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NURSE PROTOCOL FOR
DIABETES MELLITUS
IN ADULTS
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
TABLE OF CONTENTS
DIABETES
Diabetes Mellitus in Adults
Appendix A:
Continuum of Care Visits
Appendix B:
Summary of Recommendations
Appendix C:
Oral Hypoglycemic Agent and Oral Agent Adjustment
Guidelines
Appendix D:
Oral Agents for Treatment of Type 2 Diabetes
Appendix E:
FDA Approved Indications for Combination Therapy
Appendix F:
Insulin Products Available in the United States
Appendix G:
Insulin Adjustment Guidelines
Appendix H:
Treatment Algorithm of Type 2 Diabetes
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
NURSE PROTOCOL FOR
DIABETES MELLITUS IN ADULTS
DEFINITION
Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion, insulin action or
both. Diabetes is characterized by fasting plasma glucose (FPG) >126
mg/dL or random plasma glucose > 200 mg/dL (with testing on two
separate days) accompanied by symptoms. Symptoms of diabetes
mellitus are frequently due to the osmotic diuresis associated with
hyperglycemia. Complications of diabetes may be acute and/or chronic.
Acute complications include: hyperglycemia, hypoglycemia, diabetic
ketoacidosis and hyperosmolar hyperglycemic nonketotic syndrome.
The chronic complications of diabetes are most often the result of
sustained hyperglycemia and include damage, dysfunction and failure of
various organs, such as eyes, kidneys, nerves, heart and vascular
system.
ETIOLOGY
Type 1 Diabetes Mellitus
1.
Cause: inadequate or absolute lack of insulin production
secondary to destruction of the pancreatic Beta cells. Individuals
are dependent on exogenous insulin for survival. Type 1
comprises less than 10% of all cases of diabetes.
2.
Contributing factors:
a.
b.
Autoimmune mediated response.
Idiopathic (No evidence of autoimmunity is present).
Type 2 Diabetes Mellitus
1.
Cause: combination of insulin resistance and/or inadequate
insulin production. Individuals may produce excessive amounts of
insulin but they are unable to use it effectively. Insulin resistance
places increasing demands on the pancreas, which eventually
cannot compensate, resulting in a relative, and later an absolute,
hypoinsulinemic state.
2.
Risk factors:
a.
b.
c.
d.
Overweight - BMI >25 kg/m2 (see BMI chart in Nutrition
Manual). BMI >22 for Asian Americans.
Waist circumference >102cm (40 inches) for men and
>88cm (35 inches) for women.
Sedentary lifestyle.
Age >45 years old.
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e.
f.
g.
h.
i.
j.
First degree relative with diabetes.
Race – African-American, Latino, Native American, Asian
and Pacific Islander at greater risk.
History of large birth-weight babies - >9 pounds or history
of diagnosed with gestational diabetes.
History of impaired glucose tolerance or fasting
glucose >100 mg/dL (>100 is impaired fasting glucose
with 33% chance to develop diabetes in 6 years).
Hypertensive (blood pressure >140/90 mmHg).
Have HDL cholesterol level <35mg/dL and/or triglyceride
level > 250mg/dL.
Pre-diabetes
1.
2.
3.
4.
SUBJECTIVE
Impaired glucose tolerance
Patients are asymptomatic but at high risk for developing
cardiovascular disease and diabetes.
Impaired fasting glucose is 100-125 mg/dL.
Plasma glucose at 2 hour oral glucose tolerance test (75gram) between 140-199 mg/dL.
1.
The client may be asymptomatic. Elevated glucose
levels are often found in routine lab work, during evaluations for
surgery or work-up for other conditions.
2.
There may or may not be a family history or obvious risk factors.
3.
Client history may or may not reveal the following:
a.
b.
c.
d.
4.
Symptoms of hyperglycemia.
Unexplained weight loss or gain.
Previously diagnosed with “borderline diabetes,”
gestational diabetes or impaired glucose tolerance.
Past or current symptoms of coronary heart disease, heart
failure, cerebrovascular disease, peripheral vascular
disease, renal disease, gout or sexual dysfunction.
The following should be investigated and documented in chart:
a.
Current diabetes self-management routine, if previously
diagnosed, to include:
1)
Medications.
2)
Diet and eating pattern.
3)
Self-management training.
4)
Self-monitoring of blood glucose (SMBG) pattern
and results.
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5)
6)
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
5.
Exercise history.
Acute complications, emergency room visits and
hospitalizations related to diabetes.
History of infections.
Family history of diabetes.
CHD risk factors.
History of target organ damage.
Psychosocial/economic factors.
Tobacco, alcohol and recreational drug use.
Female reproductive history: menstrual history, method of
contraception, pregnancies and outcomes.
Special test results related to the diagnosis of diabetes.
Prior HbA1c records.
Immunization history.
Clients may report sudden, or insidious, onset of one or more of
the following symptoms related to diabetes:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
6.
Duration of diabetes.
Frequency of usage and indications for OTC
medications, prescriptions, and alternative
medications, home remedies, nutritional
supplements.
Frequent urination, bladder dysfunction, impotence.
Extreme thirst.
Extreme hunger.
Weight loss despite normal or increased appetite.
Blurred vision.
Fatigue, weakness, lethargy.
Nausea/vomiting.
Slow-healing wounds.
Recurrent infections.
Burning, tingling or numbness in extremities.
Sleep apnea.
The following are signs and symptoms of complications or target
organ damage:
a.
b.
c.
d.
e.
f.
g.
Visual disturbances.
Chest pain.
Shortness of breath.
Edema.
Dizziness.
Headache.
Confusion or other neurologic symptoms (e.g., difficulty
with speech or movement, facial or one-sided numbness).
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h.
OBJECTIVE
1.
