TOC  |  ENDO  | Diabetes Mellitus

Medications for Diabetes Mellitus     REF: ACP PIER 2006 | ACP Med Best Dx/Best Rx 2006 | diabetesRx2007.pdf   | DM_Meds_2011.pdf

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)         Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)       DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO) Biguanides (Metformin/Glucophage)   Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) Injectable medications: GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc)   Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Sulfonylureas: first choice for normal weight; hypoglycemia with monotherapy - stimulate insulin secretion in response to glucose.  Watch for weight gain. Glipizide  (Glucotrol) Dose: lowest effective single dose, 5mg, Usually dose 5-10 mg 1-2 tab BID (Max 40 mg/day) Glipizide (GI therapeutic system) Glucotrol XL 5-10mg tab once/day (Max 20 mg/day) Dose: lowest effective single dose, 5 mg; daily max, 20 mg Glyburide (Micronase, Diabeta) - (2nd generation) Dose: lowest effective single dose, 1.25 mg; Usually dose 1.25-2.5-5 mg 1-2 tab BID (Max 20 mg/day) Micronized glyburide (Glynase) Dose: lowest effective single dose, 1.5 mg; daily max, 6 mg Glimepiride (Amaryl) (3rd generation)   Dose: lowest effective single dose, 0.5 mg; 1,2,4 mg tab/day.  Start 1-2 mg/d, usual maintenance dose is 1-4mg once/d (Max: 8mg/d) Gliclazide/ Diamicron  80-160 mg daily, max 320 mg PO daily. Modified release Diamicron MR 30 mg PO daily, mas 120 mg daily   Combination meds: Glucovance (Glyburide and Metformin)   Avandaryl (Glimepiride and Avandia/Rosiglitazone)   Diabenese/Chlorpropamide  (1st generation) 100-250 mg 1-3 tab/d; 100-250 mg tab Orinase /Tolbutamide  (1st generation)  250-500 mg tab 1-3x/d Tolinase/Tolazamide   (1st generation) 100-500 mg tab -2x/d; 100-250-500 mg tab. Dymelor/Acetohexamide 500-750 mg once or divided.

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Biguanides - Primary action is reduction of excessive hepatic glucose output; it also has some activity on insulin resistance in skeleton muscle, though less than troglitazone.   - Metformin may cause life-threatening lactic acidosis.   - Takes about 2 wks to work well.  Do not use in renal or hepatic dysfunction, dehydrated, or hospital patients.   - Hold this med prior to IV contrast agents and for for 48 hours after.   - Avoid if ethanol abuse, heart failure, hepatic or renal insufficiency (Cr >1.4-1.5), or hypoxic states. Metformin: first choice for obese Dose: 500 - 850 mg tab 2-3x/day or 1000 mg bid with meals. (MAX 2550 mg/day) Glumetza/ Extended Metformin 500-1,000 mg dosage strength   Glucovance (Glyburide and Metformin) Avandamet (Avandia/Rosiglitazone and Metformin) Janumet (Januvia/Sitagliptin and Metformin)

