Dx¹

• Any of the Following (for T2DM)
  • FBG ≥ 126 (8hr fasting)
  • 2hr-PPG ≥ 200 (75g GTT)
  • A1C ≥ 6.5%
  • SSx of DM w/ random BG ≥ 200
• Pre-T2DM
  • FPG 100-125
  • 2hrPPG 140-199 (75g GTT)
  • A1C 5.7-6.4%
• Testing Criteria for DM
  • BMI ≥ 25 w/ 1 of the following risk factors
    • FHx of DM
    • AA, Latino, Native America, Asian, Pacific Islander
    • CVD
    • HTN
    • HDL < 35 or TG > 250
    • PCOS
    • Physical inactivity
    • Other conditions indicating insulin resistance
  • Yearly test if A1C > 5.7 (pre-diabetes)
  • Hx of GDM should be tested Q3yrs
  • Age ≥ 45yo
• If all tests are normal, repeat Q3yr or earlier if clinically suspicious

Tx^{1, 2}

• Monitoring
  • A1C at least twice yearly if meeting treatment goals
  • A1C Q3mo if not meeting goals or changing regimens
• ADA Goals
  • A1C < 7
  • FBG 80-130
  • PPG < 180
• ACCE Goals
  • A1C ≤ 6.5
• Prediabetes
  • Metformin 850mg QD x1mo then 850mg BID³
• T2DM
  • Metformin is 1st line, all pts w/o CIs should be on metformin
  • A1C < 9%, initiate monotherapy
  • A1C 9-10%, initiate dual therapy
    • Move to triple therapy if failure before moving to injectables
  • A1C ≥ 10%, initiate combination injectable therapy
    • Bolus or Premix BID or GLP-1 1st
    • Then progress to combos or basal-bolus

Drugs

• Metformin
  • Yearly B12 levels
  • Really Adjusted
• SGLT2s
  • Renal adjustments with all
  • Canagliflozin has increased amputation risk and fracture risk
  • Can cause normoglycemic DKA
  • Increased risk of UTI
  • Canagliflozin and empagliflozin have CV benefit
  • Higher LDL
• GLP-1s
  • Liraglutide has some CV benefit
  • Some have renal adjustments
  • Risk of thyroid C-cell tumors
  • Pancreatitis
  • Significant GI SEs
• DPP-4s
  • Some CHF risk
  • Renal adjustments, but no renal CI
  • Acute pancreatitis
  • Joint pain
• TZDs
  • Pioglitazone has ASCVD benefit and all have CHF risk
  • No dose adjustments, but not recommended in renal impairment d/t fluid retention
  • Fluid retention
  • Bone fractures
  • Bladder cancer (pioglitazone)
  • Higher LDL
• Sulfonylureas
  • No CV impacts
    • Older sulfonylureas have CV risk
  • Glyburide not recommended
  • Glipizide and glimeperide should be started low w/ renal impairment

Insulin

• T1DM Dosing
  • Initiate 0.4-1 U/kg QD as a basal-bolus regimine
• T2DM Dosing
  • Initiate Basal 10 U QD or 0.1-0.2 U/kg QD
  • Bolus 4 U, 0.1 U/kg, or 10% of basal
  • Adjust by 10-15% or 2-4 U once or twice weekly
  • If hypoglycemic with no other discernible cause, decrease dose by 4 U or 10-20%

DKA

References