Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation
Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation
Type 2 Diabetes Adult Outpatient Insulin Guidelines - CMA Foundation
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3<br />
Comprehensive<br />
Management of<br />
<strong>Type</strong> 2 <strong>Diabetes</strong><br />
<strong>Diabetes</strong> Care <strong>Guidelines</strong>/Flow Sheet<br />
Achieving Glycemic Control<br />
• A1c Recommendations<br />
• Blood Glucose Level Goals<br />
• Recommended Blood Glucose Treatment Goals<br />
• Monitoring Blood Glucose Levels<br />
• Proper Disposal of Syringes and Needles<br />
• Patient Logs and Worksheets<br />
• Pharmacotherapy for <strong>Diabetes</strong><br />
• Hypoglycemia<br />
Clinical Management of Hypertension<br />
• Target Blood Pressures and Self Measurement<br />
• Hypertension Treatment Algorithm, Initial Drug Choices<br />
• Pharmacotherapy for Hypertension<br />
• JNC 7 Reference Card<br />
Clinical Management of Dyslipidemia<br />
• Target <strong>Adult</strong> Cholesterol Levels<br />
• Classification of Lipid Profile<br />
• Pharmacotherapy for Dyslipidemia<br />
• ATP III At-A-Glance: Quick Desk Reference<br />
Lifestyle Interventions and Modifications<br />
• Recommended Lifestyle Modifications<br />
• Weight Loss/Maintenance<br />
• Medical Nutrition Therapy (MNT)<br />
• General Nutritional Recommendations for <strong>Diabetes</strong><br />
o Nutritional Recommendations for Weight Loss In <strong>Diabetes</strong><br />
o Physical Activity and Exercise In <strong>Diabetes</strong><br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 19
Comprehensive Management<br />
While achieving glycemic control early in the course of the disease is critical to reducing serious<br />
long term complications, so is having good control of lipids and blood pressure. Unfortunately,<br />
many people with diabetes struggle with achieving target control levels of this clinical triad.<br />
Comprehensive management of diabetes means addressing the management of blood glucose,<br />
blood pressure and lipids for all patients with diabetes to reduce the risk of common comorbidities<br />
such as heart attack, congestive heart failure and chronic kidney disease. 8<br />
This approach is supported by recently released guidelines of the American Association of Clinical<br />
Endocrinology, which also emphasize a personalized approach to care that includes consideration<br />
of patient risk factors, comorbid conditions, expected life span, and psychological, social and<br />
economic status.<br />
<strong>Diabetes</strong> Care <strong>Guidelines</strong>/Flow Sheet 2,9<br />
Individuals with diabetes should receive regular office visit exams and tests according to the<br />
following schedule:<br />
20 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TAbLe 13 <strong>Diabetes</strong> Care <strong>Guidelines</strong>/Flow Sheet<br />
Clinical<br />
Priorities<br />
History,<br />
Physical<br />
and<br />
Emotional<br />
General<br />
Care<br />
Parameters Frequency Goal/ Recommendation Date/<br />
Results:<br />
Blood Pressure Every Visit
Achieving Glycemic Control<br />
A1c Recommendations<br />
Studies have demonstrated that A1c is a strong predictor of future diabetes complications.<br />
Recent studies confirm that the A1c closely represents the average glucose over the last 3<br />
months. The table below correlates A1c with estimated average glucose. A calculator can<br />
be used to covert A1c results into estimated average glucose (eAG) at http://professional.<br />
diabetes.org/GlucoseCalculator.aspx.<br />
Note that the A1c can be affected by conditions that affect red blood cell turnover (such<br />
as anemia and hemoglobinopathies like sickle cell disease), which needs to taken into<br />
consideration especially when the A1c result does not correlate with the patient’s clinical<br />
situation or home monitored glucose levels.<br />
TAbLe 14 Correlation of A1c to Mean blood Glucose Values<br />
Table 14: Correlation of A1c to mean Blood Glucose Values<br />
A1c % estimated Average Glucose (eAG)<br />
mg/dL<br />
6 126<br />
7 154<br />
8 183<br />
9 212<br />
10 240<br />
11 269<br />
12 298<br />
The American <strong>Diabetes</strong> Association recommends that patients have A1c done at least every 6<br />
months if they have stable glucose levels that are at goal, and every 3 months in patients who are<br />
not at goal or who are changing therapy.<br />
Blood Glucose Level Goals<br />
The A1c goal for most adult patients with diabetes should be < 7.0%, in order to decrease the long<br />
term risk of complications.<br />
Some patients with long life expectancy, and no significant CVD may benefit from an even lower<br />
A1c goal (such as < 6.5%) due to evidence of a small incremental<br />
improvement of microvascular outcomes. 8<br />
22 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TAbLe 15 Recommended blood Glucose Treatment Goals<br />
Table 15: Recommended Blood Glucose Treatment Goals<br />
HgA1c < 7 7%<br />
%<br />
Monitoring Blood Glucose Levels<br />
FPG/Preprandial (before meals) 70-130 mg/dl<br />
Peak postprandial (1-2 hours<br />
after meals)<br />
Difference between preprandial<br />
and 1-2 hour postprandial<br />
Keeping blood glucose levels within a normal range is the principal goal of having patients check<br />
their blood sugar levels on a daily basis using a home meter. Patients who benefit should be<br />
encouraged to use their home glucose meters as a self-management tool to help them keep<br />
adequate control over sugar levels and minimize the risk of disease-related complications.<br />
There are many different types of blood glucose monitoring devices available on the market today.<br />
Consider the following tips when discussing glucometer options.<br />
• In most cases, the meter options and decision about what meter to use will be affected by<br />
insurance coverage. Patients should be advised to contact their health plan to find out what<br />
materials and supplies are covered.<br />
• Patients need to understand how to use their meter. They should be trained before leaving the<br />
office or referred to a certified diabetes educator for full instruction. They should also be referred<br />
to the glucometer’s website for further information. In addition, some pharmacists are able to<br />
provide point of service training on how to use personal blood glucose meters<br />
• Recommend keeping logs or a diary of blood glucose results to be reviewed at the next visit.<br />
• Patients should bring their personal meters and log books with them to every office visit.<br />
While regular monitoring of blood glucose values takes commitment on the patient’s part and is<br />
expensive, testing can help patients identify patterns, respond quickly to high or low blood sugar<br />
levels, learn how food and exercise affects sugar levels, and make appropriate lifestyle adjustments<br />
to achieve better control.<br />
Examples of common blood glucose testing times:<br />
• Immediately after waking up<br />
• Before meals<br />
• 1 to 2 hours after meals<br />
• Before and after exercising<br />
• Before driving a vehicle<br />
• At bedtime<br />
• As necessary during the night<br />
• More frequently during illness or stress (4-6 hours)<br />
< 180 mg/dl<br />
< 30-50 mg/dl<br />
* Note: higher or lower goals may be appropriate for individual<br />
patients. Goals should be individualized based on duration of<br />
diabetes, age/life expectancy, comorbid conditions, known CVD or<br />
advanced microvascular complications, hypoglycemia unawareness,<br />