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Thiazolidinediones TZD (Glitazones) - enhance insulin action (sensitivity to insulin) in muscle, adipose tissue & liver; it also reduces excessive hepatic glucose output.   It is for type II diabetes currently on insulin, yet not controlled (insulin >30 u/d) . - Side effects are weight gain and edema.     Caution: Possible liver damage.  Check LFT baseline & then every 1-2 months when clinically indicated thereafter.  Pioglitazone/Actos  15-30-45 mg tablet once daily  (Max 45 mg/day)   Rosiglitazone/Avandia  4 mg 1-2x/day  (Max 8 mg/day)   - see warning below!    Avandamet (Rosiglitazone/metformin) 1-2-4 mg/500mg tablets * NEJM May 2007;356:1   In the rosiglitazone (Avandia) group, as compared with the control group, the odds ratio for myocardial infarction was 1.43 (as 0.43% vs 0.36% in small trials, 0.57% vs 0.34% in DREAM trial, 1.85% vs 1.44% in ADOPT trial), and for death from cardiovascular causes was 1.64 (as 0.38% vs 0.19% in small trials, 0.51% vs 0.38% in DREAM trial, 0.14% vs 0.18% in ADOPT trials).   Troglitazone/Rezulin -200-400mg tab 1/d - discontinued! __________________________________ Study continues controversy over rosiglitazone (Avandia)'s cardiovascular risks  6-8-2009 A new study found that rosiglitazone doubled the risk of heart failure among type 2 diabetes patients but did not raise overall cardiovascular hospitalizations or deaths compared with standard therapy. The manufacturer-sponsored Rosiglitozone Evaluated for Cardiovascular Outcomes in Oral Agent Combination Therapy for Type 2 Diabetes, or RECORD, trial's results conflict with the findings of a 2007 study showing that rosiglitazone significantly increased the risk of myocardial infarction. The RECORD trial confirmed, however, earlier findings that rosaglitazone doubles the risk of distal fracture in older women. The study results were presented at the American Diabetes Association's annual scientific sessions over the weekend and published online by the Lancet (The Lancet, Early Online Publication, 5 June 2009doi:10.1016/S0140-6736(09)60953-3). [Findings:  321 people in the rosiglitazone group and 323 in the active control group experienced the primary outcome during a mean 5·5-year follow-up, meeting the criterion of non-inferiority (HR 0·99, 95% CI 0·85—1·16). HR was 0·84 (0·59—1·18) for cardiovascular death, 1·14 (0·80—1·63) for myocardial infarction, and 0·72 (0·49—1·06) for stroke. Heart failure causing admission to hospital or death occurred in 61 people in the rosiglitazone group and 29 in the active control group (HR 2·10, 1·35—3·27, risk difference per 1000 person-years 2·6, 1·1—4·1). Upper and distal lower limb fracture rates were increased mainly in women randomly assigned to rosiglitazone. Mean HbA1c was lower in the rosiglitazone group than in the control group at 5 years.] In the trial, 4,447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean hemoglobin A1c of 7.9% were randomly assigned to either add rosiglitazone to their existing regimen or take metformin and sulfonylurea alone. After 5.5 years follow up, HbA1c was lower in the rosiglitazone group than the standard therapy group, rosiglitazone did not increase the risk of overall cardiovascular morbidity or mortality, and rosiglitazone patients had a nonsignificant reduction in fatal and nonfatal stroke. However, heart failure causing admission to hospital or death was higher in the intervention group (hazard ratio [HR] 2.10; 95% confidence interval [CI] 1.35-3.27; risk difference per 1,000 person-years HR 2.6; CI 1.1-4.1) and upper and distal lower limb fracture rates were increased mainly in women taking rosiglitazone. The authors concluded that the data are inconclusive about rosiglitazone's effects on myocardial infarction and that the drug does not increase the risk of overall cardiovascular morbidity or mortality compared with standard glucose lowering drugs. In an interview with Modern Medicine, a study author noted that rosiglitazone should not be used by patients who have heart failure or who are at increased risk of fracture but could be considered in other type 2 diabetics, particularly obese patients. __________________________________

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Meglitinides(Non-Sulfonylurea Insulin Secretagogues) - stimulate insulin production in response to post-meal hyperglycemia.   - Side effects include hypoglycemia, while repaglinide can bring on headaches. Prandin (Repaglinide)  0.5 - 1 - 2 mg tab TID within 30 min before meals (Max 16 mg/day) Starlix (Nataglinide)   120 mg ac

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Alpha-glucosidase Inhibitor   - induce gastrointestinal carbohydrate absorption after a meal. - it delays the breakdown of complex carbohydrates in the intestine & reduces the postprandial rise in blood glucose. - least effective; must be taken at start of meals - Side effects include bloating, GI upset, pain, flatulence, and diarrhea. Acarbose/Precose 25- 50- 100 mg tid with first bite of meal.  Initially 25 mg 1x/d x2wks, then bid x2wks, then tid x2months, then may increase to 50 mg tid.. Miglitol/Glyset 25-50-100 mg tid with first bite of meal.  (Max 300 mg/day)

