The D.O.I.T. Protocol (Text Description)

The diagram of the Diabetes Outpatient Intensification Treatment (D.O.I.T.) algorithm is labeled "TCH Clinic D.O.I.T. Protocol (Diabetes Outpatient Intensification of Treatment)."

The diagram begins with a text box within a stylized circle that reads, "Diabete Type 2 A1C > 6.9%." A arrow points down from this box to a parallelogram-shaped box that reads, "All creatinines within last year: Male: <1.5, Female: <1.4." Two arrows point from this box, one labeled "Yes" and the other "No."

If "Yes", then add metformin. An arrow points down from this box to a diamond-shaped decision box that reads "Avg FBG <150" If the Avg FBG is less than 150, end the protocol. If the Avg FBG is greater than 150, add glipizide.

If "No." add glipizide. If the Avg FBG is less than 150 after adding glipizide, end protocol.

If the Avg FBG is greater than 150, check for absence of CHF, any edema, or liver disease. If yes, add pioglitazone. If the Avg FBG is less than 150, end protocol.

If the Avg FBG is greater than 150, add lantus insulin D/C sulfonylureas. If no CHF, any edema, or liver disease is found after adding glipizide and AVG FBG is greater than 150, add lantus insulin D/C sulfonylureas.

There are also five boxes on the right-hand side of the flow chart. Box 1 reads:

Notes:

Contact all patients on oral meds every 2 weeks. Contact patients on insulin every week. Use only blood sugars check in a.m. before eating anything.

Calculate the average using a minimum of at least 4 FBG's.

If there are ot 4 FBG's, then make no change. Call MDs in this order:

1. Call patient's resident MD
2. Call Daily Attending
3. Call Jill Schuermann.

Box 2 reads:

Metformin (Glucophage)

Start 500mg BID w/meals q2weeks increase dose by 500mg until max 1000 mg am + 1000 mg pm

Call Md for nausea/vomiting/abdominal pain/diarrhea or symptomatic hypoglycemia

Box 3 reads:

Glipizide (Glucotrol)

This is a sulfonylurea. When starting it, D/C others in this class: glyburide, Micronase, Diabeta.

Call MD for symptomatic hypoglycemia.

Box 4 reads:

Pioglitazone (Actos)

Start 30 mg daily w/ meals q12 weeks increase by 15 mg until max of 45 mg daily

Get LFT's every 8 weeks from start of drug until six months.

Call MD for edema, CHF, nausea, vomiting, or symptomatic hypoglycemia.

Box 5 reads:

Lantus Insulin

Start 10 units qHS Increase weekly by 10 units weekly until average FBG <150.

Call MD for symptomatic hypoglycemia.

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