Diabetes: Type 2 Basic Care - hmhmaestro.org

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Diabetes: Type 2 Basic Care

Evidence-Based Information

Assessment, Coding, Charting, and Treatment


Key Points

CME Information 3

Overview 5

Assessment Recommendations 7

Treatment Recommendations 7

Lumeris’ Most Important Considerations 10

All patients with diabetes should receive formal self-management education and participate actively in their care. 10

All overweight and obese patients with diabetes should be prescribed lifestyle interventions to promote weight loss. 10

Nutrition therapy is recommended for all patients with pre-diabetes and diabetes. 11

A combination of aerobic and resistance exercises is suggested for patients with diabetes. 11

The ADA recommends add-on glucose-lowering therapy to reduce CVD risk in select patients independent of current

A1C level. 12

Consider variation in costs between different insulin types and formulations. 15

Coding Considerations 16

ICD-10 diabetes codes are combination codes. 16

Appendix 17

Quiz 19

Course Evaluation 20

Disclaimers/Contact Us 21

References 22


CME Information

Objectives:

After participating in this activity, attendees will be able to:

• Describe screening for diabetes. Screening methods discussed include A1C, fasting plasma glucose,

and oral glucose tolerance testing.

• Identify key coding considerations for diabetes, including etiology, and complications.

• List key treatment considerations for diabetes including lifestyle management, treatment of

hyperglycemia, and monitoring.

Target Audience:

This course is designed for Internists and Family Medicine physicians, registered nurses, nurse practitioners

and physician assistants.

Methodology:

This CME course will be presented in written text format. In order to obtain CME credit, go to the Washington

University School of Medicine CME-Online website to complete the quiz. The user will need to click on a

section to read the material. A multiple-choice test is available upon completion to earn CME credits. The

estimated time to complete this activity is one hour. CME certif icates can be printed after completion of the

course.

Accreditation Statement:

Washington University is jointly accredited by the Accreditation Council for Continuing Medical Education

(ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing

Center (ANCC) to provide continuing education for the healthcare team.

Credit Statement:

Washington University designates this educational activity for a maximum of 1 hour in category 1 credit toward

the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she

actually spent in the educational study.

ACCME accreditation begins 08/21/17. Term of approval is for one-year from this date, with option for yearly

renewal.

This activity has been reviewed and is acceptable for 1.00 prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 06/21/19. Term of approval is for one-year from this date, with option for yearly renewal.

Lumeris' mission is to lead the positive evolution of healthcare by providing health care providers with the tools,

information, and financial incentives they need to practice quality medicine, thereby providing our members

access to high-quality service and affordable medical care. Our clinical decision support team is made up of

physicians, clinical pharmacists, nurse practitioners and information technology experts. Lumeris accepts no

grants, advertising or donations from the pharmaceutical industry.

Disclosure Policy:

It is the policy of Washington University School of Medicine, Continuing Medical Education to ensure balance,

independence, objectivity, and scientif ic rigor in all its education activities. All faculties participating in this

activity are expected to disclose to the audience any significant financial interest or other relationship he/she

has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation.


All authors' disclosures were reported and are indicated.

Authors are also expected to openly disclose inclusion of discussion of any off -label, experimental, or

investigational use of drugs or devices in their presentations.

These presentations are the views and experiences of the presenters. The presenters’ views do not represent

the policy or position of Washington University School of Medicine. Washington University School of Medicine,

Continuing Medical Education is the sponsor for CME credits.


Overview

Diabetes is a chronic illness that requires continuing medical care and ongoing patient self -management

education and support. It is a complex disease requiring a multidisciplinary team approach and multifactorial

risk reduction strategies. Emerging evidence identifies strategies independent of glycemic control that can

reduce patient risk for micro- and macro-vascular complications.1

Treatment decisions should be individualized, especially in the elderly. The American Diabetes Association

(ADA) recognizes the vast heterogeneity among older patients with respect to age, life expectancy, cognition,

functional status, duration of diabetes, burden of complications and comorbidities, risk for hypoglycemia, and

their ability and willingness to engage in care. They recommend an individualized approach to therapy,

particularly in the elderly, to reduce the risk of harm, treatment burden, and long-term complications.1

This document is one component of a four-part series of ACT documents related to the comprehensive

management of diabetes. This particular document focuses on the basic management of type 2 diabetes,

including diagnosis, lifestyle changes, and management of hyperglycemia, based on recommendations from

the ADA.1 Other documents in the series include:

• Diabetes: Type 1 Basic Care ACT

• Diabetes: Prevention of Cardiovascular Events ACT

• Diabetes: Prevention of Microvascular Complications ACT


Figure 1. Screening and Management of Type 2 Diabetes in Adults

Age

Adults with a BMI kg/m2 kg/m2 in patients of Asian descent) with any of the following:

• Obesity or other syndromes associated with insulin resistance

• Physical inactivity

• First-degree relative with diabetes

• Patients of African, Latino, Native American, Asian, or Pacific Island descent

• History of gestational diabetes or delivery of a baby weighing > 9 pounds

• Polycystic ovary syndrme

• Elevated CVD risk (Hypertension, HDL < 35 mg/dL, triglycerides > 250 mg/dL)

• Overt CVD

• Pre-diabetes (A1C fasting plasma glucose 100-125 mg/dL, or 2-hr post-load glucose 140-199 mg/dL)

Screen for Diabetes

• A1C or

• Fasting Plasma Glucose or

• 75 gm 2-h Oral Glucose Tolerance Test

Yes

Yes

Repeat screen at least once every 3 years

Patient Has

Diabetes

OR

Regularly screen for complications:

• Retinopathy

• Nephropathy

• Neuropathy

• PADLifestyle Modifications:

• Nutrition

• Physical activity

• Weight loss (BMI > 25)

A1C orFPG orOGTT

No

Repeat test to confirm diagnosis (required)

Yes AbnormalYes

Metformin monotherapy

A1C 9-9.9%• Dual therapy (e.g., metformin

+ sulfonylurea)

Consider insulin ± metformin

Patient has Pre-Diabetes

Normal

A1C - . FPG

100-125 mg/dL, or

OGTT 140-199 mg/dL?

NoRepeat screen

at least annually

A1C blood glucose mg/dL, or symptomatic?

Yes

A1C above goal?

Yes

No

No

Known (or high risk for) CVD, CKD, or

HF?

Consider SGLT2 or GLP-1

regardless of A1C

Yes

Add-on therapy as necessary to reach gylcemic goals (reassess every 3 mo):

• SGLT2 inhibitors

• GLP-1 agonists

• DPP-4 inhibitors

• Sulfonylureas

• Thiazolidinediones

• Insulin

No

Adapted from: American Diabetes Association. Diabetes Care. 2021;44(Suppl. 1):S1-232.


Standard of Care Recommendations

Assessment Recommendations

Screening Undiagnosed adults should be tested for diabetes or pre-diabetes if they are 1) 45 years of age or 2) have a BMI 5 kg/m2 ( kg/m2 in Asian Americans) plus 1 additional risk factors for diabetes [Level of evidence (LOE): B]. Children and adolescents should be tested for diabetes if they are overweight and have 1 additional risk factors [LOE: E] (see

Table 8 for risk factors). If normal, testing should be repeated at least every 3 years in the absence of symptoms [LOE: C].1

Diagnosis of type 2 diabetes

A1C .5 fasting plasma glucose FPG) 1 mg/dL, or oral glucose tolerance testing (OGTT) 00 mg/dL are all equally appropriate for diagnosing diabetes [LOE: B]. Unless unequivocal symptoms of hyperglycemia are present, the diagnosis must be confirmed by an additional abnormal reading, either from the same sample or another obtained as soon as possible. If two different tests are used and both are above the diagnostic threshold, the diagnosis of diabetes is confirmed. If the results are discordant, the test that is above the diagnostic threshold should be repeated.1

When using A1C to diagnose diabetes, evaluate for the presence of other factors that may af fect hemoglobin glycation, such as age, race/ethnicity, anemia, and hemoglobinopathies. A1C should not be used for diagnosis in patients with conditions associated with increased red cell turnover (e.g., sickle cell disease, pregnancy, hemodialysis, recent blood loss or transfusion, erythropoietin therapy).1

Diagnosis of pre-diabetes

“Pre-diabetes” defined as abnormally elevated glycemia that does not meet criteria for diabetes (i.e., A1C 5.7-6.4%, FPG 100-125 mg/dL, or an OGTT 140-199 mg/dL). Patients who meet criteria for pre-diabetes should be tested annually for the development of diabetes [LOE: E].1

Medical evaluation The comprehensive evaluation should consist of a medical history, physical and laboratory examination, and medication history (including adherence and adverse events); assess for the presence of/risk for complications and comorbidities; and review previous treatment and risk factor control in patients with established diabetes. The ADA also recommends assessing the 10-year risk of a first CV event to stratify patients and guide primary prevention ef forts [LOE: B].1

Patients should be engaged in developing a personalized care plan using patient-centered communication and considering his/her preferences, beliefs, literacy, and potential barriers. Self -management behaviors, psychosocial health, and health maintenance needs should be assessed at each visit.1

Follow-up A1C testing Perform the A1C test at least twice a year in patients who are meeting treatment goals and have stable glycemic control and quarterly in patients whose therapy has changed or who are not meeting glycemic goals [LOE: E].1