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

GLP (Glucagon-Like Peptide)  Analogues: Byetta (Exenatide) 5 mcg subc bid - 5 mcg subc bid, within 1 h before the morning & evening meals, may increase to 10 mcg bid subc after 1 month. - It is available in a pen that delivers 60 fixed doses of either 5 mcg or 10 mcg for 1 month supply. - It is a long-acting analogue of gut incretin hormone GLP-1 (Glucagon-like-peptide-1), called  incretin mimetics (analog)   for the treatment of type 2 diabetes (Not approved for type 1 diabetes).   - It exhibits many of the same effects as GLP-1, secreted in response to food intake, has multiple effects on the stomach, liver, pancreas and brain that work in concert to regulate blood sugar. - It reduces fasting & postprandial glucose by increasing glucose-stimulated insulin secretion, decreasing glucagon secretion, slowing gastric emptying & reducing appetite. - Nausea is a frequent side effect (44%), vomiting & diarrhea (13%); potential hypoglycemia. - An association between Byetta & acute pancreatitis, even fatal case, is suspected in some of these cases. (Precaution) - It may be used in combination with metformin, sulfonylurea or both. * More than 80% of treated patients with Byetta (Exenatide) lost weight 3-5 lbs at 30 weeks !!! Amylin Analogues: Symlin (pramlintide) 15 mcg subc before meal - 15 mcg subc before meal, titrate by 15 mcg increments up to maintenance 30-60 mcg as tolerated in Type 1 diabetes.   - In type 2 diabetes initiate 60 mcg subc before meals and increase upto 120 mcg as tolerated. - a synthetic analog of the pancreatic neuroendocrine hormone amylin, it is secreted from beta cells with insulin.   - The drug slows gastric emptying and decreases appetite and glucagon secretion after meals.

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

DPP IV Inhibitors DDP-4 enzyme naturally breaks down the GI hormone called GLP-1 (Glucagon-Like Peptide), which promotes the synthesis and release of insulin when food is consumed, lowers levels of glucagon, induces satiety by slowing gastric emptying, and possibly stimulates beta-cell growth & neogenesis. Vildagliptin (Galvus, Novartis) Sitagliptin (Januvia, Merck)  - approved October 2006 Januvia (Sitagliptin) - recommended dose of JANUVIA is 100 mg PO once daily JANUVIA™ (sitagliptin phosphate), the first and only  a new breakthrough class of DPP-4 inhibitor available in the United States for the treatment of type 2 diabetes, as monotherapy and as add-on therapy to either of two other types of oral diabetes medications, metformin or thiazolidinediones (TZDs), to improve blood sugar (glucose) control in patients with type 2 diabetes when diet and exercise is not enough. JANUVIA enhances a natural body system called the incretin system, which helps to regulate glucose by affecting the beta cells and alpha cells in the pancreas. Through DPP-4 inhibition, JANUVIA works only when blood sugar is elevated to address diminished insulin due to beta-cell dysfunction and uncontrolled production of glucose by the liver due to alpha-cell and beta-cell dysfunction. Helps control glucose without weight gain or an increased risk of hypoglycemia JANUVIA is indicated, as an adjunct to diet and exercise, as monotherapy to improve glycemic control in patients with type 2 diabetes mellitus. The recommended dose of JANUVIA is 100 mg once daily, with or without food, as monotherapy or as combination therapy with metformin or a TZD as an adjunct to diet and exercise for type 2 diabetes. JANUVIA should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. A dosage adjustment is recommended in patients with moderate or severe renal insufficiency or with end-stage renal disease(ESRD) requiring hemodialysis or peritoneal dialysis. The use of JANUVIA in combination with medications known to cause hypoglycemia, such as sulfonylureas or insulin, has not been adequately studied. Research is ongoing. The incidence of selected gastrointestinal (GI) adverse reactions in patients treated with JANUVIA 100 mg vs placebo was as follows: abdominal pain (2.3%, 2.1%); nausea (1.4%, 0.6%); and diarrhea (3.0%, 2.3%). Janumet (Sitagliptin/metformin)   50/500 or 50/1000 mg tab 1 tab bid PO

