Classification of Diabetes

Classification of Diabetes
1. Type 1 diabetes
– β-cell destruction
2. Type 2 diabetes
– Progressive insulin secretory defect
3. Gestational Diabetes Mellitus (GDM)
4. Other specific types of diabetes due to other
causes:
– Monogenic diabetes syndromes
– Diseases of the exocrine pancreas, e.g., cystic fibrosis
– Drug- or chemical-induced diabetes
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)

≥126 mg/dL
OR
2-h plasma glucose ≥200 mg/dL
during an OGTT
OR
A1C ≥6.5%
OR
Classic diabetes symptoms + random plasma glucose
≥200 mg/dL
American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
New 2018 ADA recommendation
In conditions associated with increased

red blood cell turnover, such as sickle cell
disease, pregnancy (second and third
trimesters), hemodialysis, recent blood
loss or transfusion, or erythropoietin
therapy, only plasma blood glucose
criteria should be used to diagnose
diabetes.
Summary of Blood tests
Disease A1C Fasting blood OGTT

percent Glucose mg/dl mg/dl
Diabetes 6.5 or above 126 or above 200 or above
(Types 1 & 2)
Pre-Diabetes 5.7 – 6.4 100-125 140-199
Normal 5.0 (about) 99 or below 139 or below

Risk factors for Prediabetes and T2D
www.diabetes.org/are-you-at-risk
Recommendations: Prediabetes
• Screening for prediabetes with an informal
assessment of risk factors or validated tools
should be considered in asymptomatic adults.
• Testing should begin at age 45 for all people.
• Consider testing for prediabetes in
asymptomatic adults of any age w/ BMI ≥25 or
≥23 (in Asian Americans) who have 1 or more
additional risk factors for diabetes.
• If tests are normal, repeat at a minimum of 3-
year intervals.
Human Immunodeficiency Virus (HIV)
• Patients with HIV should be screened for

diabetes and prediabetes with a fasting glucose
level every 6–12 months before starting
antiretroviral therapy and 3 months after starting
or changing antiretroviral therapy.
• If initial screening results are normal, checking
fasting glucose every year is advised.
• If prediabetes is detected, continue to measure
fasting glucose levels every 3–6 months to
monitor for progression to diabetes.
American Diabetes Association Standards of Medical Care in Diabetes. Comprehensive Medical
Evaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Post transplantation Diabetes Mellitus (PTDM):
Recommendations
• Patients should be screened after organ

transplantation for hyperglycemia, with a formal
diagnosis of PTDM being best made once a patient
is stable on an immunosuppressive regimen and in
the absence of an acute infection.
• The OGTT is the preferred test to make a diagnosis
of PTDM.
• Immunosuppresive regimens shown to provide the
best outcomes for patient and graft survival should
be used, irrespective of PTDM risk.
Classification and Diagnosis of Diabetes:
Pre Diabetes
• The primary goal of prediabetes management is
weight loss. Aim for 7% weight loss.
• Physical activity- 150 minutes per week
• Weight loss reduces insulin resistance and can
effectively prevent progression to diabetes as
well as improve plasma lipid profile and BP
• Cardiovascular risk assessment and intervention
Pharmacologic therapy:
• metformin & acarbose are proven
• May be useful: GLP-1 but no long term data
& TZD but safety concerns
Pharmacologic Interventions for Prevention: Recommendations
• Metformin therapy for prevention of type 2

diabetes should be considered in those with
prediabetes, especially for those with BMI ≥35,
those aged <60 years, and women with prior
GDM.
– Long-term use of metformin may be associated with
biochemical vitamin B12 deficiency;
– Periodic measurement of vitamin B12 levels should
be considered .
Prevention or Delay of Type 2 Diabetes

Metabolic syndrome
• Major public health challenge
– 5X risk for DM-2
– 3X risk for CVD
• NCEP III definition, ≥ 3 of 5 characteristics
– Waist circumference; > 40 in. Male and > 35 in. female
– Serum TG ≥ 150 mg/dL
– Blood pressure ≥130/≥85 mm Hg
– HDL-C < 40 mg/dL in men and < 50 mg/dL in women
– Fasting glucose ≥ 110 mg/dL
Diabetes Prevention Program
• 3234 overweight men and women with “impaired

