Type 1: SMBG and HbA1C Targets

2-2

SMBG Targets• 50More than % of values wiiiii iiiiii iiiii• - 6 100200Age < : iii -i iii iii iiiiii i/• - - 6 12 80180 - mg/dL pre meal and bedtime• - Age >1 2 : 8 0 1 4 0 m iii -i iii/ 160 2< mg/dL hours after start of meal - 100160mg/ dL bedtime• iiiiiiiiii ii iiiii( )iiii iiiiiiiiii ii iiiiii iii-i iii iiiiii iii ii d if hypoglycemia iiii iiiiiii ii iiiiiiii iii ere hypoglycemia occursHbA

1c Target• iii< 6 : 2 .5 cent age poi nt s of upper limit of normal• - 612 2Age : Within perc ent age poi nt s of upper limit of normal• 12 15Age > : Within . p er cent age poi nt s of upper limit of normal

SMBG Frequency• Minimum 4 times/day; befor 2e and hours after start of meals and at bedtime• i 3 AM ii iiiiii

Lispro Insulin (LP) Considerations• 1 unit of LP = 1 unit of Regular insulin• Administer within 15 minutes before the meal due to rapid action• May need to increase basal insulin dose• Use both pre-meal and post-meal SMBG data to make LP dose adjustments• May have reduced need for snacks between meals• Consider an additional LP insulin injection before snacks > 30 gm total carbohydrate

2-3

Plasma glucose <1 1 0 mg/ dL? Plasma glucose iiiiii110

No diabete s; evaluate for infectio -n or meta bolic disorder

No diabete s; evaluate for infectio -n or meta bolic disorder

Monitor urine detones every 4 hours; if posttive,

-see immediately; other wise obtain laboratory

fasting plasma glucose within 24 hour

Monitor urine detones every 4 hours; if posttive,

-see immediately; other wise obtain laboratory

fasting plasma glucose within 24 hour

-Consider inpatred fast ing glucose and referral to Diabetes Specialist

-Consider inpatred fast ing glucose and referral to Diabetes Specialist

Type 1: Screening and DiagnosisObtain laboratory plasma

glucose and urine ketonesObtain laboratory plasmaglucose and urine ketones

NO

YES

Immediately have patient consume meal - -with 60 75 gm carbo -hydrate; obtain labora tory plasma glucose 2 hours post meal -If < 200 mg/dL, eval uate for infection or metabolic disorder; if uncertain, consider OGTT - If > 200 mg/dL, con tinue with diagnosis

sequence

Immediately have patient consume meal - -6075with gm carbo -hydrate; obtain labora tory plasma glucose 2 hours post meal -If < 200 mg/dL, eval uate for infection or metabolic disorder; if uncertain, consider OGTT - If > 200 mg/dL, con tinue with diagnosis

sequence

NO

Fasting plasma glucose- 110125mgdL or casual plasma glucose- 140199mg/dL?

Fasting plasma glucose- i iii ii110125 casual plasma glucose- 140199mg/dL?

Fasting plasma glucose> 126mg/dL or casusl plasma glucose

> 200mg/dL and positive

Fasting plasma glucose> 126mg/dL or casusl plasma glucose

> 200mg/dL and positive

YES

NO

-Diagnosis of type 1 dia betes; move to 1Type Master DecisionPath

-If vomiting, dehydra tion, and large ketones, suspect diabetic -ketoacidosis; hospital ize immediately for insulin initiation andtreatment

-1Diagnosis of type dia betes; move to 11 Master DecisionPath

-If vomiting, dehydra tion, and large ketones, suspect diabetic -ketoacidosis; hospital ize immediately for insulin initiation andtreatment

No diabetes; evaluate forinfection, steroid use, ormetabolic disorder

No diabetes; evaluate forinfection, steroid use, ormetabolic disorder

Fasting Plasma glucose> 126mg/dL?

Fasting Plasma glucose> 126mg/dL?

YES

Plasma glucose <1 1 0 mg/ dL? Plasma glucose iiiiii110

NO

NO

YES

YES

At Diagnosis FPG > 1 2 6 mg/dL

i iiii> /

At Diagnosis FPG > 1 2 6 mg/dL

CPG > mg/dL

2-5

Insulin Stage 1

(Honeymoon)(R)/N - 0 - 0 - 0

Insulin Stage 3B

R/N - 0 - R/N - 0 LP/N - 0 - LP/N -

0

Comments

• Continue withf ood plan and exerc

-ise pro gram through

out all stages of therapy.• Initially patie

nt may be in a honeymoo

n st age during which tii iii - ber of injectio

ns and the amount of

insulin may be decreased

R = HumanRegular Insulin LP = Lispro Insulin N = HumanNPH Insulin UL = HumanUltralente Insulin 0 = None

Dose Schedule: - - -AM MIDDAY PM BEDTIME

Medications

Type 1: Master DecisionPath

Insulin Stage 2 R/N - 0 - R/N - 0

LP/N - 0 - LP/N - 0Insulin Stage 2 R/N - 0 - R/N - 0

LP/N - 0 - LP/N - 0OR

Insulin Stage 3A R/N - 0 - R - N

LP/N - 0 - LP - NInsulin Stage 3A

R/N - 0 - R - NLP/N - 0 - LP - N

Insulin Stage 4A R/N - R - R - N

LP/N - LP - LP - NInsulin Stage 4A

R/N - R - R - NLP/N - LP - LP - N

Insulin Stage 4A R/N - R - R - N

LP/N - LP - LP - NInsulin Stage 4A

R/N - R - R - NLP/N - LP - LP - N

2-8

Follow-upMedical: Within 24 hours, then office visit in 2 weekNutrition: Within 24 hours, then office visit in 2 week

