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Type 1: SMBG and HbA 1C Targets

2-2. Type 1: SMBG and HbA 1C Targets. SMBG Targets More than 50% of values within target range Age < 6: 100-200 mg/dL pre-meal and bedtime Age 6-12: 80-180 mg/dL pre-meal and bedtime Age >12: 80-140 mg/dL pre-meal < 160 mg/dL 2 hours after start of meal

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Type 1: SMBG and HbA 1C Targets

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  1. 2-2 Type 1: SMBG and HbA1C Targets • SMBG Targets • More than 50% of values within target range • Age < 6: 100-200 mg/dL pre-meal and bedtime • Age 6-12: 80-180 mg/dL pre-meal and bedtime • Age >12: 80-140 mg/dL pre-meal • < 160 mg/dL 2 hours after start of meal • 100-160 mg/dL bedtime • No severe (assisted) or nocturnal hypoglycemia • Adjust pre-meal target upward if hypoglycemia • unawareness or repeated severe hypoglycemia occurs • HbA1c Target • Age < 6: Within 2.5 percentage points of upper • limit of normal • Age 6-12: Within 2 percentage points of upper • limit of normal • Age > 12: Within 1.5 percentage points of upper • limit of normal • SMBG Frequency • Minimum 4 times/day; before and 2 hours after start of • meals and at bedtime • Check 3 AM as needed • 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. 2-3 Type 1: Screening and Diagnosis Obtain laboratory plasma glucose and urine ketones No diabetes; evaluate for infection or meta- bolic disorder Plasma glucose < 110 mg/dL? YES NO 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 Fasting plasma glucose 110-125 mgdL or casual plasma glucose 140-199 mg/dL? YES NO Fasting plasma glucose > 126 mg/dL or casusl plasma glucose > 200 mg/dL and positive NO Diagnosis of type 1 dia- betes; move to Type 1 Master DecisionPath If vomiting, dehydra- tion, and large ketones, suspect diabetic ketoacidosis; hospital- ize immediately for insulin initiation and treatment YES Monitor urine detones every 4 hours; if posttive, see immediately; other- wise obtain laboratory fasting plasma glucose within 24 hour Fasting Plasma glucose > 126 mg/dL? YES NO Consider inpatred fast- ing glucose and referral to Diabetes Specialist Plasma glucose < 110 mg/dL? YES NO No diabetes; evaluate for infection, steroid use, or metabolic disorder

  3. Type 1: Master DecisionPath 2-5 At Diagnosis FPG > 126 mg/dL CPG > mg/dL Insulin Stage 2 R/N - 0 - R/N - 0 LP/N - 0 - LP/N - 0 Insulin Stage 1 (Honeymoon) (R)/N - 0 - 0 - 0 OR Insulin Stage 3A R/N - 0 - R - N LP/N - 0 - LP - N Insulin Stage 3B R/N - 0 - R/N - 0 LP/N - 0 - LP/N - 0 Insulin Stage 4A R/N - R - R - N LP/N - LP - LP - N Insulin Stage 4A R/N - R - R - N LP/N - LP - LP - N Medications Comments R = Human Regular Insulin LP = Lispro Insulin N = Human NPH Insulin UL = Human Ultralente Insulin 0 = None Dose Schedule: AM-MIDDAY-PM-BEDTIME • Continue with food • plan and exercise pro- • gram throughout all • stages of therapy. • Initially patient may be • in a honeymoon stage • during which the num- • ber of injections and • the amount of insulin • may be decreased

  4. 2-8 Type 1: Insulin Stage 2/Start At Diagnosis Start insulin within 2-4 hours; hospitalize if acute illness or DKA at diagnosis, psychosocial factors present, or outpatient education not available Start Insulin Stage 3A-Mid • R/N - 0 - R/N - 0 • LP /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 0 • R/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 Follow-up Medical: Within 24 hours, then office visit in 2 week Nutrition: Within 24 hours, then office visit in 2 week Move to Insulin Stage 2/Adjust

