Diabetes Quick Reference Guide

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Diagnosis

  Prediabetes Type 2 DM
HbA1c 5.7%–6.4% 6.5% or higher
Fasting blood glucose Fasting blood glucose between 100-125 mg/dL 126 mg/dL or higher
Oral glucose tolerance test (2 hour blood glucose) 140 -199 mg/dL 200 mg/dL or higher
Random plasma glucose test   200 mg/dL or higher

Management

Click on a link below to jump to that section. For more in-depth management guidelines and considerations, please refer to the MSHS Ambulatory Care Pathway for Diabetes.

Management Checklist

Measure Target Frequency Next steps
HbA1c < 7% Controlled: Every 6 months

Poorly Controlled: Every 3 months		 Lifestyle modification

Adjust medication dosages

If HbA1c > 9%: Refer to endocrinology or pharmacy

Refer to care management and/or behavioral health as needed
Blood Pressure BP < 140/90

In patients with CVD, CAD, or ASCVD risk > 15%: BP <130/80		 Annually if normal Lifestyle modification

Home BP monitoring

In patients with CKD: ACE/ARB

In patients without CKD: ACE/ARB, diuretic, or CCB

In patients with resistant htn or progressive kidney disease: consider referral to nephrology or pharmacy
Lipids LDL < 100

In patients with CV disease: < 70		 Annually Lifestyle modification

Statin therapy
eGFR and uACR eGFR > 100

uACR < 30 mg/g C		 Annually

Consider semiannually if eGFR <60 or uACR > 30		 ACE/ARB if eGFR <60 or uACR >30

Consider SGLT-2i or GLP-1 RA

Intensify anti-diabetic medications to optimize glycemic control

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

Consider referral to nephrology
Retinopathy Absence of retinopathy or macular edema If normal exam: every 2 years

If retinopathy or macular edema present: annual dilated eye exam or retinal photography		 Screening can be performed by PCP office with retinal camera, optometry clinic, or ophthalmology clinic
Foot Exam No ulcerations or fungal infections

2+ pedal pulses

Normal sensory response with monofilament		 Annually Refer to podiatry to manage any abnormalities

Refer for ABI if PAD is suspected

Cardiorenal Risk Reduction in High-Risk Patients

See definitions below for risk factor inclusion criteria. This information is also available as a visual algorithm.

Risk Factor(s) Management Next Steps Further Management Considerations
ASVCD and/or indicators of high risk GLP-1 RA or SGLT-2i with proven CVD benefit If A1C above target, for patients on SGLT-2i, consider incorporating a GLP-1 RA or vice versa, or TZD (low-dose TZD may be better tolerated and similarly effective)
Heart Failure SGLT-2i with proven HF benefit in this population  
CKD (on maximally tolerated dose of ACE/ARB) SGLT-2i with primary evidence of reducing CKD progression Use SGLT2i in people with eGFR ≥20; continue until dialysis or transplant

If SGLT-2i not tolerated or contraindicated, use GLP-1 RA with proven CVD benefit

If A1C above target, for patients on SGLT2i, consider incorporating a GIP-1 RA or vice versa

 

Patients who meet the below risk factor criteria should be managed according to the table above: 

ASCVD

  • Includes individuals with established CVD (e.g., MI, stroke, revascularization)
  • May also include conditions such as transient ischemic attack. unstable angina, amputation, symptomatic or asymptomatic coronary artery disease

Indictors of High Risk

Age 55 or older with 2 or more additional risk factors including:

  • Obesity
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Albuminuria 

Heart Failure

  • Current or prior symptoms of HF with documented HFrEF or HFpEF

CKD

  • Repeated measured eGFR <60 or uACR >30

Notes

  • In people with HF, CKD, established CVD or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT-2i with proven benefit should be independent of background use of metformin
  • A strong recommendation is warranted for people with CVD and a weaker recommendation for those with indicators of high CV risk. Moreover a higher absolute risk reducation and thus lower numbers needed to treat are seen at higher levels of baseline risk and should be factored into the shared decision-making process
  • For SGLT-2i, CV/renal outcomes trials demonstrate their efficacy in reducing the risk of composite MACE, CV death, all-cause mortality, MI, HHF, and renal outcomes in individuals with T2D with established/high risk of CVD
  • For GLP-1 RA, CVOTs demonstrate their efficacy in reducing composite MACE, CV death, all-cause mortality, MI, stoke, and renal endpoints in individuals with T2D with established/high risk of CVD

Glycemic and Weight Management Goals

This information is also available as a visual algorithm.

Glycemic Management

Choose approaches that provide the efficacy to achieve goals:

  • Metformin or agent(s) including combination therapy that provide adequate efficacy to achieve and maintain treatment goals
  • Consider avoidance of hypoglycemia a priority in high-risk individuals

In general, higher efficacy approaches have greater likelihood or achieving glycemic goals. 

