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Standards of Medical Care in Diabetes - Adult/Pediatric - Inpatient/Ambulatory

Standards of Medical Care in Diabetes - Adult/Pediatric - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology


1



Standards of Medical Care in Diabetes –
Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline


Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY .......................................................................................................................3
SCOPE ................................................................................................................................................4
METHODOLOGY .................................................................................................................................4
INTRODUCTION .................................................................................................................................5
RECOMMENDATIONS .........................................................................................................................5
Type 2 Diabetes Screening (Adults) ...................................................................................................... 5
Screening for Cognitive Impairment ..................................................................................................... 6
UW HEALTH IMPLEMENTATION ..........................................................................................................7
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................................................... 11
REFERENCES .................................................................................................................................... 13



Contact for Content:
Name: Vanessa Rein, MD- Medicine - Endocrinology
Phone Number: (608) 263-5010
Email Address: vr2@medicine.wisc.edu

Name: Mary Tracy Bekx, MD - Pediatrics- Endocrinology
Phone Number: (608) 262-5619
Email Address: mtbekx@pediatrics.wisc.edu

Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2


Coordinating Team Members:
Sravanthi Nagavalli, MD- Endocrinology (SwedishAmerican Health System)
Allison Pollock, MD- Pediatrics- Endocrinology
Peter Gill, MD- Medicine- Hospitalists
Matt Anderson, MD- Medicine- Internal Medicine/General
Thomas Shiffler, MD- Medicine- Internal Medicine/General
Jeff Huebner, MD- Family Medicine/Population Health
Mitzi Regala, MD- Family Medicine
Pam Olson, MD- Family Medicine
Elizabeth Chapman, MD- Medicine- Geriatrics
Michael Kim, MD- Pediatric Emergency Medicine
Michael Wilhelm, MD- Pediatric Intensive Care
Megan Barry, PA- Medicine- Endocrinology
Nancy Williams, NP- Family Medicine
Gwen Klinkner, MS, RN, APRN, BC-AMD, CDE- Nursing- Diabetes Clinical Nurse Specialist
Cheryl Franz, RN, BSN, CDE- Clinical Support- Staff Education
Lisa Bennett, CNS- Clinics- Pediatric Specialties-AFCH
Amber Buckingham, RN- Family Medicine- General
Lynnette Alvarado, RN- Family Medicine- General
Christina McOwen, RN- Family Medicine- General
Laura Ahola, RN- Nursing- Pediatric Universal Care
Deb Soetenga- Pediatric Intensive Care
Mary Jean Erschen-Cooke, RN, MS, BSN, CPEN- Pediatric Emergency Medicine
Sara Smith-Shull, PharmD- Pharmacy Drug Policy Program
Brenda Burke, MS, RD, CDE, BC-ADM- Clinical Nutrition
Cassandra Vanderwall, MS, RDN, CDE- Clinical Nutrition
Rene Walters, MS, CDE, RD-CD- Clinical Nutrition
Sarah Hackenmueller, PhD- Clinical Laboratories
Heidi Wolf- Unity Health Insurance
Elaine Rosenblatt, MSN, FNP-BC – Unity Health Insurance
Donna Twining, CNS, APNP, BC-ADM- Group Health Cooperative of South Central Wisconsin
Sandy Onsager, RN- Physicians Plus Insurance Corporation
Jason Yelk, DO- Physicians Plus Medical Director
Christina Salm- Physicians Plus Insurance Corporation
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Karen Briggs, MSN, RN, ANP-BC- Gundersen Health Plan
Mary Reding- Gundersen Health Plan
Lori Pedretti- Gundersen Health Plan
Margaret Webster, MD- Gundersen Health System
Linda Dries, APRN- Diabetes Self-Management Center Manager (SwedishAmerican Health System)p
Tracy Palmer, RN, CDE- Chronic Disease Case Manger (SwedishAmerican Health System)
Mary Panther, RN, CDE- SwedishAmerican Health System
Kelly Logli, APN- SwedishAmerican Health System
Jennifer Kuroda- SwedishAmerican Health System

Review Individuals/Bodies:
Cheri Gangstad, RN, CDE- Diabetes Clinic
Kathy Partridge, RN- Health Connect (SwedishAmerican Health System)

Committee Approvals/Dates:
UWHC Inpatient Diabetes Quality Committee (02/23/2017)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 03/23/2017)

Release Date: April 2017 | Next Review Date: January 2018
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

3


Executive Summary
Guideline Overview
UW Health has agreed to endorse the 2017 American Diabetes Association (ADA) Standards of
Medical Care in Diabetes, with additional recommendations for screening constructed internally.
This guideline contains recommendations for diagnostic criteria and therapeutic actions which
are known or believed to favorably affect health outcomes of patients with diabetes.

Key Revisions (2017 Periodic Review)
1. Key revisions are outlined on pages s4-5 of the full ADA guideline.
2. Constructed recommendations for screening in asymptomatic adult patients using published
evidence primarily reviewed by the U.S. Preventive Services Task Force and American
Diabetes Association.
3. Added new collateral tool for the outpatient management of Type 1 diabetes in children.