Nausea and vomiting.
Physical examination
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Appearance
1)
Type 1 = Thin, ill appearance, dehydrated, may
have had significant weight loss.
2)
Type 2 = Frequently overweight or obese.
Height, weight and BMI.
Routine assessment of blood pressure (standing and
sitting or sitting and lying) to assess for dehydration and
autonomic neuropathy. Blood pressure may be greater
than 140/90 mmHg.
Extremities - assess client extremities for changes in color,
deformity, injury, sensation, temperature changes, muscle
strength and deep tendon reflexes (use a 128-Hz tuning
fork and a monofilament). Shiny spots over tibial bones,
loss of hair over lower legs and toes, ulcerations of
feet/legs, carbuncles and ulcers, lipohypertrophy or
lipoatrophy at insulin injection sites. Mouth - assess for
gum problems, tooth decay and oral candidiasis.
Optic Fundi – Assess for retinopathy including:
microaneurysm, retinal detachment, glaucoma, vitreous
hemorrhage, neovascularization, decreased extraocular
movement, narrowing, copper-wiring, or AV nicking.
Arterial Pulses – Palpate and auscultate pulses.
Neurologic - Perform a complete neurologic exam.
Decreased or absent deep tendon reflexes, numbness or
burning sensation or sensory loss may be present.
Gastrointestinal neurologic manifestation presents a
gastroparesis with nausea, vomiting and weight loss.
Neck - Palpate the thyroid for an enlarged thyroid. Assess
for hoarseness and difficulty swallowing.
Skin - Inspect for sites of previous insulin injections, shiny
spots over tibial bones, loss of hair over lower legs and
toes, ulcerations of feet/legs, carbuncles and ulcers,
lipohypertrophy or lipoatrophy at insulin injection sites.
Early on in type 2 diabetes hyperinsulinemia may be
evidenced by Acanthosis Nigricans around the neck, waist,
inguinal and axillary skin folds (dark velvety
hyperpigmentation).
Cardiovascular – Perform a cardiac exam. Orthostatic
hypotension, hypertension, decreased capillary refill,
absent pedal pulses, impaired circulation.
Abdomen - Perform abdominal exam. Palpate for an
enlarged liver.
Inspect the hands for mobility and deformities.
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2.
Diagnostic laboratory findings (Non-Pregnant Adults)
a.
b.
c.
Confirmed fasting plasma glucose level of
>126 mg/dL on at least two different occasions (on
subsequent days).
OR
Confirmed random plasma glucose level of
>200 mg/dL (with classic symptoms of diabetes), on two
different occasions.
OR
Two-hour oral glucose tolerance test (OGTT) of
>200 mg/dL.
NOTE: The OGTT is done only if diagnostic testing is
indicated and client has a normal fasting plasma glucose
level. This test is useful only if strict adherence is given to
proper OGTT procedure using 75 grams of glucose, and is
not recommended for routine clinical use.
ASSESSMENT
Diabetes Mellitus (Type 1 or Type 2)
PLAN
DIAGNOSTIC AND FOLLOW-UP STUDIES
Inform the client of the importance of abnormal results and follow-up and
referrals. If a service is not available in the clinic, the client should be
given resource/referral information that must be appropriately
documented in the client’s record. The client’s follow-through on the
recommendations should be documented at the next visit.
1.
2.
3.
4.
5.
6.
7.
8.
Glycosylated hemoglobin or HbA1c – Every six months for well
controlled patients on diet therapy or oral medication. Every three
months for patients on insulin, poorly controlled or when
medications have been changed. Treatment goal is <7%.
Total cholesterol and lipid profile annually (every 3-6 months if
abnormal or if client is taking lipid-lowering agents).
Serum creatinine, potassium, and sodium annually.
ECG annually (or as indicated).
Referral for dilated eye exam annually.
Annual microalbuminuria test.
24-hour urine collection for creatinine clearance annually (if
indicated by positive urine protein).
TSH in all type 1 diabetic patients and as indicated in type 2.
Liver function studies (LFTs) if clients are on lipid-lowering drugs
and/or metformin. If on plioglitazone or rosiglitazone, LFTs
monthly for 8 months then periodically thereafter.
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9.
10.
11.
12.
13.
14.
Complete foot exam (vascular, neurologic) initially and annually to
identify high-risk feet (peripheral neuropathy with loss of
protective sensation, evidence of increased pressure, bony
deformity, peripheral vascular disease, history of ulceration or
amputation, severe nail pathology). Foot inspection for dryness,
corns, calluses and ulcers and inquire about pain, burning,
tingling, and/or numbness at each visit.
Referral for dental exam annually.
Weight and calculation of BMI on each visit; height annually.
Referral to other specialties and services as needed.
Urine cultures as indicated. Urinalysis for ketones, protein and
sediment.
Refer to Family Planning for women of reproductive age.
THERAPEUTIC
NON-PHARMACOLOGIC
For clients with newly-diagnosed Type 2 Diabetes, a random
blood glucose <250 mg/dL OR a fasting blood glucose (FBG)
<200 mg/dL, initiate/instruct in diet modification and increased
physical activity for 4-8 weeks, and then evaluate client status. A
recent position statement from the American Diabetes
Association and European Diabetes Association
recommends starting pharmacologic agents if the HbA1c is
greater than 7%. In addition, if the client presents with three or
more symptoms of hyperglycemia, or has signs of an infection,
proceed directly to pharmacologic intervention.
1.
Medical Nutrition Therapy goals are to: (See Client
Education/Counseling Section)
a.
b.
c.
d.
e.
2.
Maintain near-normal glucose levels.
Attain and maintain desirable body weight.
Decrease fat/cholesterol intake, if needed to achieve
optimal lipid levels. Fat percentage recommendation
is dependent on desired lipid outcomes.