Follow-upMedical: Within 24 hours, then office visit in 2 weekNutrition: Within 24 hours, then office visit in 2 week

At Diagnosis

Start insulin within 2-4 hours; hospitalize if acute illness orDKA at diagnosis, psychosocial factors present, or outpatient

education not available

Move to Insulin Stage 2/Adjust

Start Insulin Stage 3A-Mid

R/N - 0 - R/N - 0LP /N - 0 - LP/N - 0

At Diagnosis

If patient arrives in AM:• Calculate total dose based on urine ketones and current weight• 0.5 U/kg for Negative to Moderate ketones• 0.7 U/kg for Large ketones

AM MIDDAY PM BT

Distribution 2/3 0 1/3 0R/N or LP/N ratio 1:2 - 1:1 -If patient arrives after 12 noon:• Calculate initial dose based on urine ketones and current weight• 0.2 U/kg for Negative to Small ketones• 0.3 U/kg for Moderate to Large ketones• Give PM dose of R/N or LP/N; ratio is 1:1• Monitor BG and ketones every 4 hours• Supplement with R or LP as needed• Calculate total dose for next day• See patient next AM

After initiating insulin, refer patient for nutrition and diabetes education

Type 1: Insulin Stage 2/Start

2-9

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?NO

YES

Type 1: Insulin Stage 2/Start

Patient in Insulin Stage 2and not at target

Patient in Insulin Stage 2and not at target

If persistent fasting -hyperglycemia or noc

turnal hypoglycemia,iiii ii Insulin Stage3A ii i iiiii iiiii-;

glycemia, move to Insulin Stage 4A ; i f more flexibility

required move to Insulin Stage 3B

If persistent fasting -hyperglycemia or noc

turnal hypoglycemia, move t o Insulin Stage

3A -; if midday hyper glycemia, move to

Insulin Stage 4A ; i f more flexibility

required move to Insulin Stage 3B

Insulin Stage 2 Pattern AdjustmentsR/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY

(MID)

PM

BEDTIME(BT)

100< mg/dL > 1 6 0 mg/dL

80< mg/dL > 1 4 0 mg/dLฏPM N1-2 U (a,b)ฏ AM R or LP

- 12 U (c,e)

ฏPM N1-2 U (a)ฏ AM R or LP

- 12 U (f,g)ฏAM N1-2 U (d,e)

ฏAM N1-2 U (f,h)

ฏ PM R or LP- 12 U (e)

ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns

-Follow up Medical: Weekly while adjusting ins ulin, then office visit

- within 1 2 months; use this - DecisionPath for follow up

See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.

2-10

Follow-upMedical: If new insulin start, daily hone contact for 3 days, then office visit within 2 weeks; 24+hour emergency phone support neededNutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks

Follow-upMedical: If new insulin start, daily hone contact for 3 days, then office visit within 2 weeks; 24+hour emergency phone support neededNutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks

At Diagnosis or from Insulin Stage 2If persistent AM hyperglycemia, nocturnal hypoglycemia, and/or

lifestyle issues requiring variation in timing of meals

Move to Insulin Stage 3A/Adjust

Start Insulin Stage 3A - - - 0R/N R N

- 1 - 11 - 1/ 0

At Di agnosi s

• Calculate total dose based on urine k etones and current weight• 05. U/kg for Negative to Moderateket ones• 07. U/kg for Large ketones

AM MIDDAY PM BT

Distribution 23 0 16/ /16/ - R/N or LP/N ratio 1:2 - -

From Insulin Stage 2• i ii iiiiiii iiiii iiii• iiii PM i ii BT• R or LP may be modified for activity aii iii iii ii i iiii• AM - R or LP may go down 1 2 units• PM - R or LP may go up 1 2 units

If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing dose as for new

di agnosi s AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg

After initiating insulin, refer patient for nutrition and diabetes education

Type 1: Insulin Stage 3A/Start

2-11

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?NO

YES

Type 1: Insulin Stage 3A/Adjust

Patient in Insulin Stage 3 A and not at target

Patient in Insulin Stage 3 A and not at target

-If persistent midafter noon hyperglycemia

or no significant improvement in 6

months,iiii ii Insulin

Stage 4A/Start

-If persistent midafter noon hyperglycemia

or no significant improvement in 6

months,iiii ii Insulin

Stage 4A/Start

Insulin Stage 3A Pattern AdjustmentsR/N - 0 - R - N or LP/N - 0 - LP - N 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY

(MID)

PM

BEDTIME(BT)

100< mg/dL > 1 6 0 mg/dL

80< mg/dL > 1 4 0 mg/dLฏBT N1-2 U (a,b)ฏ AM R or LP

- 12 U (c,e)

ฏBT N1-2 U (a)ฏ AM R or LP

- 12 U (f,g,)ฏAM N1-2 U (d,e)

ฏAM N1-2 U (f,h)

ฏ PM R or LP- 12 U (e)

ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns

-Follow up Medical: Weekly while adjusting ins ulin, then office visit

- within 1 2 months; use this - DecisionPath for follow up

See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.