Psycho-social screening

Patients should be regularly screened for the common psychological problems associated with diabetes (e.g., depression, anxiety, eating disorders, cognitive impairment) using validated tools at times when patients are most psychologically vulnerable, including at diagnosis, at routine visits, when clinical status changes, and during changes in life circumstances [LOE: B].1

Treatment Recommendations

A1C goals The ADA recommends an A1C goal of < 7% for most non-pregnant adults [LOE: A]. Lower A1C goals (e.g., < 6.5%) may be considered in younger patients with a short duration of diabetes, long life expectancy, and less co-morbidity if it can be achieved safely [LOE: C]. Less stringent A1C goals (e.g. < 8%) may be appropriate for older with patients with limited


life expectancy, advanced complications, extensive co-morbidity, long-standing diabetes, or those in whom an A1C < 7% is difficult to attain safely [LOE: B].1

Self -management education and support

Diabetes self-management education and diabetes self-management support, which have been shown to reduce costs and improve outcomes, should be offered to all patients at diagnosis and throughout their care [LOE: A].1

Nutrition therapy All patients with diabetes, pre-diabetes, or gestational diabetes should receive nutritional therapy, ideally delivered by a registered dietician familiar with nutritional therapy in diabetes [LOE: A].1

Exercise Adults with diabetes should engage in 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity plus 2-3 days/week of resistance training [LOE: B]. Children should engage in 0 minutes/day of moderate-intensity activity, which should include play and everyday activities that strengthen muscle on days/week [LOE: C].1

Weight loss in obese patients

The ADA recommends that, for all patients, BMI should be calculated and documented in the medical record at least annually [LOE: E]. Intensive behavioral interventions should be prescribed in an effort to achieve 5% loss of initial body weight to improve glycemic control and reduce the need for medication [LOE: B].1

Pharmacological and surgical approaches to weight loss

Medications may be useful adjuncts to lifestyle and behavioral therapies for weight loss in patients who have a BMI 7 kg/m2 [LOE: A]. Safety and efficacy should be assessed on a monthly basis. If 5 weight loss is not achieved within months the medication should be discontinued and other treatment options considered [LOE: A].1

Metabolic surgery is recommended in diabetic adults with a BMI 0 kg/m2 (37.5 kg/m2 in Asian Americans) and adults with BMI 35-39.9 kg/m2 (32.5-37.4 kg/m2 in Asian Americans) who fail to control their weight and comorbidities (e.g., hyperglycemia) with medical management [LOE: A]. Weight loss surgery should be considered in adults with a BMI 30-34.9 kg/m2 (27.5-32.4 kg/m2 in Asian Americans) who fail to control their weight and comorbidities (e.g., hyperglycemia) with medical management [LOE: A].1

First-line pharmacotherapy

Metformin is recommended as the first-line pharmacologic agent in most patients with type 2 diabetes [LOE: A]. Once metformin is started, it should be continued until intolerance or contraindications develop; other hypoglycemics should be added to metformin therapy [LOE: A].1,2

Glucose-lowering therapy to reduce CVD risk

Patients who have high risk for or known CVD, CKD or HF should be prescribed add-on agent therapy with a sodium-glucose co-transporter 2 (SGLT2) inhibitor or glucagon-like peptide 1 (GLP-1) receptor agonist proven to reduce CVD risk. SGLT2 or GLP-1 therapy should be prescribed independent of the patient’s A1C or individualized A1C goal [LOE: A].1

Additional therapy Most available hypoglycemic medications have similar efficacy. In patients without CVD, add-on therapy should be selected based on clinical effects, potential adverse events, ef fects on weight, patient preferences, and cost.1,2

SMBG monitoring in patients receiving insulin

Patients receiving multiple-dose or continuous insulin should check their self-monitored blood glucose (SMBG) before and occasionally after eating, at bedtime, before exercise, when hypoglycemia is suspected or treated, and prior to important tasks such as driving [LOE: B].1

SMBG monitoring in patients at low hypoglycemia risk

ADA suggests that SMBG monitoring in patients with diabetes receiving less frequent insulin or non-insulin therapies is controversial, but may be useful when prescribed as part of a broader self-monitoring program [LOE: B].1 The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinologists (ACE) do not recommend routine SMBG monitoring in type 2 diabetics at low risk of hypoglycemia, but suggest that it may be of value early in the course of disease.3

CGM monitoring ADA suggests that continuous glucose monitoring (CGM) can help improve A1C and reduce the risk of hypoglycemia in adults and children receiving continuous insulin infusions or multiple daily insulin injections. Available options include real-time CGM monitoring systems, intermittently scanned personal CGM monitoring systems, and professional CGM systems.1


Treatment risks in the elderly

Overtreatment of diabetes is common in older adults and should be avoided [LOE: B]. The ADA recommends preferentially prescribing medications with a low risk of hypoglycemia, monitoring closely, and adjusting glycemic targets and treatment regimens to avoid hypoglycemia [LOE: B]. Treatment should be simplified to the greatest extent possible while still meeting glycemic goals [LOE: B].1