Promote meal pattern consistency.
Prevent and treat acute and chronic complications of
diabetes.
Recommend increased physical activity as indicated to:
a.
b.
Promote weight and lipid control.
Individualize with consideration for existing medical
conditions such as cardiovascular disease,
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c.
d.
3.
peripheral neuropathy, arthritis, age and diabetes
medications, if any.
Reduce cardiovascular risk factors.
Decrease insulin resistance and increase
metabolism.
Self-Monitoring of Blood Glucose (SMBG):
a.
b.
c.
d.
e.
f.
g.
h.
i.
Assess effectiveness of meal plan, exercise and
medication.
Determine frequency of SMBG. Consider type of
diabetes and hypoglycemic agent. Assess client’s
willingness, financial resources and level of diabetes
control
Patients with Type 1 diabetes check 3 or more
times a day.
Pregnant women taking insulin for gestational
diabetes should check 3 or more times a day.
Patients with Type 2 diabetes who are being
treated with insulin should check 2 or more
times per day. However, it is recommended that
they check as often as needed until they reach
blood glucose targets. Once 50% of blood
glucose values are within target blood glucose
range, SMBG frequency can be modified to
treatment (e.g., diet only, 2-3 times per week;
oral medications, daily; insulin therapy 3-4 times
per day).
Frequent monitoring is essential for those on
intensive insulin therapy or pump therapy.
Individualized target blood glucose range based
on treatment regimen and age. Recommended
target: pre-meal glucose between 90-130 mg/dL,
random glucose less than 180mg/dL.
Occasionally a 2-hour post-prandial blood
glucose may be useful in evaluating control
(target <180mg/dL).
When medication, diet or medical treatment
changes, increase frequency of SMBG until 50% or
more of BG values are within target range.
Additional testing is needed during times of stress,
especially infection/illness.
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PHARMACOLOGIC
NOTE: Before initiating oral agents, assess alcohol intake,
baseline liver functions and renal function.
1.
Type 2 clients with persistently elevated blood glucose
level (>200 mg/dL random or >140 mg/dL fasting), or if
HbA1c >7% after 8 weeks:
a.
Initiate oral agents at the lowest starting dose to
prevent or minimize side effects. Instruct on
SMBG and the need of maintaining a glycemic
record (see Appendix A).
NOTE: Consider initial insulin therapy for patients who are
not adequately controlled by diet, who are symptomatic, or
have ketonuria, ketonemia, or present with severe
hyperglycemia (glucose greater than 350 mg/dL).
Be aware that insulins lispro (Humalog), aspart (Novolog)
and glulisine (Apidra) are fast-acting insulins and should be
taken 5-10 minutes before meals. Regular insulin should
be taken 30 minutes before meals. Insulin glargine
(Lantus) should never be mixed with other insulins.
b.
c.
d.
Oral agents for the treatment of type 2 diabetes dosing may be increased every 1-2 weeks until
maximum dose is reached or a second agent from a
different class may be added as combination
therapy. (See Appendix D.)
If blood glucose is controlled except for morning
hyperglycemia, consider combination therapy of an
oral agent with insulin. Add insulin at bedtime (0.10.2 U/kg NPH or glargine) subcutaneously. Dose
may be adjusted, up or down 2-4 units, every week
based on fasting morning blood glucose levels and
client’s target blood glucose range. (See Appendix
E.)
If unable to achieve target blood glucose range on
oral agent therapy or combination therapy, begin
insulin therapy with two or more injections/day:
NOTE: See Appendix F for types of insulin by
category.
Intermediate-acting + short-acting insulin
before breakfast
AND
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Intermediate-acting + short-acting insulin before
evening meal.
For initiation of therapy, the total daily dose of insulin
units is calculated by multiplying 0.3U x kg (current
weight).
a.m. p.m.
Distribution of total units
2/3
1/3
Short/Intermediate ratio
1:2
1:1
e.
f.
2.
Insulin doses may be titrated weekly until blood
glucose control is achieved (see Appendix G, Insulin
Dose Adjustment Guidelines). Consider using 70/30
or 50/50 insulin for individuals unable to mix insulins.
Clients taking short-acting insulin must be instructed
to take it prior to meals.
Instruct on signs, symptoms and treatment of
hypoglycemia, SBGM and frequency, recordkeeping, target blood glucose range and emergency
contact in case of questions or problems.
Type 1 clients will likely already be taking insulin injections.
Evaluate their existing insulin regimen and level of blood
glucose control with target blood glucose range and, if
indicated, consider insulin dose adjustment using Insulin
Dose Adjustment Guidelines in Appendix G. If newly
diagnosed, initiate insulin therapy with two injections/day
with:
Short-acting + intermediate-acting before breakfast
AND
Short-acting + intermediate-acting before dinner
To calculate total daily dose of insulin units, multiply 0.3
unit x kg (current weight).
Morning
Evening
Distribution of total units
2/3
1/3
Short-acting/
intermediate-acting ratio
1:2
1:1
Insulin dose may be titrated weekly until blood glucose
control is achieved (see Appendix G, Insulin Dose
Adjustment Guidelines.) Consider using 70/30 or 50/50
insulin for individuals unable to mix insulins.
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CLIENT EDUCATION/COUNSELING
The client and/or family participation is key to successful management
of diabetes and should be involved in decisions and goal-setting.
Prioritize information to prevent overwhelming the client. Important
factors in achieving blood glucose control are client education, behavior
change, and consistent follow-up. If goals are not being met, the
management plan needs to be revised and/or goals need to be
reassessed.