glucose tolerance”
• Low fat diet and 150 minutes of exercise 
reduced risk of progression to DM by 71%
• Metformin 850 mg bid reduced risk of developing
DM by 31%
– Was most effective in very obese, history of GDM, those
with highest BS
– Relatively less effective in older subjects
Complications of Diabetes
DM Complications
• Acute complications
– Diabetic ketoacidosis (DKA)
– Hyperosmolar, hyperglycemic state (HHS)
– Hypoglycemia
• Microvascular complications
– Retinopathy
– Nephropathy
– Autonomic neuropathy
• Macrovascular complications
– Coronary heart disease
– Peripheral vascular disease
– Stroke
• Infection
Prevention of complications
• Screen for and aggressively manage co-morbid
conditions
– BP < 130/80
– LDL-C < 100, HDL-C > 50, TG < 150
– ACEI or ARB for microalbuminuria
– Aspirin for those with CVD or if increased CV risk
• Early recognition and management of complications

– Comprehensive ophthalmologic exam
– Microalbuminuria
– Peripheral vascular assessment
– Cardiac stress test
– Autonomic neuropathies
• Maintain excellent glycemic control

Recommendations for Statin Treatment in People
with Diabetes
Depression: Recommendations
• Providers should consider annual screening of

all patients with diabetes, especially those with a
self-reported history of depression, for
depressive symptoms with age-appropriate
depression screening measures.
Comprehensive Medical Evaluation and Assessment of Comorbidities:

Glycemic Recommendations for Nonpregnant Adults with Diabetes
A1C <7.0%*
Preprandial capillary 80–130 mg/dL*

plasma glucose
Peak postprandial capillary plasma <180 mg/dL*
glucose†
* Goals should be individualized.

† Postprandial glucose measurements should be made 1–2 hours after the
beginning of the meal.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
A1C Goals in Adults: Recommendations
• A reasonable A1C goal for many nonpregnant adults is

<7% .
• Providers might reasonably suggest more stringent A1C
goals (such as <6.5%) for select individual patients if this
can be achieved without significant hypoglycemia or
other adverse effects of treatment (i.e., polypharmacy).
Appropriate patients might include those with short
duration of diabetes, type 2 diabetes treated with lifestyle
or metformin only, long life expectancy, or no significant
cardiovascular disease.
Glycemic Targets:
A1C Goals in Adults: Recommendations
• Less stringent goals (such as <8%) may be appropriate
for patients with a history of severe hypoglycemia,
limited life expectancy, advanced microvascular or
macrovascular complications, or long-standing diabetes
in whom the goal is difficult to achieve despite diabetes
self-management education, appropriate glucose
monitoring, and effective doses of multiple glucose-
lowering agents including insulin.
Glycemic Targets:
Glycemic Recommendations
• Postprandial glucose may be targeted if A1C

goals are not met despite reaching preprandial
glucose goals.

Approach to the Management of Hyperglycemia
more A1C less

Patient/Disease Features stringent 7% stringent
Risk of hypoglycemia/drug adverse effects
low high
Disease Duration
newly diagnosed long-standing
Life expectancy
long short
Important comorbidities
absent Few/mild severe
Established vascular complications
absent Few/mild severe
Patient attitude & expected

treatment efforts highly motivated, adherent, excellent less motivated, nonadherent, poor
self-care capabilities self-care capabilities
Resources & support system