2-12

Follow-upMedical: Within 24 hours, then office visit in 2 weeksNutrition: Within 24 hours, then office visit in 2 weeks

Follow-upMedical: Within 24 hours, then office visit in 2 weeksNutrition: Within 24 hours, then office visit in 2 weeks

From Insulin Stage 3AIf persistent midafternoon hyperglycemia and/or lifestyle

issues requiring variation in timing of meals

Move to Insulin Stage 4A/Adjust

Start Insulin Stage 4A - - - 0R/N R N

- - - 0LP /N LP N

From Insulin Stage 3A

• i ii iiiiiii iiiii iiii• Add MIDDAY R or LP at 20 % of curreii AM N• Decrease AM N by 50%• Increase AM R or LP by 1 unit• Increase PM R or LP by 1 unit

If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing dose as shown

AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg

AM MIDDAY PM BT

Distribution 23 0/ 13 0/ - R/N or LP/N ratio 1:1 - -

Refer patient for nutrition and diabete s eduaction

Type 1: Insulin Stage 4A/Start

2-13

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?NO

YES

Type 1: Insulin Stage 4A/Adjust

Patient in Insulin Stage 4 A and not at target

Patient in Insulin Stage 4 A and not at target

If no significantimprovement in

6 months,refer patient to a

Diabetes Specialist

If no significantimprovement in

6 months,refer patient to a

Diabetes Specialist

Insulin Stage 4A Pattern AdjustmentsR/N - R - R - N or LP/N - LP - LP - N 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY

(MID)

PM

BEDTIME(BT)

100< mg/dL > 1 6 0 /

< 8 0 /mg dL 140> mg/dLฏBT N1-2 U (a,b)ฏ AM R or LP

- 12 U (c,e)

ฏBT N1-2 U (a)ฏ AM R or LP

- 12 U (f,g,)ฏMID R or LP*1-2 U (d,e)

ฏMID R or LP1-2 U (f,h,j,k)

ฏ PM R or LP- 12 U (e)

ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns

-Follow up Medical: Weekly while adjusting ins ulin, then office visit

- within 1 2 months; use this - DecisionPath for follow up

See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.* Consider discontinuing AM N

Type 1: Insulin Adjustment Guidelines

2, 3A, 4A

2-14How to Use These Tables1. Find current insulin stage2. Find the pattern of blood glucose problem (column)3. Identify time of day (row) pattern occurs4. Recommended adjustment is given where the column and row intersect5. See notes for additional considerations

Notesa. Evaluate nocturnal hypoglycemia; check 3 AM BGb. Consider increasing bedtime snackc. Consider adding or adjusting mid-morning snackd. Consider adding or adjusting afternoon snacke. Evaluate if previous exercise is causing hypoglycemiaf. Consider adding exercise g. Consider decrease in mid-morning snackh. Consider decrease in afternoon snacki. No mid-morning snack usually needed with LPj. No afternoon snack usually needed with LPk. Consider adding AM N if long interval between middy and evening meal or afternoon hyperglycemia AM N: 50% MIDDAY R or LP dose MIDDAY R or LP: ฏ 50% AM and PM R or LP: No change No change

Insulin PatternAdjustments• Adjust insulin fr -3om day iiiiiii• Determine whic h insulin is responsible for piiiiii• - Adjust by 1 2 uni t s• Adjust only one dose at a t i me• Correct hypogly cemia first• If total dose > 1 i iiii 5

consider overinsulinization• If hyperglycemi a throughout day, correct hig hest SMBG first; if all within 50mg/dL correct AM fi r si

• For age < 6 yea rs, change pattern values to 100< mg/dL and>2 0 0 mg/dL; reduce adiiiii iii dose by 50%• - For age 6 1 2years,change pattern value to > 1 8 0 mg/dL; reduce adjustmeni dose by 50%• For hypoglycemi a unawareness ( > 1 2 ),iii iii- tern values to < 100mg/dL and > 1 6 0 m/

2-16

-Follow up Medical: Phone or office visit within 1 week, then office visit within 1month

-Follow up Medical: Phone or office visit within 1 week, then office visit within 1month

From Insulin Stage 3AIf persistent midafternoon hyperglycemia and/or lifestyle

issues requiring variation in timing of meals

Move to Insulin Stage 3B/Adjust

Start Insulin Stage 3B - - - 111/() / 0 / - - - 0UL LP LP/ UL

From Insulin Stage 2 and using R o1 11 111 AM UL

• Use current total insulin dose• Stop N• Add UL at 50% total dose• Add MIDDAY R or LP

DISTRIBUTION AM MIDDAY PM BT

R or LP (50% of total dose) 35% 25 40 0

50 33UL ( % of total dose) 0 67 0% % From Insulin Stage 2 and using R o r LP and no AM UL• Use current total insulin dose• Stop N• Add UL at 40% total dose• Add MIDDAY R

DISTRIBUTION AM MIDDAY PM BT

R or LP (60% of total dose) 35% 25 40 0% % 40 0UL ( % of total dose) 0 100 0%

If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing as above

AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg

Refer patient for nutrition and diabete s education

Type 1: Insulin Stage 3B/Start

2-17

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?

Is current total dailyinsulin dose:

< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?