  5. Type 1: Insulin Stage 2/Start 2-9 Patient in Insulin Stage 2 and not at target If persistent fasting hyperglycemia or noc- turnal hypoglycemia, move to Insulin Stage 3A; if midday hyper- glycemia, move to Insulin Stage 4A; if more flexibility required move to Insulin Stage 3B Is current total daily insulin 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 Insulin Stage 2 Pattern Adjustments R/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0 < 80 mg/dL > 140 mg/dL < 80 mg/dL > 140 mg/dL AM or 3 AM MIDDAY (MID) PM BEDTIME (BT) ฏPM N 1-2 U (a,b) ญPM N 1-2 U (a) ฏAM R or LP 1-2 U (c,e) ญ AM R or LP 1-2 U (f,g) ฏAM N 1-2 U (d,e) ญAM N 1-2 U (f,h) < 100 mg/dL > 160 mg/dL ฏPM R or LP 1-2 U (e) ญ PM R or LP 1-2 U (f) Adjust insulin based on BG patterns Follow-up Medical: Weekly while adjusting insulin, 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.

  6. 2-10 Type 1: Insulin Stage 3A/Start At Diagnosis or from Insulin Stage 2 If persistent AM hyperglycemia, nocturnal hypoglycemia, and/or lifestyle issues requiring variation in timing of meals Start Insulin Stage 3A • R/N - 0 - R - N LP /N - 0 - LP - N • At Diagnosis • 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 1/6 1/6 • R/N or LP/N ratio 1:2 - - - • From Insulin Stage 2 • Use current total dose • Move PM N to BT • R or LP may be modified for activity and timing of meals • 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 current total dose is greater than • values below, consider recalculating and redistributing dose as for new • diagnosis • AGE CURRENT TOTAL DOSE • < 12 1.0 U/kg • 12-18 1.5 U/kg • > 18 1.0 U/kg • After initiating insulin, refer patient for nutrition and diabetes education Follow-up Medical: If new insulin start, daily hone contact for 3 days, then office visit within 2 weeks; 24+hour emergency phone support needed Nutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks Move to Insulin Stage 3A/Adjust

  7. Type 1: Insulin Stage 3A/Adjust 2-11 Patient in Insulin Stage 3 A and not at target If persistent midafter- noon hyperglycemia or no significant improvement in 6 months, move to Insulin Stage 4A/Start Is current total daily insulin 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 Insulin Stage 3A Pattern Adjustments R/N - 0 - R - N or LP/N - 0 - LP - N < 80 mg/dL > 140 mg/dL < 80 mg/dL > 140 mg/dL AM or 3 AM MIDDAY (MID) PM BEDTIME (BT) ฏBT N 1-2 U (a,b) ญBT N 1-2 U (a) ฏAM R or LP 1-2 U (c,e) ญ AM R or LP 1-2 U (f,g,i) ฏAM N 1-2 U (d,e) ญAM N 1-2 U (f,h) < 100 mg/dL > 160 mg/dL ฏPM R or LP 1-2 U (e) ญ PM R or LP 1-2 U (f) Adjust insulin based on BG patterns Follow-up Medical: Weekly while adjusting insulin, 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.

  8. 2-12 Type 1: Insulin Stage 4A/Start From Insulin Stage 3A If persistent midafternoon hyperglycemia and/or lifestyle issues requiring variation in timing of meals Start Insulin Stage 4A • R/N - 0 - R - N • LP /N - 0 - LP - N • From Insulin Stage 3A • Use current total dose • Add MIDDAY R or LP at 20 % of current 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 current total dose is greater than • values below, consider recalculating and redistributing dose as shown • AGE CURRENT TOTAL DOSE • < 12 1.0 U/kg • 12-18 1.5 U/kg • > 18 1.0 U/kg • AM MIDDAY PM BT • Distribution 2/3 0 1/3 0 • R/N or LP/N ratio 1:1 - - - • Refer patient for nutrition and diabetes eduaction Follow-up Medical: Within 24 hours, then office visit in 2 weeks Nutrition: Within 24 hours, then office visit in 2 weeks Move to Insulin Stage 4A/Adjust