readily available limited
Glycemic Targets:
ACP Guidance Statements for T2DM
• 1. Personalized goals for glycemic control including
patient’s preferences, costs, patient general health &
life expectancy, harms & benefits of meds,
• 2. Goal should be A1C between 7 and 8% in most
patients with T2 DM
• 3. Clinicians should consider deintensifying
pharmacologic treatment in patients who achieve an
A1C of < 6.5%
• 4. Clinicians should treat patients to minimize
symptoms of hyperglycemia and avoid targeting an
A1C in patients with life expectancy of < 10 years
due to advanced age (> 80), residence in NH or
chronic conditions (dementia, cancer, ESRD, severe
COPD or HF) because harms outweigh benefits
T1DM
• Onset
• 10–14 years of age
• acute onset over days to weeks
• RF: other autoimmune disorders
• Symptomatic hyperglycemia
• Random glucose > 200; ketonemia
• A1c ≥ 6.5%
Diabetes Mellitus Type 1
Management T1 DM
• Activity and Nutrition
– Carb counting
• Home blood glucose monitoring
– Before and after meals and at bedtime
• Insulin
– Basal insulin
– Prandial insulin
Replacement insulin
• Recombinant human insulin or insulin analogs
– Basal insulin replacement
• Long and intermediate acting: glargine (Lantus) , detemir
(Levemir) and NPH
– Prandial insulin replacement
• Rapid acting: lispro (Humalog) , aspart (Novolog) ,
• Short acting: regular insulin
– Premixed insulin
• 70/30 (70% NPH 30% Regular)
• 75/25 mix (75% lPH, 25% lispro)
– Long-Acting newer Insulins
• Glargine U-300 (Toujeo)
• Degludec
Insulin characteristics
Insulin Onset Peak Duration
Lispro, aspart, 5-15 minutes 1-1.5 hours 3-4 hours
glulisine
Regular 30-60 minutes 2 hours 6-8 hours
NPH 2-4 hours 6-7 hours 10-20 hours
Glargine 1.5 hours Flat ~ 24 hours
Detemir 1 hour Flat 17 hours
Pre-mixed:
70/30 70% NPH and 30% regular
75/25 75% NPL and 25% lispro
50/50 50% NPL and 50% lispro
Rx Protocols
• Basal-bolus therapy
– Total insulin dose = 0.3 to 0.6 U/kg daily
– 50% of total given as long-acting at bedtime
– 50% of rapid-acting or regular insulin divided equally before
meals
– If NPH, then 30% of total dose as NPH at bedtime, 30% of
total dose as rapid-acting insulin before breakfast and 20%
before lunch and dinner
• Insulin pump – continuous, subcutaneous
insulin infusion; continuous preprogrammed
basal rate and bolus dosages for meals
– Only rapid acting insulin
– Bolus dose for meal coverage requires carb counting and
dose adjustment
Pramlintide
• FDA approved for T1DM
• Amylin analog
• Delays gastric emptying, blunts pancreatic
glucose secretion, enhances satiety
• Induces weight loss, lowers insulin dose
• Requires reduction in prandial insulin to reduce
risk of severe hypos

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
T1DM: Pancreas and Islet Transplantation
• Can normalize glucose but require lifelong
immunosuppression.
• Reserve pancreas transplantation for T1D
patients:
– Undergoing simultaneous renal transplantation
– Following renal transplant
– With recurrent ketoacidosis or severe hypoglycemia
Pharmacologic Approaches to Glycemic Treatment:

T1DM: Investigational Agents
• Metformin
• Incretin-Based Therapies
– Glucagon-Like Peptide 1 (GLP-1) Receptor Agonists
– Dipeptidyl Peptidase 4 (DPP-4) Inhibitors
• Sodium-Glucose Cotransporter 2 (SGLT2)
Inhibitors

T2DM
• Onset: usually > 45 years
• RF: Age, ***obesity, HTN, physical inactivity and
family history
– Metabolic syndrome; polycystic ovary syndrome (PCOS)
• Signs and symptoms: May be asymptomatic,
chronic skin infections, poor wound healing,
acanthosis nigrans
• Lab: A1c ≥ 6.5%; FPG ≥ 126; random glucose ≥
200 with symptoms of hyperglycemia
Recommendations: Testing for Type 2 Diabetes
• Screening for type 2 diabetes - assess risk factors or
in asymptomatic adults.
• Consider testing in asymptomatic adults of any age
with BMI ≥25 or ≥23 in Asian Americans who have 1
or more add’l DM risk factors.
• For all patients, testing should begin at age 45
years.
• If tests are normal, repeat testing carried out at a
minimum of 3-year intervals is reasonable.

Pathophysiology T2DM
• Insulin resistance – defect in muscle and fat cell use
of insulin
• Decreased pancreatic insulin secretion
• Increased glucagon production
• Incretin hormones
– GLP-1 and GIP- Released from neuroendocrine cells of GI tract in
response to food ingestion
– They Amplify glucose stimulated insulin release from pancreas
– These hormones are decreased in T2DM so less insulin secretion
• Deranged adipocyte biology

Lifestyle Management
Diabetes self management education & support;
Nutrition
Activity
Monitoring
Medications
Recommendations: Nutrition
● For people with T2D on a flexible insulin program,

education on carb counting and, in some cases, fat and
protein gram estimation can improve glycemic control.
● For people whose daily insulin dosing is fixed, a
consistent pattern of carb intake can result in improved
glycemic control and a reduced risk of hypoglycemia.

Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Protein:
• In individuals with type 2 diabetes, ingested protein
appears to increase insulin response without
increasing plasma glucose concentrations.
Therefore, carbohydrate sources high in protein
should not be used to treat or prevent hypoglycemia.

Micronutrients and herbal supplements:
• There is no clear evidence that dietary
supplementation with vitamins, minerals, herbs, or
spices can improve diabetes, and there may be
safety concerns regarding the long-term use of
antioxidant supplements such as vitamins E and C
and carotene.

