Diabetes Mellitus (1 of 42) 1 Patient presents w/ symptoms of diabetes mellitus (DM) or asymptomatic patient is screened for DM 2 PREDIABETES A DIAGNOSIS/ Patient education SCREENING No* B Lifestyle modifi cation Is DM C Pharmacological therapy confi rmed? • Metformin Yes 3 E INITIAL EVALUATION Screening & management • Detect presence of of DM complications/ diabetic complications & comorbidities comorbid conditions 4 DM CLASSIFICATION TYPE 1 DM TYPE 2 DM OTHER SPECIFIC GESTATIONAL • β-cell destruction • Progressive loss TYPES DM GDM leading to complete of β-cell insulin • Uncommon causes; insulin defi ciency secretion underlying cause or concomitant w/ disease is identifi ed insulin resistance & relative insulin defi ciency Please see Gestational Diabetes Mellitus TREATMENT TREATMENT disease management See page 2 See pages 3-6 chart for further © MIMSinformation *For individuals w/ normal test results, lifestyle management, including counselling regarding diet, physical activity, weight loss & smoking cessation, is advised. Screening should be done annually for patients w/ pre-diabetes & every 3 years for patients negative for diabetes after screening. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 2 © MIMS 2021 Diabetes Mellitus (2 of 42) TYPE 1 DM REFER TO DIABETES SPECIALIST/ ENDOCRINOLOGIST A Patient education B Lifestyle modifi cation • Medical nutrition therapy (MNT) - Match prandial insulin to carbohydrate intake, premeal blood glucose, & anticipated activity • Physical activity & exercise C Pharmacological therapy • Insulin (multiple daily injections or pumps) D CONTINUE ASSESSMENT OF MANAGEMENT GLYCEMIC CONTROL Yes PLAN Is patient able to achieve • Provide regular glycemic control? follow-up No FURTHER EVALUATION BY DIABETES SPECIALIST/ MIMSENDOCRINOLOGIST © Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 3 © MIMS 2021 Diabetes Mellitus (3 of 42) TYPE 2 DM A Patient education B Lifestyle modifi cation C Pharmacological therapy Metformin - 1st-line agent 3 See EVALUATION No MANAGEMENT Does the patient have ASCVD, on pages HF or CKD? 4, 5 & 6 Yes W/ PREDOMINANT ASCVD W/ PREDOMINANT HF W/ PREDOMINANT CKD C Pharmacological therapy C Pharmacological therapy C Pharmacological therapy • Glucagon-like peptide-1 • SGLT2 inhibitor • SGLT2 inhibitor (GLP-1) agonist either/or (preferred) or • Sodium-glucose linked • GLP-1 agonist transporter 2 (SGLT2) inhibitor D CONTINUE ASSESSMENT OF MANAGEMENT GLYCEMIC CONTROL Yes PLAN Did patient achieve glycemic • Provide regular goal after 3 months? follow-up No Patients w/ ASCVD Patients w/ HF or CKD C C Pharmacological therapy MIMS Pharmacological therapy Add either Add either • Other class not previously used (GLP-1 • Other class not previously used (GLP-1 agonist or SGLT2 inhibitor) agonist or SGLT2 inhibitor) • Dipeptidyl peptidase-4 (DPP-4) inhibitor • DPP-4 inhibitor (not Saxagliptin) in HF if not on GLP-1 agonist (if not on GLP-1 agonist) • Basal insulin • Basal insulin • iazolidinedione • Sulfonylurea • Sulfonylurea Avoid iazolidinedione in the setting of HF If glycemic goal is not met, consider intensifying If glycemic goal is not met, consider intensifying to injectable ©therapy to injectable therapy ASCVD = Atherosclerotic cardiovascular disease; CKD = Chronic kidney disease; HF= Heart failure References: American Diabetes Association. Standards of medical care in diabetes - 2021. Diabetes Care. 2021 Jan;44(Suppl 1):S116. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020 Feb;43(2):487-493. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 4 © MIMS 2021 Diabetes Mellitus (4 of 42) TYPE 2 DM W/ NO COMORBIDITIES NEED TO MINIMIZE WEIGHT GAIN OR PROMOTE WEIGHT LOSS A Patient education B Lifestyle modifi cation C Pharmacological therapy Metformin - 1st-line agent D ASSESSMENT OF GLYCEMIC CONTROL Yes Did patient achieve glycemic goal after 3 months? No C Pharmacological therapy • Glucagon-like peptide-1 (GLP-1) agonist either/or • Sodium-glucose linked transporter 2 (SGLT2) inhibitor D CONTINUE MANAGEMENT Did patient achieve Yes PLAN glycemic goal after • 3 months? Provide regular follow-up No C Pharmacological therapy • Other class not previously used (GLP-1 agonist or SGLT2 inhibitor) D No Did patient achieve Yes glycemic goal after MIMS3 months? C Pharmacological therapy Add either • DPP-4 inhibitor if not on GLP-1 agonist (preferred) • Basal insulin • iazolidinedione • Sulfonylurea If glycemic goal is not met, consider intensifying to© injectable therapy References: American Diabetes Association. Standards of medical care in diabetes - 2021. Diabetes Care. 2021 Jan;44(Suppl 1):S116. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020 Feb;43(2):487-493. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 5 © MIMS 2021 Diabetes Mellitus (5 of 42) TYPE 2 DM W/ NO COMORBIDITIES NEED TO MINIMIZE HYPOGLYCEMIA A Patient education B Lifestyle modifi cation C Pharmacological therapy Metformin - 1st-line agent D CONTINUE ASSESSMENT OF MANAGEMENT GLYCEMIC CONTROL Yes PLAN Did patient achieve glycemic • Provide regular goal after 3 months? follow-up No C Pharmacological therapy C Pharmacological therapy C Pharmacological therapy • DPP-4 inhibitor or • SGLT2 inhibitor • iazolidinedione • GLP-1 agonist D CONTINUE MANAGEMENT Did patient achieve Yes PLAN glycemic goal after • 3 months? Provide regular follow-up No C Pharmacological therapy C Pharmacological therapy C Pharmacological therapy • GLP-1 agonist or • SGLT2 inhibitor or • SGLT2 inhibitor or • DPP-4 inhibitor or • DPP-4 inhibitor or • iazolidinedione • iazolidinedione • GLP-1 agonist D CONTINUE MIMSMANAGEMENT Did patient achieve Yes PLAN glycemic goal after • No 3 months? Provide regular follow-up C Pharmacological therapy Continue adding other agents above or consider adding • Sulfonylurea or • Basal insulin If glycemic goal© is not met, consider intensifying to injectable therapy References: American Diabetes Association. Standards of medical care in diabetes - 2021. Diabetes Care. 2021 Jan;44(Suppl 1):S116. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020 Feb;43(2):487-493. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 6 © MIMS 2021 Diabetes Mellitus (6 of 42) TYPE 2 DM W/ NO COMORBIDITIES NEED TO CONSIDER TREATMENT COST* A Patient education B Lifestyle modifi cation C Pharmacological therapy Metformin - 1st-line agent D ASSESSMENT OF GLYCEMIC CONTROL Yes Did patient achieve glycemic goal after 3 months? No C Pharmacological therapy • Sulfonylurea or • iazolidinedione D CONTINUE MANAGEMENT Did patient achieve Yes PLAN glycemic goal after • 3 months? Provide regular follow-up No C Pharmacological therapy • Other class not previously used (Sulfonylurea or iazolidinedione) D Did patient achieve Yes glycemic goal after MIMS3 months? No C Pharmacological therapy • Basal insulin or • DPP-4 inhibitor or SGLT2 inhibitor If glycemic goal is not met, consider intensifying to injectable therapy *Cost of drugs may© vary between countries. Consider local recommendations to guide choice of drug. References: American Diabetes Association. Standards of medical care in diabetes - 2021. Diabetes Care. 2021 Jan;44 (Suppl 1):S116. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020 Feb;43(2):487-493. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. 7 © MIMS 2021 Diabetes Mellitus (7 of 42) INTENSIFYING TO INJECTABLE THERAPY GLP1 AGONIST1 &/OR BASAL INSULIN2 • May add basal analog or bedtime NPH insulin • Consider dose titration D ASSESSMENT OF GLYCEMIC Yes CONTINUE MANAGEMENT PLAN CONTROL • Provide regular follow-up Did patient achieve glycemic goal? • Consider GLP-1 agonist if not previously given • If on bedtime NPH, consider switching to No twice-daily NPH regimen • If HbA1c remains above target, add prandial insulin ADD PRANDIAL INSULIN (One dose w/ the largest meal or meal w/ greatest postprandial glucose excursion) • Consider titrating dose twice weekly D Did patient CONTINUE MANAGEMENT PLAN achieve glycemic goal Yes • Provide regular follow-up after 3 months? No CONSIDER OTHER INSULIN REGIMENS • Self-mixed/split insulin regimen or • Twice-daily premix insulin regimen STEPWISE PRANDIAL INSULIN Individualize dose titration • Add prandial insulin (ie 2 then 3 additional injections) • Consider dose titration D