Glycemic Control Algorithm 2

Toolkit for Implementing the Chronic Care Model in an Academic Environment

The Planned Visit Notebook includes a step-by-step description for a diabetes planned visit. The Glycemic Control Algorithm is a flowchart that takes a health professional through the steps for one part of the diabetes planned visit.


 

Text Description

The Glycemic Control Algorithm for DM2 begins with a text box that reads: 

Assess A1c result
Note: A1c result should be no older than 3 months
Two arrows lead from it. The one to the left is labeled "A1c <7.0" and points to a box that reads:
Recheck in 3 months
The one to the right is labeled "A1c >7.0" and points to a box that reads:

Planned Visit—complete assessment of glycemic control program (see Module 4 Podcast)
—Advise relevant lifestyle changes

Is patient amenable to additional oral agents therapy? See Oral Agent Classes and medication based on current efficacies of meds and a conservative estimate of potential for lifestyle change (See Module 1 Podcast)

Two arrows lead from this box to three boxes below it. The box to the left reads:

Currently on Secreatagogue
(Sulfonylureas or Medlinitide)

1st option—Titrate to maximal effective dose of secreatagogue ( A1c < 8.0)
Recheck A1c in 3 months

2nd option—Add sensitizer (TZD or Metformin) unless contraindicated—work up to maximal dose as the clinical situation warrants
Recheck A1c in 3 months

3rd option—Add other sensitizer unless contraindicated work up to maximal dose as clinical situation warrants (for example start with 500 mg Metformin up to 2000mg daily dose) with quarterly reassessments.

4th option—consider alpha-glucosidase inhibitors vs insulin
Recheck A1c in 3 months

The box in the center reads:

Already on Sensitizer

1st option—Titrate to maximal effective dose of A1c <8.0
Recheck A1c in 3 months

2nd option—Add secreatogogue (Meglinitide, Sulflonylureas)
Recheck A1c in 3 months

3rd option—Add additional sensitizer unless contraindicated
Recheck A1c in 3 months

4th option—consider alpha-glucosidase inhibitors vs insulin
Recheck A1c in 3 months

The box to the right reads:

Not amenable to addition of further oral agents

If patient is here—call Dr. Salem or contact Faculty for insulin order at that visit

Return visit or recontact in 1 week

There are two reference tables:

Table 1

Oral Agent Classes/MEDSPotential % decline A1c
SoloCombined
Sulfonlureas2%1%
Metformin2%1%
Meglinitides  
   Prendin2%1%
   Starlix1%.5%
TZDs2%1%
Alpha Glucosidase Inhibitors1%.5%
Table 2: Maximum Effective Doses
MedicationMaximum Effective Dose
Amaryl4 mg daily
Gulcotrol10 mg daily
Diabeta10 mg daily
Prandin4 mg tid
Starlix120 mg tid
Actos45 mg daily
Avandia8 mg daily
Precose150 mg tid
Glyset150 mg tid
Metformin2000 mg total daily

The following notes are at the bottom of the algorithm:

Notes:

  • If option is available—have patient call in the nurse line with home blood sugar logs weekly to make adjustments more rapidly. When at goal, recheck A1c in 3 months.
  • Any patient who has additional OA prescribe should be seen/contact within 2 week to insure adherence/tolerability of meds and to access the current HGM results and status. Option to increase oral agent dose(s) that that point.
  • Review of HGM status include w/each reassessment, tailored recommendations for frequency of HGM given with each med change.
  • Team meeting optional at any point for lack progress—as determined by nurse practitioner.

Return to Document

Current as of January 2008
Internet Citation: Glycemic Control Algorithm 2: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic2a8.html