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Outpatient Diabetes Management

Matthew Lu

Background

  • Type I Diabetes - insulin deficiency (GAD65, IA2, ZnT8 antibodies positive, Insulin and C-peptide inappropriately low)
  • Type II Diabetes - insulin resistance (generally associated with obesity)
  • Classification by HgA1c: Pre-diabetes: 5.7 to 6.4%; Diabetes: >= 6.5

Management:

  • Lifestyle changes:
    • Exercise 175 minutes weekly
    • Caloric restriction for weight loss of 10%
      • Low carb or Mediterranean diet, reduce normal portions by 10-20%, limit sugary drinks, drink large glass of water before meals
  • BP Goal generally < 130/80
    • ACE-inhibitor is first-line anti-hypertensive
  • Manage complications of diabetes
    • Increased cardiovascular risk (2-4x risk of MI, CVA or death)
      • High intensity statin if clinical ASCVD present
      • Moderate intensity statin if age > 40 or with ASCVD risk factors (LDL >100, HTN, smoking, FHx of CVD, CKD)
      • Consider aspirin if ASCVD > 10% (balanced against bleeding risk)
      • Smoking cessation
      • Baseline ECG at diagnosis
    • Retinopathy – annual retinal exams
    • Peripheral Neuropathy – annual foot exams, can use gabapentin if present
    • Autonomic Neuropathy – ED, orthostatic hypotension, gastroparesis
    • Nephropathy – annual creatinine and urine microalbumin (albumin/creatinine ratio) - need repeat measurements 3mo apart to confirm albuminuria
      • Normal: < 30mg/g
      • Moderate albuminuria: 30-300 mg/g (consider starting ACE-I)
      • Severe albuminuria: > 300 mg/g i(should be on ACE-I)
      • If persistent despite ACE-I, start SGLT2 inhibitor (if GFR allows)
      • If persistent despite SLGT2 inhibitor, start finerenone
      • Consider involving nephrology
  • Glycemic goals:
    • Fasting glucose 80-130 mg/dL, postprandial (90-120 min after meal) < 180mg/dL
    • A1c goal: generally < 7%, < 7.5% for 65 yrs, < 8% for poor health or life expectancy < 10 yrs
  • Medications for glycemic control
    • For pre-diabetes, encourage lifestyle management and consider starting metformin
    • If initial HgA1c < 9%
      • 1st agent: metformin (usually decreases HgA1c by 1-2%) – start at 500mg daily and increase by 500mg every 1-2 weeks if no GI side effects up to goal 2000mg daily
        • If eGFR < 45, then half dose
        • If eGFR < 30, then discontinue
      • 2nd agent (if HgA1c still not at goal within 3 months):
        • GLP-1 agonist generally preferred (best weight loss benefit, usually decreases HgA1c by 1%)
        • SGLT2 inhibitor preferred if pt has HF or DM nephropathy (usually decreases HgA1c by 1%)
        • Consider sulfonylurea if pt on HD
      • 3rd agent (if HgA1c still not at goal after additional 3 months)
        • GLP-1 agonist or SGLT2 inhibitor (whichever was not started as second agent)
    • If initial HgA1c > 9%
      • Start metformin AND GLP-1/DDP4-I OR insulin
  • How to initiate insulin
    • Start with long-acting insulin nightly (10 units or 0.1 units/kg/d)
      • Check fasting glucose daily and increase insulin by 2 units q 2-3 days until fasting glucose within goal (80-130mg/dL)
      • If hypoglycemia occurs, decrease insulin by 4 units or 10% (whichever is greater)
    • If A1c > 7% after 3mo, add mealtime insulin
      • Check post-prandial glucose and start with 4 units short acting insulin at meals where post-prandial glucose > 180. Adjust by 2 units q 3 days until post-prandial glucose < 180.
  • When HgA1c < 6.5% consider de-escalating medications
  • Other medication class options: sulfonylureas, DDP4-I, thiazolidinediones