Download Diabetes Management Guidelines Update: 2011

Diabetes Management Guidelines: 2011
USPHS Scientific and Training Symposium – Pharmacy Category
June 21st, 2011
CDR Ryan Schupbach, Pharm.D., BCPS, CACP, NCPS
Clinical Pharmacy Director, PHS Claremore Indian Hospital
Clinical Assistant Professor, University of Oklahoma College of Pharmacy
Objectives
• Generalize contemporary changes in guidelines
relating to the diagnosis, treatment and
medication management of diabetes
• Explore diabetes outcome measures where
pharmacist practitioners can have significant
impact
• Systematize preferred medications from
evidence-based literature in the treatment of
diabetes
Overview
• Impact of Diabetes Mellitus (DM)
• Diabetes Practice Guidelines
– Focus: 2011 ADA Standards of Medical Care
• Treatment Algorithms for Glycemic Control
– 2009 ADA/EASD guidelines for T2DM
– AACE December 2009 Update
T2DM= Type 2 Diabetes Mellitus
Diabetes Epidemiology - 2010
• Diabetes affects 25.8 million in U.S.
– 8.3% of population (>90% have T2DM)
– 19 million diagnosed; 7 million undiagnosed
• 1.9 million adults diagnosed in 2010
• 79 million people have pre-diabetes in U.S.
– 35% of adults aged 20 and older
– 50% of adults aged 65 and older
Center for Disease Control and Prevention. National Diabetes Fact Sheet, 2011.
Impact of Diabetes in the U.S.
• Diabetes is the leading cause of:
– Kidney failure
– Non-traumatic limb amputation
– New cases of blindness
• Diabetes in the 7th leading cause for death in U.S.
• Diabetes is a major cause of heart disease and
stroke
Center for Disease Control and Prevention. National Diabetes Fact Sheet, 2011.
Financial Impact of Diabetes (2007)
Total (Indirect & Direct costs) $174 billion
Direct medical costs
$116 billion
Indirect costs
$58 billion (disability, work loss, premature mortality)
“Medical expenses for patients with diabetes are more than two
times higher than for people without diabetes”
“Overall, the risk for death among people with diabetes is about
twice that of people of similar age but without diabetes. “
Center for Disease Control and Prevention. National Diabetes Fact Sheet, 2011.
Diabetes Guideline Management
• 2 main sets of guidelines utilized in U.S.
– American Diabetes Association (ADA)
– American Association of Clinical Endocrinology
(AACE)
• Lots of overlap, but AACE generally considered
“more intense”
• Evidence based, well accepted, clinically
relevant and can be easily incorporated into
clinical practice
Diabetes Guideline Management
• ADA publishes guideline update every January in
Diabetes Care journal
– Clinical Practice Recommendations
– http://professional.diabetes.org/CPR_Search.aspx
• AACE updates guidelines periodically in
Endocrine Practice journal
– April 2011
– Medical Guidelines for Clinical Practice for the
Management of Diabetes Mellitus
– www.aace.com/publications/guidelines
STANDARDS OF MEDICAL CARE
IN DIABETES—2011
ADA Evidence Grading System
for Clinical Recommendations
Level of
Evidence
A
Description
Clear or supportive evidence from adequately powered wellconducted, generalizable, randomized controlled trials
Compelling nonexperimental evidence
B
Supportive evidence from well-conducted cohort studies or
case-control study
C
Supportive evidence from poorly controlled or uncontrolled
studies
Conflicting evidence with the weight of evidence supporting
the recommendation
E
Expert consensus or clinical experience
ADA. Diabetes Care 2011;34(suppl 1):S12. Table 1.
CLASSIFICATION AND DIAGNOSIS OF
DIABETES
Classification of Diabetes
• Type 1 diabetes
– β-cell destruction
• Type 2 diabetes
– Progressive insulin secretory defect
• Gestational diabetes mellitus
• Other specific types of diabetes
– Genetic defects in β-cell function, insulin action
– Diseases of the exocrine pancreas
– Drug- or chemical-induced
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S12.
Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)
≥126 mg/dl (7.0 mmol/l)
OR
Two-hour plasma glucose ≥200 mg/dl
(11.1 mmol/l) during an OGTT
OR
A random plasma glucose ≥200 mg/dl
(11.1 mmol/l)
OR
A1C ≥6.5%
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
Criteria for the Diagnosis of Diabetes
A1C ≥6.5%
The test should be performed in a laboratory using
an NGSP-certified method standardized to the
DCCT assay*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes (Prediabetes)*
IFG: FPG 100-125 mg/dl (5.6-6.9 mmol/l)
or
IGT: 2-h plasma glucose in the 75-g OGTT
140-199 mg/dl (7.8-11.0 mmol/l)
or
A1C 5.7-6.4%
*IFG = Impaired Fasting Glucose
*IGT = Impaired Glucose Tolerance
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 3.
TESTING FOR DIABETES IN
ASYMPTOMATIC PATIENTS
Recommendations: Testing for Diabetes in
Asymptomatic Patients
• Consider testing overweight adults with one or more
additional risk factors:
Physical Inactivity
HDL <35mg/dL and/or TGY >250mg/dL
1st degree relative with DM
Polycystic Ovarian Syndrome
High risk race/ethnicity (e.g., African
American, Native American)
A1C ≥5.7%, IGT, or IFG on previous
testing
Women with baby >9 lbs or GDM
Conditions associated with insulin
resistance (e.g., severe obesity,
acanthosis nigricans)
HTN or treatment for HTN
History of CVD
• In those without risk factors, begin testing at age 45 years
• If tests are normal: Repeat testing at 3-year intervals (E)
ADA. II. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S13-S14.
DETECTION AND DIAGNOSIS OF
GESTATIONAL DIABETES MELLITUS
Recommendations:
Detection and Diagnosis of GDM
• Screen for undiagnosed type 2 diabetes at the first
prenatal visit in those with risk factors, using standard
diagnostic criteria (B)
• In pregnant women not previously known to have
diabetes, screen for GDM at 24-28 weeks gestation,
using a 75-g OGTT and the diagnostic cutpoints below (B)
• GDM diagnosis: when any of the following plasma
glucose values are exceeded:
– Fasting ≥92 mg/dl
– 1 h ≥180 mg/dl
– 2 h ≥153 mg/dl
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.
PREVENTION AND/OR DELAY OF
TYPE 2 DIABETES
Recommendations:
Prevention/Delay of Type 2 Diabetes
• Refer patients with IGT (A), IFG (E), or A1C 5.7-6.4%
(E) to support program
– Weight loss 7% of body weight
– At least 150 min/week moderate activity
• Consider metformin if multiple risk factors, especially
if hyperglycemia (e.g., A1C>6%) progresses despite
lifestyle interventions (B)
• In those with prediabetes, monitor for development
of diabetes annually (E)
ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2011;34(suppl 1):S16.
DIABETES CARE
Components of the Comprehensive Diabetes
Evaluation
• Initial Medical Evaluation
• Medical History
• Review of current treatment plan (if any)
• Physical Examination
• Laboratory Examination
• Referrals
Diabetes Care: Initial Evaluation
• A complete medical evaluation should be performed
to:
– Classify the diabetes
– Detect presence of diabetes complications
– Review previous treatment, glycemic control in patients
with established diabetes
– Assist in formulating a management plan
– Provide a basis for continuing care
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S16.
Components of the Comprehensive Diabetes
Evaluation
Physical examination
• Height, weight, BMI
• Blood pressure determination, including orthostatic
measurements when indicated
• Fundoscopic examination*
• Thyroid palpation
• Skin examination (for acanthosis nigricans and insulin injection
sites)
*See appropriate referrals for these categories.
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.
Components of the Comprehensive Diabetes
Evaluation
Physical examination
• Comprehensive foot examination
– Inspection
– Palpation of dorsalis pedis and posterior tibial pulses
– Presence/absence of patellar and Achilles reflexes
– Determination of proprioception, vibration, and monofilament
sensation
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.
Components of the Comprehensive Diabetes
Evaluation
Laboratory evaluation
• A1C, if results not available within past 2–3 months
• If not performed/available within past year:
– Fasting lipid profile, including total, LDL, HDL and triglycerides
– Liver function tests
– Test for urine albumin excretion with spot urine
albumin/creatinine ratio
– Serum creatinine and calculated GFR
– TSH in type 1 diabetes, dyslipidemia, or women >50 years of age
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.
Components of the Comprehensive Diabetes
Evaluation
Referrals
• Annual dilated eye exam
• Family planning for women of reproductive age
• Registered dietitian for MNT
• Diabetes self-management education
• Dental examination
• Mental health professional, if needed
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.