  9. Type 1: Insulin Stage 4A/Adjust 2-13 Patient in Insulin Stage 4 A and not at target Is current total daily insulin dose: < 1.0 U/kg for age < 12? < 1.5 U/kg for age < 12-18? < 1.0 U/kg for age > 18? If no significant improvement in 6 months, refer patient to a Diabetes Specialist NO YES Insulin Stage 4A Pattern Adjustments R/N - R - R - N or LP/N - LP - LP - N < 80 mg/dL > 140 mg/dL < 80 mg/dL > 140 mg/dL AM or 3 AM MIDDAY (MID) PM BEDTIME (BT) ฏBT N 1-2 U (a,b) ญBT N 1-2 U (a) ฏAM R or LP 1-2 U (c,e) ญ AM R or LP 1-2 U (f,g,i) ฏMID R or LP* 1-2 U (d,e) ญMID R or LP 1-2 U (f,h,j,k) < 100 mg/dL > 160 mg/dL ฏPM R or LP 1-2 U (e) ญ PM R or LP 1-2 U (f) Adjust insulin based on BG patterns Follow-up Medical: Weekly while adjusting insulin, 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

  10. 2-14 Type 1: Insulin Adjustment Guidelines 2, 3A, 4A How to Use These Tables 1. Find current insulin stage 2. Find the pattern of blood glucose problem (column) 3. Identify time of day (row) pattern occurs 4. Recommended adjustment is given where the column and row intersect 5. See notes for additional considerations • Insulin Pattern Adjustments • Adjust insulin from 3-day • pattern • Determine which insulin is • responsible for pattern • Adjust by 1-2 units • Adjust only one dose at a time • Correct hypoglycemia first • If total dose > 1.5 U/kg, • consider overinsulinization • If hyperglycemia throughout • day, correct highest SMBG • first; if all within 50 mg/dL • correct AM first • For age < 6 years, change • pattern values to • < 100 mg/dL and > 200 • mg/dL; reduce adjustment • dose by 50% • For age 6-12 years,change • pattern value to • > 180 mg/dL; reduce adjustment • dose by 50% • For hypoglycemia unawareness • (age > 12),change pat- • tern values to < 100 mg/dL • and > 160 mg/dL Notes a. Evaluate nocturnal hypoglycemia; check 3 AM BG b. Consider increasing bedtime snack c. Consider adding or adjusting mid-morning snack d. Consider adding or adjusting afternoon snack e. Evaluate if previous exercise is causing hypoglycemia f. Consider adding exercise g. Consider decrease in mid-morning snack h. Consider decrease in afternoon snack i. No mid-morning snack usually needed with LP j. No afternoon snack usually needed with LP k. 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: ฏ50% AM and PM R or LP: No change No change

  11. 2-16 Type 1: Insulin Stage 3B/Start From Insulin Stage 3A If persistent midafternoon hyperglycemia and/or lifestyle issues requiring variation in timing of meals Start Insulin Stage 3B • R/(UL) - R - R/UL - 0 LP/UL - LP - LP/UL - 0 • From Insulin Stage 2 and using R or LP and 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 • UL (50% of total dose) 33% 0 67% 0 • From Insulin Stage 2 and using R or 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 • UL (40% of total dose) 0 0 100% 0 • If erratic SMBG or weight gain and current total dose is greater than • values below, consider recalculating and redistributing as above • AGE CURRENT TOTAL DOSE • < 12 1.0 U/kg • 12-18 1.5 U/kg • > 18 1.0 U/kg • Refer patient for nutrition and diabetes education Follow-up Medical: Phone or office visit within 1 week, then office visit within 1 month Move to Insulin Stage 3B/Adjust

  12. Type 1: Insulin Stage 3B/Adjust 2-17 Patient in Insulin Stage 3B If AM hyperglycemia after adding PM UL, discontinue PM UL and add N at bedtime at same dose of PM UL R/UL-R-R-N or LP/UL-LP-LP-N Is current total daily insulin dose: < 1.0 U/kg for age < 12? < 1.5 U/kg for age < 12-18? < 1.0 U/kg for age > 18? If no significant improvement in 6 months, refer patient to a Diabetes Specialist NO YES Insulin Stage 3B Pattern Adjustments R(UL) - R - R/UL - 0 or LP/UL - LP - LP/UL - 0 < 80 mg/dL > 140 mg/dL < 80 mg/dL > 140 mg/dL AM or 3 AM MIDDAY (MID) PM BEDTIME (BT) ฏBT UL 1-2 U (a,b) ญBT UL 1-2 U (a) ฏAM R or LP 1-2 U (c,e) ญ AM R or LP 1-2 U (f,g) ฏMID R or LP 1-2 U (d,e) ญMID R or LP 1-2 U (f,h,j,k) < 100 mg/dL > 160 mg/dL ฏPM R or LP 1-2 U (e) ญ PM R or LP 1-2 U (f) Adjust insulin based on BG patterns Follow-up Medical: Weekly while adjusting insulin, 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.

