Application of the Diabetes Algorithm to Patients

Transcription

1 Application of the Diabetes Algorithm to Patients Apply knowledge gained from this activity to improve disease management and outcomes for patients with T2DM and obesity Note: The cases in this deck represent real patients and are designed to show how different physicians approach patient management. This information serves as a springboard for discussion, and does not imply AACE s endorsement of any specific treatment approach.

2 Case #1 Maria Newly Diagnosed Maria is a 55 year-old Hispanic woman with newly diagnosed type 2 diabetes She is active and takes care of her grandchildren while their mother works; she is chronically tired and too busy to exercise She eats the same food as her grandchildren because it is too much work to prepare two different meals No alcohol She has known hypertension, and sleep apnea Currently manages sleep apnea with a CPAP machine No history of pancreatitis, hepatitis, or congestive heart failure CAD = coronary artery disease; CPAP = continuous positive airway pressure

3 Case #1 Maria On physical exam, she looks well Height: 5 4, Weight: 187 lbs, BMI: 32 kg/m 2 BP 155/98 mmhg, HR 86 bpm Foot exam: Normal pulses and sensation Fundoscopy exam: No retinopathy BMI = body mass index; BP = blood pressure; bpm = beats per minute; HR = heart rate; kg = kilogram; lbs = pounds; m 2 = meters squared; mmhg = millimeters of mercury

4 Case #1 Maria Labs: A1C: 7.4%, triglycerides 250 mg/dl TC 228 mg/dl, LDL-C 146 mg/dl, HDL-C 32 mg/dl Creatinine 0.9 mg/dl, LFTs WNL No albuminuria Current medications: Atenolol, 50 mg daily Valsartan, 80 mg daily HCTZ, 25 mg daily A1C = glycated hemoglobin A1C; dl = deciliter; HDL-C = high density lipoproteins cholesterol; LDL-C = low density lipoprotein cholesterol; LFT = liver function test; mg = milligram; TC = total cholesterol; WNL = within normal limits

5 What are important considerations when choosing an oral agent for this patient? (a) Metformin should be considered as background therapy for MOST patients with newly diagnosed T2DM (b) Metformin is inexpensive, readily available, and likely to allow patient to achieve targeted A1C (c) Metformin should be taken WITH MEALS to minimize risk of gastrointestinal side effects (d) Few, if any, drug interactions are noted when metformin is added to other anti-diabetes agents (e) All of the above A1C=glycated hemoglobin; T2DM=type 2 diabetes mellitus.?

6 Road Map to Achieve Glycemic Goals: Maria s A1C = 7.4% Monotherapy may be effective for Maria Metformin 1 st choice (if no contraindication) Consider DPP-4 if PPG and FPG, GLP-1 if PPG, TZD if metabolic syndrome or NAFLD, AGI if PPG Do not recommend secretagogue (SU or glinide) Short-lived effect, strong risk of hypoglycemia that may increase hospitalizations in elderly patients, may increase MI risk, contraindicated for patients with renal failure If unsuccessful, move to dual oral rx Metformin still cornerstone of therapy If contraindicated, consider TZD as foundation of rx 2 nd component: usually incretin mimetic, DPP-4 inhibitor, TZD, glinide, or SU, in that order. May also consider SGLT2 blockers, colesevelam, or bromocriptine AGI = alpha glucosidase inhibitor; BG = blood glucose; DPP-4 = dipeptidyl peptidase 4; FBG = fasting blood glucose; GLP-1 = glucagon-like peptide-1; NAFLD = non-alcoholic fatty liver disease; PP = post prandial; TZD = thiazolidinediones; SU = sulfonylurea Garber AJ, et al. Endocr Pract.2017,doi: /EP CS.