Companion Documents

AMBULATORY
ξ 2017 Diabetes Guideline: Key Practice Recommendations
ξ Management of Hyperglycemia in Type 2 Diabetes

(Adult only):
ξ Preoperative Instructions for Ambulatory Procedures

(Pediatric only):
ξ Outpatient Management of Type 1 Diabetes Mellitus in Children
ξ Outpatient Management of Type 2 Diabetes Mellitus in Children

INPATIENT/EMERGENCY DEPARTMENT
ξ 2017 Diabetes Guideline: Key Practice Recommendations
ξ Management of Hyperglycemia in Type 2 Diabetes
ξ Glycemic Goals for Hospitalized Patients
ξ Steps for Coordinating Glucose Monitoring, Meals, and Medications
ξ Continuous Glucose Monitoring (CGM): Information for Clinicians

(Adult only):
ξ Adult Hypoglycemia Algorithm
ξ Adult Diabetic Ketoacidosis (DKA) Management Algorithm
ξ Adult Inpatient Insulin to Carbohydrate Ratios (ICRs)
ξ Cautions Regarding Oral Agents for Diabetes in the Hospital Setting
ξ Medication Adjustment for Hospitalized Patients who are NPO
ξ Transition from Intravenous (IV) to Subcutaneous (SC) Insulin Administration Algorithm
ξ Initiation of Insulin in Non-Critically Ill Insulin-Naïve Hyperglycemic Adult Patients Algorithm

(Pediatric only):
ξ Pediatric Hypoglycemia Algorithm
ξ Pediatric ED Diabetic Ketoacidosis (DKA) Management Algorithm


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

4


Scope
Disease/Condition(s): Diabetes mellitus

Clinical Specialty: Endocrinology, Internal Medicine, Family Medicine, Pediatrics, Obstetrics
and Gynecology, Cardiovascular Medicine, Surgery, Hospitalists, Ophthalmology, Pathology &
Laboratory Medicine, Clinical Nutrition, Pharmacy

Intended Users: Physicians, Advanced Practice Providers, Registered Nurses, Licensed
Practice Nurses, Medical Assistants, Nursing Assistants, Pharmacists, Nutritionists

Objective(s): To provide standardized, evidence-based guidelines for diabetes care throughout
a patient’s lifetime.

Target Population: Pediatric and adult patients with a prediabetes or diabetes mellitus
diagnosis. Screening recommendations also apply to asymptomatic patients.

Major Outcomes Considered:
ξ Identification of prediabetes and diabetes
ξ Blood glucose control
ξ Prevention of diabetes complications
ξ Psychosocial support
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches were conducted by the guideline workgroup members to collect
evidence for review. Expert opinion and clinical experience were also considered during
discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: See pages s6-10 of the full guideline.1

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

5


Introduction
Diabetes mellitus is a complex, chronic illness requiring continuous medical care with
multifactorial risk reduction strategies beyond glycemic control. The American Diabetes
Association (ADA)’s Standards of Care are intended to provide clinicians, patients, researchers,
payers, and other interested individuals with the components of diabetes care, general
treatment goals, and tools to evaluate the quality of care.
Recommendations
UW Health endorses the recommendations found within the full 2017 ADA guideline located
online at http://care.diabetesjournals.org/content/40/Supplement_1, except for the topics listed
in this section, as alternative recommendations are described below.
Type 2 Diabetes Screening (Adults)
The 2017 ADA Standards2 recommend universal screening in patients after age 45 years;
however, UW Health recommends targeted screening in all adult patients based on risk.

Screening for type 2 diabetes with an informal assessment of risk factors should be considered
in asymptomatic adults.2 (ADA Grade B) It is reasonable to perform a risk assessment annually.
(UW Health Very low quality evidence, weak/conditional recommendation)

Testing for type 2 diabetes should be considered in all adult patients who are overweight or
obese (BMI > 25 kg/m2 or > 23 kg/m2 in Asian Americans)2,3 and have one or more of the
following risk factors2,4 (UW Health Moderate quality evidence, weak/conditional recommendation):
ξ A1C > 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
ξ First-degree relative with diabetes
ξ High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)
ξ Women who were diagnosed with gestational diabetes mellitus (GDM)
ξ History of cardiovascular disease
ξ Hypertension (> 140/90 mmHg or on therapy for hypertension)
ξ HDL cholesterol level < 35 mg/dL and/or a triglyceride level > 250 mg/dL
ξ Women with polycystic ovary syndrome
ξ Physical inactivity
ξ Chronic glucocorticoid exposure
ξ Atypical antipsychotic use
ξ Sleep disorders, including obstructive sleep apnea, chronic sleep deprivation, and night-
shift occupation
ξ Other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans).

Testing Options
To test for type 2 diabetes, fasting plasma glucose, 2-hour plasma glucose after 75-g oral
glucose tolerance test, and A1C are equally appropriate.2 (ADA Grade B) In patients with
polycystic ovary syndrome, a 2-hour 75-g oral glucose challenge is recommended over the
other screening testing options.5-7 (UW Health Low quality evidence, strong recommendation)

Screening Frequency
The appropriate interval between screening tests is not known.2,8 In patients age > 40 years,
testing for type 2 diabetes was not associated with a reduction in all-cause, cardiovascular or
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

6


diabetes-related mortality over 10 years.9 Modeling simulation studies have found screening
every 3-5 years to be cost-effective, particularly in patients age 30 or older.8,10,11 A large open
cohort study in Japan which stratified patients age 30-74 years by risk (BMI and 10-yr.
cardiovascular risk) demonstrated that screening frequencies could be extended to 8-10 year
intervals in patients at lower risk.12 Therefore, subsequent screening tests, especially in patients
aged 18-44 years, should be based upon individual clinical judgement that is influenced by the
patient’s clinical status, any prior test results, and the presence of or changes in risk factors.
(UW Health Very low quality evidence, weak/conditional recommendation) If prior test results are
normal and patients do not demonstrate other significant risk, testing should not be repeated
more frequently than every 3 years.2 (UW Health Low quality evidence, weak/conditional
recommendation)