Recommendations: Glucose Monitoring
• Self-monitoring of blood glucose should be carried
out 3+ times daily for patients using multiple insulin
injections or insulin pump therapy (A)
• For patients using less frequent insulin injections,
noninsulin therapy, or medical nutrition therapy
alone
– SMBG may be useful as a guide to success of therapy (E)
– However, several recent trials have called into question
clinical utility, cost-effectiveness, of routine SMBG in non–
insulin-treated patients
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17.
Recommendations: A1C
• Perform A1C test at least twice yearly in patients
meeting treatment goals (and have stable glycemic
control) (E)
• Perform A1C test quarterly in patients whose therapy
has changed or who are not meeting glycemic goals (E)
• Use of point-of-care testing for A1C allows for timely
decisions on therapy changes, when needed (E)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18.
Correlation of A1C with Estimated Average Glucose
(eAG)
A1C (%)
6
Mean plasma glucose
mg/dl
mmol/l
126
7.0
7
8
154
183
8.6
10.2
9
10
11
12
212
240
269
298
11.8
13.4
14.9
16.5
These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with
type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results
into estimated average glucose (eAG) is available at http//professional.diabetes.org/GlucoseCalculator.aspx.
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.
Recommendations:
Glycemic Goals in Adults
• Lowering A1C to below or around 7%
– Shown to reduce microvascular and neuropathic
complications of diabetes
– If implemented soon after diagnosis of diabetes, associated
with long-term reduction in macrovascular disease
• Therefore, a reasonable A1C goal for many
non-pregnant adults is <7% (B)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.
Recommendations:
Glycemic Goals in Adults
• Conversely, less stringent A1C goals may be appropriate
for patients with:
– History of severe hypoglycemia, limited life expectancy,
advanced microvascular or macrovascular complications,
extensive comorbid conditions
– Those with longstanding diabetes in whom the general goal is
difficult to attain despite diabetes self-management education,
appropriate glucose monitoring, and effective doses of
multiple glucose lowering agents including insulin (C)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.
Intensive Glycemic Control and Cardiovascular
Outcomes: ACCORD
Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death
HR=0.90 (0.78-1.04)
©2008 New England Journal of Medicine. Used with permission.
Gerstein HC, et al, for the Action to Control Cardiovascular Risk in Diabetes Study Group.
N Engl J Med 2008;358:2545-2559.
Glycemic Recommendations for
Non-Pregnant Adults with Diabetes
A1C
<7.0%*
Preprandial capillary plasma glucose
70–130 mg/dl*
Peak postprandial capillary plasma
glucose†
<180 mg/dl*
*Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with
diabetes.
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
Recommendations: Bariatric Surgery
• Consider bariatric surgery for adults with BMI >35
kg/m2 and type 2 diabetes (B)
• After surgery, life-long lifestyle support and medical
monitoring is necessary (E)
• Insufficient evidence to recommend surgery in
patients with BMI <35 kg/m2 outside of a research
protocol (E)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S26.
Recommendations: Immunization
• Provide an influenza vaccine annually to all diabetic
patients ≥6 months of age (C)
• Administer pneumococcal polysaccharide vaccine to
all diabetic patients ≥2 years
• One-time revaccination recommended for those >64
years previously immunized at <65
years if administered >5 years ago
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S27.
