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Release Date: August 2016 Next Review Date: 2017
This Clinical Practice Guideline (CPG) was developed by the Quality workgroup of St. Luke’s Health Partners Clinical Integration Committee based on feedback and review from Idaho primary and specialty care providers and subject matter experts. It summarizes current medical literature, and where clear evidence is lacking, provides expert ad-vice on the diagnosis and treatment of type 2 diabetes. St. Luke’s Health Partners recognizes that the responsibility and decision making about care will be made by the healthcare provider in collaboration with his or her patient, taking into account the patient’s entire clinical situation, needs, and goals. Practice variation from these guidelines may be appropriate when clinical circumstances arise or when individual patient characteristics indicate that such changes are in the best interest of the patient.
Recommendation Summary: SLHP supports the current recommendations from the American Diabetes Association for the treatment and care of patients with diabetes. Sources:
1. Standards of Medical Care in Diabetes-2016. Diabetes Care 2016 Jan; 39 (Supplement 1) S1-S2. http://care.diabetesjournals.org/content/39/Supplement_1
2. 2016 Group Practice Reporting Option (GPRO) Web Interface Narrative Measure Specifica-
tions. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality-Measures-Standards.html
3. Park Nicollet (International Diabetes Center [IDC]) Diabetes Type 2 Glycemic Control
Diabetes Control Algorithm
*See Reference Section for IDC Type 2 Diabetes Glycemic Control Algorithm Abbreviations and Clinical Considerations
Clinical Practice Guidelines: Diabetes Mellitus Type 2
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A1c
Lipids
Complete Metabolic Panel (CMP)
Micoalbumin/Creatinine ratio
A1c persistently elevated at 9% for >3-6 months despite
aggressive treatment
Physician preference
Patient preference
Type 1 uncontrolled diabetes mellitus
Patient on insulin pump if PCP prefers
Consider Endocrinologist or Diabetologist
Initial Testing
Referral Back to PCP
A1c at goal (target)
Patient preference
Physician preference
Medication Guideline for Glucose Control
Refresh diabetes education annually
Institute initial drug monotherapy: Metformin
500 mg daily with a meal
After 1 week, if tolerated, increase to 500mg BID
with breakfast and PM meal.
In weekly intervals, if tolerated, and as clinically
appropriate, consider 1000mg BID.
Step to two drug combinations-Appendix A, IDC*
Metformin + Sulfonylurea, or Thiazolidinedione, or
DPP-4 Inhibitor, or GLP-1 receptor agonist, or Insu-
lin (usually basal)
Step to three drug combinations
See Diabetes Control Algorithm
Consider more complex insulin strategies– Appendix A
Multiple daily doses
Initial History of Present Illness to Consider Including
Age and characteristics of onset of diabetes mellitus
Eating patterns and physical activity
Treatment regimens and A1c
Self-monitoring of blood glucose (SMBG)
Knowledge of comfort level with self-management
Hypoglycemia details
Microvascular and macrovascular complications
Depression (PHQ-9) and anxiety (GAD-7) screening
Physical Exam
Height, weight and BMI
Blood pressure
Fundus
Thyroid (bruits)
Skin for acanthosis
Foot
Cardiovascular Exam
A1c Goal: <7%- repeat A1c (every 3 months >7%, every
6 months <7%, or individualized target)
Lipid Panel
M/C ratio, CMP, foot exam, retinal eye exam (annually)
Key Continual Testing
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Recommendations for Statin and Combination Treatment in People with Diabetes
Optimize Medical/ Pharmacological Therapy
Refer to nutrition education as appropriate
Diabetes Self– Management Education (DSME)
Maintain A1c <7% or according to guidelines or at goal
as determined by provider and patient
Maintain blood pressure <140-90 mmHg or at goal as
determined by provider and patient
Order aspirin use as recommended by the United States
Preventative Services Task Force (USPSTF; see Reference
Section for clarification)
Consider ACE or ARB use for hypertension/
nephropathy
Not recommended as prophylaxis for nephropathy
ACE and ARB not recommended for use together
Ensure completion of eye and foot exams
Provide tobacco cessation information or refer to pro-
gram as appropriate
Ensure influenza vaccine, pneumococcal vaccine, hepati-
tis B vaccine up to date
Follow-up Visits
Every 6 months controlled
Uncontrolled A1c<9%, every 3 months
Uncontrolled A1c>9%, every 6 weeks (provider)
Consider referral to Behavioral Health Consultant,
Certified Diabetes Educator and/ or Endocrinologist
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Lifestyle Modification Recommendations
Ophthalmologist/Optometrist
Podiatrist
Dietician
Diabetes self-management education
Dentist
Pre-conception planning
Behavioral Health Consultant
Mental Health Provider
Social Worker
Care Manager