The overall goals of education are: effective self-management skills,
enhanced clinical outcomes, and optimal quality of life. Assessment
should include the client’s educational needs, readiness to learn, and
preferred learning style. While some aspects of diabetes selfmanagement should be on an individual basis (one-on-one), group
classes can address topics appropriate for most clients (e.g., dining out,
reading labels, and physical activity) and allow clients to share and learn
from others’ experiences and recognize that others face similar
challenges.
1.
Determine mutually agreed upon blood glucose, HbA1c and lipid
goals.
2.
Address lifestyle changes:
a.
b.
c.
d.
e.
Nutrition
Use an individualized approach appropriate for the
person’s lifestyle and diabetes management goals. No
single approach has proven to be most effective. Refer all
clients to the nutritionist for assessment and selection of an
appropriate meal-planning approach. May use one of the
following basic instruction tools:
1)
“The First Step on Diabetes Meal Planning,” a basic
pamphlet based on the Food Guide Pyramid.
2)
“Healthy Food Choices,” a pamphlet with guidelines
for healthy food choices, what to eat and timing of
meals and snacks.
3)
“Idaho Plate Method,” a poster focusing on portion
control and appropriate food choices for meals and
snacks.
Physical activity.
If smoker or tobacco user, refer to local cessation program
and/or the Georgia Tobacco Quit Line, 1-877-270-STOP
(7867).
Reduce/control weight - focus on reaching reasonable
weight.
Control blood pressure <130/80 mmHg.
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f.
g.
3.
Reduce/control hyperlipidemia (LDL <100mg/dl).
Less than 2 alcohol containing beverages/day if male;
1 alcoholic beverage/day if female.
(One alcoholic beverage/day is defined as 12 oz beer, 5 oz
wine, 1.5 oz distilled spirits. Each contains approximately
15 grams alcohol). Patients should be counseled that
most mixers contain large amounts of sugar and/or fats
and should be avoided.
Instruct on survival skills:
a.
b.
c.
d.
e.
Insulin injection technique (if appropriate), proper
preparation, insulin storage, timing of injections and site
rotation.
Self-monitoring of blood glucose.
Causes, signs, symptoms, and appropriate corrective
actions for hypoglycemia and hyperglycemia.
When to call health care provider and who to call in case of
emergency.
Sick-day management.
4.
Teach preventive care of feet, eyes and mouth/teeth.
5.
Address long-term neurological, kidney, retinal and cardiac
complications.
6.
For women of childbearing age, discuss family planning in relation
to blood glucose control.
7.
Assist client to establish three short-term behavior changes.
8.
Assess and administer vaccines indicated according to the current
Advisory Committee on Immunization Practices (ACIP) childhood
or adult immunization schedule (i.e. vaccines recommended for
persons with diabetes). See the Georgia Immunization Program
Manual, Recommended Schedule and Guidelines, for current
ACIP schedules and administration guidelines for each vaccine.
The Georgia Immunization Manual may be accessed on line at
http://health.state.ga.us/publications/manuals.asp.
9.
Counsel client about alternative therapy.
10.
Emphasize prevention and risk reduction strategies for
cardiovascular disease.
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FOLLOW-UP (See Appendix A for Continuum of Care.)
The frequency of visits depends upon:
1.
The type of diabetes.
2.
Blood glucose goals and degree to which the goals are being
achieved.
3.
Changes in the treatment regimen.
4.
Presence of complications or other medical conditions.
CONSULTATION/REFERRAL
1.
Unless other instructions have been given by medical director,
refer to a physician for:
a.
b.
c.
d.
e.
Blood glucose levels >240 mg/dL.
Recurring episodes of hypoglycemia (glucose level <70
mg/dL or after one episode of severe hypoglycemia
[loss of consciousness or glucose <40 mg/dL]).
Ketones in urine.
Pregnancy (always refer).
New-onset angina, intermittent claudication, proteinuria,
acute vision loss, acute illness, influenza, kidney infection,
nausea and vomiting, urinary tract infection, fever of
unknown origin, or acute foot injury or ulceration.
2.
Refer to support groups and other community resources (e.g.,
American Diabetes Association, smoking cessation, recreation
departments).
3.
Annual referral to an eye specialist.
4.
Other specialty consultations/referrals as needed.
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APPENDIX A
Continuum of Care Visits
Client Name ________________________ MR# ___________________Phone __________
Continuum of Care Activities/Frequency
Dates
Contact Frequency
Daily for initiation of insulin or regimen change.
Weekly for initiation of oral glucose-lowering
agent(s) or change in regimen.
Routine diabetes visits
1. Every 2-3 months for clients who are not
meeting goals.
2. Every 3-4 months for all other clients.
Medical History
A. Assess treatment regimen (every regular
diabetes visit).
1. Frequency/severity of hypo- or
hyperglycemia.
2. SMBG results.
3. Patient regimen adjustments.
4. Adherence problem.
5. Lifestyle changes.
6. Symptoms of complications.
7. Other medical illnesses.
8. Medications (OTC, Rx, home remedies,
alternative medications).
9. Psychosocial issues.
10. Tobacco, alcohol, and recreational drug
use, and alternative therapies.
11. Immunization history.
Laboratory Evaluation
A. HbA1c - Goal <7.0%:
1. Quarterly if treatment changes or client is
not meeting goals.
2. Twice per year if stable.
B. Fasting plasma glucose.
C. Fasting lipid profile annually:
LDL Goal <100 mg/dl
HDL Goal >45 mg/dl, men; >55 mg/dl,
women.
D. Microalbumin measurement annually.
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Physical Examination
A. Physical examination annually.
B. Dilated eye examination annually.
C. Every regular diabetes visit:
1. Weight
2. Blood pressure- Goal <130/80 mmHg
3. Previous abnormalities on the physical
exam
D. Each visit, foot inspection for trauma.
E. Dryness, corns, calluses, ulcers. Inquire
about pain, burning, tingling, numbness.