Nonnutritive sweeteners:
• The use of nonnutritive sweeteners has the potential
to reduce overall calorie and carbohydrate intake if
substituted for caloric sweeteners and without
compensation by intake of additional calories from
other food sources. Nonnutritive sweeteners are
generally safe to use within the defined acceptable
daily intake levels.

Recommendations: Glucose Monitoring
• Most patients on multiple-dose insulin or insulin

pump therapy should do SMBG
– Prior to meals and snacks
– At bedtime
– Prior to exercise
– When they suspect low blood glucose
– After treating low blood glucose until they are
normoglycemic
– Prior to critical tasks such as driving
– Occasionally postprandially
Recommendations: Glycemic Goals in Adults
• A reasonable A1C goal for many nonpregnant adults is
<7% .
• Consider more stringent goals (e.g. <6.5%) for select
patients if achievable without significant hypos or other
adverse effects.
• Consider less stringent goals (e.g. <8%) for patients with
a history of severe hypoglycemia, limited life expectancy,
or other conditions that make <7% difficult to attain.

Pharmacologic
Approaches
to
T2DM Treatment
Treatment
• Categories of Medications
– *Biguanides
– Sulfonylureas
– TZDs
– Alpha-glucosidase inhibitors
– Pramlintide
– Incretin therapy; DPP-4 inhibitors & GLP-1 receptor
agonists
– SGLT2 inhibitors
Pharmacologic Therapy For T2DM: Recommendations
• **Metformin, if not contraindicated, is the

preferred initial pharmacologic agent for the
treatment of T2DM.
• Long-term use of metformin may be associated
with biochemical vitamin B12 deficiency,
– Long-term use of metformin may be associated with
biochemical vitamin B12 deficiency;
– Periodic measurement of vitamin B12 levels should
be considered .

Pharmacologic Therapy For T2DM: Recommendations (2)
• Consider initiating insulin therapy (with or

without additional agents) in patients with newly
diagnosed T2DM who are symptomatic and/or
have A1C >10% and/or blood glucose levels
≥300 mg/dL.
• Consider initiating dual therapy in patients with
newly diagnosed T2DM who have A1C >9%.

• In patients without atherosclerotic cardiovascular

disease (ASCVD), if monotherapy or dual
therapy does not achieve or maintain the A1C
goal over 3 months, add an additional
antihyperglycemic agent based on drug-specific
and patient factors
• A patient-centered approach should be used to
guide the choice of pharmacologic agents.
Considerations include efficacy, hypoglycemia
risk, history of ASCVD, impact on weight,
potential side effects, renal effects, delivery
method, cost, and patient preferences.
• In patients with T2DM and established ASCVD,

antihyperglycemic therapy should begin with lifestyle
management and metformin and subsequently
incorporate an agent proven to reduce major adverse
CV events and CV mortality (currently empagliflozin
and liraglutide) .
• In patients with T2DM and established ASCVD, after
lifestyle management and metformin, Canagliflozin
may be considered to reduce major adverse CV
events, based on drug-specific and patient factors
Antihyperglycemic Therapy in Adults with T2DM


harmacologic Approaches to Glycemic Treatment:

andards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85
Combination Injectable therapy in T2DM

Metformin
• Reduces hepatic glucose production

– HbA1c reduction 1% – 2%
– *No hypogylcemia
– *Neutral weight gain
– *Check renal and liver function
– Hold day of procedure and until serum creatinine
normal (or 48 hours)
– May use in patients with stable CHF, if renal function
is normal.
– Avoid in unstable or hospitalized patients with CHF.
Insulin secretagogues
Stimulate pancreatic secretion of insulin, which
reduces hepatic glucose production, and increases
muscle uptake of glucose
• Sulfonylureas (glyburide, glipizide, glimepiride)
– Typically 2 x day dosing except glimepiride
– HbA1c reduction 1% – 2%
– *Weight gain and hypoglycemia
– Caution with liver or renal dysfunction
Thiazolidinediones (TZDs)
• Insulin sensitizers, move glucose into cell
– Rosiglitazone (Avandia) and Pioglitazone (Actos)
– HbA1c reduction 1.0 – 1.5%
– *No hypoglycemia; + effect on lipid profile
– Weight gain and fluid retention. Liver dysfunction
– 1 or 2 x day; 8 to 12 weeks to achieve maximal effect
– Contraindicated with HF (Stage III and IV); possible
risk for cardiac ischemia
• FDA warning Summer 2010. Rosiglitazone
(Avandia) limited to patients who cannot be
managed with other meds
Glucagon-Like Peptide 1 (GLP-1) receptor
agonists (incretin analogs)
• Exenatide (Byetta), Liraglutide