  13. 2-18 Type 1: Insulin Adjustment Guidelines 3B How to Use These Tables 1. Find current insulin stage 2. Find the pattern of blood glucose problem (column) 3. Identify time of day (row) pattern occurs 4. Recommended adjustment is given where the column and row intersect 5. See notes for additional considerations Notes a. Evaluate nocturnal hypoglycemia; check 3 AM BG b. Consider increasing bedtime snack c. Consider adding or adjusting mid-morning snack d. Consider adding or adjusting afternoon snack e. Evaluate if previous exercise is causing hypoglycemia f. Consider adding exercise g. Consider decrease in midmorning snack h. Consider decrease in afternoon snack i. AM UL is a basal insulin and usually does not require adjusting. If PM BG > target due to a long interval between midday and evening meal, consider increasing UL by 1-2 units • Insulin Pattern Adjustments • Adjust insulin from 3-day • pattern • Determine which insulin is • responsible for pattern • Adjust by 1-2 units • Adjust only one dose at a • time • Correct hypoglycemia first • If total dose > 1.5 U/kg, • consider overinsulinization • If hyperglycemia throughout • day, correct highest SMBG • first; if all within 50 mg/dL • correct AM first • For age < 6 years, change • pattern values to < 100 • mg/dL and > 200 mg/dL; • reduce adjustment dose by • 50% • For age 6-12 years,change • pattern value to > 180 • mg/dL; reduce adjustment • dose by 50% • For hypoglycemia unaware- • ness (age > 12),change pat- • tern values to < 100 mg/dL • and > 160 mg/dL • Compensatory Adjustment • Made with R or LP insulin only • Given at times of R or LP • insulin injections • May be added or subtracted • on basis of BG, food, or exercise • Used with caution at bedtime; • 3 AM BG is used to determine • the bedtime dose • Blood Glucose Adjust R or LP • (mg/dL) • < 80 ฏ 1-2 U • 140-200 ญ 1U • 201-250 ญ 2U • 251-300 ญ 3U • > 300 ญ 4 > U

  14. Type 1: Insulin Stage 1/Adjust 2-19 Patient referred on Insulin Stage 1 (R)/N - 0 - 0 -0 Patient enters Insulin Stage 1/Maintain Continue current dose; use this DecisionPath for follow-up Follow-up Medical: Every 1-2 months SMBG and/or HbA1c within target range and patient in “honeymoon” phase? YES NO Move to Insulin Stage 2/Start

  15. Type 1: Preconception Planning 2-25 Patient planning pregnancy • History, physical exam, and • laboratory evaluation by clinician • History: Diabetes therapy and • control, miscarriages, and birth • control • Medications: If hypertensive, • switch to Methyldopa or • Hydralazine; ACE inhibitors • and beta blockers contraindicated • in pregnancy • Complications: Hypoglycemia • unawareness; DKA; retinopathy; • nephropathy; neuropathy • Discuss pregnancy-related risks • including association of hyper- • glycemia with complications; • DKA with fetal death; fetal • malformations • Physical exam: Include • funduscopic eye exam with • dilation by Ophthalmologist • Laboratory: CBC; UA/UC; thyroid • studies; screen for albuminuria; • HbA1c; EKG if diabetes duration • > 10 years • Correlate SMBG and HbA1c; assess • nutritional status selfmanagement • skills, and psychological status • SMBG Targets • Pre-meal: 80-120 mg/dL • Post-meal: < 140 mg/dL 2 • hours after start of meal • Bedtime: 100-140 mg/dL • (bedtime) • No severe (assisted) or • nocturnal hypoglycemia • Adjust if hypoglycemia • unawareness • HbA1c Target • At least 2 balues 1 mohth • apart within normal range • SMBG Frequency • 4 times/day; before meals • and 2 hours after start of • meals and at bedtime • Check 3 AM as needed Stop birth control and continue current insulin stage; maintain SMBG and HbA1c within target range until pregnancy confirmed Move to Management During Pregnancy SMBG and/or HbA1cwithin target range? YES NO • 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