F. Foot examination annually or more often in
clients with high-risk foot condition,
peripheral neuropathy with loss of protective
sensation, evidence of deformity, peripheral
vascular disease, history ulceration,
amputation.
Evaluation of Management Plan
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
Short and long-term goals.
Medications.
Blood glucose level.
Frequency/severity of hypo- or
hyperglycemia.
SMBG results.
Complications.
Control of dyslipidemia.
Blood pressure.
Weight.
Mineral and nutritional therapy.
Exercise regimen.
Adherence to self-management training:
1. Knowledge of diabetes
2. Self-management skills
Follow-up of referrals.
Psychosocial adjustment.
Smoking cessation if indicated.
Annual influenza vaccine.
Assessment for need for pneumococcal
vaccine.
Assessment for the need of all other adult
immunization(s) (i.e., tetanus, hepatitis B
and more); refer to Immunization manual.
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Appendix B
Summary of recommendations for adults with diabetes
Glycemic control
HbA1c
<7.0%*
Preprandial capillary plasma glucose
90–130 mg/dL
(5.0–7.2
mmol/L)
Peak postprandial capillary plasma glucose
<180 mg/dL
(<10.0 mmol/L)
Blood pressure
<130/80 mmHg
Lipids
LDL
<100 mg/dL
(<2.6 mmol/L) **
Triglycerides
<150 mg/dL
(<1.7 mmol/L)
HDL
>40 mg/dL (>1.1
mmol/L)
Key concepts in setting glycemic goals:
• HbA1c is the primary target for glycemic control
• Goals should be individualized
• Certain populations (children, pregnant women, and elderly) require
special considerations
• Less intensive glycemic goals may be indicated in patients with severe
or frequent hypoglycemia
• More stringent glycemic goals (i.e. a normal HbA1c, <6%) may further
reduce complications at the cost of increased risk of hypoglycemia
(particularly in those with type 1 diabetes)
• Postprandial glucose may be targeted if HbA1c goals are not met
despite reaching preprandial glucose goals
*
Referenced to a non-diabetic range of 4.0–6.0% using a Diabetes Control and Complications Trial-based assay.
Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal, generally peak levels in patients with
diabetes.
Current National Cholesterol Education Program/Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment
Panel III) guidelines suggest that in patients with triglycerides 200 mg/dL, the "non-HDL cholesterol" (total cholesterol minus HDL) be used.
The goal is 130 mg/dL (31).
For women, it has been suggested that the HDL goal be increased by 10 mg/dL.
** For patients with known coronary heart disease and other cardiovascular disorders an LDL level <70 has recently been recommended.
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Correlation between HbA1c level and mean plasma glucose levels on multiple testing
over 2–3 months
Mean plasma glucose
HbA1c (%)
mg/dL
mmol/L
6
135
7.5
7
170
9.5
8
205
11.5
9
240
13.5
10
275
15.5
11
310
17.5
12
345
19.5
Diabetes
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Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX C
Nurse Protocol for Management of Diabetes Mellitus in Adults
Oral Hypoglycemic Agent and Oral Agent Adjustment Guidelines
1.
Consider oral hypoglycemic agent or oral agent therapy for clients with Type 2 DM if:
a.
At diagnosis, if HbA1c is greater than 7%, a random plasma glucose is 250350 mg/dL, or fasting plasma glucose is 200 mg/dL with mild or no symptoms
of diabetes.
b.
If after 8-12 weeks FBG is >140 mg/dL or HbA1c >7%.
NOTE: Metformin therapy should be considered as the preferred oral agent for
most patients (in the absence of contraindications). Educate patient on
potential side effects.
2.
Clients on sulfonylurea agents (glyburide, glipizide and chlorpropamide) must be
instructed on symptoms, causes and treatment of hypoglycemia. A sulfonylureainduced facial flushing reaction may occur when some sulfonylureas are administered
with alcohol. This syndrome is characterized by facial flushing and occasional
breathlessness but without the nausea, vomiting, and hypotension seen with a true
alcohol-disulfiram reaction
3.
Self blood glucose monitoring by the client or client’s family should be done 2-4
times/day (if possible), or as previously described under non-pharmacologic therapy,
and a record maintained. SBGM record should be reviewed with the client at each
visit.
4.
Dose adjustment should be made if (See Appendix G):
a.
b.
c.
5.
HbA1c greater than 7%.
More than 50% of fasting or random BG values are outside of the target BG
range.
More than 2 (unexplained) episodes of hypoglycemia (BG less than 70 mg/dL)
occur in one week or one episode of severe hypoglycemia (loss of
consciousness or glucose <40 mg/dL).
Liver function monitoring for pioglitazone (Actos) and rosiglitazone (Avandia):
a.
b.
c.
d.
Serum transaminase levels at the initiation of therapy and periodically
thereafter.
Patients with ALT levels between 2 and 3 times the upper limits of normal at
baseline or during therapy should be evaluated to determine the cause of the
elevation and the levels should be monitored frequently.
Rosiglitazone and pioglitazone should not be used in patients with clinical
evidence of active liver disease or if ALT concentrations are >3 times normal.
If ALT >3X upper normal limits during therapy, retest promptly and discontinue
if ALT remains >3X upper normal limits.