< 1.0 U/kg for age > 18?NO

YES

Type 1: Insulin Stage 3B/AdjustPatient in Insulin Stage 3B

If AM hyperglycemia after adding PM UL, discontinue PMUL and add N at bedtime at same dose of PM UL

R/UL-R-R-N or LP/UL-LP-LP-N

Patient in Insulin Stage 3BIf AM hyperglycemia after adding PM UL, discontinue PM

UL and add N at bedtime at same dose of PM ULR/UL-R-R-N or LP/UL-LP-LP-N

If no significantimprovement in

6 months,refer patient to a

Diabetes Specialist

If no significantimprovement in

6 months,refer patient to a

Diabetes Specialist

Insulin Stage 3B Pattern AdjustmentsR(UL) - R - R/UL - 0 or LP/UL - LP - LP/UL - 0 80< mg/dL > 1 4 0 mg/dLAM

or 3 AM

MIDDAY

(MID)

PM

BEDTIME(BT)

100< mg/dL > 1 6 0 /

< 8 0 /mg dL 140> mg/dLฏBT UL1-2 U (a,b)ฏ AM R or LP

- 12 U (c,e)

ฏBT UL1-2 U (a)ฏ AM R or LP

- 12 U (f,g)ฏMID R or LP1-2 U (d,e)

ฏMID R or LP1-2 U (f,h,j,k)

ฏ PM R or LP- 12 U (e)

ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns

-Follow up Medical: Weekly while adjusting ins ulin, then office visit

- within 1 2 months; use this - DecisionPath for follow up

See Insulin Adjustment Guidelines, 2-18, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.

Type 1: Insulin Adjustment Guidelines

3B

2-18 How to Use Th ese Tables 1. Find current insulin stage 2. Find the patt ern of blood glucose problem (coluiii 3. Identify time of day (row) pattern occurs 4. Recommend ed adjustment is given where the column and row inters

ect 5. See notes foradditional considerations

Notes a. Evaluate noctur nal hypoglycemia; c heck 3 AM BG b. Consider increa sing bedtime snack c. Consider adding or adjusting - mid morning snack d. Consider adding or adjusting afternoon snack e. Evaluate if previ ous exercise is causing hypoglycemia f. Consider addingiiiiiiii g. Consider decrea se in midmorning snack h. Consider decrea se in afternoon snack i. AM UL is a basal insulin and usually does notiiiiiii adjusting. If PM BG > target due to a long interval between midday and eveni ng meal, consider i ncreasing UL - by 1 2 units

Insulin PatternAdjustments• Adjust insulin f -3rom day iiiiiii• Determine whi ch insulin is responsible foriiiiiii• - Adjust by 1 2 uni t s• Adjust only oni iiii ii i t i me• Correct hypogl ycemia first• If total dose > 15. U/kg, consider overinsulinization• If hyperglycem ia throughout day, correct hig hest SMBG first; if all withi 50n mg/dL correct AM fi r si• For age < 6 y ears, change pattern values 100 mg/dL and > 200 mg/dL; reduce adjustm ent dose by 50%• -For age 6 1 2 years,change pattern value t o>1 8 0 mg/dL; reduce adjustment dose by 50%• For hypoglyce -mia unaware 1ness (age > -2),change pat tern values to 100< mg/dL and > 1 6 0/

1 11 111111111 1djustment • Made with R or L P insulin only• Given at times of R or LP insulin injections• May be added orsubtracted on basis of BG, fo od, or exercise• Used with cautio n at bedtime; 3AM BG is used t o det er mi ne the bedtime dosi

Blood Glucose Adjust R or LP (mg/dLi 80 ฏ - i12

-140200 ฏ 1 -201250 ฏ 2 - 251300 ฏ 3 >3 0 0 ฏ 4 > i

2-19

SMBG and/or HbA1cwithin target range andpatient in “honeymoon”

phase?

SMBG and/or HbA1cwithin target range andpatient in “honeymoon”

phase?

Type 1: Insulin Stage 1/Adjust

Patient referred onInsulin Stage 1(R)/N - 0 - 0 -0

Patient referred onInsulin Stage 1(R)/N - 0 - 0 -0

Move to InsulinStage 2/Start

Move to InsulinStage 2/Start

NO

Patient enters InsulinStage 1/MaintainContinue current dose;use this DecisionPathfor follow-upFollow-upMedical: Every 1-2 months

Patient enters InsulinStage 1/MaintainContinue current dose;use this DecisionPathfor follow-upFollow-upMedical: Every 1-2 months

YES

2-25

SMBG and/or HbA1cwithin target range?

SMBG and/or HbA1cwithin target range? YE

S

Type 1: Preconception Planning

Patient planning pregnancyPatient planning pregnancy

NO

History, physical exa m, and laboratory evaluatio n by clinician• History: Diabetes t herapy and control, miscarriage s, and birth control• Medications: If hypertensive, switch to Methyldop a or Hydralazine; ACE inhibitors and beta blockers contraindicated in pregnancy• Complications: Hypoglycemia unawareness; DKA; retinopathy; nephropathy; neuropathy• -Discuss pregnancy related risks including associatio -n of hyper glycemia with complications; DKA with fetal death ; fetal malformations• Physical exam: Incl ude funduscopic eye ex amwi t h dilation by Ophthalmologist• Laboratory: CBC; U A/UC; thyroid studies; screen for albuminuria; HbA

1c ; EKG if diabet es duration > 1 0 years

Correlate SMBG andHbA1c ; assess

nutritional status self management skills, and psychologi cal status

History, physical exa m, and laboratory evaluatio n by clinician• History: Diabetes t herapy and control, miscarriage s, and birth control• Medications: If hypertensive, switch to Methyldop a or Hydralazine; ACE inhibitors and beta blockers contraindicated in pregnancy• Complications: Hypoglycemia unawareness; DKA; retinopathy; nephropathy; neuropathy• -Discuss pregnancy related risks including associatio -n of hyper glycemia with complications; DKA with fetal death ; fetal malformations• Physical exam: Incl ude funduscopic eye ex amwi t h dilation by Ophthalmologist• Laboratory: CBC; U A/UC; thyroid studies; screen for albuminuria; HbA