(Victoza),Dulaglutide (Trulicity)
• All injectionables
– Enhance post-prandial insulin release, slow gastric
absorption and promote satiety, reduce glucagon
production
– Weight loss
– No hypoglycemia
– HbA1c reduction 1.0%
• *Greatest reduction in post-prandial glucose levels
– Initial nausea experienced by most
– All contraindicated with medullary thyroid cancer or
multiple endocrine neoplasia syndrome
– All have possible association with pancreatitis
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
• Sitagliptin (Januvia) and saxagliptin (Onglyza)
– Enhance insulin secretion and reduce hepatic glucose
output
– Weight neutral
– Daily dosing
– HbA1c reduction 0.7% to 1.4%
– Greater effect on post-prandial than fasting glucose
levels
– Most common side effect: headache and
nasopharyngitis.
– May be associated with pancreatitis, pancreatic
cancer & thyroid cancer
– FDA warning about onglyza with HF patients
SGLT2 Inhibitors=
Sodium glucose cotransporter 2 inhibitors
Canagliflozin (Invokana), dapagliflozin (Forxiga)
Empagiflozin (Jardiance) & ertugliflozin (steglatro)
• ** Decrease re-uptake of glucose by the kidney
• Increases muscle insulin sensitivity and insulin-
mediated tissue glucose disposal, and lower
FPG levels
• New FDA (12/15) warning about serious UTI &
ketoacidosis
New Recommendation: Pharmacologic Therapy For
T2DM
• In patients with long-standing suboptimally
controlled type 2 diabetes and established
atherosclerotic cardiovascular disease,
empagliflozin or liraglutide should be considered
as they have been shown to reduce
cardiovascular and all-cause mortality when
added to standard care. Ongoing studies are
investigating the cardiovascular benefits of other
agents in these drug classes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
Metformin + 2nd agent
• Denmark study 4700+ patients already on
metformin, Added 2nd agent; SU, DPP-4
inhibitors, GLP-1 receptor agonists, insulin or
another agent (undefined)
• Measured proportion reaching A1c< 7%:
59% SU, 59% DPP-4, 62% GLP-1, 42% insulin , 50% for
“other” category
Bottom Line
• Begin with Metformin unless contraindicated
• Add another oral agent or Basal insulin based on
patient characteristics (weight, hypoglycemic risk,
cost, pt preference). With ASCVD; preferentially add
liraglutide or empagliflozin
• Can combine basal + prandial insulin or basal +
GLP-1 when you need to intensify insulin regimen
• To Avoid hypoglycemia: TZD, DPP-4, GLP-1 7
SGLT2
• To avoid weight gain: DPP-4, GLP-1, SGLT2
• To reduce cost: SU, TZD, Insulin
Management in Older Adults , 2
• Adjust A1C goal based on patient’s overall
health status. Determine targets & therapeutic
approaches by assessment of medical,
functional, mental, and social geriatric domains.
• Control CV risk factors; HTN, hyperlipidemia,
• Screen for depression, cognitive function
• Medical nutrition therapy and diabetes education
are Medicare benefits
• Low-impact exercise
• Prevent Hyperglycemic Hyperosmolar State
• Avoid hypoglycemia!!
DM Management in Older Adults
Considerations with Oral agents;
– Metformin; renal dz, HF
– TZDs- HF, fractures
– Secretagogues- Hypoglycemia
– Insulin- hypoglycemia, technical difficulties
– Incretin Based therapies- technical issues with GLP-1
receptor agonists. Cost of both
– SGLT2 inhibitors- no long term data
Overweight/Obesity Treatment Options in T2DM
Body Mass Index (BMI) Category (kg/m2)

25.0-26.9 27.0-29.9 30.0-34.9 35.0-39.9 ≥40
Treatment (or 23.0-26.9*) (or 27.5-32.4*) (or 32.5-37.4*) (or ≥37.5*)
Diet,
physical activity & ┼ ┼ ┼ ┼ ┼
behavioral therapy
Pharmacotherapy
┼ ┼ ┼ ┼
Metabolic surgery
┼ ┼ ┼
* Cutoff points for Asian-American individuals.

