Outdoor treatment of Type 2 Diabetes Mellitus

Diagnostic criteria of T2DM:

• FBS≥126
• PPBS≥200
• HbA1c≥6.5%

FBS HbA1c Severity Management

126-199 6.5% - 8.6% Mild Single oral agent
200-250 8.6% - 10.3% Moderate >1 oral agent
>250 >10.3% Severe Insulin

Monotherapy:
• Start with Metformin
• Titrate the dose from 500 mg to 2000 mg/day
[Glycomet SR/ Gluconorm SR - Available in dosages of
500 mg, 850 mg and 1000 mg]
• Administration: After meals
• Remember: Vitamin B12 levels fall during Metformin
therapy – level should be measured – safe is to give a B12
supplementation once/ twice a week [Nurokind OD]
• Metformin should not be used in:
1. Any form of acidosis
2. Liver disease
3. Moderate renal insufficiency [GFR <45 ml/min]
4. CCF.
 • In patients in whom Metformin is not tolerated, start with
any of the following glucose lowering drugs [GLD]:
1. DPP4 inhibitor: Sitagliptin [Januvia], Linagliptin
[Trajenta]
2. Sulfonylurea: Glimepiride [Amaryl/ Zoryl], Gliclazide*
[Glizid 40/ Diamicron-MR 30/ Diamicron XR 60]
3. Alpha glucosidase inhibitor: Voglibose [Volix].
Points to remember about the above GLDs:
• DPP4 inhibitors do not cause hypoglycemia and are very
well-tolerated but they should be rather avoided in presence
of pancreatic disease [History of acute pancreatitis or heavy
alcohol users], has to be taken after meals.
• Sulfonylureas increase insulin levels acutely and thus they
should be initiated at the lowest possible dosages and
should be taken just before a meal; should be rather
avoided in elderly individuals/ those living alone. They
reduce both fasting & postprandial glucose level. They are
metabolized in liver and excreted through kidneys – thus
should be avoided in presence of liver or renal disorders.
• Alpha glucosidase inhibitors reduce postprandial
hyperglycemia but may cause GI side effects [Ex:
Flatulence, Abdominal distension, Loose stools], should be
taken just before a meal.
*Gliclazide is now preferred over other SUs because it has a
very low risk of hypoglycemia, more selective pancreatic
receptor stimulation, superior CV benefits than other SUs and no
need of dose adjustment in case of impaired renal function.
Dual therapy:
When baseline HbA1c level is 1-2% above the target HbA1c:
Consider using the following combinations:
1. Metformin + Sulfonylurea [Glycomet-GP/ Gluconorm-G/
Amaryl-M/ Zoryl-M/ Glimy-M]
2. Metformin + DPP4 inhibitor [Janumet/ Trajenta-Duo]
3. Metformin + Alpha glucosidase inhibitor [Volix-M]
4. Metformin + SGLT2 inhibitor [Jardiance-Met].

Points to remember about SGLT2 inhibitors:

• They increase the renal glucose excretion; so, they have an
increased propensity to cause UTI and genital infections
• They do not cause hypoglycemia and they have been
shown to cause a definite decrease in cardiovascular
mortality → They should be used when the priority is
clinical CVD.

Triple therapy:
A third GLD should be added when a combination therapy
including Metformin fails to reach target HbA1c/ a triple oral
GLD/ Trio-combination may be tried before adding Insulin to
the regimen:
1. Metformin + Sulfonylurea + Alpha glucosidase inhibitor
[Volix-Trio/ Amaryl-MV/ Zoryl-MV/ Glimy-MV]
 2. Metformin + Sulfonylurea + Pioglitazone [Glimy-MP/
Pioz-MF-G/ Glizid Total P]
3. Metformin + Sulfonylurea + DPP4 inhibitor [Janumet + SU
or Trajenta-Duo + SU].

Points to remember about Pioglitazone:

• They reduce insulin resistance
• They are renal-safe
• Peripheral edema & CCF are common → Contraindicated
in CCF [class III/IV]
• Increased risk of fractures in postmenopausal women.

