Ambulatory DM

Outpatient Type 2 DM Management of BS

See DM Guidelines for summary elsewhere on this site.

Do not ignore diabetes; instead, diagnose and treat aggresively. 

-Once DM is suspected, start by providing patients with a monitor (Glucometer Elite, One Touch Ultra, or AccuCheck Advantage with Comfort Curve Strips)

-Encourage patients to test AC as well as one hour PC and to record the results as well as what they have eaten so they learn the effect of food, especially carbohydrate, on their BS results.  They do not need to test before and one hour after every meal, but without some PC testing they will not learn this most important point.   In the DCCT study, keeping post prandial BS under 180 mg/dl was associated with much lower chance of complications.  Most recent recommendations are to strive to keep post-prandial BS under 140 mg/dl!!!   Most patients discover that breakfast is much more easily controlled if it is low in starch and includes NO juice - e.g., eggs with a slice of toast; NOT cereal/fruit/toast/juice.  Starch is better tolerated at lunch and at dinner, but even then pizza, rice, fruit frequently lead to unacceptable BS elevations.  Non-startchy vegetables and seafood (or poultry) are most "heart-healthy" alternatives.   Sending the patient to the nutritionist is NOT a substitute for careful physician review of diet and records. 

-A low CHO diet is most helpful for controlling post-prandial BS, but elevated FBS requires medication.  Unless the patient is over age 80, has renal insufficiency, liver disease, or CHF, 500 mg of Glucophage (metformin) is a good starting point. Glucophage XR has less of a tendency to cause GI symptoms, but seems to be a bit less potent as well.  Can gradually increase dose of metformin to 1000 mg BID (if tolerated).   Thin patients with Type 2 diabetes are unlikely to respond to metformin.  Glucophage virtually never causes hypoglycemia, so low CHO, low calorie diet with increased activity can be followed without undue fear.  Lactic acidosis is rare and is most common in patients with CHF, liver disease, decreased GFR.   The most common cause of stopping Glucophage is nausea or diarrhea (less common with the extended release form). 

-Insulin sensitizers such as Avandia or Actos virtually never help in thin patients.  For overweight patients, they are a good choice in addition to metformin, or if metformin is not tolerated, as long as LFTs OK and volume overload is not an issue (as they frequently cause fluid retention).  Start with Avandia 4 mg/d or Actos 15 mg/d while monitoring BS, LFTs, and volume status.  It may take up to a month to see effect of these medications.  Maximum dose of Avandia is 8 mg/d, maxium dose of Actos is 45 mg/d.    Keep reviewing diet (especially sources of CHO), activity.  Avandia or Actos also do not usually cause hypoglycemia when used alone or in combination with metformin. 

-If  FBS and pre-prandial BS are usually quite good, and only issue is post-prandial elevation of BS, can try Precose (or Glyset) at beginning of meals, but many patients do not tolerate these because of flatulance.  25 mg once per day at dinner is a good place to start such fine tuning.  Such medications have no place for treatment of patients who have poorly controlled diabetes.   These medications block the conversion of starch into simple sugars in the GI tract.   They do not lower BS. 

-Patients who are generally well controlled, except for post-prandial state, who can not further restrict CHO intake and who do not tolerate Precose/Glyset, can be tried on Prandin or Starlix which behave very much like very short acting sulfonylureas (although they are not sulfonylureas).  Because of their short durationg of action, they are advertised as not likely to cause hypoglycemia, but not likely is not the same as never).  Prandin and Starlix also have no place in treatment of poorly controlled diabetes.

-For patients who do not come under acceptable control with metformin and/or a sensitizer such as Avandia or Actos, can add longer acting glyburide (Micronase/Diabeta), or shorter acting glipizide (Glucotrol), but need to warn patients of possibility of hypoglycemia.  

-When a combination such as metformin + Avandia + Micronase fails to bring BS under acceptable control (while patient is doing self monitoring AC and 1 hour PC, striving to keep to low CHO diet, increasing activity), then need to consider adding insulin, especially if FBS is elevated.   To treat elevated FBS, add a long acting insulin at dinner (or HS) such as Ultralente, Lantus, or NPH (NPH is usually the least desirable since most patients have a rapid peak response to it and it then wears off quickly.)  Gradually raise the PM dose of the long-acting insulin while continuing the daytime pills (e.g., Glucophage + Avandia + Glucotrol).  The pills are much more likely to work when the FBS is close to normal.     [Some patients are reluctant to start insulin and you might want the input of endocrine service at that time.]

-After FBS has been normalized with PM dose of long acting insulin, if pills don't control BS during the day, can add fast acting insulin as as Regular before meals and possibly long acting insulin at breakfast and possibly taper off of pills.  Very rapid acting insulins such as Humalog or Novolog work very nicely in insulin pumps, but are only rarely work better than Regular when given before meals, as they frequently work too fast.

In summary, an example of the treatment of an overweight patient with Type 2 diabetes might be as follows:

1.  Lower CHO diet, monitor BS AC and 1 hour PC and record results as well as what was eaten.

2.  If not contraindicated, add metformin 500 mg or Glucophage XR 500 at dinner, and gradually increase dose as tolerated.

3. If not contraindicated, add Avandia 4 mg daily or Actos 15 mg daily, and raise dose every 1-2 months, while monitoring LFTs and volume status.

4. If necessary, add Micronase/Diabeta (glyburide) or Glucotrol (glipizide) and warn of possible hypoglycemia.(can start with these for thinner patients).

5. If necessary, add PM dose of Ultralente or Lantus, raising dose until FBS improved.

6. If necessary, add Regular insulin AC meals.  If before lunch and/or before dinner BS remain elevated (even on a lower CHO diet) also add Ultralente in AM. 

As noted in DM Guidelines elsewhere on this site, arrange yearly ophtalmology exam, check for elevated BP, neuropathy, elevated cholesterol, urine microalbumin; monitor A1c and share results with patient.   

N.B.:  Although diet is extremely important, it needs to be individualized and negotiated with the patient.  There really is no "one size fits all" diabetic diet.  Activity helps considerably in controlling BS, as does weight loss.  But weight loss is a long-term goal (which may not be attainable), so it is usually most fruitful to focus first on restricting juice and carbohydrate and working on calories and weight loss long term.  If you have difficutly understanding the effect of different foods on BS, come to Endocrine Clinic.  If you have trouble with this concept,  you won't be able to explain it to the patients.

6 Food Groups:

- Fat (margerine, butter, mayonnaise, oil):  NO CHO

- Meat (eggs, cheese, nuts, fish, chicken...): NO CHO

- Vegetables (1 cup raw, 1/2 cup cooked = 1 serving) = only 5 gm CHO

- Fruit (1 serving, 1 medium apple) - 15 gm CHO

- Dairy (1 serving, 1 cup milk) - 12 gm CHO

- Starch (1 serving, 1 slice bread, 1/3 cup cooked rice) - 15 gm CHO

Example of a relatively low CHO "diabetic diet"

breakfast:  15 gm CHO (cheese omlette with 1 slice bread, coffee, NO juice, NO bagel)

snack: nuts

lunch: 30 gm CHO (2 slices bread as partof a tuna sandwich, another scoop of tuna, salad, some veggies)

snack: cheese, veggies

dinner: 45 gm CHO (fish or chicken, salad, vegetables, potato or corn, small fruit, diet soda) - cheese or nuts

Once BS well controlled, can try to see if more CHO is tolerated. 

 References:  Silvio E.Inzucchi - "DiabetesFactsand Guidelines" from theYaleDiabetesCenter