PREVENTION AND MANAGEMENT OF
DIABETES COMPLICATIONS
Recommendations: Hypertension/
Blood Pressure Control
• Measure blood pressure at every diabetes visit
• A goal systolic blood pressure <130 mmHg is
appropriate for most patients with diabetes (C)
• Patients with diabetes should be treated to a
diastolic blood pressure <80 mmHg (B)
• Patients with more severe hypertension (≥140/≥90
mmHg) at diagnosis or follow-up
– Should receive pharmacologic therapy in addition to
lifestyle therapy (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension/
Blood Pressure Control
Treatment
• Pharmacotherapy for DM patients with hypertension
– Pair with a regimen that includes either an ACE inhibitor or
angiotensin II receptor blocker
– If one class is not tolerated, the other should be substituted
• If needed to achieve blood pressure targets
– Thiazide diuretic should be added to those with estimated
GFR ≥30 ml x min/1.73 m2
– Loop diuretic for those with an estimated GFR <30 ml x
min/1.73 m2 (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations:
Dyslipidemia/Lipid Management
• In most adult patients
– Measure fasting lipid profile at least annually
• In adults with low-risk lipid values (LDL <100 mg/dl,
HDL >50 mg/dl, and triglycerides <150 mg/dl)
– Lipid assessments may be repeated every 2 years (E)
• To improve lipid profile in patients with diabetes,
recommend lifestyle modification (A), focusing on
–
–
–
–
Reduction of saturated fat, trans fat, cholesterol intake
Increased n-3 fatty acids, viscous fiber, plant stanols/sterols
Weight loss (if indicated)
Increased physical activity
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:
Dyslipidemia/Lipid Management
• Statin therapy should be added to lifestyle therapy,
regardless of baseline lipid levels, for diabetics:
– with overt CVD (A)
– without CVD who are >40 years of age and have one or
more other CVD risk factors (A)
• In individuals without overt CVD
– Primary goal is an LDL <100 mg/dl (2.6 mmol/l) (A)
• In individuals with overt CVD
– Lower LDL goal of <70 mg/dl, using a high dose of a statin
is an option (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Glycemic, Blood Pressure,
Lipid Control in Adults
A1C
<7.0%*
Blood pressure
<130/80 mmHg†
Lipids:
LDL cholesterol
<100 mg/dl‡
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on:
duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications,
hypoglycemia unawareness, and individual patient considerations.
†Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.
‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of statin, is an option.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31. Table 12.
Recommendations: Antiplatelet Agents
• Consider aspirin therapy (75–162 mg/day) (C)
– As primary prevention in type 1 or type 2 diabetics at
increased cardiovascular risk (10-year risk >10%)
– Includes most men >50 years of age or women >60 years
of age who have at least one additional major risk factor
• Family history of CVD, HTN, Smoking, Dyslipidemia, Albuminuria
• Aspirin should not be recommended for CVD
prevention for diabetic adults at low CVD risk, since
potential bleeding likely offset potential benefits (C)
• 10-year CVD risk <5%: men <50 and women <60 years of age
with no major additional CVD risk factors
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
Recommendations: Antiplatelet Agents
• Use aspirin therapy (75–162 mg/day)
– Secondary prevention strategy in those with diabetes with a
history of CVD (A)
• For patients with CVD, documented aspirin allergy
– Clopidogrel (75 mg/day) should be used (B)
• Combination therapy with ASA (75–162 mg/day) and
clopidogrel (75 mg/day)
– Reasonable for up to 1 year after acute coronary syndrome (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
Recommendations: Smoking Cessation
• Advise all patients not to smoke (A)
• Include smoking cessation
counseling and other forms
of treatment as a routine
component of diabetes care (B)
*If not contraindicated.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
Recommendations: Nephropathy Treatment
• In patients with type 1 diabetes, hypertension, and any
degree of albuminuria
– ACE inhibitors shown to delay progression of nephropathy (A)
• In type 2 diabetes, hypertension, and microalbuminuria
– Both ACE inhibitors and ARBs shown to delay progression to
macroalbuminuria (A)
• In type 2 diabetes, hypertension, macroalbuminuria,
and renal insufficiency (serum creatinine >1.5 mg/dl)
– ARBs shown to delay progression of nephropathy (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
DIABETES CARE IN SPECIFIC SETTINGS
Recommendations:
Diabetes Care in the Hospital
• All patients with diabetes admitted to the hospital
should have:
– Their diabetes clearly identified in the medical record (E)
• An order for blood glucose monitoring, with results
available to the health care team (E)
• Goals for blood glucose levels:
– Critically ill patients: 140-180 mg/dl (A)
– More stringent goals, such as 110-140 mg/dl may be
appropriate for selected patients, if achievable without
significant hypoglycemia (C)
– Non-critically ill patients: base goals on glycemic control,
severe comorbidities (E)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Recommendations:
Diabetes Care in the Hospital
• A hypoglycemia management protocol should be
adopted and implemented by each hospital or hospital
system
– Establish a plan for treating hypoglycemia for each patient;
document episodes of hypoglycemia in medical record and track
• Obtain A1C for all patients if results within previous 2-3
months unavailable (E)
• Patients with hyperglycemia who do not have a diagnosis
of diabetes should have appropriate plans for follow-up
testing and care documented at discharge (E)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
STRATEGIES FOR IMPROVING
DIABETES CARE
Provider and Team Behavior Change
• Facilitate timely and appropriate intensification of
lifestyle and/or pharmaceutical therapy of patients
who have not achieved beneficial levels of blood
pressure, lipid, or glucose control
• Research on the comprehensive chronic care (CCM)
model suggests additional strategies to improve
diabetes care including:
– Consistent, evidence-based care guidelines
– Collaborative, multidisciplinary teams
– Audit and feedback of process and outcome data to
providers
– Alterations in reimbursement
ADA. IX. Strategies for Improving Diabetes Care. Diabetes Care. 2010;33(suppl 1):S47.