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

INSULIN treatment        Rapid-Acting  |  Short-Acting  |  Intermediate-Acting  |  Long-Acting  | Combination  |   New Inhaled Insulin  | Non-insulin subc   RAPID-ACTING:  as Humalog & Novolog insulin Onset: 10-30 min  |  Peak: 30-60 min  |  Duration:  3-5 h    (Medical Letter September 2002) Humalog insulin analog is faster but shorter duration action than Human regular insulin.  Use within 15 min before meals. Injection, solution, aspart, human: NovoLog®: 100 units/mL (10 mL vial) NovoLog® [PenFill®]: 100 units/mL (3 mL cartridge) Injection, solution, lispro, human: Humalog®: 100 units/mL (1.5 mL cartridge, 3 mL disposable pen, 10 mL vial) Injection, Apidra (insulin glulisine) given within 15 min premeal or within 20 min after starting a meal. SHORT-ACTING:  Regular insulin Onset: 30-60 min  |  Peak:  1.5-2 h  |  Duration:  5-8 h   Injection, solution, regular, human: Humulin® R: 100 units/mL (10 mL vial) Novolin® R: 100 units/mL (1.5 mL prefilled syringe, 10 mL vial) Novolin® R [PenFill®]: 100 units/mL (1.5 mL cartridge, 3 mL cartridge) Injection, solution, regular, human, buffered : * Velosulin® BR [Discontinued]: 100 units/mL (10 mL vial) Injection, solution, regular, purified pork: Regular Iletin® II: 100 units/mL (10 mL vial)   INTERMEDIATE-ACTING:  NPH or Lente insulin Onset: 1-2 h  |  Peak: 4-8 h  |  Duration: 10-20 h Injection, suspension, lente, human [zinc]: Humulin® L, * Novolin® L [Discontinued]: 100 units/mL (10 mL vial) Injection, suspension, lente, purified pork [zinc]: Lente® Iletin® II: 100 units/mL (10 mL vial) [Discontinued] Injection, suspension, NPH, human [isophane]: Humulin® N: 100 units/mL (3 mL disposable pen, 10 mL vial) Novolin® N: 100 units/mL (1.5 mL prefilled syringe, 10 mL vial) Novolin® N [PenFill®]: 100 units/mL (1.5 mL cartridge, 3 mL cartridge) Injection, suspension, NPH, purified pork [isophane]: NPH Iletin® II: 100 units/mL (10 mL vial) Injection, Levemir [insulin determir (rDNA origin)] subc once or twice daily Onset of action: 2–3 h;  Duration of action: 9–24 hr;  Peak action: variable modest peak: 6–10 hr   LONG-ACTING:  Ultralente insulin Injection, suspension, Ultralente®, human [zinc]: Humulin U Ultralente®: 100 units/mL (10 mL vial) Onset: 2-4 h  |  Peak: 8-20 h  |  Duration: 16-24 h Injection, solution, glargine, human: Lantus ® (Insulin glargine - rDNA origin) once a day injection, start 10  IU daily (about the same dose as NPH) 100 unit/mL (10 mL vial) Onset: 1-3 h  | Peak: no  peak |  Duration: 20-24 h   Pramlintide (Amylin) subc Adjunct to insulin for patients who fail to achieve glycemic control with insulin alone Inject subcutaneously before meals Dose: 15 µg initially, titrate upward as necessary to 30–60 µg Reduce preprandial insulin by 50% initially   COMBINATION, INTERMEDIATE-ACTING: Injection, aspart protamine human suspension 70% and rapid-acting aspart human solution 30% (NovoLog® Mix 70/30): 100 units/mL (3 mL cartridge, 3 mL prefilled syringe) Injection, lispro protamine human suspension 75% and rapid-acting lispro human solution 25% (Humalog® Mix 75/25™): 100 units/mL (3 mL disposable pen, 10 mL vial) Injection, NPH human insulin suspension 50% and short-acting regular human insulin solution 50% (Humulin® 50/50): 100 units/mL (10 mL vial) Injection, NPH human insulin suspension 70% and short-acting regular human insulin solution 30%: Humulin® 70/30: 100 units/mL (3 mL disposable pen, 10 mL vial) Novolin® 70/30: 100 units/mL (1.5 mL prefilled syringe, 10 mL vial) Novolin® 70/30 [PenFill®]: 100 units/mL (1.5 mL cartridge, 3 mL cartridge)   NEW Insulin Inhaled insulin (Exubera - Pfizer)   - NEW 2006 !                      See  NEJM Inhaled Insulin 2007 article   Onset of action: 15–30 min; Peak action: 1.5–2 hr; Duration of action: 6–8 hr   Dose:  1 mg for pts 30-39.9kg, and then add 1 mg for every 20 kg in patient over 40 kg. Supply: 1-mg and 3-mg blister pakcs.  The 1-mg pack is approximately equivalent to 3 units of subc regular insulin, 3-mg pck is about 8 units of subc regular insulin. Jan. 27, 2006 — The first inhaled insulin (Exubera) was approved today by the US Food and Drug Administration (FDA) for the treatment of adult patients with type 1 and type 2 diabetes. An inhaled powder form of recombinant human insulin (rDNA), the drug and delivery system is the first new insulin formulation introduced since the discovery of insulin in the 1920s, according to the FDA. FDA recommends pulmonary function testing at the start of Exuber therapy, at 6 months, and every year thereafter.   Exubera is used 10-15 min before meals for prandial insulin coverage only; patients still need subc injections of long-acting insulins for basal coverage. Exubera is contraindicated in patients with preexisting lung disease and in smokers.

Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase)        | Biguanides (Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset)      | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors  (Vildagliptin/Galvus, Sitagliptin/Januvia PO)  | Insulin, etc  Rx , New Inhaled Insulin (Exubera)

Correlation of HgA1c to Average Blood Glucose  6% - 135 mg/dL |  7% - 170 mg/dL  |   8% - 205 mg/dL  |   9% - 240 mg/dL  |  10% - 275 mg/dL  |  11% - 310 mg/dL  | 12% - 345 mg/dL Each 1% above 6% add 35 mg/dl to the base 135 mg/dL.

2006 General Guidelines for Management of Patients Presenting with High Blood Sugars                    See also  Diabetic Ketoacidosis

For blood glucose 300 - 500 mg/dl: Give 10 units Regular or Novolog (Aspart) insulin + 10 units NPH insulin subcutaneously. Order the following STAT labs the day of the visit: " RBS, lytes, BUN, Cr, ketones (add appropriate lab studies if not done recently i.e. non-fasting DM panel (HbA1c, urine Microalbumin, non-fasting HDL, LDL, ALT). If DCC follow-up is desired, schedule same-day (SDD) appointment for the next working day. Phone: 8-327-2440 (Imperial ext. 72440) or Fax a referral: 8-327-2402 (Imperial ext. 72402) Order stat FBS, ketones and lytes if abnormal on day of initial visit. Start oral agent and give diabetes education packet. " Order on Health Connect or give prescription for One Touch Ultra glucose meter kit with extra strips (Sure Step, if elderly). " Please call DCC or patient may contact the Call Center to schedule for a meter instruction class (60-90 minutes) at DCC Imperial Bldg. B Suite 327, # 8-327-2440 (Imperial ext. 72440). **It is important that patient is told to bring his/her machine to the class. Recheck blood sugar before patient is discharged home. Goal: blood sugar <300. Review with patient the need to force fluids and eat on schedule. For blood glucose greater than 500 mg/dl  (but glucose less than 700 mg/dL and serum CO2>20): Give 15 units Regular or Novolog (Aspart) insulin + 10 units NPH insulin subcutaneously. Order the following STAT labs on the day of the visit: RBS, lytes, BUN, Cr, ketones " Add appropriate lab studies if not done recently i.e.,non -fasting DM panel (HbAlc, urine microalbumin, and non-fasting HDL, LDL, ALT). Start IV hydration with 1 liter normal saline. Give 20 meq KCl p.o. if K+ is <3.5. " Blood sugar should be checked hourly. " Call DCC 8-327-2440 (Imperial ext. 72440) if assistance is needed. During after-hours, send the patient to ED for hydration and further treatment after initial insulin injection. If DCC follow-up is desired, schedule same-day (SDD) appointment for the next working day. Phone: 8-327-2440 (Imperial ext. 72440) or Fax a referral: 8-327-2402 (Imperial ext. 72402) Labs to be done before follow-up visit: stat FBS, ketones, and lytes (if abnormal on day of initial visit). Start oral agent or add insulin if indicated. " Give diabetes education packet and encourage pt. to attend MHE classes. " Order on Health Connect or give prescription for One Touch Ultra glucose meter kit and extra strips (Sure Step, if elderly). " Please call DCC or patient may contact the Call Center to schedule for a meter instruction class (60-90 minutes) at DCC Imperial Bldg. B, Suite 327, tie line 8-327-2440 (Imperial ext. 72440). **It is important that patient is told to bring his/her machine to the class. " Insulin instruction classes (60 minutes) can also be scheduled at DCC 8-327-2440 (Imperial ext. 72440). **Please provide patient with prescriptions for insulin and syringes before discharge. Include a separate written order that notes dose of insulin you want patient to be started on. Recheck blood sugar before patient is discharged home. Goal: blood sugar <300. Review with patient the need to force fluids and eat on schedule. For blood glucose >700 mg/dl or C02 <20, patients should be sent to Emergency Room Department after giving insulin and 20 meq KCL p.o if K+ is <3.5. If patient appears dehydrated, start one liter normal saline IV and transport by ambulance. Endocrinology (KP Imperial Diabetic Clinic 2-2006)

       2011