Diabetes
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Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX D
Oral Agents for Treatment of Type 2 Diabetes
Generic Name
Trade
Name
Starting Dose
Next Increase
Next Increase
Next Increase
Maximum
Dose
Glyburide
(2n generation
sulfonylurea)
Diabeta,
Micronase
1.25 mg (renal
and/or hepatic
impaired) 2.55mg every
morning with
food
1 week:
Increase
increment of
2.5 mg daily
1 week:
Increase
increment of
2.5 mg daily
(divide dose to
twice a day if
> 10 mg per
day)
1 week:
Increase
increment of
2.5 mg daily
(divide dose to
twice a day if >
10 mg per day)
10 mg
morning
10 mg
evening
Glyburide
(2n generation
sulfonylurea)
Glyburide/
Metformin
Glynase,
PresTab,
Pfizer,
Glycron,
Zoetica,
Diabeta and
Micronase
Glucovance
(2nd generation
sulfonylurea/biguanides)
Glipizide
(2nd generation
Glucotrol
20 mg total
0.75 (renal
and/hepatic or
geriatric) 1.5 –
3 daily
2-10 days
Increase by
1.5-3.0 mg
daily
2-10 days
Increase by
1.5—3.0 mg
daily (divide
the dose to
twice a day)
2-10 days
Increase by
1.5-3.0 mg
daily
12mg (Most
patients not
benefit from
>15mg/ day)
.
(Initial
therapy)
1.25/250 mg
every day with
a meal
OR
1.25/250 mg
twice a day
with meals, if
FBG > 200
mg/dl or
HbA1c > 9%
2 weeks:
Increase
increment of
1.25/250 mg
daily
OR
(From initial)
2.5/500 mg
every morning
1.25/250mg
every evening
2 weeks:
Increase
increment of
1.25/250 mg
daily
OR
2.5/500 mg
every morning
2.5/500 mg
every evening
2 weeks:
Increase
increment of
1.25/250mg
daily
OR
3.75/750 mg
every morning
2.5/500 mg
every evening
(From initial)
10/2000 mg
total daily
OR
(2nd line
therapy)
2.5/500 mg
twice a day
with meals
NOTE:
The initial
dosage of
combination
product
should not
exceed the
daily dosage
the patient
received of
the products
given
separately.
2.5 mg
(geriatric or
hepatic
(From 2nd line)
3.75/750 mg
every morning
2.5/500 mg
every evening
(From 2nd
line) 3.75
mg/750mg
every
morning
3.75/750 mg
every
evening
(From 2nd line)
5.0
mg/1000mg
every morning
3.75/750 mg
every evening
3 – 7 days:
Increase
increment of
3 – 7 days:
Increase
increment of
3 - 7 days:
Increase
increment of
Diabetes
From 2nd
line)
20/2000 mg
40 mg total
in divided
doses
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for 2008
Generic Name
Trade
Name
sulfonylurea)
Starting Dose
Next Increase
Next Increase
Next Increase
Maximum
Dose
disease) - 5
mg (30 min.
before
breakfast)
2.5 – 5 mg
daily
2.5 – 5 mg
daily
2.5 – 5 mg
daily (divide
dose to twice a
day if greater
than 15 – 20
3 months:
15-20 mg every
morning
maximum
15 mg/
dose.
2 weeks:
Increase
increment of
2.5/250 mg or
2.5/500 mg
Use same
tablet as
initiated for
increment,
twice a day
dosing with
stronger dose
in the morning,
with meals.
(Initial
therapy)
10/2000 mg
total daily
Glipizide
extendedrelease
Glucotrol XL
2.5-5 mg
every morning
3 months:
5-10 mg every
morning
3 months:
10-15 mg
every morning
Glipizide/
Metformin
(2nd generation
sulfonylurea/big
uanides)
Metaglip
(Initial
therapy)
2.5/250 mg
daily with
meal
2 weeks:
Increase
increment of
2.5/250 mg or
2.5/500 mg
Use same
tablet as
initiated for
increment,
twice a day
dosing with
stronger dose
in the morning,
with meals.
2 weeks:
Increase
increment of
2.5/250 mg or
2.5/500 mg
Use same
tablet as
initiated for
increment,
twice a day
dosing with
stronger dose
in the
morning, with
meals.
2.5/500 mg
twice a day
with meals
(for FBS 280
– 320 mg/dL)
(2nd
line
therapy)
Increase
increment of
5/500 mg
(2nd line
therapy)
2.5 – 5/500
mg twice a
day with
meals
Chlorpropamide
(1st generation
sulfonylurea)
Diabinese
Metformin
(Monitor SCr &
liver function)
(biguanide)
Glucophage
100 – 125 mg
am (geriatric)
(2nd
(2nd line
therapy)
Increase
increment of
5/500 mg
line
therapy)
Increase
increment of
5/500 mg
20 mg every
morning.
(2nd line
therapy)
20/2000 mg
total daily
3 – 5 days:
Increase
increment of 50
– 125 mg daily
in the morning
3 – 5 days:
Increase
increment of
50 – 125 mg
daily in the
morning
3 – 5 days:
Increase
increment of 50
– 125 mg daily
in the morning
750 mg
every
morning
(there is
usually no
improvemen
t at greater
than 500
mg)
500 mg every
morning with
meal and
500mg every
evening with
meal.