7 Maria What are her lifestyle considerations? Lifestyle modifications are essential elements of her therapy What would you counsel Maria on? (a) Healthy eating, including portion control, low fat intake and carbohydrate counting (b) Recommend she begin a regular physical activity routine (c) Recommend weight loss of 5% to 10% to improve glycemic control and cardiovascular risk (d) All of the above

8 Maria What is her blood pressure target? Maria s BP is 155/98 mm Hg; what BP target would you set for Maria? (a) <140/90 mm Hg (b) <130/80 mm Hg (c) <120/80 mm Hg (d) At this point, her BP is not an important focus of treatment BP = blood pressure; mm Hg = millimeters of mercury

9 How will you address Maria s current blood pressure? What approach would you take in response to Maria s BP of 155/98 mm Hg? (a) Increase HCTZ dose (b) Increase atenolol dose (c) Increase valsartan dose (d) Add another agent (e) Do not treat at this time, her BP is managed well enough BP = blood pressure; mm Hg = millimeters of mercury

10 Maria has the distinctive lipid triad profile seen in type 2 diabetes What does this atherogenic profile consist of? (a) High triglycerides, low HDL cholesterol, high LDL cholesterol particles (b) Normal triglycerides, low HDL cholesterol, high LDL cholesterol particles (c) High triglycerides, high HDL cholesterol, high LDL cholesterol particles HDL = high density lipoproteins; LDL = low density lipoproteins?

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12 Maria How do you treat her LDL-C levels? Maria s LDL-C is currently 146 mg/dl, what interventions would you take at this time to bring her level down to the target of <100 mg/dl? (a) Begin a statin (b) Focus on therapeutic lifestyle changes (TLC) and re-assess in 3 months (c) Don t treat, her levels aren t significantly elevated (d) A & B? dl = deciliter; LDL-C = low density lipoproteins; mg = milligram

13 Maria Treatment Plan Maria is started on metformin, 500 mg BID She is started on simvastatin, 40 mg daily (can switch to atorvastatin 40 later) Her valsartan dose is increased to 160 mg/dl She is counseled on TLC to reduce LDL-C levels She is instructed to have a checkup in 3 months, including lipid and A1C assessment A1C = glycated hemoglobin A1C; BID = twice daily; dl = deciliter; LDL = low density lipoproteins; mg = milligram; TLC = therapeutic lifestyle changes.

14 Maria 3-month Checkup Maria returns for her 3-month checkup She has reduced consumption at fast food outlets and has stopped consuming sugary drinks She has been walking 10 minutes a day 2 times per week She has been monitoring blood glucose levels on occasion, but was unclear what her target fasting and postprandial levels should be

15 Maria 3-month Checkup Height: 5 4, Weight: 185 lbs, BMI: 32 kg/m 2 Reduction of 2 lbs over 3 months BP 140/94 mm Hg, HR 80 BPM Foot exam: normal pulses and sensation Fundoscopy exam: no retinopathy BMI = body mass index; BP = blood pressure; bpm = beats per minute; HR = heart rate

16 Maria 3-month Checkup Labs: A1C: 7.0%, triglycerides: 230 mg/dl, TC: 182 mg/dl, LDL-C: 123 mg/dl, HDL-C: 38 mg/dl Home SMBG readings: mg/dl fasting, mg/dl postprandial No changes in other labs No albuminuria Current medications: - Metformin, 500 mg BID - Atenolol, 50 mg daily - Simvastatin, 20 mg daily - HCTZ 25 mg daily - Valsartan, 120 mg daily - Vitamin D3, 2000 IU daily A1C = glycated hemoglobin a1c; dl = deciliter; HDL-C = high density lipoproteins cholesterol; HR = heart rate; lb = pounds; LDL-C = low density lipoproteins cholesterol; LFT = liver function test; mg = milligram; TC = total cholesterol; WNL = within normal limits.

17 Maria What is your next step with treatment for glycemic control? In light of Maria s new lab work, how will you proceed with glycemic management? (a) Her A1C was reduced to 7.0%, so no new intervention is needed (b) Change Maria s statin therapy to a more potent statin (atorvastatin or rosuvastatin) and titrate to achieve LDL goal (c) Increase atenolol to 100 mg/day or add calcium channel blocker to control blood pressure (d) All of the above? A1C = glycosylated hemoglobin A1C; BG = blood glucose.