individual patient considerations.<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 23<br />
Comprehensive<br />
management of<br />
type 2 diabetes
Notes:<br />
• Patients on multiple daily doses of insulin should generally check at least 3-4 times per day.<br />
• Patients who are not on insulin may consider choosing an occasional meal and check both<br />
before and 1-2 hours after that meal, to see how the content of the meal affects the glucose<br />
levels.<br />
Recommend immediate checking of blood sugar levels using a personal meter if the patient thinks<br />
their blood sugar is low or they experience any of the following signs:<br />
• Weakness<br />
• Fatigue<br />
• Dizziness or shakiness<br />
• Excessive sweating<br />
• Fast heart rate<br />
• Headache<br />
• Hunger<br />
• Nervousness or irritability<br />
• Blurred vision<br />
Common patient barriers to using personal blood glucose meters and routine monitoring include:<br />
• Test strips can be expensive. Some insurance providers limit the number of strips patients can<br />
purchase each month.<br />
• Need to have testing supplies on hand.<br />
• Testing can be inconvenient and interrupt daily activities.<br />
• Fingersticks can cause pain and discomfort. (Many meters can be used painlessly in alternate<br />
sites. Patients should check their glucometer instruction manual.)<br />
• Monitoring is a constant reminder of the diagnosis.<br />
• Fear that elevated results mean their diabetes is worse or insulin is needed.<br />
• Belief that results place judgment on self-management efforts.<br />
24 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
Proper Disposal of Syringes and Needles<br />
On September 1, 2008 a new California law went into effect prohibiting the disposal of home<br />
generated sharps waste in California residents’ trash or recycling containers and requiring that all<br />
such waste be transported to a collection center in an approved sharps container. This includes<br />
needles, pen needles, intravenous needles, lancets and other devices that are used to penetrate<br />
the skin for medication administration. 27<br />
Table 16: Household Sharps Waste Disposal Options<br />
TAbLe 16 Household Sharps Waste Disposal Options<br />
Pharmacies<br />
Hospitals<br />
Local Household<br />
Hazardous Waste<br />
Programs<br />
Mail-Back Service<br />
You can also look for<br />
this information here<br />
Local jurisdictions’<br />
sharps collection<br />
programs<br />
Collection programs<br />
Some drug stores take back their customers’ needles, especially in small<br />
quantities<br />
Hospitals may take back sharps from patients using regular outpatient<br />
services<br />
Call your local household hazardous waste agency and ask if they collect<br />
needles (sharps) at their collection facilities or on household hazardous<br />
waste days<br />
A list of sharps waste mail-back services authorized for use in California is<br />
available from the California Department Of Public Health (CDPH) at<br />
http://www.cdph.ca.gov/certlic/medicalwaste/Pages/MailBackSharps.aspx<br />
Your local white pages’ government section may list your city’s or county’s<br />
household hazardous waste department<br />
Visit the Earth 911.org at http://earth911.com/website or call 1-800-<br />
CLEANUP (1-800-253-2687), a service of Earth 911<br />
Visit the Local Enforcement Agency Directory at<br />
http://www.calrecycle.ca.gov/LEA/Directory/default.asp<br />
Sharps and Medication Disposal Directory at<br />
http://www.calrecycle.ca.gov/HomeHazWaste/HealthCare/Collection<br />
Local Jurisdiction Sharps Collection Programs at<br />
http://www.calrecycle.ca.gov/HomeHazWaste/Sharps/LocatorProgrm.pdf<br />
This spreadsheet could help jurisdictions that don’t currently have<br />
collection programs to set up their own sharps collection program<br />
Needle Destruction Devices. The U.S. Food and Drug Administration (FDA) currently only lists the<br />
“Disintegrator” as a needle destruction device approved for use by self-injectors.<br />
Sharps Containers. The California Department of Public Health Medical Waste Management Program is<br />
recommending the use of sharps containers approved by the FDA. After accessing the FDA website, type<br />
“sharps” in the search box. The container names will display alphabetically.<br />
Listserv: To receive periodic information about sharps, subscribe to the Sharps and Medication Disposal<br />
Listserv.<br />
Contact: Please contact pharmasharps@calrecycle.ca.gov for questions or more information.<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 25<br />
Comprehensive<br />
management of<br />
type 2 diabetes
Patient Logs and Worksheets<br />
Patient blood glucose daily logs, diabetes health records and healthy goal worksheets are helpful<br />
tools that promote better self-management and increase medication adherence by reminding<br />
patients to check their blood glucose levels and track daily activities. Many logs and worksheets<br />
also contain simple tools and tips to help patients adhere to recommended therapies and promote<br />
making lifestyle changes necessary to manage their type 2 diabetes. Such logs and worksheets<br />
can help guide health care providers by patient discussions, support adjustments to prescribed<br />
therapies and educate patients about type 2 diabetes and the importance of effective selfmanagement.<br />
See the Patient Resources section Chapter 6, page 95 of this reference guide for a selection of<br />
sample logs, goal worksheets and more.<br />
Pharmacotherapy for <strong>Diabetes</strong> 28,29<br />
The clinical approach to managing diabetes starts with lifestyle/behavior modification, weight loss,<br />
physical activity promotion, and dietary control (see page 56). However, most patients with type<br />
2 diabetes will also need oral or insulin medications to help achieve glycemic control. Healthcare<br />
providers should take into consideration any individual patient cardiovascular risk factors and the<br />
potential impact of side effects including fluid retention and weight gain when prescribing oral and<br />
injectable diabetes medications. Of note, diabetes progresses over time, requiring adjustments to<br />
the medication regimen.<br />
Often using multiple drugs is necessary to achieve adequate glycemic control and reduce the risk of<br />
co-morbid cardiovascular disease and complications. In some cases, the use of combination drugs<br />
can help to simplify patient drug regimens and hopefully lead to better compliance or fewer copays.<br />
The following tables highlight common oral and injectable medications used to treat and manage<br />
diabetes.<br />
26 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TAbLe 17 Oral Medications<br />
Drug class Generic name brand name(s) Mechanism of<br />
action<br />
biguanides Metformin Fortamet<br />
Glucophage<br />
Glucophage XR<br />
Glumetza<br />
Riomet<br />
Inhibits liver<br />
glucose<br />
production,<br />
q muscle glucose<br />
uptake<br />
Sulfonylureas Glimepiride Amaryl q pancreatic<br />
insulin<br />
production<br />
Glipizide Glipezide ER<br />
Glipezide XL<br />
Glucotrol<br />
Glucotrol XL<br />
Glyburide Diabeta<br />
Glynase<br />
Micronase<br />
Glycron<br />
Meglitinides Repaglinide Prandin q insulin released<br />
from pancreas<br />
Thiazolidinediones<br />
(TZDs)<br />
Alpha-glucosidase<br />
inhibitors<br />
bile acid<br />
sequestrant<br />
Nateglinide Starlix<br />
Pioglitazone Actos q skeletal muscles<br />
Avandia<br />
glucose uptake<br />
Rosiglitazone**<br />
**Restricted use by<br />
FDA due to possible<br />
increased CV risk<br />