Weight Management

  • Set individualized weight management goals
  • General lifestyle advice: medical nutrition therapy/eating patterns/physical activity
  • Intensive evidence-based structured weight management
  • Consider medication for weight loss
  • Consider metabolic surgery

When choosing glucose-lowering therapies, consider regimen with high-to-very-high dual glucose and weight efficacy.

  Efficacy for glucose lowering Efficacy for weight loss
Dulaglutide  Very high (high dose) High
Semaglutide Very high Very high
Tirzepatide Very high Very high
Liraglutide   High
Insulin Very high  
Combination Oral/Injectable (GLP-1 RA/insulin) Very high  
Other GLP-1 RA High Intermediate
Metformin High Neutral
SGLT-2i High Intermediate
Sulfonylurea High  
TZD High  
DPP-4i Intermediate Neutral

 

If A1C above target, identify barriers to goals: 

  • Consider DSMES referral to support self-efficacy in achievement of goals
  • Consider technology (e.g., diagnostic CGM) to identify therapeutic gaps and tailor therapy
  • Identify and address determinants of health that impact achievement of goals

If injectable therapy is needed to reduce A1C

This information is also available as a visual algorithm.

Follow the below steps in order to escalate therapy as needed until patient reaches A1C goal

Consider GLP-1 RA in most patients prior to insulin

  • Initiate appropriate starting dose for agent selected (varies within the class)
  • Titrate gradually to maintenance dose (varies within the class)
  • If the patient is already on GLP-1 RA or dual GIP and GLP-1 RA, GLP-1 RA is not appropriate, or insulin is preferred, move to the next step

Add basal insulin

  • Choice of basal insulin should be based on patient-specific considerations, including cost

Add basal analog or bedtime NPH insulin

  • Start 10 IU a day OR 0.1-0.2 IU/kg a day
  • Titrate: set FPG target and choose evidence-based titration algorithm, (e.g., increase 2 units every 3 days) to reach FPG target without hypoglycemia
  • For hypoglycemia determine cause; if no clear reason lower dose by 10-20%

Assess adequacy of basal insulin dose

  • Evaluate for overbasalization (basal dose >0.5 units/kg/day, elevated bedtime-morning or post-preprandial differential, hypoglycemia, or high glycemic variability)

If above A1C target and not already on GLP-1 RA or dual GIP and GLP-1 RA

  • Consider these classes If A1C remains above target despite adequately titrated basal analog or bedtime NPH4 OR once basal dose >0.5 IU/kg OR FPG at target

If on bedtime NPH, consider converting to twice-daily NPH regimen

  • Conversion based on individual needs and current glycemic control

One possible approach (example)

  • Total dose = 80% of current bedtime NPH dose
  • 2/3 given in the morning
  • 1/3 given at bedtime
  • Titrate based on individual needs

Add prandial insulin

  • Usually one dose with the largest meal or meal with the greatest PPG excursion
  • Prandial insulin can be dosed individually or mixed with NPH as appropriate

Initiation: 4 IU a day or 10% of basal insulin dose

  • If A1C <8% (64mmol/mol) consider lowering the basal dose by 4 IU a day or 10% of basal dose

Titration: increase dose by 1-2 IU or 10-15% twice weekly

  • For hypoglycemia determine cause; if no clear reason lower corresponding dose by 10-20%

If the patient is still above their A1C target, choose one of the below pathways

  • Stepwise additional injections of prandial insulin (i.e., two, then three additional injections); proceed to full basal-bolus regimen (i.e., basal insulin and prandial insulin with each meal)
  • Consider self-mixed/split insulin regimen to adjust NPH and short/rapid-acting insulins separately 
    • Total NPH dose = 80% of current NPH dose
    • 2/3 given before breakfast and 1/3 given before dinner
    • Add 4 IU of short/rapid-acting insulin to each injection or 10% of reduced NPH dose
    • Titrate each component of the regimen based on individualized needs
  • Consider twice daily premix insulin regimen 
    • Initiation is usually unit per unit at the same total insulin dose, but may require adjustment to individual needs
    • Titrate based on individualized needs

Notes

  • Consider insulin as the first injectable if evidence of ongoing catabolism, symptoms of hypoglycemia are present, when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg.dK [16.7 mmol/L]) are very high, or a diagnosis of type 1 diabetes is a possibility
  • When selecting GLP-1 RA, consider: patient preference, A1C lowering, weight-lowering effect, or frequency of injection; if CVD present, consider GLP-1 RA with proven CVD benefit
  • For patients on GLP-1 RA and basal insulin combination, consider use of a fixed-ration combination product (iDegLira or iGlarLixi)
  • Consider switching from evening NPH to a basal analog if the patient develops hypoglycemia and/or frequently forgets to administer NPH with an AM dose of a long-acting basal insulin
  • If adding prandial insulin to NPH, consider initiation of a self-mixed or premixed insulin regimen to decrease the number of injections required

Medications

Medication Classes for Diabetes Management

Use the table below to compare different classes of diabetes medications and their impact on weight, major adverse cardiovascular events (MACE), kidney disease, and more. More detail on considerations and cautions for specific agents are below the chart. 