18 Maria Questions for Discussion TLC decreased Maria s LDL-C, however it was not sufficient to reduce it to her target of <100 mg/dl What intervention should be added to her treatment to help her meet her LDL-C goal? What intervention should be added to help Maria meet her blood pressure goal? TLC = therapeutic lifestyle changes; dl = deciliter; LDL-C = low density lipoprotein cholesterol; mg = milligram.

19 Case #2 Lucy Lucy is a 56 year-old Caucasian woman with a 5-year history of type 2 diabetes She has a desk job working as a consultant and eats most meals on the go or at her desk She tries to get a 20-minute walk in a couple times a week; however, she has trouble finding the time She has been treated for dyslipidemia for 2 years with a statin Lucy does not smoke or drink alcohol She has a family history of CHD; her mother died of a MI at 62 years of age CHD = coronary heart disease; MI = myocardial infarction.

20 Case #2, Lucy Diabetes Checkup Lucy has scheduled a visit with you to establish care She moved to the area 1 year ago and has not seen anyone to manage her diabetes during that time No complaints except a gradual 10 lb weight gain over the past year She has been trying to cut back on calories lbs = pounds

21 Case #2, Lucy Diabetes Checkup Height: 5 6, Weight: 210 lb, BMI: 34 kg/m 2 BP 150/90 mm Hg, HR 82 bpm Foot exam: normal pulses, decreased sensation bilaterally Fundoscopy exam: nonproliferative retinopathy She has been taking regular BP measurements at home Home measurements range from 145/84 158/92 mmhgtaken at bedtime BMI = body mass index; BP = blood pressure; bpm = beats per minute; HR = heart rate; kg = kilogram; lbs = pounds; m 2 = meters squared; mm Hg = millimeters of mercury

22 Lucy Diabetes Checkup A1C at last checkup 1.5 years ago was 7.5% Current labs: A1C: 8.4%, FPG 150 mg/dl Triglycerides 286 mg/dl, TC 235 mg/dl, LDL-C 146 mg/dl, HDL-C 32 mg/dl Serum creatinine 1.2 mg/dl, LFTs normal Urine albumin: 90 mg/g creatinine Current medications: - Metformin, 1000 mg BID for 5 years - Glimepiride, 4 mg QD for 2 years - Lovastatin, 40 mg QD for 2 years - Hydrochlorothiazide, 50 mg QD for 1 year A1C = glycated hemoglobin A1C; BID = twice daily; dl = deciliter; FBG = fasting blood glucose; g=gram; HDL-C = high density lipoproteins cholesterol; LDL-C = low density lipoproteins cholesterol; LFT = liver function test; mg = milligram; QD = once daily; TC = total cholesterol; WNL = within normal limits

23 Lucy Questions for Discussion Is Lucy a candidate for adding another oral/injectable agent such as a GLP-1 mimetic, DPP-4 inhibitor, or TZD? Is it time to consider insulin? DPP-4 = dipeptidyl peptidase 4; GLP-1 = glucagon-like peptide-1; TZD = thiazolidinediones

24 Which medication would you add next to Lucy s therapy? (a) TZD (b) DPP-4 inhibitor (c) GLP-1 agonist (d) Basal insulin? DPP-4 = dipeptidyl peptidase 4; GLP = glucagon-like peptide-1; TZD = thiazolidinediones.