Relatively healthy older patients with diabetes may be treated to a lower A1C goal (e.g., < 7-7.5%). However, more conservative glycemic goals (e.g., < 8-8.5%) should be emphasized in patients with significant functional impairment, cognitive decline, or comorbidity [LOE: C].1

Insulin cost Consider variation in costs between different insulin types and formulations (Table 3).1

Tobacco cessation Advise all patients against using tobacco products or e-cigarettes [LOE: A]. Support and counseling for smoking cessation should be a routine component of diabetic care [LOE: A].1

Immunization The ADA recommends following the most recent Advisory Committee on Immunization Practices (ACIP) guidelines for the routine vaccination of adults and children, including inf luenza, pneumococcal, and COVID-19 vaccination [LOE: A].1


Lumeris’ Most Important Considerations

All patients with diabetes should receive formal self-management education and

participate actively in their care.

Diabetes management should be built around the patient and his/her family and support system. Care should

be individualized and delivered through collaboration between the patient’s support network and the care team .

Diabetes self-management education and diabetes self -management support empower patients to participate

actively in their care by giving them the tools to knowledge, skills, and attitudes necessary to effectively

manage their diabetes.1

Self-management education and support, which is associated with reduced A1C and weight, increased use of

primary care, improved quality of life, reduced all-cause mortality, and lower medical costs, should be offered

to all patients [LOE: A] at critical points in their care, including 1) at diagnosis, 2) annually, 3) when

complications arise, and, 4) during transitions in care [LOE: E]. Interventions that are > 10 hours over 6-12

months are associated with better outcomes.

Interventions should be culturally- and age-appropriate and may be delivered in an individual or group setting.1

The patient’s ability to self -manage should be assessed at every visit; care decisions should consider the

patient’s level of self -efficacy (e.g., treatment burden, ability to self -manage, and level of social and family

support).1

All overweight and obese patients with diabetes should be prescribed lifestyle

interventions to promote weight loss.

The ADA recommends that, for all patients, BMI should be calculated and documented in the medical record at

least annually [LOE: E]. More frequent monitoring may be necessary under specific clinical circumstances such

as comorbid heart failure or unexplained weight fluctuations [LOE: B]. Strong evidence supports that weight

management in an overweight or obese patient is effective in the prevention and treatment of diabetes. While

loss of only 5% of initial body weight can improve glycemic control and reduce the need for medication; greater

weight loss is associated with greater benefits.1

Table 1. BMI Categories BMI category BMI (kg/m2)

Underweight < 18.5 Healthy weight 18.5-24.9 Overweight 25-29.9 Obese 30-39.9 Morbidly obese 0 Adapted from: Centers for Disease Control and Prevention. URL: https://www.cdc.gov/obesity/adult/defining.html. Updated: September 17, 2020. Accessed: January 29, 2021.

Abbreviations: BMI = body mass index


In an effort to produce a 5% weight loss, overweight and obese patients with diabetes should be prescribed 6

months of high-intensity diet physical activity and behavioral interventions 1 sessions) that achieve an

energy deficit of 500-750 kcal/day [LOE: A]. When available, patients who meet their short-term weight loss

goals should be prescribed long-term, comprehensive weight management programs that provide at least

monthly contact and reinforce adherence to weight monitoring, diet, and exercise recommendations [LOE: A].

Interventions using very low-calorie diets ≤ 800 kcal/day) or total meal replacements should be reserved for

carefully selected patients under the care of trained practitioners in medical care settings with close monitoring

[LOE: B].1

Weight loss medications may be a useful adjunct to lifestyle modifications and behavioral counseling in

diabetic patients with a BMI 7 kg/m2; however, the risk of harm must be weighed against the potential

benefits [LOE: A]. If the patient fails to lose 5% of their starting weight within the first 3 months of medication

therapy, it should be discontinued and replaced with a different medication or therapeutic approach [LOE: A].1

Nutrition therapy is recommended for all patients with pre-diabetes and diabetes.

ADA guidelines suggest that individualized nutritional therapy delivered as part of a comprehensive education

and support intervention can reduce A1C by up to 2%. All patients with diabetes should be offered such

therapy, ideally delivered by a registered dietician familiar with nutritional therapy in diabetes [LOE: A]. There

are few data to suggest an optimal proportion of calories from macronutrients for all patients with diabetes.