  Biguanides Sulfonylureas (2nd gen) Thiazolidinediones DPP-4 inhibitors SGLT2 inhibitors GLP-1 RAs GIP and GLP-1 RA Insulin
Efficacy High High High Intermediate Intermediate - high High - very high Very high High - very high
Hypoglycemia No Yes No No No No No Yes
Weight Impact Neutral (potential for modest loss) Gain Gain Neutral Loss (intermediate) Loss (intermediate - very high) Loss (very high) Gain
MACE Potential benefit Neutral Potential benefit* Neutral Benefit* Neutral* Under investigation Neutral
Heart Failure Neutral Neutral Increased risk Potential risk* Benefit* Neutral* Under investigation Neutral
DKD Progression Neutral Neutral Neutral Neutral Benefit* Benefit* Under investigation  

.

Notes and Considerations

Biguanides

! Contraindicated with eGFR <30

  • Gastrointestinal side effects common (diarrhea, nausea)
  • Potential for B12 deficiency

Sulfonylureas (2nd generation)

  • Glyburide is not recommended in CKD
  • Initiate glipizide and glimepiride conservatively to avoid hypoglycemia
  • FDA Special Warning on increased risk of cardiovascular mortality based on studies of an older sulfonylurea (tolbutamide)

Thiazolidinediones

  • Pioglitazone may have a potential benefit for MACE
  • No renal dose adjustment required
  • Generally not recommended in renal impairment due to potential for fluid retention
  • FDA Black Box warning  for congestive heart failure
  • Fluid retention (edema, heart failure)
  • Benefit in NASH
  • Risk of bone fractures
  • Bladder cancer

DPP-4 inhibitors 

  • Potential risk with heart failure and saxagliptin
  • Renal dose adjustment required for sitagliptin, saxagliptin, alogliptin; can be used in renal impairment
  • No dose adjustment required for linagliptin
  • Potential risk of acute pancreatitis
  • Joint pain
  • Bullous pemphigoid

SGLT2 inhibitors

  • Empagliflozin, canagliflozin have benefit in MACE
  • Empagliflozin, canagliflozin, dapagliflozin, ertugliflzoin have benefit in heart failure
  • Empagliflozin, canagliflozin, dapagliflozin have benefit in DKD progression
  • Renal dose adjustment required for canagliflozin, dapagliflozin, empagliflozin
  • In patients with CKD, use in people with eGFR >20 ; continue until initiation of dialysis or transplant
  • DKA risk (all agents, rare in T2DM)
  • Genitourinary infections
  • Risk of volume depletion, hypotension
  • Risk of Fournier’s gangrene

GLP-1 RAs

  • Once weekly exenatide is neutral for heart failure
  • DKD progression benefit (driven by albumin uria outcomes) with dulaglutide, liraglutide, semaglutide (SQ)
  • Renal dose adjustment required for exenatide
  • Caution when initiating or increasing dose due to potential risk of acute kidney injury in patient with renal impairment reporting severe adverse GI reactions
  • FDA Black Box warning: risk of thyroid C-cell tumors (semaglutide, liraglutide, dulaglutide, exenatide extended release) and Multiple Endocrine Neoplasia Syndrome (MEN) Type 2
  • Gastrointestinal side effects common (nausea, vomiting, diarrhea)
  • Acute pancreatitis risk

GIP and GLP-1 RA

  • No renal dose adjustment
  • Caution when initiating or increasing dose due to potential risk of acute kidney injury in patient with renal impairment reporting severe adverse GI reactions
  • FDA Black Box warning: risk of thyroid C-cell tumors (semaglutide, liraglutide, dulaglutide, exenatide extended release) and Multiple Endocrine Neoplasia Syndrome (MEN) Type 2
  • Gastrointestinal side effects common (nausea, vomiting, diarrhea)
  • Acute pancreatitis risk

Insulin

  • Lower insulin doses required with a decrease in eGFR; titrate per clinical response
  • Injection site reactions
  • Higher risk of hypoglycemia with human insulin (NPH or premixed formulations) vs. analogs