  16. 2-26 Type 1: Management During Pregnancy • 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 necessary • Nutrition • Increase calories 300/day in the second and third trimesters • Adequate weight gain according to table below • BMI • %DBW (wt/ht2=kg/m2) Wt. Gain • 90% <19.8 28-40 lbs. • 90-120 19.8-26 20-35 lbs. • >120 >26 15-25 lbs. • Self-Management Education • Emphasize hypoglycemia prevention/treatment • Instruct family member on glucagon administration • Instruct on self adjustment of insulin as appropriate • No skipped meals

  17. 2-27 Type 1: Food Plan and Exercise Establish Food Plan and Exercise • Medical Nutrition Therapy • Guidelines (non-pregnant) • Total fat: 30% total calories; • ries; less if BMI > 27 kg/m2 • or LDL > 130 mg/dL • Saturated fat: < 10 % total • calories; < 7% with LDL • > 130 mg/dL • Cholesterol: < 300 mg/day • If BMI > 27 kg/m2, • decrease calories by • 10-20% and add exercise • If BP > 130/85 mm/Hg, • reduce sodium to • < 2400 mg/day • If albumin > 300 mg/24 • hour or creatinine • > 300 mg/g, reduce protein • to 0.8g/kg/day or ~10% • total calories • Assessment • Food history or 3 day food • record (meals, times, portions) • Nutrition adequacy • Height/weight/BMI; see BMI • Chart, 4-3 • Weight goals/eating disorders • Psychosocial issues (denial, • anxiety, depression) • Economic/cultural factors • Nutrition/diabetes knowledge • Readiness to learn/barriers to • learning • Work/school/sports schedules • Fitness level (strength, flexibility, • endurance) • Exercise (times, duration, types) • Tobacco/alcohol use • Vitamin/mineral supplements • Goals • SMBG/HbA1c in target • Desirable body weight (adults) • Normal growth and development • (children) • Consistent carbohydrate intake • Regular exercise • Plan • Establish adequate calories for • growth and development/rea- • sonable body weight • Set meal/snack times • Integrate insulin regimen with • food plan • Set consistent carbohydrate • intake • Establish regular exercise regi- • men based on fitness level • Establish adequate calories for • pregnancy/lactation/recovery • from illness Calorie Requirements Adults 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 > age 55: DBW x 10 kcal Children/Method 1 First year: 1000 kcal Age 1-10: Add 100 kcal/year Age 11-15: Boys add 200 kcal/year; girls add 100 kcal/year Age > 15: Boys add for activity (23 kcal/lb very active, 18 kcal/lb normal, 16 kcal lb inactive); girls calculate as adult Children/Method 2 First year: 1000 kcal Age 1-3: Add 40 kcal/inch Age > 3: Boys 125 kcal x age; girls 100 kcal x age; add up to 20%kcal for activity

  18. 3-2 Gestational: SMBG and Weight Gain Targets • 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 • Negative • SMBG Frequency • Test 7 times/day; before and 1-2 hours 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 for 1 week, then every other AM Weight Gain Guidelines %DBW BMI GAIN 90% <19.8 28-40 lbs. 90-120 19.8-26 20-35 lbs. >120 >26 15-25 lbs. Target weight gain for significantly obese women (BMI > 29 kg/m2): ~ 15 lbs