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26 Road Map to Achieve Glycemic Goals: Lucy s A1C = 8.4% If Lucy was drug-naïve, dual therapy would be an appropriate first step However, dual oral Rx is currently proving unsuccessful; it is time to consider triple therapy If triple oral Rx fails to achieve A1C goal within 2-3 months, insulin therapy will be needed AGI = alpha glucosidase inhibitor; BG = blood glucose; DPP-4 = dipeptidyl peptidase 4; FBG = fasting blood glucose; GLP = glucagon-like peptide- 1; MET = metformin; NAFLD = non-alcoholic fatty liver disease; PP = post prandial; TZD = thiazolidinediones; SU = sulfonylurea. Garber AJ, et al. Endocr Pract.2017,doi: /EP CS.

27 Lucy How will you address her current blood pressure? What approach would you take in response to Lucy s BP of 150/90 mm Hg? (a) Increase thiazide dose (b) Add an ACE inhibitor or an angiotensin II antagonist (c) Recommend dietary changes consistent with the DASH diet (d) Do not treat at this time, her BP is managed well enough (e) Both b & c ACE = angiotensin-converting enzyme; BP = blood pressure; DASH = Dietary Approaches to Stop Hypertension.?

28 Management of Lucy s Lipid Levels Assess CVD risk: Does Lucy have a CVD risk equivalent?» Yes - T2DM Does Lucy have any major independent risk factors?» Yes - 58 y/o, BP 150/90 mm Hg, family history of CVD, HDL <40 mg/dl Lucy s LDL goal <100 mg/dl BP = blood pressure; CVD = cardiovascular disease; dl = deciliters; HDL = high density lipoproteins; LDL = low density lipoproteins; mg = milligrams; T2DM = type 2 diabetes mellitus; y/o = year old. Garber AJ, et al. Endocr Pract. 2013;19:

29 Lucy How do you treat her LDL levels? Lucy s LDL levels need to be reduced from 146 mg/dl to <100 mg/dl; what interventions would you take to bring her levels down? (a) Add an additional lipid-lowering agent (b) Focus on TLC and re-assess in 3 months (c) Add an additional lipid lowering agent and TLC (d) Switch Lucy from current low-potency statin to a higherpotency statin dl = deciliter; LDL = low density lipoproteins; mg = milligram; TLC = therapeutic lifestyle changes.?

30 Lucy Treatment plan Lucy is started on ramipril, 5 mg/dl and liraglutide As per prescribing instructions, liraglutide is initiated at 0.6 mg SQ QD for 1 week, then uptitrated to 1.2 mg and a week later to 1.8 mg SQ QD Her lovastatin dose is discontinued and she is started on atorvastatin, 40 mg QD Her glimepiride dose is reduced to 2 mg QD due to the introduction of liraglutide She is counseled on TLC and the DASH diet She is instructed to follow-up in 3 months for a checkup, including lipid and A1C reassessment A1C = glycated hemoglobin A1C; BID = twice daily; DASH = Dietary Approaches to Stop Hypertension; dl = deciliter; DSME = diabetes self management education; LDL = low density lipoproteins; mg = milligram; QD = once daily; SQ = subcutaneous

31 Concerns Related To GLP-1 Initiation Prior to initiating liraglutide, what concerns should be addressed with the patient? 1. Ask if the patient has a personal or family history of medullary carcinoma of the thyroid 2. Make certain the patient does NOT have a prior history of pancreatitis 3. Have patient contact the clinician immediately should she develop any abdominal pain associated with nausea and vomiting 4. Advise patient that the drug may affect her satiety. If she feels full she should not continue eating as this may induce nausea and vomiting

32 Lucy 3-month Checkup Lucy returns for her 3-month checkup She has lost 5 lbs since her last visit She has been getting minutes of aerobic physical activity 3 days a week and takes a 40-minute yoga class weekly She has continued to watch her caloric intake

33 Lucy 3-month Checkup Results of reapplied SMBG shows Lucy s pre-meal blood glucose ranging from 90 to 154 mg/dl Her home BP log demonstrates a slight decrease in BP Home BP measurements: 134/80 mm Hg 142/84 mm Hg Height: 5 6, Weight: 205 lbs, BMI: 33 kg/m 2 BP 132/84 mm Hg, HR 78 bpm Foot exam and fundoscopy exam: no change since prior visit BMI = body mass index; BP = blood pressure; bpm = beats per minute; DASH = Dietary Approaches to Stop Hypertension; HR = heart rate; mm Hg = millimeters of mercury; SMBG: self-monitoring of blood glucose