Diabetes Treatment Algorithms
Step 1
Step 2
Step 3
TIER 1: WELL-VALIDATED THERAPIES
At diagnosis:
Lifestyle
+
metformin
Lifestyle +
metformin
+
Intensive
insulin
Lifestyle + metformin
+
Basal insulin
Lifestyle + metformin
+
sulfonylurea
TIER 2: LESS WELL-VALIDATED THERAPIES
Lifestyle + metformin
+ pioglitazone
No hypoglycemia
Edema/CHF
Bone loss
Lifestyle +
metformin
+ pioglitazone
+
sulfonylurea
Lifestyle + metformin
+ GLP-1 agonist
No hypoglycemia
Weight loss
Nausea/vomiting
Lifestyle +
metformin
+
basal
insulin
Diabetes Care, Vol. 32, 2009, 193-203.
A1C 6.5 – 7.5%**
A1C 7.6 – 9.0%
A1C > 9.0%
Under Treatment
Drug Naive
Symptoms
Monotherapy
MET † DPP4 1
Dual Therapy 8
TZD 2
GLP-1
AGI 3
2 - 3 Mos.***
MET
+
GLP-1 or DPP4
1
2 - 3 Mos.
TZD 2
+
GLP-1 or DPP4 1
+
INSULIN
± Other
Agent(s) 6
GLP-1
or DPP4 1
MET
GLP-1
or DPP4 1
+ TZD 2
Colesevelam
MET
+
MET
AGI 3
2 - 3 Mos.***
Triple Therapy
MET +
GLP-1 or
DPP4 1
TZD 2
+
Glinide or SU
2 - 3 Mos.
INSULIN
± Other
Agent(s) 6
+
TZD
± SU 7
2
GLP-1
or DPP4 1
INSULIN
± Other
Agent(s) 6
± TZD 2
*
May not be appropriate for all patients
**
For patients with diabetes and A1C < 6.5%,
pharmacologic Rx may be considered
***
If A1C goal not achieved safely
† Preferred initial agent
GLP-1
or DPP4 1
+ SU 7
TZD 2
2 - 3 Mos.***
4,7
***
+
***
Triple Therapy 9
Glinide or SU 5
TZD
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
Dual Therapy
MET
No Symptoms
INSULIN
± Other
Agent(s) 6
AACE/ACE Algorithm for Glycemic Control
Committee
Cochairpersons:
Helena W. Rodbard, MD, FACP, MACE
Paul S. Jellinger, MD, MACE
Zachary T. Bloomgarden, MD, FACE
Jaime A. Davidson, MD, FACP, MACE
Daniel Einhorn, MD, FACP, FACE
Alan J. Garber, MD, PhD, FACE
James R. Gavin III, MD, PhD
George Grunberger, MD, FACP, FACE
Yehuda Handelsman, MD, FACP, FACE
Edward S. Horton, MD, FACE
Harold Lebovitz, MD, FACE
Philip Levy, MD, MACE
Etie S. Moghissi, MD, FACP, FACE
Stanley S. Schwartz, MD, FACE
1 DPP4 if  PPG and  FPG or GLP-1 if  PPG
2 TZD if metabolic syndrome and/or
nonalcoholic fatty liver disease (NAFLD)
3 AGI if  PPG
4 Glinide if  PPG or SU if  FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagogue
with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that
cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy,
insulin should be considered
Available at www.aace.com/pub
© AACE December 2009 Update.
SUMMARY
Diabetes Management Guidelines: 2011
USPHS Scientific and Training Symposium – Pharmacy Category
June 21st, 2011
CDR Ryan Schupbach, Pharm.D., BCPS, CACP, NCPS
Clinical Pharmacy Director, PHS Claremore Indian Hospital
Clinical Assistant Professor, University of Oklahoma College of Pharmacy
[email protected]