Pharmacist
Consider Including the Following Individuals or Services on Care Team
High-Intensity and Moderate-Intensity Statin Therapy
High-Intensity Statin Therapy Moderate-Intensity Statin Therapy
Lowers LDL Cholesterol by ≥50%
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
Lowers LDL cholesterol by 30% to <50%
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Pitavastatin 2-4 mg
Offer diabetes education program (approved by ADA or
AADE) for newly diagnosed
Refresh diabetes education annually
Assess depression and anxiety by performing PHQ-9 and
GAD-7 at least annually
Guiding Patient Behavior Change
Use Motivational Interviewing strategies (see Tools and Resources section)
Patient-centered (discuss patient agenda and goals)
Guiding style -encourage self-based problem solving
“dancing not wrestling, guiding not directing, consulting not instructing”
Active listening – more listening and less talking; reflect what you hear
Open ended questions to evoke patient’s desires, concerns and reactions
Affirm and acknowledge positive effort and steps
Share information in a concise and potent manner (not lengthy and comprehensive)- Evoke, Offer, Evoke pattern
Remember provider empathy is key to patient behavior change
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Guiding Patient Behavior Change (continued)
Goal Setting
Focus on where they are not where they should be
Start with one behavior at a time
Help plan small, achievable steps towards goal– think shaping
Track progress for accountability– log, emails to nurse, phone app
Acknowledge and reward success
Measure to Guide Performance
Diabetes: Hemoglobin A1c Poor Control. Percentage of patients aged 18-75 years with diabetes mellitus who had
most recent hemoglobin A1c greater than 9.0%.
United States Preventive Services Task Force (USPSTF): Aspirin Guidelines
The USPSTF recommends initiating low-dose aspirin
use for the primary prevention of cardiovascular dis-
ease (CVD) and colorectal cancer (CRC) in adults aged
50-59 years who have 10% or greater 10– year CVD
risk, are not at an increased risk for bleeding, have a
life expectancy of at least 10 years, and are willing to
take low-dose aspirin daily for at least 10 years.
(Grade B)
The decision to initiate low-dose aspirin use for the
primary prevention of CVD and CRC in adults aged 60-
69 years who have a 10% or greater 10-year CVD risk
should be an individual one. Persons who are not at
an increased risk for bleeding, have a life expectancy
of at least 10 years, and are willing to take low-dose
aspirin daily for at least 10 years are more likely to
benefit. Persons who place a higher value on the po-
tential benefits than the potential harms may choose
to initiate low-dose aspirin. (Grade C)
The current evidence is insufficient to assess the bal-
ance of benefits and harms of initiating aspirin use for
the primary prevention of CVD and CRC in adults
younger than 50 years. (Grade I)
The current evidence is insufficient to assess the bal-
ance of benefits and harms initiating aspirin use for
the primary prevention of CVD and CRC in adults aged
70 years or older. (Grade I)
Guideline Adoption and Recommendation
This Clinical Practice Guideline has been adopted based on nationally recognized evidenced-based sources or on a consensus of panel experts, and is based on the most recent medical evidence at the time of the report. SLHP adopts guidelines to help providers and patients make decisions about health care for specific conditions, but are not a sub-stitute for professional medical advice.
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Tools and Resources
Pearls for Diabetes
Management of Hyperglycemia in Type 2 Diabetes: http://care.diabetesjournals.org/content/35/6/1364 Position Statement of the American Diabetes Associ-
ation (ADA) and the European Association for the study of Diabetes (EASD). http://care.diabetesjournals.org/content/36/2/490
Miller, W & Rollnick (2013). Motivational Interview-ing: Helping People Change (3rd Ed). Guilford Press, New York
Given the complex nature of this disease, look for op-portunities to involve care team members such as be-havioral health providers and diabetic educators espe-cially at the time of diagnosis
Revisit the need for Diabetes Self-Management Educa-tion annually and during transition to insulin
Optimize workflows to track diabetic eye exam results in your EMR
Consider endocrinology and/or behavioral health con-
sult for those with persistently elevated A1c levels Consider cost, side effects and comorbidities in selec-
tion of therapy Stress lifestyle modification continuously Routine testing for depression (PhQ-9) and anxiety
(GAD-7) with appropriate referral as indicated Utilize a disease registry and pre-visit planning to en-
hance care
IDC Type 2 Diabetes Glycemic Control Algorithm Abbreviations and Clinical Considerations As referenced in the Medical Management Section