1-2 weeks:
1000 mg every
morning
500 mg every
evening
with meals
2 weeks:
850 mg every
morning
850 mg every
evening with
meals
1700 mg
total daily in
divided
doses
850 mg in the
morning
with meals
850 mg in the
morning with
meal
500 mg in the
evening with
1-2 weeks:
1000 mg
every morning
500 mg every
evening
with meals
850 mg three
times a day
with meals
OR
1000 mg in
250 mg every
morning
(others)
Diabetes
2550 mg
total daily in
divided
doses
7.19
Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
Generic Name
Metformin
extendedrelease
(Monitor SCr &
liver function)
Trade
Name
Glucophage
XR
Acarbose
(AlphaGlucosidase
Inhibitor)
Do not use in
pts with SCr > 2
mg/dL
Precose
Glimepiride
(2nd generation
sulfonylurea)
Amaryl
Starting Dose
500 mg with
evening meal
Next Increase
Next Increase
meal
OR
850 my in the
morning with
meal
850 mg in the
evening with
meal
1 week:
1000 mg with
evening meal
the morning
1000 mg in
the evening
with meals
1 week:
1500 mg with
evening meal
Next Increase
Maximum
Dose
1 week:
2000 mg with
evening meal
OR
1000 mg twice
daily with
meals
2000 mg
total daily in
divided
doses
25 mg daily
with first bite
of main meal,
increasing
over few days
to three times
a day with
meals
Gradually
increase dose
every 4 – 8
weeks
50 mg three
times a day
Gradually
increase dose
every 4 – 8
weeks
100 mg twice
a day
1 mg with
breakfast or
first main
meal
(geriatric)
2 weeks:
Increase
increment of 1
mg daily
2 weeks:
Increase
increment of 1
mg daily
2 weeks:
Increase
increment of 1
mg daily
1 week:
Double the
daily dose and
give in up to 4
divided doses
in response to
changes in
patient’s meal
pattern
1 week:
Double the
daily dose and
give in up to 4
divided doses
in response
to changes in
patient’s
meal pattern
1 week:
Double the
daily dose and
give in up to 4
divided doses
in response to
changes in
patient’s meal
pattern
May convert
to
conventional
metformin
dosing
50 mg three
times a day
if wt < 60 kg
(132 lbs)
100 mg
three times
a day if wt >
60 kg (132
lbs)
8 mg daily
1 - 2 mg with
breakfast or
first main
meal
(others)
Repaglinide
(meglitinide
analogue)
Prandin
0.5 mg for
patients not
previously
treated with a
blood glucose
lowering agent
at 15 min.
before meal
1-2 mg 15 to
30 minutes
before each
meal for
patients
Diabetes
16 mg total
daily in
response
to changes
in patient’s
meal
pattern
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
Generic Name
Trade
Name
Starting Dose
Next Increase
Next Increase
Next Increase
Maximum
Dose
previously
treated with
blood glucose
lowering
agents
Nateglinide
(insulin
secretagogue)
Starlix
Miglitol (alphaglucosidase
inhibitor)
Glyset
Pioglitazone
Actos
15 - 30 mg
daily
The dose may
be increased in
increments up
to 45 mg daily
45 mg daily
Avandia
4 mg daily
OR
2 mg twice a
day
8 - 12 weeks:
8 mg daily
OR
4 mg twice a
day
8 mg daily
(Thiazolidinedione)
120 mg three
times a day
1 to 30
minutes prior
to meals
OR
60 mg three
times a day
before meals
(If near goal
HbA1c)
25 mg with
first bite of
main meal,
increasing
over few days
to three times
a day with
meals
(Monitor liver
function)
Rosiglitazone
(Thiazolidinedione)
(Monitor liver
function)
Special Note:
Rosiglitazone
has been
associated
with the new
onset or
worsening of
macular edema
in diabetic
patients
(Lexicomp
1/5/2006
Update)
120 mg
three times
a day
4 – 8 weeks:
50 mg three
times a day
with meals
Diabetes
3 months:
100 mg three
times a day
with meals
300 mg total
daily in
divided
doses
7.21
Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
Generic Name
Trade
Name
Starting Dose
Next Increase
Rosiglitazone/
Metformin
(Thiazolidinedione/biguanide)
Avandamet
Therapy
should be
The dosage of
a fixed
combination
may be titrated
upward, not
exceeding 500
mg of
metformin
and/or 4 mg
rosiglitazone or
a maximum
daily dosage of
2 gm of
metformin and
8 mg of
rosiglitazone is
reached
8 mg/2 Gm
total daily
Sitagliptin DPP
IV Inhibitors
Januvia
none
100 mg/day
individualized
in patients
already
receiving
metformin
100 mg/once
daily (Lower
doses for
GFR<60ml/
minute
Diabetes
Next Increase
Next Increase
Maximum
Dose
7.22
Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX E
FDA Approved Indications for Combination Therapy
Sulfonylurea
Sulfonylurea
Metformin
50-60
mg/dL
decrease in
FBG
1.7%-2.2%
decrease in
HbA1c
Insulin
40-50
mg/dL
decrease in
FBG
0.8-1.1%
decrease in
HbA1c
Metformin
Acarbose
Miglitol
50-60
mg/dL
decrease
in FBG
1.7%2.2%
decrease
in HbA1c
40-50
mg/dL
decrease
in FBG
0.9-1.3%
decrease
in HbA1c
30-60
mg/dL
decrease
in PPG
0.6-0.8%
decrease
in HbA1c
0.8%
decrease
in HbA1c
91.5
mg/dL
below
baseline
treatment
with
insulin
1.9%
below
baseline
treatment
with
insulin
1.8 mg/dL
increase
from
insulin
monother
apy
Repaglinide
Rosiglitazone
Pioglitazone
50 mg/dL
decrease in
FBG
1.2%
decrease in
HbA1c
40 mg/dL
decrease in
FBG
1.4-1.7%
decrease in
HbA1c
30-50 mg/dL
decrease in
FBG
0.6-0.8%
decrease in
HbA1c
40 mg/dL
decrease in
FBG
1.4%
decrease in
HbA1c
30-50 mg/dL
decrease in
FBG
0.7-1.0%
decrease in
HbA1c
FBG = Fasting blood glucose
PPG = Post-prandial glucose
HbA1c = Hemoglobin A1c
Diabetes
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Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX F
Insulin Products Available in the United States
Insulin
Rapid acting (onset <15 minutes,
peak 30-90 minutes, duration 3-5
hours).
Humalog
Humalog Cartridges
Novolog
Apidra
Exubera (nasal)
Short-Acting (onset 30-60 minutes,
peak 50-120 minutes, duration 5-8
hours).
