excretion for response and progression.
Consider referral to a nephrologist.
Neuropathy
Screening for distal symmetric polyneuropathy
performed at diagnosis and annually in all patients.
Distal symmetric polyneuropathy screen using
pinprick, vibration (128-hertz tuning fork), 10-gm
monofilament, deep tendon reflexes (pick 2).
Autonomic neuropathy, screen for symptoms of
resting tachycardia, exercise intolerance,
constipation, gastroparesis, erectile dysfunction,
hypoglycemic unawareness, impaired
neurovascular function.
Consider:
o Special diagnostic testing and
consultation with medical specialist.
o Medications, alterations in MNT,
specialized procedures, and check B12
level.

Foot Care
Foot exam with every visit, including light touch,
vibratory sensation, palpation and visual
examination.
Educate about potential foot problems and
regularly reinforce lifetime surveillance and
precautions.
Risk of ulcers are increased with:
o diagnosed with diabetes for >10 years
o male
o poor glucose control
o cardiovascular, renal, neuropathic or retinal
complications
o history of previous ulcer
o severe nail pathology
o bony deformities
Consider referral to podiatrist, orthopedic
surgeon, vascular surgeon, or rehabilitation
specialist.
Referral for Diabetes Management
If desired goals not met, consider referral to
endocrinologist, co-management with diabetes
team, or enhanced education.
References
American Association of Clinical
Endocrinologists Comprehensive Diabetes
Management Algorithm 2013. Endocrine
Practice,19(1):1-48
Inzucchi SE, et al. (2012). Management of
hyperglycemia in type 2 diabetes: a patient-
centered approach: position statement of the
American Diabetes Association (ADA) and the
European Association for the Study of Diabetes
(EASD). Diabetes Care, 35(6): 1364-79.
James PA, et al. (2014). Evidence-Based
Guideline for the Management of High Blood
Pressure in Adults: Report From the Panel
Members Appointed to the Eighth Joint National
Committee (JNC 8). Journal of the American
Medical Association, 311(5):507-520.
Pignone M, et al. (2010). Aspirin for primary
prevention of cardiovascular events in people
with diabetes -- A position statement of the
American Diabetes Association, a scientific
statement of the American Heart Association,
and an expert consensus document of the
American College of Cardiology Foundation.
Diabetes Care, 33(6):1395-1402.
Standards of Medical Care in Diabetes 2014 -
Diabetes Care, 7(1) S14-80.
Stone NJ, et al. (2013). ACC/AHA Cholesterol
Guideline Panel- Treatment of blood cholesterol
to reduce atherosclerotic cardiovascular disease
risk in adults: Synopsis of the 2013 ACC/AHA
cholesterol guideline. Annals of Internal
Medicine, 160(5):339-343.
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Quality Measures
Percent of patients that receive:
o HbA1c
o Lipid panel
o Microalbumin / creatinine ratio
Percent of patients with each of the following
referrals:
o Dietary or nutrition
o Weight management
o Cardiology
o Sleep medicine
Average value quarterly:
o A1c
o blood pressure
o LDL cholesterol
o BMI
Report use of ACE inhibitor/ARB with
concomitant hypertension diagnosis
Report use of statin for >age 40.
Number of hits to guideline on EBP OneSource
website
Guideline Authors
Kathleen Dungan, MD, MPH
Benjamin ODonnell, MD
David Bradley, MD
Guideline Approved
April 23, 2014. Fourth Edition
Disclaimer: Clinical practice guidelines and algorithms at The
Ohio State University Wexner Medical Center (OSUWMC) are
standards that are intended to provide general guidance to
clinicians. Patient choice and clinician judgment must remain
central to the selection of diagnostic tests and therapy.
OSUWMCs guidelines and algorithms are reviewed
periodically for consistency with new evidence; however, new
developments may not be represented.
Copyright 2014, The Ohio State University Wexner Medical
Center. No part of this publication may be reproduced in any
form without permission in writing from The Ohio State
University Wexner Medical Center.
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Appendix: Diabetes Mellitus Medication Table