1c ; EKG if diabet es duration 10> years

Correlate SMBG andHbA1c ; assess

nutritional status self management skills, and psychologi cal status

Work with patient to establish BG control• Reassess current therapy• Start or adjust intensified regimen as needed See Insulin Stage 3A or 4A• Continue with birth control• Consider co-management with a Diabetes Specialist

Work with patient to establish BG control• Reassess current therapy• Start or adjust intensified regimen as needed See Insulin Stage 3A or 4A• Continue with birth control• Consider co-management with a Diabetes Specialist

Stop birth control and continue current insulinstage; maintain SMBGand HbA1c within targetrange until pregnancy

confirmedMove to Management

During Pregnancy

Stop birth control and continue current insulinstage; maintain SMBGand HbA1c within targetrange until pregnancy

confirmedMove to Management

During Pregnancy

SMBG Targets• - -Pre meal: 80 120mg/dL• - Post meal: < i iiii 140

2 hours after sta rt of meal• Bedtime: 1- 00140m/ (bedtime)• No severe (as sisted) or nocturnal hypoglycemia• Adjust if hypoglycemia unawarenessHbA

1c Target• At least 2 balu es 1 mohth apart within no r mal r ange

SMBG Frequency• 4 times/day; before meals and 2 hours a fter start of meals and at bedt i me• Check 3 AM asneeded

Type 1: Management During Pregnancy

2-26

Maternal Monitoring• Baseline: Thyroid functions, if not done• Each visit: Dipstick UA; UC as appropriate; verify SMBG• Every 4 weeks: HbA1C• First trimester: Eye exam with dilation by Ophthalmologist (follow-up as indicated) Screen for albuminuria If complications exist or develop, refer patient to Diabetes Specialist and other specialists as necessaryNutrition• Increase calories 300/day in the secon

d and third trimesters• Adequate weight gain according to ta

ble below BMI

%DBW (wt/ht2=/ 2 ) Wt. Gain

9 0 % 198< . - 2840 lbs. - 90120 19

-826 - 2035 lbs. 120 26 - 1525 lbs.

- Self Management Education• Emphasize hypoglycemia prevention/iiiiiiiii• Instruct family member on glucagon admi ni st r at i on• Instruct on self adjustment of insulin a

s appropriate• No skipped meals

Type 1: Food Plan and Exercise

2-27 Medical Nutriti on Therapy Guidelines (no-n pregnant)

• i: 3 0% otal calories; ries; less if BMI > 2 7 kg/m2

or LDL > 130 mg/• Saturated fat: < 10% total calories; < 7% w ith LDL > 1 3 0 mg/dL• Cholesterol: < 3 00mg/day• If BMI > 27 kg/2m , decrease calorie s by - 1020% an d add exercise

• If BP > 130/85mm/Hg, reduce sodium ti 2400< mg/day• If albumin > 30 0 24mg/ hour or creatinini > 3 0 0 mg/g, reduce protein 08to . g/kg/da y or ~10% total calories

Calorie RequirementsAdults

Most men/active women: DBW x 15 kcal Most women/inactive

men/most adults > age 55: DBW x 13 kcal

Inactive women/obese adults/inactive adults

55> age : DBW x 10 kcal Children/Method1

100First year: 0 kcal - Age 1 10: Add 100kcal/year - Age 11 15: Boys a 200

kcal/year; girls add 100 kcal/year

Age > 15: Boys ad d for activity (2 3 kcal/lb very active, 1 8 kcal/lb

normal, 16 kcal lb i nactive); girlsiiiiiiiii ii iiiii

Children/Method2

100First year: 0 kcal - Age 1 3: Add 40 kcal/inch Age > 3: Boys 125 kcal x age; 100girls kcal x age; add up to iii iiii20iiii

Establish Food Plan and Exercise

Assessment

• Food history or 3 day food record (meals, ti mes, portions)• Nutrition adequaii• Height/weight/B MI; see BMI Char t -i43• Weight goals/eatiii iiiiiiiii• Psychosocial issu es (denial, anxiety, depression)• iiiiii iiiiiiiiii l factors• Nutrition/diabete s knowledge• iiiiiiiii ii iiii n/barriers to l ear ni ng• Work/school/spor ts schedules• Fitness level (str ength, flexibility, endurance)• Exercise (times,iiiiiiiii iiiiii• iiiiiiiiiiiiiii use• iiiii iiii iiiiii supplements

Goals• SMBG/HbA

1c i n tar get• Desirable body w eight (adults)• Normal growth a nd development (children)• Consistent carbo hydrate intake• Regular exercise

Plan• Establish adequa te calories for growth and devel-opment/rea sonable body weiiii• Set meal/snack tiiii• Integrate insulin r egi men wi t h food plan• Set consistent carbohydrate intake• Establish regular -exercise regi men based on fit ness level• Establish adequa te calories for pregnancy/lactation/recovery from illness

Gestational: SMBG and Weight Gain Targets

3-2

SMBG Targets• All values within target range• - - Pre meal and bedtime: 60 95 mg/dL• - Post meal: < 120 mg/dL 2 hours after start of meal; < 140 mg/dL 1 hour after start of meal

Urine Ketones Target• Negat i ve

SMBG Frequency• - 7 12Test times/day; before and h ours after start of meals and at bedtime• - Minimum 4 times/day; fasting and 1 2 hours after start of meals

Urine Ketones Monitoring • Test every AM 1for week, then every other AM

Weight Gain Guidelines %DBW BMI

GAIN 90% 198< . - 2840 lbs. - -90120 19826.