(only use if unable to<br />
use other options.)<br />
Acarbose Precose Inhibits<br />
carbohydrate<br />
absorption by<br />
the small intestine<br />
Colesevelam<br />
hydocloride<br />
Welchol Lipid t polymer<br />
that binds bile<br />
acids in the<br />
intestine, t<br />
reabsorption.<br />
The exact A1c t<br />
action is currently<br />
unknown.<br />
Potential side<br />
effects<br />
Cramping, nausea,<br />
diarrhea, vomiting,<br />
gas, loss of appetite,<br />
metallic taste<br />
Hypoglycemia, GI<br />
upset, weight gain<br />
(note: avoid<br />
glyburide in elderly<br />
and those with renal<br />
insufficiency due<br />
to increased risk of<br />
hypoglycemia in this<br />
population.)<br />
Hypoglycemia,<br />
weight gain, joint<br />
pain<br />
Hypoglycemia,<br />
edema, headache,<br />
mild anemia, weight<br />
gain, muscle pain,<br />
URI, sinusitis<br />
Cramping, diarrhea,<br />
gas, GI upset/pain,<br />
weight loss.<br />
Need to treat<br />
hypoglycemia with<br />
glucose<br />
Constipation,<br />
nasopharyngitis,<br />
dyspepsia,<br />
hypoglycemia,<br />
nausea, hypertension<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 27<br />
Comprehensive<br />
management of<br />
type 2 diabetes
TABLe 17 Oral Medications<br />
Drug class Generic name brand name(s) Mechanism of<br />
action<br />
Dipeptidyl<br />
peptidase-4<br />
(DPP-4) inhibitor<br />
Combination<br />
drugs<br />
Sitagliptin Januvia Enzyme inhibitor,<br />
suppresses<br />
release of<br />
glucagon by<br />
pancreas<br />
Potential side<br />
effects<br />
Runny/stuffy<br />
nose, sore throat,<br />
headache, stomach<br />
pain, diarrhea<br />
Saxagliptin Onglyza Upper respiratory<br />
tract infection,<br />
urinary tract<br />
infection, headache<br />
Linagiptin Tradjenta t blood sugar by<br />
q incretin levels<br />
Metformin HCL/<br />
glyburid, Micro<br />
Glyburide,<br />
Micronized<br />
Metformin/<br />
glipizide<br />
Metformin HCL<br />
/Pioglitazone<br />
HCL<br />
Metformin/<br />
Sitagliptin<br />
Glimepiride /<br />
Pioglitazone<br />
Glimepiride/<br />
Rosiglitazone<br />
Rosiglitazone/<br />
Metformin HCL<br />
Repaglinide/<br />
Metformin HCL<br />
Saxagliptin/<br />
Metformin<br />
Glucovance See mechanism<br />
of action for<br />
Glycron<br />
Glynase<br />
Metaglip<br />
Actopuls Met<br />
Janumet<br />
Duetact<br />
Avadaryl<br />
Avandamet<br />
Prandimet<br />
Kombiglyze XR<br />
each drug in the<br />
combination,<br />
listed separately<br />
above.<br />
Upper respiratory<br />
infection, stuffy or<br />
runny nose, sore<br />
throat, muscle pain,<br />
headache<br />
See side effects for<br />
each drug in the<br />
combination, listed<br />
separately above.<br />
28 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TABLe 18 Non-<strong>Insulin</strong> Injectables<br />
Drug class Generic name brand name Mechanism of<br />
action<br />
Amylin analog<br />
emptying sugar<br />
Incretin<br />
mimetics<br />
<strong>Insulin</strong> <strong>Guidelines</strong><br />
Pramlintide Symlin Synthetic amyin<br />
which aids in<br />
the absorption<br />
of glucose by<br />
slowing stomach<br />
emptying,<br />
promoting fullness,<br />
and preventing<br />
secretion of<br />
glucagon from the<br />
liver.<br />
Exenatide Byetta q insulin secretion<br />
in the presence of<br />
elevated plasma<br />
glucose levels<br />
Liraglutide Victoza<br />
q insulin secretion<br />
in the presence of<br />
elevated plasma<br />
glucose levels,<br />
and delays gastric<br />
emptying.<br />
Potential side<br />
effects<br />
Nausea; decrease<br />
appetit, vomiting,<br />
dizziness, indigestion<br />
and stomach pain.<br />
Hypoglycemia when<br />
used with insulin<br />
Headache, nausea<br />
and vomiting,<br />
(titration dependent)<br />
diarrhea, dizziness,<br />
possible increased<br />
risk of pancreatitis<br />
(Victoza: watch for<br />
thyroid cancer due<br />
to increased risk in<br />
animal models)<br />
Consider using the <strong>Diabetes</strong> Coalition of California (DCC) insulin guidelines when starting and<br />
titrating insulin in patients with type 2 diabetes. For additional information, please visit the DCC’s<br />
website at www.diabetescoalitionofcalifornia.org.<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 29<br />
Comprehensive<br />
management of<br />
type 2 diabetes
TAbLe 19 DDC <strong>Insulin</strong> <strong>Guidelines</strong><br />
<strong>Diabetes</strong> Coalition of California<br />
<strong>Type</strong> 2 <strong>Diabetes</strong> <strong>Adult</strong> <strong>Outpatient</strong> <strong>Insulin</strong> <strong>Guidelines</strong><br />
This product may be reproduced with the citation: “Developed by the <strong>Diabetes</strong> Coalition of California, October 2010”<br />
See Web site (www.diabetescoalitionofcalifornia.org) for the latest version and disclaimer. Page 1 of 5<br />
30 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
<strong>Diabetes</strong> Coalition of California<br />
<strong>Type</strong> 2 <strong>Diabetes</strong> <strong>Adult</strong> <strong>Outpatient</strong> <strong>Insulin</strong> <strong>Guidelines</strong><br />
This product may be reproduced with the citation: “Developed by the <strong>Diabetes</strong> Coalition of California, October 2010”<br />
See Web site (www.diabetescoalitionofcalifornia.org) for the latest version and disclaimer. Page 2 of 5<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 31<br />
Comprehensive<br />
management of<br />
type 2 diabetes
<strong>Diabetes</strong> Coalition of California<br />
<strong>Type</strong> 2 <strong>Diabetes</strong> <strong>Adult</strong> <strong>Outpatient</strong> <strong>Insulin</strong> <strong>Guidelines</strong><br />
This product may be reproduced with the citation: “Developed by the <strong>Diabetes</strong> Coalition of California, October 2010”<br />
See Web site (www.diabetescoalitionofcalifornia.org) for the latest version and disclaimer. Page 3 of 5<br />
32 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 33<br />
Comprehensive<br />
management of<br />
type 2 diabetes
34 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TABLe 20 <strong>Insulin</strong> Injectables<br />
Drug class Generic name brand<br />
name<br />
Rapid-acting Lispro Humalog 5-15 min 30-90<br />
min<br />
Aspart Novolog 5-15 min 30-90<br />
min<br />
Glulisine Apidra 5-15 min 30-90<br />
min<br />
Onset Peak Duration Comments<br />
< 5 hr Clear<br />
< 5 hr<br />
< 5 hr<br />
Short acting Regular (R) Human 30-60 min 2-3 hr 5-8 hr Clear<br />
Intermediate<br />
acting<br />
NPH (N) Human 2-4 hr 4-10 hr 10-16 hr Cloudy<br />
Long acting Detemir Levemir 3-8 hr 3-4 hr<br />
(50%)<br />
No peak<br />
Premixed –<br />
human<br />
6-24 hr,<br />
dose<br />
dependent<br />
Glargine Lantus 2-4 hr No peak 20-24 hr<br />
75% insulin<br />
lispro protamine<br />
suspension/<br />
25% insulin<br />
lispro<br />
50% insulin<br />
lispro protamine<br />
suspension/<br />
50% insulin<br />
lispro<br />
70% insulin<br />
aspart protamine<br />
suspension/ 30%<br />
insulin aspart<br />
70% NPH/ 30%<br />
regular<br />
Humalog<br />
Mix 75/25<br />
Humalog<br />
Mix 50/50<br />
NovoLog<br />
Mix 70/30<br />
70% NPH/<br />
30%<br />
regular<br />
Note: Nausea and vomiting can be lessened or avoided with dose titration.<br />
Clear,<br />
typically<br />
taken once<br />
daily (example<br />
before evening<br />
meals or at<br />
bedtime). Helps<br />
prevent high<br />
morning blood<br />
glucose values.<br />
5-15 min Dual 10-16 hr Cloudy<br />
5-15 min Dual 10-16 hr<br />
5-15 min Dual 10-16 hr<br />
30-60 min Dual 10-16 hr<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 35<br />