Generic Name Brand Starting Dose Max Dose Cost*

Name

Biguanides
Metformin Glucophage 250 mg p.o. bid 1000 mg p.o. bid #60 500 mg = $15 (generic)
#60 1000 mg = $25 (generic)
Sulfonylureas
Glipizide Glucotrol 5 mg/day 40 mg/day #60 5 mg = $9 (generic)
#60 10 mg = $9 (generic)
Glyburide DiaBeta, 2.5-5 mg/day in single/ 20 mg/day #30 1.25 mg = $9 (generic)
Micronase (regular) divided doses #30 2.5 mg = $7 (generic)
#30 5 mg = $7 (generic)
Gynase, PresTab 1.5-3 12 mg/day
(micronized) mg/day in single/ divided
doses
Glimepiride Amaryl 1-2 mg/day 8 mg/day #30 1 mg = $21 (generic)
#30 2 mg = $30 (generic)
#30 4 mg = $49 (generic)
Combination Agents
Metformin/ Glucovance 250 / 1.25 daily 2000/10 mg/day #60 2.5/500 mg = $82 (brand only)
glyburide #60 5/500 = $85 (brand only)
Thiazolidinediones
Pioglitazone Actos 15 mg/day 45 mg/day #30 15 mg = $180 (brand only)
#30 30 mg = $274 (brand only)
#30 45 mg = $283 (brand only)
Rosiglitazone Avandia 4 mg/day 8 mg/day #30 2 mg = $91 (brand only)
#30 4 mg = $143 (brand only)
#30 8 mg = $250 (brand only)
-Glucosidase Inhibitors
Acarbose Precose 25 tid 50-100 mg tid #90 25 mg = $74 (generic)
#90 50 mg = $79 (generic)
#90 100 mg = $81 (generic)
Miglitol Glyset 25 tid 100 mg tid #90 25 mg =$111.99
#90 50 mg = $120.00
#90 100 mg =$125.99 (brand only)
Meglitinides
Repaglinide Prandin 0.5-2 mg by mouth q.a.c. 16 mg/day #90 0.5 mg $40 (brand only)
#90 1 mg = $60 (brand only)
#90 2 mg = $60 (brand only)
Nateglinide Starlix 60 mg by mouth q.a.c. 120 mg q.a.c. #90 60 mg = $65 (generic)
#90 120 mg = $65 (generic)
DPP-4 Inhibitors/combinations
Sitagliptin Januvia 100 mg by mouth daily #30 25 mg = $305 (brand only)
#30 50 mg = $253 (brand only)
#30 100 mg = $212 (brand only)
Sitagliptin/ Janumet 50 / 500 mg bid 100 / 2000 mg/day #60 50/500 mg = $213 (brand only)
metformin #60 50 / 1000 mg = $245 (brand only)
Saxagliptin Onglyza 2.5 mg daily 5 mg daily #30 2.5 mg = $300 (brand only)
#30 5 mg = $300 (brand only)
Saxagliptin/ Kombiglyze@ 2.5 / 500 mg daily 5/1000 mg/day #60 2.5/500 mg = $209 (brand only)
Metformin
Linagliptin Tradjenta 5 mg daily 5 mg daily #30 5 mg = $300 (brand only)
GLP-1 Analogues/Receptor Mimetics
Exenatide Byetta 5 mcg SQ bid 10 mcg SQ bid #1 5 mcg pen = $275 (brand only)
#1 10 mcg pen = $340 (brand only)
Exenatide once Bydureon 2 mg SQ once weekly 2 mg SQ once
weekly weekly
Liraglutide Victoza 0.6 mg SQ daily for 1 1.8 mg/day #1 2 pens of 18 mg/3 ml solution = $384
week (brand only)
Miscellaneous
Pramlintide Smylin 60 mcg SQ q.a.c. 120 mcg SQ q.a.c. #1 5.4 ml of 1000 mcg/ml solution =
$461.64 (brand only)

*Prices obtained January 2014 from www.Drugpriceinfo.com or www.drugs.com