Humulin R Regular
Humulin R Cartridges
Novolin R
Novolin R Penfill
Novolin R
Intermediate-Acting (onset 1-3
hours, peak unpredictable 7-15
hours, duration 20 hours).
Humulin L (Lente)
Humulin N (NPH)
Humulin N Cartridges
Novolin L
Novolin N
Novolin N Penfill
Novolin N prefilled
Long-Acting (onset 4-6 hours, peak
unpredictable, duration 16-20
hours).
Long Acting (24Hrs)
(onset 1.1 hours, no peak, duration
24 hours)
Glargine (Lantus)
Detemir (Levemir)
SMBG reflecting insulin action
Dose 10-20 minutes before meals
Dose 30 minutes before meals
Dose - before dinner
Every evening/bedtime – breakfast
Before breakfast
Lantus: Dose once daily at the same time of
day.
Detemir: Dose once or twice daily
Diabetes
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
Insulin
Mixtures Humulin 50/50
Humulin 70/30
Humulin 70/30 (cartridge)
Novolin 70/30
Novolin 70/30 Penfill
Novolin 70/30 Prefilled
Humalog 75/25
Humalog 50/50
Novolog 70/30
The onset, peak, and duration of
action of these mixtures would
reflect a composite of the
intermediate and short or rapid
acting components with one peak of
action.
SMBG reflecting insulin action
Before meals/ bedtime
Diabetes
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX G
Insulin Adjustment Guidelines
1.
Decisions regarding insulin adjustments are dependent upon:
a.
b.
c.
d.
Knowledge of the action time and duration of action of the various insulin
preparations available. (Refer to Appendix F.)
The client’s blood glucose monitoring records to identify patterns of glucose
levels.
Assessment of client’s follow through with nutritional recommendations and
activity.
The degree of acceptable glycemic control for each individual client.
2.
An increase or decrease of 1-2 units in the appropriate insulin may cause a difference
of 40-50 mg/dL in the glucose level. Adjustments should be made in one dose at a
time increments and the response/result evaluated carefully before making additional
changes.
3.
Suggested adjustments:
Before breakfast
Before Lunch
Before
Evening Meal
Bedtime
short-acting
intermediate-acting
1.
Intermediate-acting
+
short acting
2.
Intermediate-acting
+
short acting
short-acting
short-acting
intermediate-acting
3.
short-acting
short-acting
short-acting
long-acting
Diabetes
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
Glucose Outside Range
Possible Adjustment
High
increase every evening or bedtime
intermediate-acting or long-acting
insulin
Low
decrease every evening or bedtime
intermediate- acting or long-acting
insulin
High
add or increase morning shortacting insulin
Low
decrease morning short-acting
insulin
High
increase morning intermediateacting or long-acting insulin OR
lunchtime short-acting insulin
Low
decrease AM intermediate-acting or
long-acting insulin OR lunchtime
short-acting insulin
High
add or increase dinner short-acting
insulin
Low
Low
decrease dinner short-acting insulin
decrease intermediate-acting or
long- acting insulin, OR change predinner NPH/Lente to bedtime
FBG
Before Lunch
Before Dinner
Before Bedtime (HS)
During Night
Diabetes
7.27
Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
APPENDIX H
T
TREATMENT ALGORITHM OF TYPE 2 DIABETES
Nutrition and Physical Activity Inadequate?
FPG > 120 mg/dL
HbA1c > 7%
First-Line Therapies
Sulfonylureas or Metformin or Acarbose or Rosiglitazone or Pioglitazone
Lean
Overweight
Postprandial Renal Impairment Renal Impairment
Dyslipidemic Hyperglycemic Insulin Resistant
Insulin Resistant
Insulin Resistant
MONOTHERAPY INADEQUATE?
FPG > 130 mg/dL
HbA1c > 7%
MONOTHERAPY
ADEQUATE?
FPG < 130 mg/dL
HbA1c < 7%
INITIATE ORAL COMBINATION
THERAPY
CONTINUE
COMBINATION THERAPY
ADEQUATE?
FPG < 130 mg/dL
HbA1c < 7%
CONTINUE
COMBINATION THERAPY INADEQUATE?
FPG > 130 mg/dL
HbA1c > 7%




Diabetes
Consider:
Referral to a specialist
Adding Bedtime insulin or third oral agent
Switching to insulin
If uncontrolled on insulin, Add Rosiglitazone, or
Pioglitazone or Metformin
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for 2008
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
American Diabetes Association, Standards of Medical Care for Patients with Diabetes
Mellitus. Diabetes Care, Vol. 30, Supplement 1, 2007, pp. S4-S41.
M.J. Franz, Diabetes Education and Program Management, A Core Curriculum for
Diabetes Education, Fifth Edition, American Association of Diabetes Educators,
Chicago, 2003, pp. 25-99. (Current)
Constance R. Uphold and Mary Virginia Grant, Clinical Guidelines in Family Practice,
Fourth Edition, Barmarrae Books Inc., Gainesville, FL, 2003. pp.164-180. (Current)
Joint National Committee on Detection, Evaluation and Treatment of High Blood
Pressure, The Seventh Report-JNC7 Express, NIH Publication No. 03-5233, May
2003, pp. 14-19. (Current)
Lexi-Drugs OnlineTM, Lexi-Comp DatabaseTM, Lexi-Comp, Inc., Hudson, Ohio,
March 29, 2007.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3126-3138, 3140-3211.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
Georgia Dietetic Association Diet Manual and Nutrition Practice Guidelines, Georgia
Dietetic Association, 2004. (Current)
American Diabetes Association, Management of Hyperglycemia in Type 2
Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy,
Diabetes Care, Vol.29, 2006, pp. 1963-1972.
Diabetes
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Diabetes
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