┼ Treatment may be indicated for selected, motivated patients.
Obesity Management for the Treatment of Type 2 Diabetes:
Diabetes Care
in the Hospital
What makes glucose control difficult in the
hospital setting?
Diabetes Care in the Hospital: Recommendations
• Perform an A1C on all patients with diabetes or

hyperglycemia (BG > 140) admitted to the hospital
if not performed in the prior 3 months.
• All patients should have order for glucose
monitoring
– Eating: pre-meal and at bedtime
– NPO: Q 4–6 hours for insulin adjustment
• Insulin should be administered using validated

written or computerized protocols.
Diabetes Care in the Hospital:
Recommendations: Diabetes Care in the Hospital
• Insulin therapy should be initiated for treatment of

persistent hyperglycemia starting at a threshold
≥180 mg/dL. Then a target glucose of 140–180
mg/dL is recommended for the majority of critically
ill and noncritically ill patients.
• More stringent goals, such as 110-140 mg/dL,
may be appropriate for selected patients, if this
can be achieved without significant hypoglycemia
American Diabetes Association. Standards of Medical Care in Diabetes.
Diabetes care in the hospital. Diabetes Care 2018
Recommendations: Diabetes Care in the Hospital
• Basal insulin or basal + bolus correction regimen is

the preferred treatment for noncritically ill patients
with poor oral intake or those who are taking
nothing by mouth.
• An insulin regimen with basal, nutritional &
correction components is the preferred treatment
for noncritically ill patients with good nutritional
intake.
• The sole use of sliding scale insulin in the
inpatient hospital setting is strongly discouraged.
American Diabetes Association. Standards of Medical Care in Diabetes.
Diabetes care in the hospital. Diabetes Care 2017;40(Suppl. 1):S120–S127
General rules
• Evening before surgery;
– Insulin pump; can have usual basal rate.

– Then cover with short-acting insulin prn
– Consider 10-20% reduction in usual dose of basal

insulin (glargine or detemir) . If NPH is given at
bedtime, consider a 50% reduction in dose
– Cover with short-acting insulin prn
periop
Pre-anesthesia area:
Start IV insulin for patients undergoing major surgery
Major surgery includes; chest or abdominal cavity, vascular
bypass, transplant, spinal or brain surgery requiring general
anesthesia, total hip or knee replacement, surgery
anticipated to be longer than 4 hours. (joslin rec)
Intraop
monitor BG q 2hrs
IVF without dextrose
If IV insulin needed use a D5W at KVO to provide glucose
Non-Major surgery-. If BG > 180 begin IV regular insulin
Major surgery- IV insulin.
??
• Which factor is not important when choosing
another oral agent to use in combination with
metformin?
• A. mechanism of action is similar to metformin
• B. Dosing frequency
• C. Impact on FPG and PPG levels.
• D. consideration of hypoglycemia risk with oral
agents
?
• Jack is a 52 yo construction worker who operates heavy machinery

with T2DM dx’d 1 yr ago. Hx of prior smoking, + Fh of DM. Jack
tells you he’s not ready for any injections!
• Meds; Metformin 750 mg bid, lisinopril 10 mg daily & simvastatin 10
mg daily
• BMI 29 BP 135/83 A1C 7.4% creat 0.9 FPG 135
• How would you adjust his regimen?

• A. Add Insulin
• B. Add Glipizide
• C. Add a TZD
• D. Add GLP-1
?
• At Jack’s next visit 3 mo later his A1c is 6.6% but
he complains he’s gained some weight.
• He’s not sure about TZD as there’s been reports
on Tv of risk of bone fx and bladder cancer.
• How would you adjust his regimen?
• A. decrease TZD dose
• B. D/c TZD, initiate DPP-4
• C. D/C TZD, initiate insulin
• D. Initiate triple therapy with TZD, metformin &
DPP-4
Extra questions
• Damian is a 58-year-old Hispanic male with a 12-year history
of type 2 diabetes, hypertension and dyslipidemia who comes
in for a follow-up appointment. His medications include
metformin 1000 mg BID, enalapril 20 mg BID, HCTZ 25 mg
BID and simvastatin 40 mg QHS. He has no evidence of CVD
or other medical problems. He states that he was told to
check his blood glucose levels with a meter twice daily, but
only checks sporadically, usually in the morning before
breakfast. He says that when he checks his blood glucose
levels, they are always "good," but did not bring the meter or
any numbers with him to the clinic. His weight has increased
by 10 lb since the last visit (BMI 32). His A1C today is 8.3%.
• What is the most appropriate A1C goal for this patient?
•
• < 6.5, < 7, < 7.5, < 8 , < 8.5