Comprehensive<br />
management of<br />
type 2 diabetes
Hypoglycemia<br />
There are many drugs including oral diabetes medication and insulin that can decrease blood<br />
sugar levels, resulting in increased risk for hypoglycemic events. The risk of experiencing drug<br />
interactions and negative side effects relative to the expected benefits should be discussed with the<br />
patient when deciding medication regimens to treat and control diabetes.<br />
In particular, beta blockers are known to have adverse interactions with insulin by masking the signs<br />
and symptoms of hypoglycemia. In some cases beta blockers can also increase overall chances of<br />
developing high blood sugar.<br />
Clinical Management of Hypertension 23<br />
The National Heart Lung and Blood Institute (NHLBI), JNC-7 guidelines recommend that<br />
patients with hypertension receive interventional therapies that include a combination of lifestyle<br />
modifications (see Chapter 5, page 79) and pharmacologic therapies to reach target blood pressure<br />
values and decrease long term cardiovascular risk. JNC-7 emphasizes that adoption of healthy<br />
lifestyles by individuals with high blood pressure is critical to preventing and lowering blood<br />
pressure and overall body weight. See JNC-7 Reference Cards, pages 43-44.<br />
Target Blood Pressures and Self Measurement<br />
By treating hypertension to reach target blood pressure values, the risk of developing<br />
cardiovascular complications and mortality is greatly reduced. The NHLBI recommends the<br />
following target blood pressures for individuals with and without related complications:<br />
Table 21: Target Blood Pressure<br />
TAbLe 21 Target blood Pressure<br />
With hypertension, no additional compelling<br />
conditions<br />
For patients with diabetes or chronic kidney<br />
disease<br />
Optimal (Normal)<br />
Less Than 140/90 mm Hg<br />
Less Than 130/80 mm Hg<br />
Less Than 120/80 mm Hg<br />
Patients with high blood pressure should be advised to self monitor at home and work, as a<br />
practical approach to understanding and managing this chronic disease. Self measurements are<br />
also useful in assessing the difference between home and in medical office values commonly<br />
associated with white coat hypertension, also referred to as white coat syndrome. Monitoring<br />
through self measurement will help patients reach target blood pressure values by offering further<br />
insight into the effect of medically supervised management strategies on blood pressure control.<br />
Hypertension Treatment Algorithm, Initial Drug Choices<br />
In addition to lifestyle modifications highlighted in the JNC-7 guidelines, initial hypertensive<br />
therapies may require the use of medications to reach goal. Most patients frequently require a<br />
combination of medications from different antihypertensive drug classes when a single medication<br />
fails to achieve adequate control of blood pressures.<br />
36 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
separate prescriptions or in fixed-dose combinations. (See figure 1.) The initiation<br />
of drug therapy with more than one agent may increase the likelihood of<br />
achieving the BP goal in a more timely fashion, but particular caution is<br />
advised in those at risk for orthostatic hypotension, such as patients with diabetes,<br />
autonomic dysfunction, and some older persons. Use of generic drugs<br />
or combination drugs should be considered to reduce prescription costs.<br />
FIGuRe 3 Algorithm for Treatment of Hypertension<br />
Figure 1. Algorithm for treatment of hypertension<br />
Stage 1<br />
Hypertension<br />
(SBP 140–159 or DBP<br />
90–99 mmHg)<br />
Thiazide-type diuretics<br />
for most. May consider<br />
ACEI, ARB, BB, CCB,<br />
or combination.<br />
Lifestyle Modifications<br />
Not at Goal Blood Pressure (
Pharmacotherapy for Hypertension 23<br />
Today there are number of commonly used antihypertensive medications in different drug classes.<br />
Many patients with hypertension may require two or more antihypertensive medications from<br />
different drug classes and in combination to reach goal.<br />
Thiazide diuretics are considered the initial therapy for hypertension in most patients and can be<br />
useful in helping to achieve control of elevated blood pressure levels. Thiazide may be used as a<br />
stand-alone agent or in combination with other drug classes<br />
Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs)<br />
are also considered ideal medications for the treatment of patients with diabetes and hypertension.<br />
Both ACE and ARBs inhibitors provide positive effects on renal function and may result in improved<br />
insulin sensitivity. 30<br />
A patient receiving drug therapy for hypertension should receive regular and routine follow-up to<br />
adjustment medications as necessary to reach target blood pressure measurements and prevent<br />
cardiovascular complications. Patients with related co-morbidities including heart failure and<br />
diabetes may require more frequent office visits and lab testing to reach goal.<br />
The following tables list commonly used antihypertension medications. There are currently six<br />
commonly used classes of medications used to treat hypertension:<br />
• ACE Inhibitors<br />
• ARBs (angiotensin II receptor antagonists)<br />
• Calcium channel blockers<br />
• Thiazide diuretics<br />
• Beta blockers<br />
• Alpha blockers or alpha-adrenergic blockers<br />
38 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TABLe 22 Oral Blood Pressure Lowering Medications<br />
Drug class/<br />
category<br />
Angiotensin-<br />
Converting<br />
enzyme (ACe)<br />
Inhibitors<br />
Angiotensin II<br />
Receptor blockers<br />
(ARbs)<br />
Calcium Channel<br />
blockers,<br />
Dihydropyridines<br />
Generic name brand name(s) Mechanism of<br />
action<br />
Benazepril Lotensin Prevents the<br />
formation of<br />
Captopril Capoten<br />
angiotensin II<br />
Enalapril Vasotec<br />
Vasotec IV<br />
Fosinopril Monopril<br />
Lisinopril Prinivil<br />
Zestril<br />
Moexipril Univasc<br />
Perindopril Aceon<br />
Quinapril Accupril<br />
Ramipril Altace<br />
Trandolapril Mavik<br />
Candesartan Atacand Prevents the<br />
interaction of<br />
Eprosartan Teveten angiotensin<br />
Irbesartan Avapro<br />
II with tissue<br />
receptors<br />
Losartan Cozaar<br />
Olmesartan Benicar<br />
Telmisartan Micardis<br />
Valsartan Diovan<br />
Amlodipine Norvasc Blocks calcium<br />
Felodipine Plendil<br />
Isradipine DynaCirc<br />
DynaCirc CR<br />
Nicardipine Cardene<br />
Cardene SR<br />
Cardene IV<br />
Nifedipine Adalat<br />
Adalat CC<br />
Afeditab CR<br />
Nifedical XL<br />
Procardia<br />
Procardia XL<br />
Nisoldipine Sular<br />
channels in<br />
muscle cells of<br />
the heart and<br />
blood vessels<br />
Common side<br />
effects<br />
Cough, elevated<br />
potassium<br />
levels, low<br />
blood pressure,<br />
dizziness,<br />
headache,<br />
drowsiness,<br />
weakness,<br />
abnormal taste,<br />
rash<br />
Cough, elevated<br />
blood potassium<br />
levels, low<br />
blood pressure,<br />
dizziness,<br />
headache,<br />
drowsiness,<br />
diarrhea,<br />
abnormal taste,<br />
rash<br />
Constipation,<br />
nausea,<br />
headache, rash,<br />
edema, low<br />
blood pressure,<br />
drowsiness,<br />
dizziness,<br />
difficulty<br />
breathing,<br />
wheezing<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 39<br />
Comprehensive<br />
management of<br />
type 2 diabetes
TABLe 22 Oral Blood Pressure Lowering Medications<br />
Drug class/<br />
category<br />
Calcium Channel<br />