Medication Formulations

Class Compound Trade names Available dosages Starting dose* Max daily dose
Biguanides Metformin Glucophage 500 mg, 850 mg, 1000 mg (IR) 500 mg qd 2000 mg
Biguanides Metformin Glumetza 500 mg, 1000 mg (ER) 500 mg qd 1500 mg
Sulfonylureas  Glimepiride Amaryl 1 mg, 2 mg, 4 mg 1 mg qd 8 mg
Sulfonylureas  Glipizide Glucotrol 5 mg, 10 mg (IR) 5 mg qd 40 mg
Sulfonylureas  Glipizide Glucotrol XL 2.5 mg, 5 mg, 10 mg (XL) 2.5 mg qd 20 mg
Sulfonylureas  Glyburide Glynase PresTab 1.5 mg, 3 mg, 6 mg** 1.5 mg qd 12 mg**
Thiazolidinediones Pioglitazone Actos 15 mg, 30 mg, 45 mg 15 mg qd 45 mg
Meglitinides (glinides) Nateglinide Starlix 60 mg, 120 mg 60 mg tid ac 360 mg
Meglitinides (glinides) Repaglinide Prandin 0.5 mg, 1 mg, 2 mg 0.5 mg tid ac 16 mg
DPP-4 inhibitors Alogliptin Nesina 6.25 mg, 12.5 mg, 25 mg 25 mg qd 25 mg
DPP-4 inhibitors Saxagliptin Onglyza 2.5 mg, 5 mg 5 mg qd 5 mg
DPP-4 inhibitors Linagliptin Tradjenta 5 mg 5 mg qd 5 mg
DPP-4 inhibitors Sitagliptin Januvia 25 mg, 50 mg, 100 mg 100 mg qd 100 mg
SGLT2 inhibitors Ertugliflozin Steglatro 5 mg, 15 mg 5 mg qd 15 mg
SGLT2 inhibitors Dapagliflozin Farxiga 5 mg, 10 mg 5 mg qd 10 mg
SGLT2 inhibitors Empagliflozin Jardiance 10 mg, 25 mg 10 mg qd 25 mg
SGLT2 inhibitors Canagliflozin Invokana 100 mg, 300 mg 100 mg qd 300 mg
SGLT2 inhibitors Bexagliflozin Brenzavvy 20 mg 20 mg qd 20 mg
GLP-1 RAs Exenatide (ER) Bydureon BCise 2 mg powder for suspension or pen 2 mg qw 2 mg†
GLP-1 RAs Exenatide Byetta 5 mcg, 10 mcg pen 5 mcg bid 20 mcg
GLP-1 RAs Dulaglutide Trulicity 0.75 mg, 1.5 mg, 3.0 mg, 4.5 mg 0.75 mg qw 1.5 mg†
GLP-1 RAs Semaglutide Ozempic 0.25 mg. 0.5 mg, 1 mg, 2 mg pens 0.25 mg qw 2 mg†
GLP-1 RAs Semaglutide Rybelsus 3 mg, 7 mg, 14 mg (tablet) 3 mg qd 14 mg
GLP-1 RAs Liraglutide Victoza 0.6 mg, 1.2 mg, 1.8 mg 0.6 mg qd 1.8 mg
GIP & GLP-1 RA Tirzepatide Mounjaro 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg,15 mg per 0.5 mL in single-dose pen 2.5 mg qw 15 mg†

* No renal/hepatic impairment
** Micronized
† Administered once weekly

Diabetes and Heart Disease

Risk factors for ASCVD and Heart Failure should be assessed annually, using prognostic tools such as the ASCVD Risk Calculator Use the 10 year risk of a first ASCVD event 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 medications in patients with heart failure

  • 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

When to Refer

Consider referring the patient to specialty care in the below cases.

Endocrinology

  •  A1c > 9, despite 6 months of adherent therapy 
  • Recurrent hypoglycemia 
  • Continuous subcutaneous insulin therapy

Cardiology

  • Treatment of concomitant cardiac disease (CAD, HF), and orthostatic hypotension
  • Optimize treatment of lipid disorders

Nephrology

  • Clarify the cause of CKD, manage the complications of CKD, and all stage 4 CKD (eGFR <30)
  • KidneyIntelX™ medium or high risk score

KidneyIntelX™ is a diagnostic blood test that predicts risk of progressive decline in kidney function in patients with type 2 diabetes and existing Diabetic Kidney Disease at stages 1-3 (eGFR 30-59 or UACR ≥ 30). 

Disclosure:  KidneyIntelX™ is based on innovative technology developed by Mount Sinai faculty and licensed to Renalytix. Mount Sinai has equity ownership in Renalytix. If you order KidneyIntelX for your patient, please inform them of Mount Sinai’s financial interest with the company, and that their test results will be incorporated into a real-world evidence study designed to evaluate the utility and impact of KidneyIntelX™ testing in a large urban healthcare system. The study has been reviewed and approved by the Mount Sinai PPHS/IRB and does not require patient written consent.

Team-Based Care

Leverage the support of additional care team members to effective manage patients with chronic conditions. Available services include:

Next Steps

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