Damian
• What is the best pharmacologic option for lowering
Damian’s blood glucose?
• Discontinue metformin and initiate a sulfonylurea

• Discontinue metformin and initiate a long-acting
insulin in the evening
• Add another oral anti-hyperglycemic agent to his
metformin
• Add a rapid-acting insulin analogue to his metformin
• Reinforce lifestyle (diet and increased physical
activity) and have him return in 6 months
• Which class of anti-hyperglycemic agent is NOT
associated with weight gain? SATA
• Long-acting insulin
• SGLT-2 inhibitors
• Sulfonylureas
• DPP-4 inhibitors
• 2 and 4
??
• A 72 yo man with HTN, prior MI, mild HF, and renal impairment
(creat 1.6) and a BMI of 32 kg/m2 presents with newly diagnosed
T2DM and an A1C of 7.4%. Which of the following oral
antihyperglycemic therapies would you recommend?
• A. Metformin
• B. DPP-4 inhibitor
• C. TZD
• D. SU
Hospital case
• A 75-year-old with a 35-year history of T2DM presents to the ED
with progressive shortness of breath, orthopnea, and peripheral
edema during the past week.
• PMH: CABG 10 years ago, HTN, and hyperlipidemia.
• He denies recent chest pain or angina.
• PE: BP 152/88 mmHg, HR 88, RR18 .
• Bilateral crackles at both lung bases, peripheral edema, and S3
gallop.
• CXR + evidence of congestive heart failure. An echocardiogram
revealed an ejection fraction of 38% and dilated cardiomyopathy.
After ruling out acute myocardial infarction, he responded to heart
failure treatment with diuretics, ACE-inhibitors, low-dose beta-
blockers, and statin therapy.
• The admission glucose was 168 mg/dl; HbA1c was 7.2%. His
antidiabetic therapy included saxagliptin 5 mg/day and glargine 25
units in the morning. During the hospital stay, his blood glucose
were between 80 and 180 mg/dl on glargine 22 units and Humalog 6
units before meals. The patient is ready to be discharged.
What to do?
• Restart previous antidiabetic regimen with saxagliptin
and glargine
• b. Continue glargine at pre-admission dose and start

empaglifozin 10 mg day
• c. Discharge on basal bolus regimen at same hospital

dose
• d. Discharge on sitagliptin/metformin 50/1000 twice daily
• e. Continue preadmission therapy with saxagliptin 5

mg/day and glargine 25 units and add low-dose
metformin at 500 mg twice daily
Case #2
• 38 y.o. woman in for follow-up T2DM
– Meds: metformin 1000 mg BID x 1 year, benazepril 40 mg,
simvastatin 10 mg
– Home BGs
• Fasting 120–160
• Post-prandial 190–300
– ROS: neg except nocturia x 2/night
– Wgt: 221; BMI 37
– Vitals: 138/92
– Labs: TC 189, TG 435, HDL 23, LDL direct 80; TSH 2.2,
creatinine 0.9
• Thoughts? Concerns? Plans?
Case 3
Pete, 45 yo male with T2DM, diagnosed 2 years ago.. 10 yr hx of HTN.
+ FH for DM. On metformin 1500 mg/day. Pt has strong dislike of
injections.
BMI 32. BP 150/80 (takes Enalapril 30 mg/day)
Labs: A1C 7.8%. FPG 155 GFR nl LDL 105
What is target A1c?