Therefore, distribution of carbohydrate, protein, and fat intake should be individualized based on current eating

patterns, patient preferences, and metabolic goals.1

The ADA recommends that people with diabetes or pre-diabetes preferentially consume carbohydrates from

whole grains, fruits, vegetables, legumes, and dairy products, especially those higher in fiber and lower in

glycemic load, while avoiding sugary foods and beverages [LOE: B]. A diet rich in monounsaturated fats, long-

chain omega-3 fatty acids, and nuts and seeds (i.e., a Mediterranean-style diet) is recommended to optimize

glucose metabolism and prevent and treat CVD [LOE: B]. Current evidence does not support supplementation

of vitamins, minerals, or herbs to improve glycemic control [LOE: C]. Alcohol consumption can place people

with diabetes (particularly those taking insulin or insulin secretagogues) at risk for delayed hypoglycemia and

should be limited to 1 drink/day in women and 2 drinks/day in men [LOE: C]. For patients who regularly

consume sugar-sweetened beverages, short-term replacement with artif icially sweetened beverages may help

reduce calorie intake if additional calories from other sources are not consumed to offset the deficit. However,

the ADA recommends decreasing intake of sweetened beverages of any type and emphasizing water intake

[LOE: B].1

A combination of aerobic and resistance exercises is suggested for patients with

diabetes.

In the absence of contraindications, adults with diabetes should perform at least 150 min/week of moderate -

intensity or 75 minutes of vigorous aerobic activity spread over at least three days per week and resistance

training 2-3 times per week without more than two consecutive days without exercise [LOE: B]. Children should

engage in 60 minutes/day of physical activity, including vigorous aerobic as well as age-appropriate muscle-

and bone-strengthening activities on at least three of those days [LOE: C]. Older adults with diabetes should

engage in activities to improve balance and flexibility (e.g. yoga or tai chi) 2-3 times/week [LOE: C]. ADA also

recommends that all adults, particularly diabetics, move more and sit less. Prolonged sitting should be

interrupted every 30 minutes [LOE: C].1


The patient’s age risk for hypoglycemia, level of comorbidity, and previous physical activity level should be

considered. Patients on insulin and insulin secretagogues may be at higher risk of hypoglycemia with exercise

and may need to ingest additional glucose for low pre-exercise glucose levels. Proliferative diabetic retinopathy

or severe non-proliferative diabetic retinopathy may contraindicate vigorous aerobic or resistance exercise.

Patients with severe peripheral neuropathy should be thoroughly assessed to ensure that they are not at risk of

injury during exercise and be educated to wear proper footwear and inspect their feet for injury daily . People

with autonomic neuropathy should undergo a cardiac evaluation before beginning physical activity more

intense than that to which they are accustomed.1

The ADA recommends add-on glucose-lowering therapy to reduce CVD risk in

select patients independent of current A1C level.

The ADA recommends that, in the absence of contraindications, metformin be the initial drug of choice for most

patients with type 2 diabetes [LOE: A], including those with heart failure with or without impaired renal function.

Metformin may be continued safely (with dosage reductions) down to a GFR of 30 ml/min, but patients should

be educated to stop the medication in the case of vomiting, diarrhea, or dehydration . Once metformin is

started, it should be continued until intolerance or contraindications develop; other hypoglycemics should be

added to metformin therapy [LOE: A].1

Patients who are at high risk for or have known CVD, CKD, or HF should be prescribed an SGLT2 inhibitor

(e.g., empaglif lozin) or GLP-1 receptor agonist (e.g., liraglutide) proven to reduce CVD risk independent of the

patient’s A1C or individualized A1C goal [LOE: A].1 If the current regimen at maximum tolerated dose fails to

achieve the A1C target within 3 months, an additional hypoglycemic agent should be added [LOE: A]. After

optimizing therapy for CVD risk, add-on therapy should be selected based on clinical effects, potential adverse

events, effects on weight, patient preferences, and cost.1,2

If patients present with symptoms of hyperglycemia, signs of catabolism (e.g., weight loss), or marked

hyperglycemia A1C 10 and/or blood glucose 00 mg/dL) , the ADA recommends early insulin therapy

[LOE: E]. Initial dual therapy should be considered in patients who present with an A1C 1.5% above their

individualized goal. The medication regimen, should be reviewed and adjusted every 3-6 months [LOE: E].1


Table 2. Selected Medications

Generic (Brand) Name Usual Dosea

Renal failure dosing?a

Generic Avail?a

Discount Generic Program?b

Approx. Cost per Monthc Notes

Biguanides

Metformin (Glucophage)

IR: 500-1000 mg PO twice daily

Yes Yes

Yes $4

Notable adverse events: Asthenia, abdominal discomfort, flatulence, diarrhea, nausea, vomiting, flushing

Boxed Warning: The reported incidence of lactic acidosis is very low (0.03 per 1000 patient-years). Do not initiate metformin in patients with a CrCl < 45 ml/min. If GFR falls below 45 ml/min, consider the risks and benefits of continuing therapy. Discontinue metformin if GFR falls below 30 ml/min.