blockers, Non-<br />
Dihydropyridines<br />
Generic name brand name(s) Mechanism of<br />
action<br />
Diltiazem Cardizem<br />
Cardizem CD<br />
Cardizem LA<br />
Cardizem SR<br />
Cartia XT<br />
Dilacor XR<br />
Diltia XT<br />
Nu-Diltiaz<br />
Taztia XT<br />
Tiazac<br />
Verapamil Apo-Verap<br />
Calan<br />
Calan SR<br />
Covera-HS<br />
Isoptin<br />
Isoptin SR<br />
Verelan<br />
Verelan PM<br />
Blocks calcium<br />
channels in<br />
muscle cells of<br />
the heart and<br />
blood vessels<br />
Thiazide diuretics Chlorothiazide Diuril Inhibits sodium<br />
Chlorthalidone Hygroton<br />
Thalitone<br />
Hydrochlorothiazide Esedrix<br />
HCTZ<br />
Hydro-chlor<br />
Hydro-D<br />
HydroDIURIL<br />
Microzide<br />
Novo-<br />
Hydrazide<br />
Oretic<br />
Polythiazide Renese<br />
Indapamide Lozol<br />
Metolazone Zaroxolyn<br />
and chloride<br />
reabsorption<br />
from the distal<br />
convoluted<br />
tubules in the<br />
kidneys<br />
Loop diuretics Bumetanide Bumex Inhibits sodium<br />
Furosemide Lasix<br />
and chloride<br />
reabsorption<br />
Torsemide Demadex from the loop<br />
Ethacrynic Acid Edecrin<br />
of Henle in the<br />
kidneys<br />
Potassium sparing<br />
diuretics<br />
Amiloride Midamor Prevents sodium<br />
reabsorption<br />
without lower<br />
Triamterene Dyrenium potassium levels<br />
Common side<br />
effects<br />
Constipation,<br />
nausea,<br />
headache, rash,<br />
edema, low<br />
blood pressure,<br />
drowsiness,<br />
dizziness,<br />
difficulty<br />
breathing,<br />
wheezing<br />
Dizziness,<br />
lightheadedness,<br />
blurred vision,<br />
loss of appetite,<br />
itching, stomach<br />
upset, headache,<br />
weakness, rash,<br />
gout, muscle<br />
pain,<br />
40 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TABLe 22 Oral Blood Pressure Lowering Medications<br />
Drug class/<br />
category<br />
Aldosterone<br />
receptor blockers<br />
Generic name brand name(s) Mechanism of<br />
action<br />
Eplerenone Inspra Blocks the action<br />
Spironolactone Aldactone<br />
of aldosterone<br />
beta blockers Atenolol Tenormin Blocks the<br />
beta blockers<br />
w/ intrinsic<br />
sympathomimetic<br />
activity<br />
Betaxolol Kerlone<br />
Bisoprolol Monocor Zibeta<br />
Metoprolol<br />
Extended<br />
Lopressor<br />
Toprol-XL<br />
Nadolol Corgard<br />
Propranolol Inderal<br />
Inderal LA<br />
InnoPran XL<br />
Timolol Blocadren<br />
action of<br />
epinephrine and<br />
norepinephrine<br />
on B-adrenergic<br />
receptors<br />
Acebutolol Sectral Exerts low level<br />
agonist activity<br />
Penbutolol Levatol<br />
at B-adrenergic<br />
receptors site<br />
while acting as<br />
Pindolol Visken a receptor site<br />
antagonist<br />
Alpha-blockers Doxazosin Cardura Inhibits the alpha<br />
1 adrenergic<br />
nervous system,<br />
Prazosin Minipress causing muscle<br />
relaxation and<br />
dilation of blood<br />
vessels<br />
Terazosin Hytrin<br />
Common side<br />
effects<br />
Cough,<br />
diarrhea, flu<br />
like symptoms,<br />
headache,<br />
stomach pain<br />
Dizziness,<br />
lightheadedness,<br />
drowsiness,<br />
blurred vision,<br />
rash, itching,<br />
swelling<br />
Dizziness,<br />
lightheadedness,<br />
drowsiness,<br />
headache,<br />
constipation,<br />
loss of appetite,<br />
dry mouth, stuffy<br />
nose, blurred<br />
vision, trouble<br />
sleeping<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 41<br />
Comprehensive<br />
management of<br />
type 2 diabetes
TABLe 22 Oral Blood Pressure Lowering Medications<br />
Drug class/<br />
category<br />
Combined Alpha &<br />
beta blockers<br />
Direct<br />
vasodilators<br />
Central alpha<br />
agonists<br />
Generic name brand name(s) Mechanism of<br />
action<br />
Carvedilol Coreg<br />
Coreg CR<br />
Labetalol Normodyne<br />
Trandate<br />
Blocks alpha-,<br />
beta1-, and<br />
beta2-adrenergic<br />
receptor sites<br />
Hydralazine Apresoline Smooth muscle<br />
relaxant, causing<br />
Minoxidil Loniten<br />
arterial dilation<br />
Clonidine<br />
Clonidine patch<br />
Catapres<br />
Catapres-TTS<br />
Duracion<br />
Methyldopa Aldomet<br />
Reserpine Novoreserpine<br />
Reserfia<br />
Guanfacine Tenex<br />
Centrally acting<br />
alpha-adrenergic<br />
agonist<br />
Common side<br />
effects<br />
Dizziness, fatigue,<br />
headache,<br />
diarrhea, edema,<br />
dry eyes, scalp/<br />
skin tingling<br />
Dizziness, fatigue,<br />
headache,<br />
diarrhea, edema,<br />
Skin Irritation,<br />
itching, contact<br />
dermatitis, hives,<br />
swelling and<br />
sensitivity<br />
Dizziness,<br />
lightheadedness,<br />
drowsiness,<br />
dry mouth,<br />
constipation<br />
42 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
Reference Card From the<br />
Seventh Report of the Joint National Committee on Prevention,<br />
Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)<br />
T R E A T M E N T<br />
Principles of Hypertension Treatment<br />
• Treat to BP
Principles of Lifestyle Modification<br />
• Encourage healthy lifestyles for all individuals.<br />
• Prescribe lifestyle modifications for all patients with prehypertension<br />
and hypertension.<br />
• Components of lifestyle modifications include weight reduction, DASH<br />
eating plan, dietary sodium reduction, aerobic physical activity, and<br />
moderation of alcohol consumption.<br />
Blood Pressure Measurement Techniques<br />
Method Notes<br />
Two readings, 5 minutes apart, sitting in chair.<br />
Confirm elevated reading in contralateral arm.<br />
In-office<br />
Indicated for evaluation of “white coat hypertension.”<br />
Absence of 10–20 percent BP<br />
decrease during sleep may indicate increased<br />
CVD risk.<br />
Ambulatory BP monitoring<br />
Lifestyle Modification Recommendations<br />
Modification Recommendation Avg. SBP Reduction Range †<br />
Provides information on response to therapy.<br />
May help improve adherence to therapy and is<br />
useful for evaluating “white coat hypertension.”<br />
Patient self-check<br />
5–20 mmHg/10 kg<br />
Maintain normal body weight<br />
(body mass index 18.5–24.9<br />
kg/m2 ).<br />
Weight<br />
reduction<br />
8–14 mmHg<br />
Adopt a diet rich in fruits,<br />
vegetables, and lowfat dairy<br />
products with reduced content<br />
of saturated and total fat.<br />
DASH eating<br />
plan<br />
2–8 mmHg<br />
Reduce dietary sodium intake to<br />
Clinical Management of Dyslipidemia 9,31,32,33<br />
Addressing dyslipidemia is a key component in preventing long term cardiovascular disease in<br />
individuals with type 2 diabetes. Many patients with diabetes have elevated cholesterol values,<br />
which can lead to greater risk of developing cardiovascular disease or acute cardiovascular events.<br />
Diabetic dyslipidemia is a recognizable and modifiable patient risk factor that should be identified<br />
and treated early to prevent complications.<br />
Published by the National Heart Lung and Blood Institute (NHLBI), the ATP III guidelines are an<br />
evidence-based set of recommendations that focus on intensive cholesterol-lowering therapy. The<br />
guidelines address the primary prevention of coronary heart disease (CHD) in persons with multiple<br />
risk factors by managing elevated patient cholesterol levels to reach goal. The ATP III <strong>Guidelines</strong><br />
At-a-Glance Quick Desk Reference which outlines the step by step sequence of cholesterol<br />
management has been provided. The NHLBI and the American <strong>Diabetes</strong> Association recommend<br />
prescribing lifestyle modifications and cholesterol lowering medications to reach the following<br />
target (optimal) adult cholesterol levels:<br />