- 2035 lbs. 120 - 26 1525> lbs.

Target weight gain for significantly obes e women

29 2 15(BMI > kg/m ): ~ lbs

3-3

With risk factors: Screen atfirst prenatal visitNo risk factors: screen at24-28th gestational weekScreen with 50 gram glucosechallenge test (GCT)

With risk factors: Screen atfirst prenatal visitNo risk factors: screen at24-28th gestational weekScreen with 50 gram glucosechallenge test (GCT)

Monitor fastng and 2 hours after start of meal; start foodplan If average fasting BG i 95mg/dL - 2or average hour post meal BG i 120mg/dL, treat with food plan and 32repeat OGTT at weeks

See FoodPl an/St ar t -i38

2Monitor fastng and hours after start of meal; start foodplan If average fasting BG i 95mg/dL - 2or average hour post meal BG i 120mg/dL, treat with food plan and 32repeat OGTT at weeks

See FoodPl an/St ar t -i38

Gestational: Screening and Diagnosis

Patient is pregnantPatient is pregnant

YES

50 gram glucose challenge (GCT) test abnormal (plasma glucose > 140mg/dL or whole blood > 120mg/dL?

50 gram glucose challenge (GCT) test abnormal (plasma glucose > 140mg/dL or whole blood > 120mg/dL?

NO

NO

Perform 100 gram oral glucose tolerance test (OGTT) within 3 days of positive screen

Perform 100 gram oral glucose tolerance test (OGTT) within 3 days of positive screen

Two abnormalOGTT values?Two abnormalOGTT values?

YES

Diagnosis of gestational diabetes

Move to GestationalMaster DecisionPath

Diagnosis of gestational diabetes

Move to GestationalMaster DecisionPath

N O

With risk factors: Rescreen 24 32at and weeks; if normal 32at weeks, no further t est i ng No risk factors: No furthert est i ng

With risk factors: Rescreen 24 32at and weeks; if normal 32at weeks, no further t est i ng No risk factors: No furthert est i ngWith risk factors: RepeatOGTT at 32 weeks No risk factors: No furthertesting

With risk factors: RepeatOGTT at 32 weeks No risk factors: No furthertesting

One abnormal value?One abnormal value?

YES

Risk Factors• - -BMI > 27 (especially waist to iiiii i ii1• -2Family history of type dia -betes (especially first degree relatives)• Age > 30• Multiparity• Previous gestational diabetes: - - -Macrosomic or large for gesta tional age infant• -Previous impaired glucose toler ance (IGT) with fasting BG - 110125mg/dL• -Previous impaired fasting glu 2cose (IGT) with hour OGTT - 140199mg/dL• American Indian; African American; Asian American; Mexicah/Hispanic American; Pacific Islander

N O

PLASMA WHOLE BLOOD Fasting i 105mg/dL i 90mg/dL 1 hour i 190mg/dL i 165mg/dL 2 hour i 165mg/dL i 145mg/dL 3hour i 145mg/dL i 125mg/dL

100 gram Oral Glucose Tolerance Test

3-5

Food Plan Stage

Insulin Stage 2

R/N - 0 - R/N - 0 LP/N - 0 - LP/N -

0

Gestational: Master DecisionPath

OR

At Diagnosisiiii iiiiiii

plasma glucose 95< mg/dL

At Diagnosis OGTT f ast i ng

plasma glucose 95< mg/dL

At Diagnosis*iiii iiiiiii

plasma glucose> 95mg/dL

At Diagnosis* OGTT f ast i ng

plasma glucose> 95mg/dL

Insulin Stage 3A

R/N - 0 - R - NIf persistent midafternoonhyperglycemia, start InsulinStage 4A

Food Plan Stage

R = Human Regular InsulinN = Human NPH Insulin0 = None

Dose Schedule:

AM - MIDDAY - PM - BEDTIME

Medications

• Continue with food plan and exercise program throughout all stages of therapy• Lispro (LP) insulin has not been tested during pregnancy

Medications

* Plasma Glucose criteria for starting each therapy may be modified

Type 1: Insulin Adjustment Guidelines

3B

3-8

• 1 CHO = 1 c arbohydrate serving = 1 5 gm carbohydrate ; - 6090 caloriii• 1Meat/Sub = 1 oz serving 28 7( gm) = gm protein; 5 -gm fat; 5 0 1 00 calories• 1 Added Fat = 1 serving = 5 45gm fat;calories• Vegetables =- 12 servings/da y with each meal; not counted in plan

Assessment

•

Food history or- 3day food record (meals an d snacks with times and portions)

•

Nutrition adequacy

•

Weight gain/change

•

Exercise times,duration, and type

•

Fitness level (str ength, flexi bility, endurancei

•

Alcohol use

•

Vitamin and min -eral suppoe mentGoals

•

- Good pre natalnutrition

•

Proper weight g ain based on BMI

•

SMBG within tar get r ange

•

Negative ketoniiPlan

• Two carbohydra te choices at breakfast and consistent bedtime snack• Set meal and sn ack times• Set consistent carbohydrate intake at meals and snacks to meet BG targ ets(see sample food plan)• Encourage regul ar exercise based on usual activity prior to pregnancy