XR: 1000-2000 mg PO once daily

No $40

Sulfonylureas

Glipizide (Glucotrol)

IR: 5-40 mg PO divided 1-2 times/day

Yes Yes

Yes $4 Notable adverse events: Tremor, nausea, dyspepsia, diarrhea, flatulence, flushing, syncope

NOTE: Doses above 15 mg/day of the XL formulation should be divided and given before meals containing adequate calories

XL: 5-20 mg PO once daily Yes $9

Glimepiride (Amaryl) 2-4 mg once PO daily with first main meal

Yes Yes Yes $10

Notable adverse events: Nausea, vomiting, diarrhea, constipation, abdominal pain, rash, photosensitivity

Thiazolidinediones

Pioglitazone (Actos) 15-30 mg PO once daily No Yes Yes $15

Notable adverse events: Headache, myalgia, edema, heart failure

Boxed Warning: Do not use in patients with symptomatic heart failure. Monitor for symptoms of heart failure, particularly when initiating therapy or increasing the dose. If symptoms develop, consider discontinuing pioglitazone or reducing the dose.

GLP-1 Antagonists

Liraglutide (Victoza) 1.2 mg SC once daily No No No $350

Notable adverse events: Injection site reactions, headache, nausea, vomiting, diarrhea, tachycardia, fatigue, nervousness, constipation, abdominal discomfort, pancreatitis

Boxed Warning: Contraindicated in patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.

Dulaglutide (Trulicity) 0.75 mg SC once weekly No No No $1500

SGLT2 Inhibitors


Empagliflozin (Jardiance) 10 mg PO once daily Yes No No $600

Notable adverse events: Urinary tract infections, hypotension, acute kidney injury, hyperkalemia, dyslipidemia, polydipsia, polyuria, nausea

NOTE: Do not use in patients with a GFR < 45 ml/min/1.73 m2

Boxed Warning: The FDA warns that cases of necrotizing fasciitis has been reported with SGLT2 inhibitors.

Boxed Warning: Two large randomized controlled trials reported an approximately 2-fold increase in lower limb amputations in patients with known CVD or CVD risk factors treated with canagliflozin.

Canagliflozin (Invokana) 100-300 mg PO once daily Yes No No $500

Dapagliflozin (Farxiga) 5-10 mg po once daily Yes No No $500

a Based on information from Facts & Comparisons. Some patients may require individualized dosing of certain medications. Refer to each drug’s prescribing information for de tailed recommendations. b Substantially discounted generic medications (e.g., “$4 generics”) may be available through certain health plans or pharmacie s. Individual lists are available from each retailer. c Approximate monthly cost estimated from wholesale acquisition cost (WAC). Actual pricing may vary.

Abbreviations: PO = oral, IR = immediate release, XR = extended release, XL: extended release, SC = subcutaneous, SGLT2 = sodium/glucose cotransporter 2, GFR = glomerular filtration rate, FDA = US Food and Drug Association, CVD = cardiovascular disease


Consider variation in costs between different insulin types and formulations.

According to the ADA, insulin prices have risen steadily at a rate several times that of other medical

expenditures.1 Due to the variability in cost and the wide variety of insulin types and formulations available,

accurate estimation of costs is diff icult. Insulin is integral to the care of many patients with diabetes, many of

whom find the costs prohibitive. Prescribers can lessen the financial impact of insulin therapy by being

selective about which formulations and dosage forms they prescribe and using more expensive products only

when absolutely necessary to ensure the safe achievement of the target A1C. The choice of formulation should

be based on patient preferences, costs, insulin type, and the ability of the patient to self -administer insulin.

Table 3. Approximate Costs of Available Insulin Formulations < $30

per 1000 units $125-199

per 1000 units $200-299

per 1000 units ≥ $300

per 1000 units

Regular (Relion*) vial

NPH (Relion*) vial

Regular 70/30 (Relion*) vial

Regular (Humulin, Novolin) vial

NPH (Humulin, Novolin) vial

Regular 70/30 (Humulin, Novolin)

vial

Lispro (Admelog) vial**

Lispro (Admelog) pen**

Aspart (Novolog) vial

Lispro (Humalog) vial

Lispro 75/25 (Humalog) vial

Lispro 50/50 (Humalog) vial

Glulisine (Apidra) vial

Glargine (Lantus) pen

Glargine (Lantus) vial

Glargine (Toujeo), pen

Detemir (Levemir) pen

Glargine (Basaglar) pen**

NPH (Humulin) pen

Regular 70/30 (Humulin) pen

Aspart (Novolog) pen

Aspart 70/30 (Novolog) vial

Aspart 70/30 (Novolog) pen

Lispro (Humalog) pen

Lispro 75/25 (Humalog) pen

Lispro 50/50 (Humalog) pen

Detemir (Levemir) vial

Glulisine (Apidra) pen

Degludec (Tresiba) pen

Human insulin (Afrezza) inhaler

Approximate monthly cost based on average wholesale price (AWP). Actual pricing may vary.

