Unit II: Evidence-Based Guidelines for the Management of Diabetes

Texas Diabetes Council (2012-B) Treatment Algorithms

  • Glycemic Control Algorithm for Type 2 Diabetes Mellitus in Adults
  • Insulin Algorithm for Type 1 Diabetes Mellitus in Children and Adults
  • Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults
  • IV Insulin Infusion Protocol for Critically Ill Adult Patients in the ICU Setting

http://www.TDCtoolkit.org/algorithms-guidelines/



Clinical Goals for Blood Pressure and Lipids

In 1995 the American Diabetes Association specified goals with regard to blood pressure and nutrition of persons with diabetes. These were updated in 2008 and reflect today's recommendations (American Diabetes Association, 2018):

1. Achieve and maintain optimal serum lipid levels – those that reduce the risk for vascular disease.

2. Achieve and maintain blood pressure at or below 140/80.

3. Prevent or reduce the rate of development of complications by making changes in lifestyle and nutritional intake.

4. Address individual needs in terms of nutrition (personal interests, cultural issues), as well as the individual's willingness to make changes.

5. Provide adequate calories to attain and/or maintain reasonable weight, growth, and development, and to meet increased needs during pregnancy and lactation, or recovery from illness.

Agents and Interventions Used to Treat Hypertension and Hyperlipidemia in the Individual with Diabetes

Unfortunately, two other life-threatening conditions are often associated with diabetes: hypertension and hyperlipidemia. The American Diabetes Association (2018) recommends control of systolic blood pressure in persons with diabetes to < 140 mm Hg. The initial drug of choice to treat hypertension in the individual with diabetes with a BP of 140/90 to <160/100 is an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) – whichever is tolerated -- because these drugs have nephro-protective effects (they tend to protect the kidneys). If the BP is > 160/100, treatment is to be initiated with two antihypertensive drugs (American Diabetes Association, 2018). An updated algorithm for the treatment of hypertension in the person with diabetes has been included as a figure in Chapter 9, Cardiovascular Disease and Risk Manageement: Standards of Medical Care in Diabetes – 2018. (The algorithm addresses treatment guidelines for people with diabetes as well as those with diabetes and signs of kidney disease.)

Likewise, the American Diabetes Association (2018) recommends therapies for people with diabetes to reduce LDL (low-density lipoprotein) levels to < 100 mg/dL (unless cardiovascular disease is present, in which case the goal is < 70 mg/dL), to increase the HDL (high density lipoproteins) level to > 40 mg/dL in males and > 50 in females, and to reduce the TG (triglyceride) level to < 150 mg/dL (p. S38). The American Diabetes Association recommends that people with diabetes should have a fasting lipid profile obtained at least annually unless lipid values reflect low risk, in which case they should be obtained every two years (2018, p. S86).

Lifestyle management inclusive of increased physical activity (if current time engaged in physical activity is less than 150 minutes per week), smoking cessation, medical nutrition therapy, and weight loss (where warranted) are advised for all persons with diabetes and may result in the achievement of lipid goals. More specific recommendations are made for those with underlying cardiovascular disease, however.

Significant revisions in the recommendations by the American Diabetes Association for lipid management in patients with diabetes were made in 2014 and remain in today's recommendations: Statin therapy (in addition to lifestyle management) is advised for individuals with diabetes who also have overt cardiovascular disease (CVD) even if lipid levels are normal, are over the age of 40, and have one or more of the following risk factors: family history of hypertension, CVD, smoking, dyslipidemia, or albuminuria, provided the patient has no contraindications for statin therapy (American Diabetes Association, 2014, p. S38). In the 2018 American Diabetes Association Standards of Medical Care in Diabetes, the addition of ezetimibe was recommended for those people with diabetes who have experienced a major cardiovascular event (S93). In patients with poor glycemic control and high triglycerides, effective reductions in triglycerides may be obtained by acquiring glycemic control.

The goals for blood pressure, LDL cholesterol, HDL cholesterol, and triglycerides for non-pregnant adults recommended by the American Diabetes Association (2018) are provided in the following table, but detailed recommendations should be reviewed in Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes (American Diabetes Association, 2018, pgs S86-S104.)

Blood Pressure and Lipid Goals

  • Blood pressure
  • LDL cholesterol
  • HDL cholesterol
     
  • Triglycerides
  • < 140/80 mm Hg*
  • < 100 mg/dL**
  • > 40 mg/dL (men)
    > 50 mg/dL (women)
  • < 150 mg/dL

*or < 130/80 in younger individuals if such levels can be achieved without undue treatment burden

**With regard to individuals with overt atherosclerotic CVD, a lower LDL cholesterol goal (< 70 mg/dL) using a high dose statin is an option, or adding drugs that inhibit cholesterol absorption in the small intestine (cholesterol-absorption inhibitors, e.g. ezetimibe).