Refer for nutrition and diabetes education within 48hours

Start Food Plan

Sample Food Plan

MEAL CHO MEA T/SUB FAT

Bkfat. 2- -01 01

- Snack 1 2 - -01 01

- -Lunch 3 4 2 - 3 12

- Snack 1 2 -0 01

- Dinner 3 4 2- -4 12

- Snack 1 2 -0 01

-Follow up Medical: Phone within 3 days to review SMBG, urine ketones, and food records, then office visit - within 1 2 weeks

-Follow up Medical: Phone within 3 days to review SMBG, urine ketones, and food records, then office visit - within 1 2 weeks

Move to Food Plan/AdjustMove to Food Plan/Adjust

3-9

SMBG and/or HbA1cwithin target range andpatient in “honeymoon”

phase?

SMBG and/or HbA1cwithin target range andpatient in “honeymoon”

phase?

YES

Gestational: Food Plan/Adjust

Patient in Food PlanStage

Patient in Food PlanStage

NO

Patient enters FoodPlan/Maintain

Continue current therapy; use this -DecisionPaht for follow up

-Follow up - Medical: Phone 1 2 times/week Office visit every 2 weeks

Patient enters FoodPlan/Maintain

Continue current therapy; use this -DecisionPaht for follow up

-Follow up - Medical: Phone 1 2 times/week Office visit every 2 weeks

Move to Insulin Stage2,or Insulin Stage 3 A

Move to Insulin Stage2,or Insulin Stage 3 A

• If elevated postprandial BG, decrease carbohydrate at meals if appropriate; redistribute carbohydrate (calories) to other times of the day• If positive ketones or insufficient weight gain, add or increase bedtime snack;assess adequacy of caloric intake; add more food at snack times; assess undereating to avoid taking insulin

Adjust food plan based on BG, ketone, or weight; use this DecisionPath for-follow up

-Follow up - Medical: Phone 1 2 times/week

Office visit every 2 weeks - 24Education: Every weeks as needed

- Nutrition: Every 2 4 weeks as needed

• If elevated postprandial BG, decrease carbohydrate at meals if appropriate; redistribute carbohydrate (calories) to other times of the day• If positive ketones or insufficient weight gain, add or increase bedtime snack;assess adequacy of caloric intake; add more food at snack times; assess undereating to avoid taking insulin

Adjust food plan based on BG, ketone, or weight; use this DecisionPath for-follow up

-Follow up - Medical: Phone 1 2 times/week

Office visit every 2 weeks - 24Education: Every weeks as needed

- Nutrition: Every 2 4 weeks as needed

Food Plan Adjustments

3-12Gestational: Insulin Stage 2/Start

- - - 0 0R/N R/N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight

AM MIDDAY PM BTDistribution 23 0 13 0/ / - -R/N ratio 1:2 1:1

Refer patient for nutrition and diabetes education

- - - 0 0R/N R/N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight

AM MIDDAY PM BTDistribution 23 0 13 0/ / - -R/N ratio 1:2 1:1

Refer patient for nutrition and diabetes education

At Diagnosis or from Food Plan StageStart insulin within 24 hours. Hospitalize if

medically necessary

At Diagnosis or from Food Plan StageStart insulin within 24 hours. Hospitalize if

medically necessary

Start Insulin Stage 2

Move to Insulin Stage 2/AdjustMove to Insulin Stage 2/Adjust

Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port neededEducation: Within 24 hours, then office visit in 2 weeks

Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port neededEducation: Within 24 hours, then office visit in 2 weeks

3-13

Is current total dailyinsulin dose:< 1.5 U/kg?

Is current total dailyinsulin dose:< 1.5 U/kg? N

O

Gestational: Insulin Stage 2/Adjust

Patient in Insulin Stage 2Patient in Insulin Stage 2

-If persistent AM hyper glycemia or

nocturnal hypo glycemia, move to

Insulin Stage 3A/Start

-If persistent AM hyper glycemia or

nocturnal hypo glycemia, move to

Insulin Stage 3A/Start

Insulin Stage 2 Pattern Adjustm R/ - - - 0 0N R/N

AM

MIDDAY

(MID)

PM

BEDTIME

(BT)

Pattern of BG in mg/dL

-Pre meal - Post meal 2 hr > 120 60 90< > 90 1 140

Adjust insulin based on BG patternsFollow-upMedical: Weekly while adjusting insulin, then office visit within 1-2 months; use this DecisionPath for follow-up Education: Every 2-4 weeks as needed

See Insulin Adjustment Guidelines, 3-18, for adjustment considerationsdesignated by each letter.

YES

ฏAM R

(j)

ฏAM R (b,k)

ฏPM N (a,h,n)

ฏPM R

(k)

ฏ PM

R

(k)

ฏAM N

(c,k)

ฏPM N

(a,d)

ฏAM N

(j,m)

ฏAM R

(j,l)

ฏAM R

(j)

ฏAM R

(f,j)

ฏAM N

(a,k)

ฏAM N (c,k)ฏAM N (k)

3-14Gestational: Insulin Stage 3A/Start

- - - 0R/N R N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight

AM MIDDAY PM BTDistribution 23 0 16 16/ / / - - -R/N ratio 1:2

From Insulin Stage 2• Use current total dose• Move PM N to bedtime (BTi• R may be modified for activity and timing of meals• AM - R may go down 1 2 units• PM - R may go up 1 2 units Refer patient for nutrition and diabetes education