Adapted from: American Diabetes Association. Diabetes Care. 2021;44(Suppl 1):S1-232.

NPH = neutral protamine Hagedorn

Regular 70/30 = 70% NPH and 30% regular insulin

Aspart 70/30 = 70% aspart protamine suspension and 30% insulin aspart

Lispro 75/25 = 75% lispro protamine suspension and 25% insulin lispro

Lispro 50/50 = 50% lispro protamine suspension and 50% insulin lispro

* Relion insulin is only available at Walmart stores

** Biosimilar preparation


Coding Considerations

ICD-10 diabetes codes are combination codes.

ICD-10 diabetes codes are combination codes that include the type of diabetes, the body system affected, and

the complications affecting that body system. ICD-10 diabetes codes are not classified as controlled or

uncontrolled. Instead, ICD-10 classifies inadequately controlled, out of control, and poorly controlled diabetes

by type with hyperglycemia. For example:

• E08.65 Diabetes mellitus due to underlying condition with hyperglycemia

• E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia

• E10.65 Type 1 diabetes mellitus with hyperglycemia

• E11.65 Type 2 diabetes mellitus with hyperglycemia

• E13.65 Other specified diabetes mellitus with hyperglycemia

With ICD-10, as many diabetes codes within a particular category as are necessary to describe all of the

complications of the disease may be used. Different ICD-10 diabetes categories should not be used at the

same time (i.e., a code within E08 should not be used at the same time as a code within E11).

ICD-10 codes should be sequenced based on the reason for a particular encounter.

Table 4. ICD-10 CM Diabetes Categories Code Prefix Description

E08 Diabetes Mellitus due to underlying condition

E09 Drug or chemical induced diabetes mellitus

E10 Type 1 diabetes mellitus

E11 Type 2 diabetes mellitus

E13 Other specified diabetes mellitus

NOTE: This is not an exhaustive list of codes possibly relevant to this condition; see ICD-10-CM for additional relevant codes.

Table 5. ICD-10 CM Type 2 Diabetes Mellitus Codes Code Description

E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma

(NKHHC)

E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma

E11.641 Type 2 diabetes mellitus with hypoglycemia with coma

E11.649 Type 2 diabetes mellitus with hypoglycemia without coma

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.9 Type 2 diabetes mellitus without complications

NOTE: This is not an exhaustive list of codes possibly relevant to this condition; see ICD-10-CM for additional relevant codes.

Use additional code to identify any insulin use (Z79.4 “Long-term (current) use of insulin”). Note: This is not an

exhaustive list of codes possibly relevant to this condition; see ICD-10-CM for additional relevant codes.


Appendix

Table 6. ADA Evidence-Grading System for Clinical Practice Recommendations

Level of Evidence Description

A

Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including: • Evidence from a well-documented multicenter trial • Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence i.e. the “all or none” rule developed by the Centre for Evidence-Based Medicine at Oxford

Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including: • Evidence from a well-conducted trial at one or more institutions • Evidence from a meta-analysis that incorporated quality ratings in the analysis

B

Supportive evidence from well-conducted cohort studies, including: • Evidence from a well-conducted prospective cohort study or registry • Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including: • Evidence from randomized clinical trials with one or more major or three or

more minor methodological flaws that could invalidate the results • Evidence from observational studies with high potential for bias (such as case

series with comparison to historical controls) • Evidence from case series or case reports Conf licting evidence with the weight of evidence supporting the recommendation

E Expert consensus or clinical experience Adapted from: American Diabetes Association. Diabetes Care. 2021;44(Suppl 1); S1-232.

Table 7. The American College of Physicians Guideline Grading System

Quality of Evidence

Strength of Recommendation Benefits Clearly Outweigh Risks and Burden or Risks and Burden Clearly

Outweigh Benefits

Benefits Finely Balanced with Risks and Burden

High Strong Weak Moderate Strong Weak Low Strong Weak

Insuf f icient evidence to determine net benefits or risks Adapted from: American College of Physicians. Ann Intern Med. 2012;156:218-231.


Table 8. Risk Factors for Diabetes in Adults

Table 9. Recommended Statin Regimens in Adults with Diabetes Recommended Statin Regimens

High-intensity statin regimens Atorvastatin 40 mg, 80 mg Rosuvastatin 20 mg, 40 mg

Moderate-intensity statin regimens

Atorvastatin 10 mg, 20 mg

Rosuvastatin 5 mg, 10 mg Simvastatin 20 mg, 40 mg Pravastatin 40 mg, 80 mg Lovastatin 40 mg, 80 mg Fluvastatin XL 80 mg Pitavastatin 1-4 mg

NOTE: The specific statins and doses in bold were evaluated in RCTs reviewed by the American College of Cardiology/American Heart Association Expert Panel. Statin and doses in italics are approved the U.S. FDA but were not tested in the RCTs reviewed.