Insulin therapy is T2DM:

• Start with Insulin Glargine [LANTUS: Long acting] single
dose at bedtime: 0.2-0.4 U/Kg/Day: 12-24 Units SC OD or,
Insulin Degludec [Ryzodeg]: Start with 10 Units SC OD
• Insulin dose may be increased in 10% increments according
to SMBG [self-monitoring of blood glucose] readings
• Individuals who require >1 unit/kg/day of long acting
insulin, should be considered for combination therapy with
Metformin/ Pioglitazone
• Initially, basal insulin may be sufficient; but as diabetes
progresses, it might be necessary to add short acting insulin
[Insulin Aspart: NovoRapid or Regular Human Insulin:
Human Actrapid] upto 3 times before meal
• Short acting insulin-analogues [NovoRapid] should be
injected just before meal and Regular insulin [Actrapid]
should be injected 30 min before meal
• Meal-related SC insulin regimens [T2DM/ T1DM]:
A. 50-75% of the total dose to be provided as long acting
insulin, rest to be administered as short acting insulin in
3 divided doses before meal
Ex: If total daily insulin requirement is 40 U→ 20-30
units Lantus may be administered at bedtime and rest 10-
20 units may be administered before meal [4-6 units
NovoRapid/ Human Actrapid before breakfast, lunch and
dinner].

B. Huminsulin or Human Mixtard [30/70: Regular Human

Insulin 30% + NPH Human Insulin 70%]:
Give 2/3rd of total daily dose 10 min before breakfast
(8AM)
Give 1/3rd of total daily dose 10 min before dinner
(8PM).
Ex: If total daily insulin requirement is 30 U→ 20 units
Human Mixtard may be administered 10 min before
 breakfast [8AM] and rest 10 units may be administered
10 min before supper/ early dinner [8PM].

Mandatory advices to be given to a person using insulin:

1. Symptoms and management of hypoglycemia have been
thoroughly discussed with the patient & family members
2. Do not administer intravenously/ intramuscularly
3. Rotate injection sites within the same region from one
injection to the next [to reduce the risk of lipodystrophy]
4. Never share an injection pen/ syringe with another person.

Associated conditions:
Hypertension
• Target SBP/DBP in a patient with DM+HTN: 140/80
• Start with ARB → Then add CCB → Add Thiazide with
caution in case of severely uncontrolled BP
• Start the patient on an ARB [preferably Telmisartan] even
in the absence of HTN if the patient has persistent
microalbuminuria/ urinary ACR >30.
 Dyslipidemia
• All people with T2DM and without established CVD who
are ≥40 years old and have LDL cholesterol >100 mg/dL,
should start treatment with a statin
• All people with T2DM and established CVD should start
treatment with high intensity statin [highest recommended
dose of atorvastatin or rosuvastatin], or the statin should be
selected and up-titrated to reach an LDL cholesterol target
<70 mg/dL
• Longest acting statin: Rosuvastatin [half-life: 19 hr]
• It is important to note that Fenofibrate [Triglyceride
reducing agent] reduce the progression of retinopathy in
diabetics.

Important charts about Indoor Management of DM

Sliding Scale Insulin
RBS Low dose Medium High dose Very high
(mg/dL) regimen dose regimen dose
regimen regimen
100-150 0 2 4 6
151-200 2 6 8 10
201-250 4 8 12 14
251-300 6 10 14 18
301-350 8 12 16 22
>350* 10 14 18 24

*Might need to start Insulin infusion.

 ICU protocol for Insulin infusion for Hyperglycemia
• Start infusion by dissolving 40 units of Regular Human
Insulin [1 ml of 40 units/ml] in 39 ml of Normal saline
• Before start insulin infusion, flush line with 5 ml infusion
• Before start insulin infusion, check serum K+ level
CBS [mg/dL] Insulin [ml/hr]
80-110 Nil
111-140 1 ml/hr
141-200 2 ml/hr
201-250 3 ml/hr
251-300 4 ml/hr
301-350 5 ml/hr
>350 6 ml/hr

• Recheck CBS after every 1 hour

• If CBS decreased by >150 mg/dL in one hour, then
decrease infusion rate by 1 ml/hr
• If CBS is dropped to 70-80 mg/dL, then stop insulin
infusion and recheck CBS after 20 mins; if symptomatic
administer 100 ml of 25% Dextrose
• Aim is to keep CBS in between 100-150 mg/dL.

Made from the following references by Dr. Prithwiraj Maiti [+91-9679473128]:

1. Harrison’s Principles of Internal Medicine, 20th Edition [2018]
2. Clinical Practice Recommendations for managing Type 2 Diabetes in
Primary Care [International Diabetes Federation – 2017]
3. Apollo Gleneagles Hospital ICU protocol.