  19. 3-3 Gestational: Screening and Diagnosis • Risk Factors • BMI > 27 (especially waist-to- • hip ratio > 1) • Family history of type 2 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 • 110-125 mg/dL • Previous impaired fasting glu- • cose (IGT) with 2 hour OGTT • 140-199 mg/dL • American Indian; African • American; Asian American; • Mexicah/Hispanic American; • Pacific Islander Patient is pregnant With risk factors: Screen at first prenatal visit No risk factors: screen at 24-28th gestational week Screen with 50 gram glucose challenge test (GCT) 50 gram glucose challenge (GCT) test abnormal (plasma glucose > 140 mg/dL or whole blood >120 mg/dL? NO YES With risk factors: Rescreen at 24 and 32 weeks; if normal at 32 weeks, no further testing No risk factors: No further testing Perform 100 gram oral glucose tolerance test (OGTT) within 3 days of positive screen With risk factors: Repeat OGTT at 32 weeks No risk factors: No further testing Two abnormal OGTT values? NO NO YES One abnormal value? Diagnosis of gestational diabetes Move to Gestational Master DecisionPath YES NO Monitor fastng and 2 hours after start of meal; start food plan If average fasting BG > 95 mg/dL or average 2 hour post-meal BG > 120 mg/dL, treat with food plan and repeat OGTT at 32 weeks See Food Plan/Start, 3-8 PLASMA WHOLE BLOOD Fasting > 105 mg/dL > 90 mg/dL 1 hour > 190 mg/dL > 165 mg/dL 2 hour > 165 mg/dL > 145 mg/dL 3 hour > 145 mg/dL > 125 mg/dL 100 gram Oral Glucose Tolerance Test

  20. Gestational: Master DecisionPath 3-5 At Diagnosis OGTT fasting plasma glucose < 95 mg/dL Food Plan Stage Insulin Stage 2 R/N - 0 - R/N - 0 LP/N - 0 - LP/N - 0 At Diagnosis* OGTT fasting plasma glucose > 95 mg/dL OR Insulin Stage 3A R/N - 0 - R - N If persistent midafternoon hyperglycemia, start Insulin Stage 4A *Plasma Glucose criteria for starting each therapy may be modified Food Plan Stage R = Human Regular Insulin N = Human NPH Insulin 0 = 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

  21. 3-8 Type 1: Insulin Adjustment Guidelines 3B • Assessment • Food history or 3-day food • record (meals and snacks • with times and portions) • Nutrition adequacy • Weight gain/change • Exercise times, duration, • and type • Fitness level (strength, flexi • bility, endurance) • Alcohol use • Vitamin and mineral suppoe- • ment • Goals • Good pre-natal nutrition • Proper weight gain based on • BMI • SMBG within target range • Negative ketones • Plan • Two carbohydrate choices at • breakfast and consistent • bedtime snack • Set meal and snack times • Set consistent carbohydrate • intake at meals and snacks • to meet BG targets (see • sample food plan) • Encourage regular exercise • based on usual activity prior • to pregnancy • Refer for nutrition and diabetes • education within 48 hours • 1 CHO = 1 carbohydrate • serving = 15 gm carbohydrate; • 60-90 calories • 1Meat/Sub = 1 oz serving • (28 gm) = 7 gm protein; 5 • gm fat; 50-100 calories • 1 Added Fat = 1 serving = • 5 gm fat; 45 calories • Vegetables = 1-2 servings/day • with each meal; not counted in • plan Sample Food Plan Start Food Plan MEAL CHO MEAT/SUB FAT Bkfat. 2 0-1 0-1 Snack 1-2 0-1 0-1 Lunch 3-4 2-3 1-2 Snack 1-2 0 0-1 Dinner 3-4 2-4 1-2 Snack 1-2 0 0-1 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/Adjust

  22. Gestational: Food Plan/Adjust 3-9 Patient in Food Plan Stage Patient enters Food Plan/Maintain Continue current therapy; use this DecisionPaht for follow-up Follow-up Medical: Phone 1-2 times/week Office visit every 2 weeks SMBG and/or HbA1c within target range and patient in “honeymoon” phase? YES NO 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 • Education: Every 2-4 weeks as needed • Nutrition: Every 2-4 weeks as needed Food Plan Adjustments

  23. Gestational: Insulin Stage 2/Start 3-12 At Diagnosis or from Food Plan Stage Start insulin within 24 hours. Hospitalize if medically necessary Start Insulin Stage 2 R/N - 0 - R/N - 0 At Diagnosis Calculate total dose at 0.4 U/kg based on current weight AM MIDDAY PM BT Distribution 2/3 0 1/3 0 R/N ratio 1:2 - 1:1 - Refer patient for nutrition and diabetes education Follow-up Medical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed Education: Within 24 hours, then office visit in 2 weeks Move to Insulin Stage 2/Adjust

