Diabetes Quick Reference

Here you will find quick reference guides to help you diagnose and manage diabetes in your primary care practice with medication guidelines and cost information, as well as target benchmarks and management considerations for comorbid heart failure.

Ready to take the next steps to excellence in managing diabetes in primary care? Review the Mount Sinai Diabetes Care Pathway or discover services available to MSHP Clinically Integrated Network providers to achieve team-based care. 

 

Download a print-friendly PDF of this guide

 

Diagnosing Prediabetes and Type 2 DM

 

Prediabetes

HbA1c between 5.7% – 6.4%

Fasting blood glucose between 100 – 125 mg/dl

An Oral Glucose Tolerance Test 2 hour blood glucose between 140 mg/dl – 199 mg/dl

Type 2 DM

A hemoglobin A1c (HbA1c) level of 6.5% or higher, or

A fasting plasma glucose (FPG) level of 126 mg/dL or higher

A 2-hour plasma glucose level of 200 mg/dL or higher during a 75-g oral glucose tolerance test (OGTT)

A random plasma glucose of 200 mg/dL or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis

 

Medications

Oral Diabetes Medication Algorithm

 

Medication List, Dosing, & Cost

Anti-diabetic medication list median monthly (30-day) cost of maximum approved daily dose

Medication Class

Compound(s)

Common Trade Names

Dosage strength/product (if applicable)

Starting Dose (no renal/hepatic dysfuntion)

Maxmimum approved daily dose*

Median AWP (min, max)†

Biguanides

Metformin

Glucophage Riomet

500 mg (IR)

500 mg qd

2,000 mg

$84 ($4, $85)
     

850 mg (IR)

  

2,550 mg

$108 ($6, $109)
     

1,000 mg (IR)

  

2,000 mg

$87 ($4, $88)
   

Fortamet, Glucophage XR, Glumetza, 

Riomet ER

500 mg (ER)

500 mg qd

2,000 mg

$89 ($87, $7,412)
     

750 mg (ER)

  

1,500 mg

$74 ($65, $74)
     

1,000 mg (ER)

  

2,000 mg

$242 ($242, $7,214)

Sulfonylureas (2nd generation)

Glimepiride

Amaryl

1 mg, 2 mg, 4 mg

1 mg qd

8 mg

$74 ($71, $198)
 

Glipizide

Glucotrol

5 mg, 10 mg (IR)

5 mg qd

40 mg (IR)

$75 ($67, $97)
   

Glucotrol XL

2.5 mg, 5 mg, 10 mg (XL)

2.5 mg qd

20 mg (XL)

$48
 

Glyburide

Glynase PresTabs

1.5 mg, 3 mg, 6 mg (micronized)

1.5 mg qd

12 mg (micronized)

$50 ($48, $71)
   

None in USA

1.25 mg, 2.5 mg, 5 mg

2  mg qd

20 mg

$93 ($63, $103)

Thiazolidinediones

Pioglitazone

Actos

15 mg, 30 mg, 45 mg

15 mg qd

45 mg

$348 ($283, $349)
 

Rosiglitazone

Avandia

2 mg, 4 mg

2 mg qd

8 mg

$407

Meglitinides (glinides)

Nateglinide

Starlix

60 mg, 120 mg

60 mg tid ac

360 mg

$155
 

Repaglinide

Prandin

0.5 mg, 1.0 mg, 2 mg

0.5 mg tid ac

16 mg

$878 ($162, $897)

DPP-4 inhibitors

Alogliptin

Nesina

6.25 mg, 12.5  mg, 25 mg

25 mg qd

25 mg

$234
 

Saxagliptin

Onglyza

2.5 mg, 5 mg

5 mg qd

5 mg

$505
 

Linagliptin

Trajenta

5 mg

5 mg qd

5 mg

$523
 

Sitagliptin

Januvia

25 mg, 50 mg, 100 mg

100 mg qd

100 mg

$541

SGLT2 inhibitors

Ertugliflozin

Steglatro

5 mg, 15 mg

5 mg qd

15 mg

$338
 

Dapagliflozin

Farxiga

5 mg, 10 mg

5 mg qd

10 mg

$591
 

Empagliflozin

Jardiance

10 mg, 25 mg

10 mg qd

25 mg

$591
 

Canagliflozin

Invokana

100 mg, 300 mg

100 mg qd

300 mg

$593

GLP-1 RAs

Exenatide (extended release)

Bydureon, Bydureon Bcise

2 mg powder for suspension or pen

2 mg qweek

2 mg**

$840
 

Exenatide

Byetta

5 mcg, 10 mcg pen

5 mcg bid

20 mcg

$876
 

Dulaglutide

Trulicity

0.75mg, 1.5 mg, 3.0 mg, 4.5 mg

0.75 mg qweek

1.5 mg**

$911
 

Semaglutide

Ozempic

0.5 mg, 1 mg pens

0.25 mg qweek

1 mg**

$927
   

Rybelsus

3 mg, 7 mg, 14 mg (tablet)

3 mg qday

14 mg

$927
 

Liraglutide

Victoza, Saxenda

6 mg/ml, 18 mg/3 mL pen

0.6 mg qweek

1.8 mg

$1,106
 

Lixisenatide

Adlyxin

300 mcg/3 mL pen

10 mcg qday

20 mcg

$744

 

AWP, average wholesale price; DPP-4, dipeptidyl peptidase 4; ER and XL, extended release; GLP-1 RA, glucagon-like peptide 1 receptor agonist; IR, immediate release; N/A, data not available; SGLT2, sodium–glucose cotransporter 2.