Targeting <strong>Adult</strong> Cholesterol Levels<br />
Table TABLe 23: Classification 23 Classification of Lipid of Lipid Profile Risk<br />
LDL Cholesterol – Primary Target of Therapy (mg/dL)<br />
In addition to recommending primary preventive strategies that include therapeutic lifestyle<br />
modifications and lipid modifying medications, healthcare providers should evaluate patients for<br />
preventable secondary causes of dyslipidemia that include:<br />
• Chronic renal failure<br />
• <strong>Diabetes</strong><br />
• Hypothyroidism<br />
• Obstructive liver disease<br />
• Medications that affect LDL and HDL cholesterol levels, including:<br />
o Progestins<br />
o Corticosteroids<br />
o Anabolic steroids<br />
There have been a number of recent clinical trials demonstrating that lowering LDL cholesterol<br />
levels using secondary prevention strategies can also help reduce the risk of developing major<br />
cardiovascular disease. Secondary prevention of dyslipidemia focuses on decreasing the<br />
overall risk of developing cardiovascular disease, acute coronary events, stroke, and mortality in<br />
people identified with chronic heart disease by lowering LDL cholesterol to a level less than 100<br />
mg/dL by: 34<br />
• Increase or intensify lifestyle modifications<br />
• Recommend weight loss and increased physical activity for people with risk factors<br />
• Delay use or intensification of LDL lowering medication and institute treatment of other lipid<br />
or non-lipid risk factors<br />
• Consider use of other lipid modifying drugs to treat elevated triglyceride or low HDL<br />
cholesterol<br />
Most lipid problems associated with a chronic illness are hereditary, and early consideration of<br />
lifelong medication management is important. Although lifestyle modification, diet and exercise<br />
are effective in combination with the use of pharmacotherapy, diet and exercise alone do not<br />
correct the underlying genetic disorder. Lowering LDL cholesterol levels through the use of<br />
secondary prevention strategies in combination with appropriate lifestyle modifications can<br />
greatly reduce an individual’s risk of developing diabetes related complications, experience<br />
cardiovascular events and premature mortality.<br />
46 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
Pharmacotherapy for Dyslipidemia 23<br />
To reach optimal lipid levels, most patients will require lipid modifying medications combined<br />
with Therapeutic Lifestyle Changes (TLC). While reducing serum LDL cholesterol is the primary<br />
target of treatment in clinical lipid management, some people may also benefit from therapies<br />
to lower triglycerides and/ or increase HDL cholesterol levels. Some individuals will require<br />
combined drug therapies to reach target treatment goals that result in a reduction of LDL<br />
cholesterol levels and, when advisable, raise HDL cholesterol levels.<br />
Statins, also known as HMG-CoA reductase inhibitors, are currently considered the most<br />
effective, practical, and commonly prescribed class of drugs that target reducing LDL<br />
cholesterol levels. The statins are generally well tolerated by most people and have a lower risk<br />
of adverse side effects and/or risk of drug to drug interactions.<br />
In some cases, drug therapies may need to be tailored to address specific dyslipidemias,<br />
including very high LDL cholesterol, elevated serum triglycerides, low HDL cholesterol and<br />
atherogenic dyslipidemia in persons with type 2 diabetes. Consideration should also be given<br />
to prescribing drug therapies that target both lipid and non-lipid causes of metabolic syndrome<br />
and insulin resistance.<br />
There are several classes of lipid modifying and LDL lowering medications available to treat<br />
dyslipidemia, including:<br />
• Statins (HMG-CoA reductase inhibitors)<br />
• Cholesterol absorption inhibitors<br />
• Niacin (nicotinic acid)<br />
• Fibric acid derivatives<br />
• Bile acid sequestrants<br />
• Combination drugs<br />
Currently only nicotinic acid (niacin) has been approved for over the counter (OTC) use. The<br />
following table lists commonly used dyslipidemia treatment medications.<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 47<br />
Comprehensive<br />
management of<br />
type 2 diabetes
TABLe 24 Dyslipidemia Treatment Medications 69<br />
Drug class/<br />
category<br />
Statins<br />
(HMG-CoA<br />
Reductase<br />
Inhibitors)<br />
Cholesterol<br />
Absorption<br />
inhibitors<br />
Niacin<br />
(Nicotinic<br />
Acid)<br />
Generic name brand name(s) Mechanism of<br />
action<br />
Atorvastatin Calcium Lipitor Inhibits HMG-<br />
CoA reductase,<br />
causing a slow<br />
Fluvastatin Sodium Lescol<br />
Lescol XL<br />
Lovastatin Alctocor<br />
Altoprev<br />
Mevacor<br />
Pravastatin Sodium Pravachol<br />
Rosuvastatin Sodium Crestor<br />
Simvastatin Zocor<br />
Pitavastatin Livalo<br />
down in the<br />
production of<br />
cholesterol and<br />
q the removal of<br />
LDL-cholesterol<br />
by the liver<br />
Ezetimibe Zetia Inhibits intestinal<br />
cholesterol<br />
absorption and<br />
reduces liver<br />
cholesterol stores<br />
Nicotinic acid Endur-Acin<br />
Nia-Bid<br />
Niac<br />
Nacels<br />
Niacor<br />
Niaspan<br />
Nicobid<br />
Nico-400<br />
Nicolar<br />
Nicotinex<br />
Nicotinic Acid<br />
Slo-Niacin<br />
Vitamin B<br />
Inhibits fatty acid<br />
release from<br />
adipose tissue<br />
and inhibits liver<br />
production of<br />
fatty acids and<br />
triglycerides;<br />
q HDL levels,<br />
t triglycerides and<br />
LDL cholesterol<br />
Potential side<br />
effects<br />
Headache,<br />
nausea, vomiting,<br />
constipation,<br />
diarrhea, rash,<br />
weakness,<br />
muscle pain,<br />
rhabdomyolysis<br />
Diarrhea,<br />
abdominal pain,<br />
back pain, joint<br />
pain, sinusitis,<br />
allergic reactions<br />
Stomach<br />
upset, flushing,<br />
headache, allergic<br />
reactions<br />
48 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
TABLe 24<br />
Lipid<br />
combinations<br />
Fibric acid<br />
derivatives<br />
bile acid<br />
sequestrants<br />
Dyslipidemia Treatment Medications 69<br />
Lovastatin/Niacin, Advicor t LDL cholesterol,<br />
triglyceride, and<br />
total cholesterol<br />
levels, q HDL<br />
cholesterol<br />
Simvastatin/Niacin Simcor tTotal cholesterol<br />
– LDL and<br />
triglycerides.<br />
Slightly q HDL<br />
Simvastatin<br />
Ezetimibe<br />
Amlodipine<br />
Atorvastatin<br />
Fenofibrate Antara,<br />
Lipofen<br />
Lofibra<br />
Tricor<br />
Triglide<br />
Trilipix<br />
Gemifibrozil Lopid<br />
Cholestyramine,<br />
Cholestyramine light<br />
See statin and<br />
niacin side effects<br />
Warmth, redness,<br />
dizziness,<br />
sweating or<br />
chills, headache,<br />
stomach or back<br />
ache, runny<br />
nose or other<br />
symptoms<br />
Vytorin t LDL cholesterol Headache,<br />
nausea, vomiting,<br />
diarrhea, muscle<br />
pain, abnormal<br />
liver tests<br />
Caduet t LDL cholesterol<br />
and triglycerides<br />
in the blood, while<br />
q levels of HDL<br />
cholesterol<br />
LoCHOLEST<br />
LoCHOLEST<br />
Light<br />
Prevalite<br />
Questran<br />
Questran Light<br />
Cholestipol Cholestid<br />
Colesevelam WeChol<br />
t Liver production<br />
of VLDL and<br />
q triglyceride<br />
blood<br />
t LDL cholesterol<br />
by binding with<br />
cholesterol<br />
containing<br />
bile acids in<br />
the intestines,<br />
eliminated in the<br />
stool<br />
Headache,<br />
dizziness,<br />
drowsiness,<br />
flushing, diarrhea,<br />
abdominal pain,<br />
weakness, joint<br />
pain<br />
Nausea, stomach<br />
