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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