- - - 0R/N R N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight

AM MIDDAY PM BTDistribution 23 0 16 16/ / / - - -R/N ratio 1:2

From Insulin Stage 2• Use current total dose• Move PM N to bedtime (BTi• R may be modified for activity and timing of meals• AM - R may go down 1 2 units• PM - R may go up 1 2 units Refer patient for nutrition and diabetes education

At Diagnosis or from Food Plan Stageor Insulin Stage 2

Start insulin within 24 hours. Hospitalize ifmedically necessary

At Diagnosis or from Food Plan Stageor Insulin Stage 2

Start insulin within 24 hours. Hospitalize ifmedically necessary

Start Insulin Stage 3A

Move to Insulin Stage 2/AdjustMove to Insulin Stage 2/Adjust

Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed

Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed

3-15

Is current total dailyinsulin dose: < 1.5 U/kg?

Is current total dailyinsulin dose: < 1.5 U/kg?N

O

Gestational: Insulin Stage 3A/Adjust

Patient in Insulin Stage 3A

Patient in Insulin Stage 3A

If persistent midafternoonhyperglycemia, move to

Insulin Stage 4A

If persistent midafternoonhyperglycemia, move to

Insulin Stage 4A

Insulin Stage 2 Pattern Adjustm R/ - - - 0 0N R/N

AM

MIDDAY

(MID)

PM

BEDTIME

(BT)

Pattern of BG in mg/dL

-Pre meal - Post meal 2 hr > 120 60 90< > 90 1 140

Adjust insulin by 10% or 2 units, whichever is greaterFollow-upMedical: Phone 1-2 time/week; office visit every 2 weeks; use this DecisionPath for follow-up Education: Every 2-4 weeks as needed

See Insulin Adjustment Guidelines, 3-18, for adjustment considerationsdesignated by each letter.

YES

ฏAM N

(j)

ฏAM R (b,k)

ฏ N (a,n)

ฏPM R

(k)

ฏ PM

R

(k)

ฏAM N

(c,k)

ฏBT N

(a,d)

ฏAM N

(j,m)

ฏAM R

(j,l)

ฏAM R

(j)

ฏAM R

(f,j)

ฏAM R

(b,k)

ฏAM N (c,k)ฏAM N (k)

Gestational Insulin Adjustment Guidelines

3-18

How to Use These Tables1. Find current insulin stage2. Find the pattern of blood glucose problem (column)3. Identify time of day (row) pattern occurs4. Where the column and row intersect, see recommended changes5. See notes for additional considerations

Notesa. Evaluate nocturnal hypoglycemia; check 3 AM BGb. Consider increasing mid-morning snackc. Consider increasing afternoon snackd. Consider increasing bedtime snacke. Consider giving injection 45 minutes before mealf. Consider decreasing carbohydrate at breakfast g. If post AM increase, increase AM snackh. Consider Insulin Stage 3Ai. Consider Insulin Stage 4Aj. Consider adding exercisek. Evaluate if previous exercise is causing hypoglycemial. Consider decreasing mid-morning snackm. Consider decreasing afternoon snackn. Consider decreasing bedtime snack

Insulin Pattern Adjustments• Adjust insulin from 2-3 day BG pattern• Determine which insulin is responsible for pattern• Adjust insulin by 10% or 2 U, whichever is greater• Adjust PM/BT N for 3 AM hypoglycemia or hyperglycemia

4-2Impaired Glucose Homeostasis

Assess Nutritional Needs• HbA1c, SMBG, lipid profile, albuminuria• - Food history or 3 day food record (meals and smacks with time and snacks with times and portions)• Nutrition adequacy• Height/weight/BMI• iiiiiiiiiiii iiiiiiiii/• Exercise times, duration, and type Determine Nutritional Goals• SMBG and HbA 1c within target range• Weight, BP, and lipids in acceptable range• Consistent carbohydrate intake

Design Food Plan Set meal and snack times Set consistent carbohydrate intake at meals and snacks to meet BG targets Design Exercise Plan• Encourage regular exercise based on cardiovascular fitness age, weight, history• - -Low intensity warm up and cool down - 5075 20 3% maximum aerobic capacity for minutes, times/week

Refer patient for nutrition and diabetes education

Assess Nutritional Needs• HbA1c, SMBG, lipid profile, albuminuria• - Food history or 3 day food record (meals and smacks with time and snacks with times and portions)• Nutrition adequacy• Height/weight/BMI• Weight goals/eating disorders• Exercise times, duration, and type Determine Nutritional Goals• SMBG and HbA 1c within target range• Weight, BP, and lipids in acceptable range• Consistent carbohydrate intake

Design Food Plan Set meal and snack times Set consistent carbohydrate intake at meals and snacks to meet BG targets Design Exercise Plan• Encourage regular exercise based on cardiovascular fitness age, weight, history• - -Low intensity warm up and cool down - 5075 20 3% maximum aerobic capacity for minutes, times/week

Refer patient for nutrition and diabetes education

At Diagnosis Impaired fasting glucose (IFG), fasting

- 110125plasma glucose mg/dL, - 2 140199and/or hr OGTT value mg/dL

At Diagnosis Impaired fasting glucose (IFG), fasting

- 110125plasma glucose mg/dL, - 2 140199and/or hr OGTT value mg/dL

Establish food and Exercise Plan

-Follow up Medical: Within 3 months

Nutrition: As meeded

-Follow up Medical: Within 3 months

Nutrition: As meeded