It is important to recognize that not all of the risk factors are weighted equally. The following
alternative testing frequencies may need to be considered based on the presence of comorbid
clinical conditions or prescription therapies:
ξ Patients with HIV should be screened for diabetes and prediabetes with a fasting
glucose every 6-12 months before starting antiretroviral therapy and 3 months after
starting or changing antiretroviral therapy. If initial screening results are normal, checking
fasting glucose every year is advised. If prediabetes is detected, continue to measure
fasting glucose levels every 3-6 months to monitor for progression to diabetes.13 (ADA
Grade E)
ξ Annually screen people who are prescribed atypical antipsychotic medications for
prediabetes or diabetes.13 (ADA Grade B)
ξ At least annual monitoring for the development of diabetes in those with prediabetes is
suggested.14 (ADA Grade E) Prediabetes is defined as an A1C of 5.7-6.4%, impaired oral
glucose tolerance (140-199 mg/dL), or impaired fasting glucose (100-125 mg/dL) on
previous testing.2
ξ It is suggested that patients with polycystic ovary syndrome and normal glucose
tolerance be rescreened every 2 years or sooner if additional risk factors are identified.5
Those with impaired glucose tolerance should be screened annually.5
ξ Women with a history of gestational diabetes mellitus (GDM) should have lifelong
screening for the development of diabetes or prediabetes at least every 3 years.2 (ADA
Grade B)


Screening for Cognitive Impairment
In lieu of the screening recommendations outlined within the 2017 ADA Standards2, UW Health
does not recommend screening for cognitive impairment in most adult patients. Refer to the UW
Health Preventive Health Care – Adult/Pediatric – Ambulatory Guideline for more information.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

7


UW Health Implementation
Potential Benefits:
ξ Diabetes prevention
ξ Diabetes diagnosis
ξ Disease management

Potential Harms:
ξ Risk for hypoglycemia
ξ Medication side effects

Pertinent UW Health Policies & Procedures
AMBULATORY
1. UWMF Policy 101.050- Hypoglycemia Management Delegation Protocol
2. UWMF Policy 104.034- Infection Prevention During the Use of Point of Care Devices
3. UWMF Policy 102.072 – Administering a Subcutaneous Injection

INPATIENT
1. UW Health Clinical Policy 2.3.19– Subcutaneous Insulin Pump (Patient’s Own) and
Continuous Glucose Monitor Use in the Hospital Setting (Adult and Pediatric)
2. UWHC Departmental Policy 13.24 AP– Hypoglycemia, Care of the Hospitalized Patient
(Adult and Pediatric)
3. UWHC Departmental Policy 11.26 – Nova Stat Strip® Blood Glucose Meter: Use and
Maintenance
4. Pharmacy Operating Procedure, U-500 Insulin 500 units/1 mL: Storage, Order Entry,
Preparation, and Dispensing

Patient Resources
1. Health Facts For You (Category: Diabetes, Endocrine)
2. Healthwise® Patient Instructions (Category: Diabetes and Endocrinology)
3. Health Information- Diabetes
4. Pre-Diabetes Class Schedule
5. Take Back Control of Your Diabetes
6. Nutrition Information- Eating Guidelines for Diabetes
7. Nutrition Information- How Food Affects Your Blood Sugar
8. Nutrition Information- Sample Menus for Managing Diabetes
9. www.uwhealth.org- Diabetes Management
10. www.uwhealthkids.org- Type 1 Diabetes Resources
11. www.uwhealthkids.org- Type 1 Diabetes Resources
12. Kids Health- Can Diabetes Be Prevented?
13. Kids Health- Diabetes Center
14. Kids Health- Treating Type 1 Diabetes
15. Kids Health- Treating Type 2 Diabetes
16. Kids Health- Type 1 Diabetes: What is it?
17. Kids Health- Type 2 Diabetes: What is it?
18. Kids Health- What is Gestational Diabetes?

Guideline Metrics
ACO
1. Diabetes: Hemoglobin A1C Poor Control
2. Diabetes: Eye Exam
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

8



WCHQ
1. Diabetes Care
2. High Blood Pressure

HEDIS
1. Comprehensive Diabetes Care
2. Statin Therapy for Patients with Diabetes
3. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using
Antipsychotic Medications
4. Diabetes Monitoring for People with Diabetes and Schizophrenia

Inpatient TJC Certification
1. Diabetes Patient Education Documentation
2. Severe Hypoglycemia Monitoring
3. Hyperglycemia Incidence
4. Discharge Appointments within 30 Days

Inpatient Diabetes Quality Committee
1. Patient Satisfaction During Hospitalization
2. A1C Testing
3. 30-Day All-Cause Readmission Rates for Diabetes Patients
4. Hypoglycemia Cause Documentation
5. Manifestations of Poor Glycemic Control
6. Hypoglycemia in Patients Receiving Insulin (HIIN measure)

CPG Workgroup-Derived
1. Patient education/nutrition counseling for patients with prediabetes
2. Rate or timing of follow-up appointments/care for patients with prediabetes
3. % of pediatric patients with PHQ-2 screening completed
4. A1C control in pediatric patients