34 Labs: Lucy 3-month Checkup A1C: 6.5% TG: 180 mg/dl, TC: 181 mg/dl, LDL: 105 mg/dl, HDL: 40 mg/dl BG: 138/82 mg/dl Serum creatinine 1.2 mg/dl, LFTs normal Urine albumin: 20 mg/g creatinine Current medications: - Metformin, 1000 mg BID - Glimepiride, 2 mg QD - Liraglutide, 1.8 mg SQ QD - Atorvastatin, 40 mg QD - Hydrochlorothiazide, 50 mg QD - Ramipril, 5 mg QD - Vitamin D3, 2000 IU QD - ASA, 81 mg QD A1C = glycated hemoglobin A1C; FBG = fasting blood glucose; BID = twice daily; QD = daily; cc = with food; BMI = body mass Index; BP = blood pressure; HR = heart rate; mg = milligram; lb = pounds; LFT = liver function test; SMBG self-monitoring of blood glucose; SQ = Subcutaneous; TC = total cholesterol; TG = triglycerides; WNL = within normal limits; ASA Aspirin, IU = International Units.

35 Lucy What is your next step to manage her LDL levels? Lucy s LDL levels have been reduced from 146 mg/dl to 105 mg/dl; how do you proceed with treatment? (a) Advise Lucy to continue TLC (b) Increase her statin dose to 80 mg/dl and retest in 3 months, or switch to a more potent statin (c) Add a second lipid-lowering agent (d) Both a & b? (e) None of the above dl = deciliter; LDL = low density lipoproteins; mg = milligram; TLC = therapeutic lifestyle changes

36 Case #3 John John is a 62 year-old African American man, with type 2 diabetes, diagnosed 10 years ago He works as a electrician and has irregular meal times He tries to avoid sweets He smokes 1 pack a day and drinks 1-2 beers a night He is 3 months late on his 6-month checkup He has a history of CAD, depression, and hypertension CAD = coronary artery disease

37 Case #3, John Diabetes Checkup John reports feeling anxious sometimes for no clear reason; at these times, his hands become clammy and tremble and he becomes sweaty Height: 6 2, Weight: 234 lbs, BMI: 30 kg/m 2 BP 184/100 mm Hg, HR 90 bpm ROS negative except poor glucose control BMI = body mass Index; BP = blood pressure; HR = heart rate; lb = pounds; ROS = review of systems

38 Case #3, John Diabetes Checkup Current labs: - A1C: 9.4%; - Home blood glucose ranges: FPG mg/dl; premeal mg/dl Serum creatinine: 2.3 mg/dl, LFTs normal, urine albumin: 92 mg/g creatinine, TC 153 mg/dl, LDL 70 mg/dl, HDL 41 mg/dl, TG 225 mg/dl egfr 44 ml/min Current medications: Metformin, 1000 mg BID Glimepiride, 4 mg QD Sitagliptin, 100 mg QD ASA, 81 mg QD Benazepril, 40 mg QD Simvastatin, 40 mg QD Escitalopram, 10 mg QD A1C = glycated hemoglobin; ASA = aspirin; BID = twice daily; BMI = body mass Index; BP = blood pressure; CGM = continuous glucose monitoring; egrf = estimated glomerular filtration rate; FBG = fasting blood glucose; HDL = high density lipoproteins; HR = heart rate; lb = pounds; LDL = low density lipoproteins; LFT = liver function test; mg = milligram; ROS = review of systems; TC = total cholesterol; TG = triglycerides; WNL = within normal limits; QD = once daily.