What to do??
Pete is worried about weight gain!
Case 4
• 76 y o widow, lives alone. T2DM diagnosed 16 yrs ago. No history of CV events.
Mild neuropathy in her toes. 2 episodes of hypoglycemia in past month. Found
unconscious at 5 pm 2 days ago, treated by paramedics. BS at that time 38,
treated with glucagon.
• BMI 31
• Labs; SMBG 50-300
• A1C 8.7%
• GFR 55, Creat 1.1
• Her Meds: Metformin 500 mg bid
• Glimepiride 4 mg daily
• NPH Insulin 15 U @ 6 am and 10 pm.
• Zestril 5 mg daily
• Lipitor 20 mg daily
• What to Do??
• What is appropriate A1C goal for this woman??
Case #5
• 78 y.o. woman admitted from her assisted living
facility with chest pain. PMH of T2DM treated
with Lantus 18 units at HS and Humalog 2 units
before meals. En route FSBG = 48; received 15
gm CHO. ED labs, glucose 98.
• What do you think?
• Would you make any changes to her regimen?
Case study 6
• 69 yo male withn5 yr hx of T2DM. He has been trying to lose weight
and increase his exercise for the past 6 months without success. He
had been started on glyburide (Diabeta), 2.5 mg every morning, but
had stopped taking it because of dizziness, often accompanied by
sweating and a feeling of mild agitation, in the late afternoon.
• He also takes Lipitor 10 mg daily. He does not test his blood glucose
levels at home and expresses doubt that this procedure would help
him improve his diabetes control.
• During the past year, A.B. has gained 22 lb. Since retiring, he has
been more physically active, playing golf once a week and
gardening, but he has been unable to lose more than 2–3 lb. He has
never seen a dietitian and has not been instructed in self-monitoring
of blood glucose (SMBG). By self reports, his diet is rich in carbs.
his hemoglobin A1c (A1C) has never been <8%. His blood pressure
has been measured at 150/70, 148/92, and 166/88 at previous office
visits.
Case 6
• Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6
kg/m2
• Fasting capillary glucose: 166 mg/dl
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right
arm 140/90 mmHg
• Pulse: 88 bpm; respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and
accommodation, Fundi-clear, no arteriolovenous nicking, no
retinopathy
• Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and
dorsalis pedis pulses 2+ bilaterally
• Neurological assessment: diminished vibratory sense to the
forefoot, absent ankle reflexes, monofilament felt only above
the ankle
Case 6
• Labs: BUN 18 Creat 1.0 Na 141 K 4.3
• FBG 178
• LDL 84 HDL 43 TG 177
• A1C 8.1
• LFTS WNL
• Urine microalbuminuria 45 mg (nl < 30)
• PLAN??
Case,
• At d/c pt discontinued linagliptin. He continued
pio and lira. He will f/u to get a recheck on his
creatinine and GFR to determine if he can
restart metformin 500 mg bid

Classification of Diabetes

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Classification of Diabetes

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Classification of Diabetes

Fasting plasma glucose (FPG)

American Diabetes Association Standards of Medical Care in Diabetes.

In conditions associated with increased

Disease A1C Fasting blood OGTT

Pre-Diabetes 5.7 – 6.4 100-125 140-199

Normal 5.0 (about) 99 or below 139 or below

• Patients with HIV should be screened for

• Patients should be screened after organ

• Metformin therapy for prevention of type 2

Prevention or Delay of Type 2 Diabetes

• 3234 overweight men and women with “impaired

• Early recognition and management of complications

• Maintain excellent glycemic control

• Providers should consider annual screening of

Comprehensive Medical Evaluation and Assessment of Comorbidities:

Preprandial capillary 80–130 mg/dL*

* Goals should be individualized.

American Diabetes Association Standards of Medical Care in Diabetes.

• A reasonable A1C goal for many nonpregnant adults is

• Postprandial glucose may be targeted if A1C

American Diabetes Association Standards of Medical Care in Diabetes.

more A1C less

Patient attitude & expected

Resources & support system

American Diabetes Association Standards of Medical Care in Diabetes.

Pharmacologic Approaches to Glycemic Treatment:

Pharmacologic Approaches to Glycemic Treatment:

American Diabetes Association Standards of Medical Care in Diabetes.

• Deranged adipocyte biology

● For people with T2D on a flexible insulin program,

American Diabetes Association Standards of Medical Care in Diabetes.

American Diabetes Association Standards of Medical Care in Diabetes.

American Diabetes Association Standards of Medical Care in Diabetes.

American Diabetes Association Standards of Medical Care in Diabetes.

• Most patients on multiple-dose insulin or insulin

American Diabetes Association Standards of Medical Care in Diabetes.

• **Metformin, if not contraindicated, is the

Pharmacologic Approaches to Glycemic Treatment:

• Consider initiating insulin therapy (with or

Pharmacologic Approaches to Glycemic Treatment:

• In patients without atherosclerotic cardiovascular

• In patients with T2DM and established ASCVD,

Pharmacologic Approaches to Glycemic Treatment:

Pharmacologic Approaches to Glycemic Treatment:

harmacologic Approaches to Glycemic Treatment:

Pharmacologic Approaches to Glycemic Treatment:

• Reduces hepatic glucose production

• Exenatide (Byetta), Liraglutide

American Diabetes Association Standards of Medical Care in Diabetes.

Body Mass Index (BMI) Category (kg/m2)

* Cutoff points for Asian-American individuals.

• Perform an A1C on all patients with diabetes or

• Insulin should be administered using validated

• Insulin therapy should be initiated for treatment of

• Basal insulin or basal + bolus correction regimen is

• Evening before surgery;

– Insulin pump; can have usual basal rate.