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Clinical Practice Guidelines
ξ UW Health Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
ξ UW Health Preventive Health Care – Adult/Pediatric – Ambulatory
ξ UW Health Prevention and Management of Obesity – Adult – Ambulatory
ξ UW Health Prevention and Management of Obesity – Pediatric – Ambulatory
ξ UW Health Parenteral Nutrition – Pediatric/Neonatal – Inpatient/Ambulatory
ξ UW Health Parenteral Nutrition – Adult – Inpatient/Ambulatory
ξ UW Health Tobacco Cessation – Adult/Pediatric – Inpatient/Ambulatory
ξ UW Health Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory
ξ UW Health Prevention of Contrast-Induced Nephropathy – Adult – Inpatient/Ambulatory


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

9


Best Practice Alerts (BPA)
ξ Hypoglycemia Cause Documentation (Inpatient)

Practice Protocols
ξ Wisconsin Insulin Infusion Standard Dose – Adult – Practice Protocol
ξ Wisconsin Insulin Infusion HIGH Dose – Adult – Practice Protocol (ICU Only)

Delegation Protocols
ξ Adjusting Insulin for Pediatric Patients Protocol – Ambulatory [65]
ξ Blood Glucose Testing and Insulin Delivery Supplies Ordering – Adult/Pediatric – Outpatient [110]
ξ Diabetes Lab Ordering – Adult – Outpatient [21]
ξ Diabetes Mellitus Medication Titration – Adult – Outpatient – Endocrine Diabetes Clinic/UWMF Health
and Education Department [88]
ξ Diabetes Mellitus Medication Titration – Adult – Primary Care [87]
ξ Intravenous (IV) to Subcutaneous (SQ) Insulin Transition Delegation Protocol – Adult – Inpatient [97]
ξ OB/GYN and Women’s Health Gestational Diabetes Screening and Treatment Protocol [22]
ξ Referral to Diabetes Education - Ambulatory [58]
ξ Perioperative Medication Management – Adult – Inpatient/Ambulatory [149]
ξ Perioperative Normoglycemia for Surgical Patients – Adult – Inpatient/Ambulatory [PILOT]

E-Consults
ξ UWOP EConsult to Endocrinology- Diabetes Mellitus [5027]

Flowsheets/Worksheets
ξ Insulin Infusion Worksheet
ξ Point of Care Glucose Flow Sheet

Order Sets & Smart Sets
ξ Diabetes [101]
ξ Diabetes F/U ACHC [155]
ξ Chronic Disease- Care Team [3672]
ξ Diabetes Mellitus Type 1 [3185]
ξ Ped Diabetes Mellitus [2599]
ξ Ped Endodiabetes- Office Visit [2595]
ξ ED – Diabetic Ketoacidosis – Pediatric [3464]
ξ ED – Clinical Decision Unit – Diabetic Ketoacidosis – Adult [6120]
ξ ED/IP - Diabetic Ketoacidosis - Adult - Admission [1335]
ξ IP - Diabetic Ketoacidosis – Pediatric - Intensive Care – Admission [1196]
ξ IP - Diabetes - Newly-diagnosed - Pediatric - Admission [1235]
ξ ED/IP - Diabetes Management With Pump - Adult - Supplemental [3139]
ξ IP - Diabetes Management With Pump - Pediatric - Supplemental [2187]
ξ ED/IP - Diabetes Management Without Pump - Adult - Supplemental [3140]
ξ IP - Diabetes Management Without Pump - Pediatric - Supplemental [2183]
ξ IP - Diabetic Discharge Supplies - Adult - Supplemental [4797]
ξ IP - Diabetic Discharge Supplies - Pediatric - Supplemental [4555]
ξ ED/IP - Insulin Infusion - Adult - Supplemental [1345]
ξ ED/IP - Diabetes - Insulin Transition - IV to Subcutaneous – Adult - Supplemental [5254]
ξ IP - Cardiac Surgery - Adult - Postoperative [2821]
ξ IP/OP – Perioperative Normoglycemia for Surgical Patients Delegation Protocol – Adult [6133]




Contains Diabetes Management Order Panel.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

10


Order Panels
ξ Insulin Infusion- Pediatric [191555]
ξ Hypoglycemia Management (Adult) [191576]

Reporting Workbench Reports
ξ Diabetes – possible patients (general printing letter size)
ξ Diabetes and Hypertension Patients
ξ Diabetes patients (general printing letter size)
ξ Diabetes patients (huddle printing legal size)
ξ Diabetes patients, A1c>= 7 & not on metformin (general printing letter size)
ξ Diabetes Patients (using Diabetes Concept Grouper)- All IP Units
ξ Multi-Condition

Telephone Triage Protocols
ξ Diabetes- Low Blood Sugar: Pediatric After-Hours (Schmitt 2016)
ξ Diabetes- Low Blood Sugar: Adult After Hours (Schmitt-Thompson 2016)
ξ Diabetes: Control Problems (RelayHealth 2014)



Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

11


Appendix A. Evidence Grading Scheme(s)

Table 1. ADA Grading Scheme
Level of
Evidence Description
A Clear evidence from well-conducted, generalizable RCTs that are adequately
powered, including:
ξ Evidence from a well-conducted multicenter trial
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling nonexperimental evidence, i.e., “all or none” rule developed by the Center
for Evidence-Based Medicine at the University of Oxford
Supportive evidence from well-conducted RCTs that are adequately powered,
including:
ξ Evidence from a well-conducted trial at one or more institutions
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis
B Supportive evidence from well-conducted cohort studies
ξ Evidence from a well-conducted prospective cohort study or registry
ξ Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C Supportive evidence from poorly controlled or uncontrolled studies
ξ Evidence from randomized clinical trials with one or more major of three or
more minor methodological flaws that could invalidate the results
ξ Evidence from observational studies with high potential for bias (such as case
series with comparison with historical controls)
ξ Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience



Figure 1. GRADE Methodology adapted by UW Health


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

12


Table 2. GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

Table 3. GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.






Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

13


References
1. Association AD. 1. Promoting Health and Reducing Disparities in Populations. Diabetes
Care. 2017;40(Suppl 1):S6-S10.
2. Association AD. 2. Classification and Diagnosis of Diabetes. Diabetes Care.
2017;40(Suppl 1):S11-S24.
3. Selph S, Dana T, Blazina I, Bougatsos C, Patel H, Chou R. Screening for type 2
diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force. Ann
Intern Med. 2015;162(11):765-776.
4. Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American association of clinical
endocrinologists and american college of endocrinology - clinical practice guidelines for
developing a diabetes mellitus comprehensive care plan - 2015. Endocr Pract. 2015;21
Suppl 1:1-87.
5. Wild RA, Carmina E, Diamanti-Kandarakis E, et al. Assessment of cardiovascular risk
and prevention of cardiovascular disease in women with the polycystic ovary syndrome:
a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-
PCOS) Society. J Clin Endocrinol Metab. 2010;95(5):2038-2049.
6. Hurd WW, Abdel-Rahman MY, Ismail SA, Abdellah MA, Schmotzer CL, Sood A.
Comparison of diabetes mellitus and insulin resistance screening methods for women
with polycystic ovary syndrome. Fertil Steril. 2011;96(4):1043-1047.
7. Lerchbaum E, Schwetz V, Giuliani A, Obermayer-Pietsch B. Assessment of glucose
metabolism in polycystic ovary syndrome: HbA1c or fasting glucose compared with the
oral glucose tolerance test as a screening method. Hum Reprod. 2013;28(9):2537-2544.
8. Johnson SL, Tabaei BP, Herman WH. The efficacy and cost of alternative strategies for
systematic screening for type 2 diabetes in the U.S. population 45-74 years of age.
Diabetes Care. 2005;28(2):307-311.
9. Simmons RK, Echouffo-Tcheugui JB, Sharp SJ, et al. Screening for type 2 diabetes and
population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised
controlled trial. Lancet. 2012;380(9855):1741-1748.
10. Kahn R, Alperin P, Eddy D, et al. Age at initiation and frequency of screening to detect
type 2 diabetes: a cost-effectiveness analysis. Lancet. 2010;375(9723):1365-1374.
11. Einarson TR, Bereza BG, Acs A, Jensen R. Systematic literature review of the health
economic implications of early detection by screening populations at risk for type 2
diabetes. Curr Med Res Opin. 2017;33(2):331-358.
12. Ohde S, McFadden E, Deshpande GA, et al. Diabetes screening intervals based on risk
stratification. BMC Endocr Disord. 2016;16(1):65.
13. Association AD. 3. Comprehensive Medical Evaluation and Assessment of
Comorbidities. Diabetes Care. 2017;40(Suppl 1):S25-S32.
14. Association AD. 5. Prevention or Delay of Type 2 Diabetes. Diabetes Care.
2017;40(Suppl 1):S44-S47.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)
When to Screen - Adults
As
ym
pt
o
ma
tic

Ad
u
lt
s

Patients of any age with BMI
> 25 kg/m2 (or > 23 kg/m2 in
Asian Americans) AND one
or more additional risk
factors. (UW Health Moderate
quality evidence, weak/conditional
recommendation)
If results are normal, do
not repeat testing more
frequently than every 3
years (UW Health Low quality
evidence, weak/conditional
recommendation)
Adult Risk Factors
ξ A1C > 5.7%, IGT, or IFG on previous testing
ξ First-degree relative with diabetes
ξ High risk race/ethnicity (e.g., African American, Latino,
Native American, Asian American, Pacific Islander)
ξ Women diagnosed with GDM
ξ History of CVD
ξ HTN (> 140/90 mmHg or on HTN therapy)
ξ HDL < 35 mg/dL and/or TG level > 250 mg/dL
ξ Women with polycystic ovary syndrome
ξ Physical inactivity
ξ Chronic glucocorticosteroid exposure
ξ Atypical antipsychotic use
ξ Sleep disorders, including OSA, chronic sleep
deprivation, and night - shift work
ξ Other clinical conditions associated with insulin
resistance (e.g., severe obesity, acanthosis nigricans)
Pr
eg
n
a
nt
W
o
me
n In pregnant
women with risk
factors, test for
undiagnosed
type 2 diabetes
at first prenatal
visit.
(ADA Grade B)
Test for
GDM at
24-28
wks. using
OGTT.
(ADA Grade
E)
Screen women with GDM
for persistent diabetes at
4 -12 wks. postpartum
using the OGTT. (ADA
Grade E)
Women with a history of
GDM should have lifelong
screening at least every 3
yrs. (ADA Grade B)
Co
mo
rb
id

