Physicians Pocket Card

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1. ABC DE ’s OF DIABETES CARE

A = A1c (yearly)
B = Blood Pressure (at every visit)
C = Cholesterol (yearly)
D = Dysalbuminuria (Urine albumin yearly)
E = ( E nteric-coated) aspirin (daily)

2. TREATMENT STRATEGIES

Make diagnosis and classify:

• If Type 1, consider referral to Endocrinologist
• If Type 2, begin diabetes education and
• Assess glycemic control and determine TARGET HbA1c (Target goals and therapies MUST be individualized - see #3 below)
• If HbA1c above target, and MNT fails, institute metformin (if BMI >25 & serum creatinine <1.5 mg/dL) alone or in combination with insulin secretagogue [sulfonylurea (glucovance, metaglip), prandin, starlix].
• If target not achieved with metformin/insulin secretagogue, reevaluate compliance with MNT + exercise, then:
• Consider adding insulin , thiazolidinedione (avandia , avandamet, actos), or a -glucosidase inhibitor (precose , glyset) as 3rd line therapy.
• Referral to Endocrinologist recommended if A1c >10%
• Self monitoring of blood glucose (SMBG):
  1. Patient to demonstrate proficiency with techniques Meter testing skills, drawing insulin
  2. STABLE patients on MNT/oral drugs: Recommend 50 strips/90 days Monitor 2-3 times weekly, more often when indicated i.e. acute illness
  3. STABLE patients on insulin therapy: Recommend 100 strips/50 days
     Monitor 2 times daily, more often when indicated i.e. acute illness

3. GLYCEMIC CONTROL

Target A1c should be individualized by patient's age and diabetic complications: retinopathy, nephropathy, and/or neuropathy

Complications

Age   Without   With :
<75      7%         8%
>75       8%         9%

Higher targets are appropriate for patients who have poor medical prognosis, are elderly, have compliance problems, hypoglycemic unawareness or intellectual deficits.

4. EYE CARE

Annual dilated retinal examination by an Eye Care Specialist

5. FOOT CARE

• Annual foot exam includes:
  • Foot inspection
  • Check pedal pulses
  • Assess sensation using approved monofilament
• Document ALL components of foot exam in progress note.
• Educate patient about foot hygiene and proper footwear.
• Refer at-risk patient to Podiatrist: i.e. insensate, ulcers

6. LIPID CONTROL

• Measure FULL lipid profile annually
• TARGET Total Cholesterol/HDL-Cholesterol Ratio <5

7. HYPERTENSION

• Blood Pressure check at each visit
• TARGET blood pressure to LESS THAN 120/70 mm Hg
• Consider ACE inhibitor first line (or ARB if cough from ACE, hyperkalemia or creatinine >1.5 mg/dL)
• Thiazide diuretics should be used second line

8. RENAL

• Annual urinalysis for albumin ( NOT protein)
• Evaluate for albuminuria by doing albumin/creatinine ratio on spot urinalysis TARGET albumin to <10 mg per day
• If >10 mg albumin initiate ACE Inhibitor even if normotensive (microalbuminuria)
• If >300 mg albumin: obtain 24-hour urine albumin to assess for nephropathy (macroalbuminuria)
• Institute ACE inhibitor/ARB therapy in ALL patients with microalbuminuria, nephropathy (macroalbuminuria)
• Annual serum creatinine: If creatinine >2.5 mg/dL referral to a nephrologist recommended

9. HEALTH MAINTENANCE

• ASA 81-325 mg daily
• Immunizations (Influenza, pneumococcal, PPD)
• Emphasize proper dental care
• Emphasize proper nutrition and regular exercise program
• Smoking cessation counseling if appropriate