39 What do John s symptoms of anxiety, trembling, sweating, and clammy hands suggest? (a) Hyperglycemia (b) Hypoglycemia (c) Hypothyroidism (d) GERD? GERD = gastroesophageal reflux disease

40 Symptoms of Hypoglycemia Are Like Falling in Love for the First Time! You get nervous and jittery You get hot and sweaty Your heart starts beating rapidly And last you want to say something intelligent, but only gibberish comes out! H.Rettinger, M.D.

41 John s Self-monitoring Blood Glucose Download Frequent episodes of hypoglycemia due to sulfonylurea and chronic kidney disease

42 What would you do next to adjust John s treatment? (a) Stop metformin and add basal insulin (b) Stop glimepiride and add basal insulin (c) Only continue sitagliptin and add basal insulin (d) Stop all oral medications and start basal/bolus insulin?

43 Road Map To Achieve Glycemic Goals: John s A1C = 9.4% John is already on triple therapy with A1C still >9%; likely having hypoglycemia He may continue sitagliptin, as this will decrease potential need for bolus insulin and reduce post-prandial glycemic variability; however, due to his increased Cr, his sitagliptin dose should be reduced to 50 mg Basal insulin should be initiated Hypoglycemia was driven by the SU and that is why it was stopped Garber AJ, et al. Endocr Pract. 2017, doi: /ep cs. AGI = alpha glucosidase inhibitor; BG = blood glucose; DPP-4 = dipeptidyl peptidase 4; FBG = fasting blood glucose; GLP = glucagon-like peptide- 1; MET = metformin; NAFLD = non-alcoholic fatty liver disease; PP = post prandial; TZD = thiazolidinediones; SU = sulfonylurea; Cr=Creatinine.

44 How will you manage John s current BP? John s current BP is 182/100 mm Hg, pulse 90: how will you approach management of his BP? (a) Counsel on diet and lifestyle changes (b) Start John on a beta-blocker, carvedilol 6.25 mg BID (given known CAD, rapid pulse) and schedule a follow up visit in 1 week (c) Recommend reductions in his alcohol consumption (d) Recommend a smoking cessation program? (e) All of the above BID = twice daily; BP = blood pressure; CAD = coronary artery disease; mg = milligram; mm Hg = millimeter of mercury

45 John starts with basal analog insulin 10 units at bedtime John gave himself the first injection in the office, using an insulin pen He was provided with a self-titration schedule He was prescribed carvedilol 6.25 mg BID (does not increase blood glucose) He was counseled to perform SMBG fasting and at bedtime He was taken off glimepiride He was taken off metformin BID = twice daily; BP = blood pressure; mg = milligrams; SMBG = self-monitored blood glucose.

46 John BP Check-up Visit At 1-week follow up, John s BP is 156/92 mm Hg His carvedilol dose is increased to 12.5 mg BID His wife is very supportive in helping him make dietary changes He is referred to a dietitian for help with specific food questions He is doing well with insulin pen injections, and has been following his self-titration schedule BID = twice daily; BP = blood pressure; mg = milligram; mm Hg = millimeters of mercury.

47 John 3-month Checkup Height: 6 2, Weight: 228 lbs, BMI: 29 kg/m 2 BP 130/84 mm Hg, HR 68 bpm Foot and fundoscopy exam: no change since prior visit Labs: A1C: 7.9% Serum creatinine: 2.3 mg/dl Urine albumin : 60 mg/g, LFTs normal Current medications: Sitagliptin, 50 mg QD ASA, 81 mg 50 U/d long-acting insulin analog Benazepril, 40 mg QD Simvastatin, 40 mg QD Escitalopram, 10 mg QD Carvedilol, 12.5 mg BID A1C = glycated hemoglobin A1C; ASA = Aspirin; BID = twice daily; BMI = body mass Index; BP = blood pressure; dl = deciliter; FBG = fasting blood glucose; g = gram; HDL = high density lipoproteins; HR = heart rate; lb = pounds; kg = kilogram; LDL = Low density liproproteins; LFT = liver function test; m 2 = meters square; mg = milligram; ROS = review of systems; SMBG = self blood glucose monitoring; SQ = Subcutaneous; TC = total cholesterol; TG = triglycerides; WNL = within normal limits; QD = once daily; hs = before bed.