Co
n
d
it
io
n
Annually screen
patients on
atypical
antipsychotic
therapy. (ADA
Grade B)
Patients with HIV should be screened with fasting glucose every 6-12 months before staring
antiretroviral therapy and 3 months after starting or changing antiretroviral therapy. If normal,
recheck every year. If prediabetes, recheck every 3-6 months.
(ADA Grade E)
When to Screen- Pediatrics
As
ym
pt
o
ma
tic

Ch
il
dr
en
Patients > 10 yrs. (or at onset of puberty if
earlier) with BMI > 85th percentile for age and
sex, weight for height > 85th percentile, or
weight > 120% of ideal for height AND two or
more additional risk factors. (ADA Grade E)
If results
normal,
repeat testing
every 3 years.
(ADA Grade C)
Pediatric Risk Factors
ξ First or second-degree relative with type 2
diabetes
ξ High risk race/ethnicity (e.g., Native American,
African American, Latino, Asian American,
Pacific Islander)
ξ Signs of insulin resistance or conditions
associated with insulin resistance (acanthosis
nigricans, HTN, dyslipidemia, polycystic
ovarian syndrome, or small-for-gestational-age
birth weight)
ξ Maternal history of diabetes or GDM during
pregnancy
C
hi
ld
re
n

w
it
h
C
ys
t
i
c
F
ib
ro
si
s Annually screen for cystic-fibrosis related diabetes (CFRD)
with OGTT by age 10 yrs. (ADA Grade B)
A1C is not a recommended test. (ADA Grade B)
Testing Options/Results (ADA Grade B)
(Test should be repeated if abnormal result) Post- Diagnosis Testing for Prediabetes or Diabetes
A1C
5.7- 6.4% Prediabetes
Perform A1C at
least twice a year
if meeting
treatment goals
(i.e., stable
glycemic control).
(ADA Grade E)
Perform A1C
quarterly if
therapy
changes or
when not
meeting
glycemic
goals.
(ADA Grade E)
Consider
obtaining A1C in
patients
admitted to the
hospital if result
not available in
the previous 3
months.
(ADA Grade E)
Prediabetics
should be
tested at least
annually.
(ADA Grade E)
> 6.5% Diagnosis
Fasting
Plasma
Glucose *
100- 125 mg/dL Prediabetes
> 126 mg/dL Diagnosis
2-h PG
on 75-g
OGTT
140- 199 mg/dL Prediabetes
> 200 mg/dL Diagnosis
*Blood glucose rather than A1C should be used to
diagnose acute onset of type 1 if symptoms of
hyperglycemia present. (ADA Grade E)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)

Glycemic Targets (should be individualized)
Adults
A1C < 7.0% (ADA Grade A ) ξ Goals should be individualized based on duration of diabetes, age/life
expectancy, comorbid conditions, known CVD or advanced microvascular
complications, hypoglycemia unawareness, and individual patient
considerations.
ξ Postprandial values may be targeted if A1C goals not met despite reaching
premeal glucose targets. Postprandial glucose measurements should be
made 1-2 hours after beginning the meal.
Preprandial
glucose
80-130 mg/dL
Post-prandial
glucose
< 180 mg/dL
Pediatrics
A1C < 7.5% (ADA Grade E) ξ Goals should be individualized, and lower goals may be reasonable based
on a benefit-risk assessment (e.g., achieved w/o excessive hypoglycemia).
ξ Blood glucose goals should be modified in patients with frequent
hypoglycemia or hypoglycemia unawareness.
ξ Postprandial blood glucose values should be measured when there is a
discrepancy between preprandial values and A1C levels and to help assess
preprandial insulin doses in those on basal-bolus or pump regimens.
Before meals 90-130 mg/dL
Bedtime/overnight 90-150 mg/dL
Pregnant
Women
Gestational Diabetes (GDM) Preexisting type 1 or type 2
A1C < 6-6.5% (ADA Grade B)
Fasting glucose < 95 mg/dL < 95 mg/dL
Post-prandial
glucose
< 140 mg/dL (1-hr.)
< 120 mg/dL (2-hr.)
< 140 mg/dL (1-hr.)
< 120 mg/dL (2-hr.)
Alternative targets may be considered if optimal ranges cannot be achieved without significant hypoglycemia.
Individualization
of Goals

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Physical
Activity &
Medical
Nutrition
Therapy
Most adults with type 1 (AD A Grade C) and type 2 (A DA Grade B) should
engage in at least 150 min. per week of moderate-to-vigorous intensity
physical activity, spread over at least 3 days/week with no more than 2
consecutive days without exercise. Adults with type 1 ( ADA Grade C)
and type 2 (ADA Grade A) should engage in 2-3 sessions/week of
resistance exercise on non-consecutive days.
Children with diabetes or
prediabetes should be
encouraged to engage in at
least 60 min. of daily physical
activity. (ADA Grade B)
An individualized medical nutrition therapy program, preferably by a registered dietitian, is
recommended for all patients with type 1 or 2 diabetes. (ADA Grade A)

Patients prescribed a flexible insulin therapy program, education on how to use carbohydrate counting
and in some cases fat and protein gram estimation to determine mealtime insulin dosing can
improve glycemic control. (ADA Grade A)

Patients with impaired glucose tolerance (IGT) (ADA Grade A), impaired fasting glucose (IGF) (ADA Grade
E), or A1C 5.7-6.4% (ADA Grade E) should be referred to a dietitian for intensive nutrition and physical
activity counseling, targeting loss of 7% of body weight and increasing physical activity.