†Calculated for 30-day supply (AWP) for dose highlighted and underlined in bold; median AWP listed alone when only one product and/or price.

*Utilized to calculate median AWP (min, max); generic prices used, if available commercially.

**Administered once weekly.

Management Targets

Screening/Management Target

Benchmark

Frequency

Next Step if uncontrolled/positive finding

 Comments

HgbA1c Test

<7%

Every 6 months if controlled

Every 3 months if uncontrolled

Lifestyle modification

Escalate dosing of diabetes medication

Referral to endocrinologist or pharmacist if HgbA1c >9%

Care Management/Behavioral Health referral as indicated

  

Blood Pressure Control

BP <140/90 or <130/80 in select pts with CVD, CAD, or ASCVD risk > 15%*

Annually if normal

Lifestyle modification

Home BP monitoring

If no CKD, use ACE/ARB, diuretic, or CCB

If CKD preent: ACE/ARB

If resistant hypertension or progressive kidney disease, consider referral to nephrology or clinical pharmacy program

  

Lipid Management

LDL is <100 mg/dL

With CV disease, target is <70 mg/dL.

Annually

Lifestyle modification

Statin therapy

  

Monitoring for Diabetic Kidney Disease (eGFR and UACR)

eGFR >100

UACR <30 mg/g C

Annually but consider semiannually if eGFR <60 or UACR > 30 mg/g of C

ACE/ARB if eGFR <60 or UACR >30

Consider use of SGLT-2i or GLP-RA

Intensify diabetes medications to optimize glycemic control

Dietary intake of ~0.8g protein/kg weight per day

Consider nephrology referral

  

Retinopathy Screening

Absence of retinopathy or macular edema

If retinopathy or macular edema present, annual dilated eye exam or retinal photography

Annual evaluation by ophthalmologist if retinopathy or macular edema present

Screening can be performed in PCP office with a retinal camera; optometry clinic or ophthalmology clinic.

Foot Exam

No ulcerations or fungal infections, 2+ pedal pushes, normal sensory response with monofilament

Annually

Referral to podiatrist for management of any abnormalities

Refer for Ankle Branchial Index (ABI) if Peripheral Arterial Disease (PAD) suspected

  

 

Type 2 Diabetes and Heart Disease (Atherosclerotic Vascular Disease (ASVD) and Heart Failure (HF))

  • Ideally, risk factors for ASVD and Heart Failure should be assessed annually, using prognostic tools such as the ASCVD Risk Calculator. The 10 year risk of a first ASCVD event used to guide interventions.

  • Screening

    • Testing is indicated for typical/atypical chest pain, signs/symptoms of other vascular disease, or an abnormal ECG.

    • Exercise testing with/without echocardiography is the recommended initial test. Pharmacologic stress echo or nuclear imaging is indicated for those who are unable to exercise or have significant resting ECG abnormalities.

    • Routine screening for ASCVD with CT calcium scores/CT angiography in asymptomatic high risk patients is not recommended. 

  • Antiplatelet Therapy

    • ASA (75-162 mg daily) may be used for primary prevention in diabetic patients aged 50-75 years with at least one additional ASCVD risk factors (family hx, dyslipidemia, hypertension, tobacco use, CKD/albuminuria) and not at increased risk of bleeding.

    • ASA (75-162 mg/d) maybe used for secondary prevention, in diabetic patients with known ASCVD (prior MI/stroke).

    • Clopidogrel may be used in patients with known ASA allergy.

  • In patients with known or multiple risk factors for ASCVD and/or CKD, an SGLT-2i or a GLP-1 RA should be part of the medication regimen.

  • Heart Failure

    • In patients with HF (with or without diabetes), a SGLT-2i may be used to reduce HF hospitalizations

    • Contraindicated:

      • DPP-4 Saxagliptin is associated with an increased risk hospitalization for HF and is contraindicated in HF patients.

      • Thiazolidinediones are also contraindicated in patients with heart failure

Next Steps

Read the  Mount Sinai Diabetes Pathway for in-depth, evidence-based guidelines for managing your heart failure outpatients

Explore Team-Based Care services available to you and your practice as a member of MSHP's Clinically Integrated Network

Need a consult? Connect with our experts

 

Back to the Condition Management Hub