48 John SMBG Log John brought in examples of his SMBG log Time BG (mg/dl) Time BG (mg/dl) Time BG (mg/dl) 8:00 (fasting) 126 7:30 (fasting) 134 8:00 (fasting) 136 1:00 (post-lunch) Missed reading 1:00 (post-lunch) 214 1:00 (post-lunch) 229 5:30 (post-dinner) 210 6:30 (post-dinner) Missed reading 5:30 (post-dinner) 240 9:30 (bedtime) :00 (bedtime) 219 9:30 (bedtime) 197 BG= blood glucose; dl = deciliter; mg = milligram; SMBG=self-monitoring of blood glucose

49 John What is the best option? (a) Increase his basal insulin dose (b) Add a rapid-acting insulin with each meal (c) Add rapid acting analog to his largest meal (d) Switch to premix insulin?

50 Options When Not at Goal with One Injection of Basal Insulin Basal Plus Add prandial insulin at main meal or Switch to Basal/Bolus or Switch to a premixed insulin analog Divide dose in half and give twice daily (breakfast and dinner) after meals if feeding uncertain

51 John Basal Plus Bolus Mealtime Insulin Use rapid-acting analogs, not regular insulin Easier timing, less postprandial hypoglycemia Can be taken up to 15 minutes after starting to eat May start with 1 injection, at largest meal; however most patients need a dose with each meal 4 units and titrate OR by weight U/kg OR 1 U/15 gms CHO and titrate Titrate to: <140 mg/dl 2 hours post-prandial OR <110 mg/dl next meal or bedtime Stop oral SUs/glinides when prandial insulin is started CHO = carbohydrates; dl = deciliter; kg = kilogram; mg = milligram, SU = sulfonylurea; U = unit.

52 John 3-month Follow-up Height: 6 2, Weight: 210 lbs, BMI: 27 kg/m 2, BP: 130/78 mm Hg, HR: 80 bpm Foot exam: no change since prior visit Labs: A1C: 6.4%; FPG: mg/dl; 2-h PPG: mg/dl Serum creatinine: 2.1 mg/dl Urine albumin: 20 mg/g, LFTs normal Current medications: 50 U long-acting analog insulin SQ hs 12 U rapid-acting insulin SQ with breakfast and lunch 15 U rapid-acting insulin SQ with dinner John will follow up in 3 months Benazepril 40 mg QD Simvastatin 40 mg QD Escitalopram 10 mg QD Carvedilol 12.5 mg BID ASA 81 mg QD ASA = Aspirin; A1C = glycated hemoglobin A1C; BID = twice daily; BMI = body mass Index; BP = blood pressure; dl = deciliter; FBG = fasting blood glucose; HDL = high density lipoproteins; g= gram; HR = heart rate; kg = kilogram; m 2 = meter squared; lb = pounds; LDL = low density lipoproteins; LFT = liver function test; mg = milligram; PPG = postprandial glucose; ROS = review of systems; SMBG = self-monitoring of blood glucose; SQ = subcutaneous; TC = total cholesterol; TG = triglycerides; U = units; WNL = within

53 And Finally: The 5 Keys of Successful Diabetes Self-management 1. Know your metabolic targets (A1C, lipids, blood pressure) 2. Understand how to achieve your metabolic targets 3. Stop smoking 4. Take your medicines 5. Make sure your doctor/provider understands the complexities of diabetes management Unger J. Diabetes Management in Primary Care, 2 nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012.

54 Bill Polonsky, PhD, CDE, Director, Diabetes Behavioral Institute. San Diego, CA. The number one complication of wellcontrolled diabetes is