Diabetes Prevention Programs & Resources:
ξ UW Health Classes Offered by Health and Nutrition Education
ξ UW Health Preventive Cardiology (Active /iving and /earning “A//” class)
ξ YMCA
ξ Wisconsin Institute for Healthy Aging
ξ Illinois Department of Public Health Diabetes Prevention and Control
ξ Centers for Disease Control and Prevention (National Programs)
Metformin
Metformin therapy for type 2 prevention should be
considered in patients with prediabetes, especially
those with BMI > 35 kg/m2, age < 60 years,
women with prior GDM, and/or those with rising
A1C despite lifestyle interventions. (ADA Grade A)

Metformin may be safely used in patients with
eGFR > 30 mL/min/1.73 m2. Patients should be
advised to stop in cases of nausea, vomiting, or
dehydration. Metformin is contraindicated in
patients with advanced renal insufficiency or
significant heart failure.

Long- term metformin use (> 5 years 1) may be
associated with vitamin B12 deficiency;
therefore periodic measurement should be
considered, especially in patients with anemia or
peripheral neuropathy. (ADA Grade B)
Insulin is the
preferred
treatment for
hyperglycemia
in GDM (ADA
Grade A), due to
concerns about
the concentration
of metformin on
the fetal side of
the placenta. All
oral agents lack
long-term safety
data.
When insulin treatment is not
required, initiation of
metformin is recommended.
Self-
Management
& Education
All should participate in diabetes self-management education (DSME) to facilitate knowledge, skills,
and ability necessary for diabetes self-care and in diabetes self-management and support (DSMS) to
assist with implementing and sustaining skills and behaviors needed for ongoing self-management,
both at diagnosis and as needed thereafter. (ADA Grade B)
Note:
Compliance
Reminder
Definition of diabetes per Medicare for DSMT and MNT ELIGIBILITY - must meet one of the below:
- Fasting blood sugar > 126 mg/dL on two different occasions
- Random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes
- 2 hour post - glucose challenge > 200 mg/dL on two different occasions
Medicare does not recognize an A1C test to diagnose a patient with diabetes.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Psychosocial
Issues2
Consider annual depression screening in all patients with diabetes
and/or a self-reported history of depression or depressive symptoms.
(ADA Grade B) Consider assessment for depression beginning at
diagnosis of diabetes complications or when there are significant
changes in medical status. (ADA Grade B) Patients can be screened for
depression using the PHQ-2 and PHQ-9.
Patients with comorbid diabetes and depression should receive a
stepwise collaborative care approach for depression management.
(ADA Grade A)

Consider screening for anxiety in patients exhibiting anxiety or worry
regarding diabetes complications, insulin injections or infusions,
taking medications, and/or hypoglycemia that interfere with self-
management behaviors and those who express fear, dread, or
irrational thoughts and/or show anxiety symptoms such as avoidance
behaviors, excessive repetitive behaviors, or social withdrawal. Refer
for treatment if anxiety is present. (ADA Grade B) Patients can be
screened using the Generalized Anxiety Disorders-7 (GAD-7).

Consider screening for disordered or disrupted eating using validated
screening measures when hyperglycemia and weight loss are
unexplained based on self-reported behaviors related to medication
dosing, meal plan, and physical activity. A review of the medical
regimen is recommended to identify potential treatment-related
effects on hunger/calorie intake. (ADA Grade B)

Routinely monitor patients for diabetes distress, particularly when
treatment targets are not met and/or at the onset of diabetes
complications. (ADA Grade B) If identified, the patient should be referred
for diabetes education to address areas of diabetes self-care.
Patients can be screened using the Diabetes Distress Scale (DDS).
Assess psychosocial issues
and family stresses at
diagnosis and routine follow-up
care. Provide appropriate
referrals to mental health
professionals and consider
them as members of team.
(ADA Grade E)

Patients can be screened for
depression using the PHQ-2
and PHQ-9 or PHQ-A.

Patients can be screened for
anxiety using the Screen for
Child Anxiety Related
Disorders (SCARED).

Patients age 8-17 years with
Type 1 diabetes can be
screened for diabetes distress
using the Diabetes Distress
Scale (DDS) scale.
Tobacco Use All patients should be advised not to use tobacco products (ADA Grade A) or e-cigarettes (ADA Grade E) .
Eye Exam
Patients should have an initial dilated eye exam
within 5 yrs. or diagnosis if type 1, or shortly after
diagnosis if type 2. (ADA Grade B)

If no indication of retinopathy, repeat every 2
years. If retinopathy, repeat at least annually.
(ADA Grade B)
Women with
pre-existing
diabetes should
have eye exam
in 1st trimester,
with follow-up 1
yr. postpartum.
(ADA Grade B)
Dilated eye exam at age > 10
or after puberty, whichever is
earlier, once diagnosed with
type 1 for 3-5 yrs. (ADA Grade B)

Repeat every 1-2 yrs. per eye
care professional.
(ADA Grade E)
Foot Exam
Perform a comprehensive foot evaluation at least annually to identify
risk factors for ulcers and amputations. (ADA Grade B)

All patients should have their feet inspected at every visit.
(ADA Grade C )
Consider annual foot exam
puberty or age > 10 yrs. once
diagnosed with type 1 for 5 yrs.
(ADA Grade E)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Blood
Pressure
Goals
Target blood pressure < 140/90 mmHg
(ADA Grade A)