  24. Gestational: Insulin Stage 2/Adjust 3-13 Patient in Insulin Stage 2 If persistent AM hyper- glycemia or nocturnal hypo glycemia, move to Insulin Stage 3A/Start Is current total daily insulin dose: < 1.5 U/kg? NO YES Insulin Stage 2 Pattern Adjustm R/N - 0 - R/N - 0 Pattern of BG in mg/dL Pre-meal Post-meal 2 hr > 120 < 60 > 90 < 90 1hr >140 ฏ PM N (a,d) ฏ AM N (a,k) ญAM R (f,j) AM MIDDAY (MID) PM BEDTIME (BT) ญPM N (a,h,n) ฏ AM R (b,k) ฏ AM N (c,k) ญ AM R (j,l) ญAM R (j) ฏ AM N (c,k) ญ AM N (j,m) ฏ AM N (k) ญAM R (j) ฏ PM R (k) ญ PM R (k) - - Adjust insulin based on BG patterns Follow-up Medical: 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 considerations designated by each letter.

  25. Gestational: Insulin Stage 3A/Start 3-14 At Diagnosis or from Food Plan Stage or Insulin Stage 2 Start insulin within 24 hours. Hospitalize if medically necessary Start Insulin Stage 3A • R/N - 0 - R-N • At Diagnosis • Calculate total dose at 0.4 U/kg based on current weight • AM MIDDAY PM BT • Distribution 2/3 0 1/6 1/6 • R/N ratio 1:2 - - - • From Insulin Stage 2 • Use current total dose • Move PM N to bedtime (BT) • 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 Follow-up Medical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed Move to Insulin Stage 2/Adjust

  26. Gestational: Insulin Stage 3A/Adjust 3-15 Patient in Insulin Stage 3A If persistent midafternoon hyperglycemia, move to Insulin Stage 4A Is current total daily insulin dose: < 1.5 U/kg? NO YES Insulin Stage 2 Pattern Adjustm R/N - 0 - R/N - 0 Pattern of BG in mg/dL Pre-meal Post-meal 2 hr > 120 < 60 > 90 < 90 1hr >140 ฏ BT N (a,d) ฏ AM R (b,k) ญAM R (f,j) AM MIDDAY (MID) PM BEDTIME (BT) ญ BTN (a,n) ฏ AM R (b,k) ฏ AM N (c,k) ญ AM R (j,l) ญAM N (j) ฏ AM N (c,k) ญ AM N (j,m) ฏ AM N (k) ญAM R (j) ฏ PM R (k) ญ PM R (k) - - Adjust insulin by 10% or 2 units, whichever is greater Follow-up Medical: 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 considerations designated by each letter.

  27. 3-18 Gestational Insulin Adjustment Guidelines How to Use These Tables 1. Find current insulin stage 2. Find the pattern of blood glucose problem (column) 3. Identify time of day (row) pattern occurs 4. Where the column and row intersect, see recommended changes 5. See notes for additional considerations • 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 Notes a. Evaluate nocturnal hypoglycemia; check 3 AM BG b. Consider increasing mid-morning snack c. Consider increasing afternoon snack d. Consider increasing bedtime snack e. Consider giving injection 45 minutes before meal f. Consider decreasing carbohydrate at breakfast g. If post AM increase, increase AM snack h. Consider Insulin Stage 3A i. Consider Insulin Stage 4A j. Consider adding exercise k. Evaluate if previous exercise is causing hypoglycemia l. Consider decreasing mid-morning snack m. Consider decreasing afternoon snack n. Consider decreasing bedtime snack

  28. Impaired Glucose Homeostasis 4-2 At Diagnosis Impaired fasting glucose (IFG), fasting plasma glucose 110-125 mg/dL, and/or 2 hr OGTT value 140-199 mg/dL Establish food and Exercise Plan • 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 HbA1c 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 • 50-75% maximum aerobic capacity for 20 minutes, 3 times/week • Refer patient for nutrition and diabetes education Follow-up Medical: Within 3 months Nutrition: As meeded

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