Adapted from: Grundy SM, et al. J Am Coll Cardiol. 2018 Nov; published ahead of print. American Diabetes Association. Diabetes Care. 2019;42(Suppl 1):S1-193. Abbreviations: CVD = cardiovascular disease, ADA = American Diabetes Association

Adults Obesity or other syndromes associated with insulin resistance Physical inactivity First-degree relative with diabetes Patients of African, Latino, Native American, Asian, or Pacific Island descent Gestational diabetes Polycystic ovary syndrome Elevated CVD risk (BP > 140/90 mm Hg or on BP meds, HDL < 35 mg/dL, triglycerides > 250 mg/dL) Overt CVD Pre-diabetes A1C 5.7 fasting plasma glucose 100-125 mg/dL, or 2-hr post-load glucose 140-199 mg/dL)

Children and Adolescents History of maternal diabetes or gestational diabetes (during pregnancy with the child) First- or second-degree relative with type 2 diabetes Child is of African, Latino, Native American, Asian, or Pacific Island descent Evidence of insulin resistance Conditions associated with insulin resistance (e.g., hypertension, hyperlipidemia, polycystic ovary syndrome) Adapted from: American Diabetes Association. Diabetes Care. 2021;44(Suppl 1); S1-232.


Quiz

(Choose the one most appropriate answer)

1. The ADA recommends that all of the following be performed at least annually in ALL patients with type 2

diabetes except _____?

a. A1C measurement

b. Calculation and documentation of BMI

c. Psycho-social screening

d. All of the above

BT is a 58-year-old obese male with coronary artery disease (s/p MI in 2018) and atrial f ibrillation who you

have just diagnosed with type 2 diabetes. His labs reveal hyperglycemia and an A1C of 8.1%, but are

otherwise unremarkable.

2. Which is the most appropriate initial therapy for BT?

a. Glimepiride monotherapy

b. Glimepiride plus metformin

c. Metformin monotherapy

d. Metformin plus insulin

BT returns for his 1-month follow up. He reports adherence to the medication regimen and has tolerated it well

with only mild gastrointestinal adverse events. He has had no episodes of hypoglycemia.

3. What is the best choice for BT’s medication regimen?

a. Double the dose of metformin

b. Add insulin to the regimen

c. Add liraglutide to the regimen to reduce the risk of CVD

d. Recheck the A1C before making any therapeutic decisions

e. No changes to the regimen are required

4. What is the most accurate statement about the use of SMBG as a part of BT’s therapeutic regimen?

a. SMBG is standard of care for patients with type 2 diabetes

b. SMBG may be beneficial as part of a broader self -management and education program

c. BT should be taught to check his blood sugar 6-10 times/day to optimize his therapy

d. SMBG is not appropriate for patients not on insulin

5. Once metformin is started, it should be continued; other hypoglycemics should be added to metformin

therapy.

a. True

b. False


Course Evaluation

1 = poor 2 = fair 3 = good 4 = very good 5 = excellent

1. How would you rate the course overall? 1 2 3 4 5

2. How helpful was the information presented in this program? 1 2 3 4 5

3. How timely and relevant was the information presented? 1 2 3 4 5

4. Would you recommend this course to a peer? YES_____ NO______

5. After completing this program, do you anticipate changing any patient care practices?

YES _____ NO_____

If yes, what do you anticipate changing?

6. Topics suggested for future courses:

7. Comments and suggestions for improvement:


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document including, without limitation, any warranty of completeness, timeliness or accuracy, and shall not be

liable for any decision made in connection with the information contained herein.

The information under Coding Considerations is solely to be used as an aid in selecting the correct ICD-10-CM

diagnosis code based on documentation in the patient's medical record and is not to be used to diagnose a

particular condition. The information under the Coding Considerat ions is not a substitute for ICD-10-CM, ICD-

10-CM Official Guidelines for Coding and Reporting or AHA Coding Clinic for ICD-10-CM. Not all applicable

codes may be presented herein.

This document is provided by Lumeris solely for educational purposes. The information herein is not intended

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Documents are updated regularly. Please check online to see the

most recent version.

Revised March 2021 by EWA


References

1 American Diabetes Association. Standards of medical care in diabetes–2021. Diabetes Care. 2021;44(Suppl. 1):S1-232. 2 Qaseem A, Barry MJ, Humphrey LL, et al. Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update from the American College of Physicians. Ann Intern Med. 2017;166(4):279-290. 3 Bailey TS, Grunberger G, Bode, BW, et al. American Association of Clinical Endocrinologists and American College of Endocrinology 2016 outpatient glucose monitoring consensus statement. Endocr Pract. 2016;22(2):231-261.

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