upset, diarrhea,<br />
liver inflammation,<br />
formation of<br />
gallstones<br />
Constipation,<br />
abdominal<br />
pain, bloating,<br />
vomiting,<br />
diarrhea,<br />
weight loss and<br />
flatulence<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 49<br />
Comprehensive<br />
management of<br />
type 2 diabetes
National Cholesterol Education Program High<br />
ATP III <strong>Guidelines</strong> At-A-Glance<br />
Quick Desk Reference<br />
(NHLBI 2001 including updates from the NCEP Report 2004)<br />
1<br />
Step 1<br />
2<br />
Step 2<br />
3<br />
Step 3<br />
Determine lipoprotein levels–obtain complete lipoprotein profile after<br />
9- to 12-hour fast.<br />
ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)<br />
LDL Cholesterol – Primary Target of Therapy<br />
< 100<br />
(optional goal: < 70)* Optimal<br />
100-12<br />
9<br />
Near<br />
optimal/<br />
above<br />
optimal<br />
130-15<br />
9<br />
Borderline<br />
high<br />
160-18<br />
9<br />
High<br />
> 190<br />
Very<br />
high<br />
Total Cholesterol<br />
< 200<br />
200-23<br />
9<br />
> 240<br />
HDL Cholesterol<br />
< 40<br />
> 60<br />
Identify presence of clinical atherosclerotic disease that confers high risk<br />
for coronary heart disease (CHD) events (CHD risk equivalent):<br />
■ Clinical CHD<br />
■ Symptomatic carotid artery disease<br />
■ Peripheral arterial disease<br />
■<br />
■<br />
Desirable<br />
Borderline<br />
High<br />
Low<br />
High<br />
Abdominal aortic aneurysm<br />
<strong>Diabetes</strong><br />
high<br />
*An LDL-C goal of =200 mg/dL plus non-HDL-C >=130 mg/dL<br />
with low HDL-C [140/90 mmHg or on antihypertensive medication)<br />
Low HDL cholesterol (60 mg/dL counts as a “negative” risk factor; its presence removes one<br />
risk factor from the total count.<br />
N A T I O N A L I N S T I T U T E S O F H E A L T H<br />
N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E<br />
Blood Cholesterol<br />
50 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
4<br />
Step 4<br />
5<br />
Step 5<br />
6<br />
Step 6<br />
If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess<br />
10-year (short-term) CHD risk (see Framingham tables).<br />
Three levels of 10-year risk:<br />
■ >20% — CHD risk equivalent<br />
■ 10-20%<br />
■
7<br />
Step 7<br />
Consider adding drug therapy if LDL exceeds levels shown in Step 5 table:<br />
■ Consider drug simultaneously with TLC for CHD and CHD equivalents<br />
■ Consider adding drug to TLC after 3 months for other risk categories.<br />
Drugs Affecting Lipoprotein Metabolism<br />
Drug Class Agents and Lipid/Lipoprotein Side Effects Contraindications<br />
Daily Doses Effects<br />
HMG CoA reductase<br />
inhibitors (statins)<br />
Bile acid sequestrants<br />
Nicotinic acid<br />
Fibric acids<br />
Lovastatin (20-80 mg)<br />
Pravastatin (20-40 mg)<br />
Simvastatin (20-80 mg)<br />
Fluvastatin (20-80 mg)<br />
Atorvastatin (10-80 mg)<br />
Rosuvastatin (5-40 mg)<br />
Pitavastatin (1-4 mg)<br />
Cholestyramine (4-16 g)<br />
Colestipol (5-20 g)<br />
Colesevelam (2.6-3.8 g)<br />
Immediate release<br />
(crystalline) nicotinic acid<br />
(1.5-3 gm), extended<br />
release nicotinic acid<br />
(Niaspan ® ) (1-2 g),<br />
sustained release<br />
nicotinic acid (1-2 g)<br />
Gemfibrozil<br />
(600 mg BID)<br />
Fenofibrate<br />
(48 mg,145 mg,200 mg)<br />
Clofibrate<br />
(1000 mg BID)<br />
Fenofibric Acid<br />
(45mg, 135 mg)<br />
Cholesterol adsorption Ezetimibe (10 mg)<br />
inhibitors<br />
Lipid combination Ezetimibe/simvastatin<br />
(10/10 mg to<br />
10/80 mg)<br />
LDL ↓18-55%<br />
HDL ↑5-15%<br />
TG ↓7-30%<br />
LDL ↓15-30%<br />
HDL ↑3-5%<br />
TG No change<br />
or increase<br />
LDL ↓5-25%<br />
HDL ↑15-35%<br />
TG ↓20-50%<br />
LDL ↓5-20%<br />
(may be increased in<br />
patients with high TG)<br />
HDL ↑10-20%<br />
TG ↓20-50%<br />
Myopathy<br />
Increased liver<br />
enzymes<br />
Gastrointestinal<br />
distress<br />
Constipation<br />
Decreased absorption<br />
of other drugs<br />
Flushing<br />
Hyperglycemia<br />
Hyperuricemia<br />
(or gout)<br />
Upper GI distress<br />
Hepatotoxicity<br />
Dyspepsia<br />
Gallstones<br />
Myopathy<br />
LDL ↓18%<br />
Upper respiratory<br />
apoB ↓15-16%<br />
infections<br />
TG ↓ 7-9% Diarrhea<br />
Arthralgia<br />
LDL<br />
apoB<br />
TG<br />
↓ 46-58%<br />
↓35-47%<br />
↓ 26-31%<br />
Headache<br />
Increased ALT<br />
Myalgia<br />
Upper respiratory<br />
tract infection<br />
Diarrhea<br />
Absolute:<br />
• Active or chronic<br />
liver disease<br />
Relative:<br />
• Concomitant use of<br />
certain drugs*<br />
Absolute:<br />
• dysbetalipoproteinemia<br />
• TG >400 mg/dL<br />
Relative:<br />
• TG >200 mg/dL<br />
Absolute:<br />
• Chronic liver disease<br />
• Severe gout<br />
Relative:<br />
• <strong>Diabetes</strong><br />
• Hyperuricemia<br />
• Peptic ulcer disease<br />
Absolute:<br />
• Severe renal disease<br />
• Severe hepatic<br />
disease<br />
Statin contraindications<br />
apply when used with a<br />
statin.<br />
Active liver disease or<br />
unexplained persistent<br />
elevation of hepatic<br />
transminase levels<br />
Women who are pregnant<br />
or who may become<br />
pregnant<br />
Nursing mothers<br />
* Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (�brates and niacin should be used with<br />
appropriate caution).<br />
52 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011
8<br />
Step 8<br />
Identify metabolic syndrome and treat, if present, after 3 months of TLC.<br />
Criteria for Clinical Diagnosis of Metabolic Syndrome<br />
Measure (any 3 of 5 constitute<br />
diagnosis of metabolic syndrome<br />
Elevated waist circumference*†<br />
Elevated triglycerides<br />
Reduced HDL-C<br />
Elevated blood pressure<br />
Elevated fasting glucose<br />
Treatment of the Metabolic Syndrome<br />
Categorical Cutpoints<br />
>102 cm (>40 in) in men<br />
>88 cm (>35 in) in women<br />
>150 mg/dL (1.7 mmol/L)<br />
or<br />
On drug treatment for elevated triglycerides‡<br />
85 mmHg diastolic blood pressure<br />
or<br />
On antihypertensive drug treatment in a<br />
patient with a history of hypertension<br />
>100 mg/dL<br />
or<br />
On drug treatment for elevated glucose<br />
*To measure waist circumference, locate top of right iliac crest. Place a measuring tape in a horizontal plane around abdomen at<br />
level of iliac crest. Before reading tape measure, ensure that tape is snug but does not compress the skin and is parallel to floor.<br />
Measurement is made at the end of a normal expiration.<br />
†Some US adults of non-Asian origin (eg, white, black, Hispanic) with marginally increased waist circumference (eg. 94-101 cm<br />
[37-39 inches] in men and 80-87 cm [31-34 inches] in women) may have strong genetic contribution to insulin resistance and<br />
should benefit from changes in lifestyle habits, similar to men with categorical increases in waist circumference. Lower waist<br />
circumference cutpoint (eg, >90 cm [35 inches] in men and >80 cm [31 inches] in women) appears to be appropriate for Asian<br />
Americans.<br />
‡Fibrates and nicotinic acid are the most commonly used drugs for elevated TG and reduced HDL-C. Patients taking one of these<br />
drugs are presumed to have high TG and low HDL.<br />
Reference: Grundy, et al. (2005). Diagnosis & Mgmt of the Metabolic Syndrome. Table 2. AHA/NHLBI Scientific Statement. Circulation. 112: 2735-2752.<br />
■ Treat underlying causes (overweight/obesity and physical inactivity):<br />
– Intensify weight management<br />
– Increase physical activity.<br />
■ Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:<br />
– Treat hypertension<br />
