• Joslin Diabetes Center. Clinical guideline for pharmacological management of type 2 diabetes. Boston (MA): Joslin Diabetes Center; 2007 Jan 12. 9 p. [91 references]

This is the current release of the guideline.

This guideline will be reviewed periodically and modified to reflect changes in clinical practice and available pharmacological information.

Type 2 diabetes mellitus

Diagnosis
Management
Treatment

Endocrinology
Family Practice
Internal Medicine

Advanced Practice Nurses
Physician Assistants
Physicians

To support clinical practice and influence clinical behavior to improve outcomes and assure quality of care according to accepted standards for the pharmacological management of type 2 diabetes

Non-pregnant adults with type 2 diabetes mellitus

1. Diagnosis
   • Casual plasma glucose
   • Fasting plasma glucose
   • Oral glucose tolerance test
2. Treatment
   • Glycemic control goals
   • Initial treatment
     • Mild presentation
     • Moderate presentation
     • Severe presentation
   • Oral antihyperglycemic therapy:
     • Metformin
     • Thiazolidinediones
     • Insulin secretagogue
     • Alpha–glucosidase inhibitor
     • Combination therapy
   • Insulin
     • Rapid-acting
     • Short-acting
     • Intermediate-acting
     • Long-acting
     • Pre-meal insulin mixture
   • Exenatide

Glycemic control: fasting plasma glucose, 2-hour postprandial glucose, and bedtime glucose levels, percent hemoglobin

Searches of Electronic Databases

Review of all new papers on selected topics in PubMed, MEDLINE, OUID, Cochrane databases

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Review

Not stated

Expert Consensus

Not stated

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

The guideline was approved by the Joslin Clinical Oversight Committee on 1/12/07.

Definitions of the recommendation and evidence level grades (1A to 2C) are provided at the end of the "Major Recommendations" field.

¹Laboratory methods measure plasma glucose. Most glucose monitors approved for home use calibrate whole blood glucose readings to plasma values. Plasma glucose values are 10-15% higher than whole blood glucose values. It is important for people with diabetes to know whether their meters and strips record whole blood or plasma results.

²The true goal of care is to bring A1C as close to normal as safely possible. [1C] A goal of < 7% is chosen as a practical level for most patients using medications that may cause hypoglycemia to avoid the risk of that complication. Achieving normal blood glucose is recommended if it can be done practically and safely. [1B]

The guideline recommendations are presented in a series of algorithms on the following topics:

• Initial Treatment Strategy
• Considerations for Selecting Initial Oral Antihyperglycemic Therapy

Refer to the original guideline document for more information.

Definitions:

The original guideline document contains clinical algorithms for:

• Initial Treatment Strategy
• Considerations for Selecting Initial Oral Antihyperglycemic Therapy

The type of supporting evidence is identified and graded for each recommendation.

Appropriate pharmacological management of type 2 diabetes

• Hypoglycemia
• Thiazolidinediones can be used in renal impairment but may increase fluid retention

• Metformin is contraindicated in the following conditions:
  • Creatinine > 1.4 (women)
  • Creatinine > 1.5 (men)
  • Intravenous (IV) contrast
  • Congestive heart failure (CHF)
  • Dehydration
  • Alcohol excess
  • > 80 years of age (unless creatinine clearance is normal)
• Thiazolidinediones are contraindicated in the following conditions:
  • Class III or IV CHF
  • Liver function tests > 2.5 times upper limit of normal
• Insulin secretagogues (sulfonylurea or short-acting secretagogue) are contraindicated in the following conditions:
  • Sulfonylureas in severe liver or renal disease
• Alpha-glucosidase inhibitors are contraindicated in the following conditions:
  • Chronic intestinal disorders
  • Acarbose in cirrhosis
  • Acarbose and miglitol in renal impairment (creatinine > 2.0)
• Exenatide is contraindicated in gastroparesis requiring treatment with metoclopramide
• Inhaled insulin is contraindicated in smokers, recent smokers and patients with underlying lung disease

This Clinical Guideline is not intended to serve as a mandatory standard, but rather provides a set of recommendations for patient care management. These recommendations are not a substitute for sound and reasonable clinical judgment or decision-making and do not exclude other options. Clinical care must be individualized to the specific needs of each patient and interventions must be tailored accordingly. The guideline has been created to address initial presentation and treatment strategies in the adult non-pregnant patient population.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• Joslin Diabetes Center. Clinical guideline for pharmacological management of type 2 diabetes. Boston (MA): Joslin Diabetes Center; 2007 Jan 12. 9 p. [91 references]

Not applicable: The guideline was not adapted from another source.

2007 Jan 12

Joslin Diabetes Center - Hospital/Medical Center

Joslin Diabetes Center

Joslin Clinical Oversight Committee

Committee Members: James Rosenzweig, MD (Chairperson); Richard Beaser, MD; Elizabeth Blair, MS, CS-ANP, CDE; Patty Bonsignore, MS, RN, CDE; Amy Campbell, MS, RD, CDE; Cathy Carver, ANP, CDE; Jerry Cavallerano, OD, PhD; Om Ganda, MD; John W. Hare, MD; Lori Laffel, MD, MPH; Melinda Maryniuk, MEd, RD; William Petit, MD; Kristi Silver, MD; Susan Sjostrom, JD; Kenneth Snow, MD; Robert Stanton, MD; William Sullivan, MD; Howard Wolpert, MD; Martin J. Abrahamson, MD (ex officio)

Not stated

This is the current release of the guideline.

This guideline will be reviewed periodically and modified to reflect changes in clinical practice and available pharmacological information.

None available

None available

This NGC summary was completed by ECRI Institute on April 19, 2007. The information was verified by the guideline developer on May 10, 2007. This summary was updated by ECRI Institute on September 5, 2007 following the U.S. Food and Drug Administration advisory on the Thiazolidinedione class of antidiabetic drugs. This summary was updated by ECRI Institute on November 6, 2007, following the U.S. Food and Drug Administration advisory on Byetta (exenatide). This summary was updated by ECRI Institute on November 28, 2007 following the U.S. Food and Drug Administration advisory on the Avandia (rosiglitazone maleate) Tablets. This summary was updated by ECRI Institute on March 10, 2008 following the U.S. Food and Drug Administration advisory on Avandia (rosiglitazone maleate). This summary was updated by ECRI Institute on April 21, 2008 following the U.S. Food and Drug Administration advisory on Exubera (insulin human rDNA origin) Inhalation Powder.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.