– Use aspirin for CHD patients to reduce prothrombotic state<br />
– Treat elevated triglycerides and/or low HDL (as shown in Step 9).<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 53<br />
Comprehensive<br />
management of<br />
type 2 diabetes
9<br />
Step 9<br />
Treat elevated triglycerides.<br />
ATP III Classification of Serum Triglycerides (mg/dL)<br />
200 mg/dL after LDL goal is reached, set<br />
secondary goal for non-HDL cholesterol (total – HDL)<br />
30 mg/dL higher than LDL goal.<br />
Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories<br />
Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL)<br />
CHD and CHD Risk Equivalent
Hard Coronary Heart Disease (10-Year Risk)<br />
Men Women<br />
Estimate of 10-Year Risk for Men<br />
(Framingham Point Scores)<br />
Age Points<br />
20-34 -9<br />
35-39 -4<br />
40-44 0<br />
45-49 3<br />
50-54 6<br />
55-59 8<br />
60-64 10<br />
65-69 11<br />
70-74 12<br />
75-79 13<br />
Total<br />
Cholesterol<br />
Points<br />
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79<br />
Lifestyle Interventions and Modifications 36,37,38,39<br />
Therapies focused on modification of patient lifestyle (Therapeutic Lifestyle Changes or TLC),<br />
including medical nutrition therapy (MNT) and exercise programs, are essential to achieving<br />
glycemic, lipid and blood pressure control, moderate weight loss and reduction of cardiovascular<br />
risk factors.<br />
Tips for Supporting Lifestyle Change<br />
• Encourage lifestyle modifications that reduce total caloric intake, saturated and trans fat<br />
consumption and cholesterol and sodium intake such as:<br />
o Consume carbohydrates from fruits, vegetables whole grains, legumes and low-fat milk<br />
o Monitor carbohydrate intake<br />
o Consume a variety of fiber-rich foods like beans, berries and greens<br />
o Limit sodium intake<br />
• Encourage moderate to vigorous physical activity to improve glucose, lipid and blood pressure<br />
values<br />
• Refer patients to registered dietician and/or to Medical Nutrition Therapy for additional support<br />
• Encourage patients to quit smoking<br />
TABLe 25 Recommended Lifestyle Modifications<br />
Target Therapy Goal Recommendations<br />
Overweight and obesity Healthy weight and BMI Advise weight reduction to optimize BMI<br />
≥18.5 and
Weight Loss/Maintenance<br />
Even a moderate loss of 5-10% of overall body weight in patients with diabetes will result in<br />
improvement of blood glucose, blood pressure and lipids profile.<br />
Nearly 80% of patients who lose weight will gradually regain it if they are not supported by a<br />
weight maintenance program. The keys to a successful weight maintenance program are patient<br />
motivation and team support from health care providers. Effective management of overweight<br />
and obesity can be delivered by a variety of healthcare providers including primary care providers,<br />
registered dietitians, nutritionists, exercise physiologists, nurses, and psychologists.<br />
Achieving and maintaining an appropriate body weight requires daily effort, good dietary/<br />
nutritional behaviors and adequate physical activity. Combined management approaches (diet,<br />
exercise and behavior modification) are likely to produce better results than any single approach.<br />
Healthcare providers should encourage patients to consult their health plan for weight loss/<br />
maintenance programs that may be covered by their policy.<br />
Medical Nutrition Therapy (MNT) 9,36,40,41<br />
Medical Nutrition Therapy (MNT) services involve a nutritional assessment, specific diet planning,<br />
and counseling services to prevent or treat an illness or medical condition. MNT counseling<br />
services are typically provided by a registered dietitian (RD) focusing on behavior and lifestyle<br />
changes with the goal of addressing nutrition problems and associated medical conditions,<br />
such as diabetes. MNT goals for the treatment of diabetes focus on interventions to maintain<br />
blood glucose, lipids, and blood pressure within a normal range in order to prevent or slow the<br />
rate of development of the chronic complications of the disease. In addition, MNT can be useful<br />
in helping patients with diabetes to achieve and maintain a healthy body weight. During each<br />
counseling session, the RD works with patients to assess individual needs, determine goals,<br />
develop a care plan, and monitor overall progress towards treatment goals.<br />
Coverage for and access to MNT services vary by health insurance program or carrier. Patients<br />
should consult with their health insurance evidence of coverage booklet or call their health plan<br />
regarding coverage for MNT services. Medicare currently covers MNT services for people with<br />
diabetes or renal disease as a means of helping to manage the condition covering. Medicare<br />
covers 3 hours of one-on-one counseling the first year, and 2 hours each subsequent year.<br />
Beneficiaries may be able to receive more hours of treatment with a physician’s referral if the<br />
condition, course of treatment or diagnosis changes. Physicians must prescribe MNT services for<br />
Medicare recipients and renew the referral annually as necessary. 41<br />
For a list of CPT codes for MNT, please go to chapter 7, page 139.<br />
<strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011 57<br />
Comprehensive<br />
management of<br />
type 2 diabetes
General Nutritional Recommendations for <strong>Diabetes</strong> 36<br />
• Regular and individualized meal planning advice.<br />
• Total carbohydrate (in grams) monitoring to help control glycemia.<br />
• Balance calories from foods and beverages with calories used.<br />
• Consume varieties of nutrient and vitamin rich foods and beverages.<br />
• Limit saturated fat intake to < 7% of total calories.<br />
• Limit intake of trans fats.<br />
• Limit cholesterol intake to < 200 mg/day.<br />
• Limit sodium intake to < 1,500 mg/day (in patients with hypertension) with a diet high in fruits,<br />
vegetables, and low-fat dairy products to lower blood pressure.<br />
• Daily alcohol intake should be limited to < 1 drink/day for women and < 2 drinks/day for men)<br />
Table 26: Modifiable Nutrients and Fats<br />
TABLe 26 Modifiable Nutrients and Fats<br />
Saturated fat < 7% of total calories<br />
Polyunsaturated<br />
fat<br />
Up to 10% of total calories<br />
Monounsaturated<br />
fat<br />
Up to 20% of total calories<br />
Total fat 25-35% of total calories<br />
Cholesterol < 200 mg/day<br />
Carbohydrates 50-60% of total calories<br />
Protein Approx. 15% of total calories<br />
Soluble fiber 10-25 g/day<br />
Plant<br />
stanols/sterols<br />
2 g/day<br />
Total calories Balance energy intake with expenditure<br />
Nutritional Recommendations for Weight Loss In <strong>Diabetes</strong> 9<br />
• Moderate decreases in calories (500-1000 kcal/day) can result in progressive weight loss of<br />
1-2 lbs/week.<br />
• Low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1<br />
year) for weight loss.<br />
• Physical activity and behavior modification are important components of weight loss<br />
programs and are most helpful in maintenance of weight loss.<br />
Physical Activity and exercise In <strong>Diabetes</strong> 9<br />
• At least 150 minutes of moderate/intense aerobic activity per week (30 minutes, five days a<br />
week)<br />
• In the absence of contraindications, people with type 2 diabetes should be encouraged to<br />
perform resistance training 3 days/week<br />
58 <strong>CMA</strong> FoundAtion . diAbetes And CArdiovAsCulAr diseAse Provider reFerenCe guide . july 2011