Lower targets, such as <130/80 mmHg, may be
appropriate for patients at high risk of CVD, if
achieved without undue treatment burden.
(ADA Grade C)
120- 160/80 - 105
mmHg
(ADA Grade E)
< 90th percentile for age, sex
and height (ADA Grade E)
Lipids
Screen at first diagnosis, initial medical
evaluation, and every 5 years thereafter, or
more frequently if indicated (ADA Grade E)

Intensify lifestyle therapy and optimize glycemic
control if triglyceride levels > 150 mg/dL and/or
low HDL < 40 mg/dL (men), < 50 mg/dL (women).
(ADA Grade C)

Ezetimibe in addition to moderate-intensity statin
may be considered in patients with recent acute
coronary syndrome and LDL > 50 mg/dL (AD A
Grade A) or in patients with history of ASCVD who
cannot tolerate high-intensity statins. (ADA Grade E )
Potentially
teratogenic
medications
(ACE inhibitors,
statins, etc.)
should be
avoided.
(ADA Grade B)
Screen using fasting lipid
profile if > 10 yrs. of age soon
after diagnosis (after glucose
control has been established).
(ADA Grade E)
If abnormal, annual monitoring
is reasonable. If LDL within
accepted risk level (< 100
mg/dL), a lipid profile repeated
every 3- 5 yrs. is reasonable.
(ADA Grade E)


After age 10, addition of statin
is reasonable (after MNT and
lifestyle changes) if LDL > 160
mg/dL or LDL > 130 mg/dL
and one or more CVD risk
factors, following
reproductive counseling and
implementation of effective
birth control due to the
potential teratogenic effects
of statins.
(ADA Grade E)
Age Risk Statin Dose**
< 40
yrs.
At Risk* Moderate or High (ADA Grade C)
ASCVD High (ADA Grade A)
40-75
yrs.
None Moderate (ADA Grade A)
At Risk* High (ADA Grade B)
ASCVD High (ADA Grade A)
> 75
yrs.
None Moderate (ADA Grade B)
At Risk* Moderate or High (ADA Grade B)
ASCVD High (ADA Grade A)
* ASCVD Risk Factors: LDL > 100 mg/dL, high BP, smoking,
overweight/obesity, family history of premature ASCVD.

**In addition to lifestyle therapy.
Aspirin
Consider aspirin therapy for primary prevention in those with type 1 or
type 2 diabetes at increased cardiovascular risk (10-year risk > 10%)
and are not at increased risk of bleeding. (ADA Grade C)

Aspirin is not recommended for ASCVD prevention in patients at low
ASCVD risk, such as patients age < 50 years with no other major
ASCVD risk factors. (ADA Grade C)

Aspirin therapy is recommended for secondary prevention in patients
with diabetes and a history of ASCVD. (ADA Grade A)


References
1. Aroda VR, Edelstein SL, Goldberg RB, et al. Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes
Study. J Clin Endocrinol Metab. 2016;101(4):1754-1761.
2. Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial Care for People With Diabetes: A Position Statement of
the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
3. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. 2017;40(Suppl 1):S1-135.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pharmacologic Therapy in Type 2 Diabetes:
A Patient-Centered Approach
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org



References:
1. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the
American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38(1):140-149.
2. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. 2017;40(Supplement 1):S67-S70.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 3/23/2017 | Last Reviewed 3/23/2017
Qu est i on s? C on ta ct In p a t i en t Di ab et es Qu a lit y C ommi tt ee
This reference is meant to reflect best practice. Provider orders (or delegated authority) are required to enact .
All Patients
 If p ossi b le, sch edu le t est ea rly i n th e da y.
 M oni t or b lood glu c ose freq u ent ly (b ef ore a n d a ft er p roc edu re). If p roc ed u re i s lon ger than 1 hour, m on i t or b lood glu c ose d u rin g th e p roc edu re (op ti mall y, ev er y h ou r).
 Hyp og l yc emi a : Glu c ose t a b let s c an be u sed b y t h e p at i ent a t an y t i me b efore or a ft er t h e p roc edu re i f sa fe t o swa l lo w. Use IV d ext ros e d u rin g th e p roc ed u re i f th e p at i ent i s seda t ed.
 Qu est i on s rela t ed t o medi ca ti on a dj u stmen t before/after contrast sh ou ld b e resol ved b y re fer ri n g t o UW Hea lt h Gu i d eli n e: C on t ra st -In d u c ed Neph ropa th y – Ad u lt – In p a t i en t/ Amb u la t ory.
Type 1 Diabetes
 B e su re th ere i s a lwa ys b a sal in su li n prescri b ed (in j ect i on s, pu mp, or in su li n d rip ) ; ketoacidosis (“DKA”) can occur if insulin levels are not maintained.
 C orrec t i on i n su lin (sli din g sca les) sh ou ld n ever b e u sed a s th e sole i n su lin bu t in st ead used only as a supplement to the patient’s basal in su li n regi men (gla rgi n e, NPH, or d et emi r) .
Type 2 Diabetes
 Pa t i ent s t rea t ed b y d i et a lon e sh ou ld ha ve b lood glu c ose mon i t orin g at mi nimu m t o rec ogn i ze h yp erg l yc emi a a nd t h en t rea t a s in di ca t ed.
 In gen era l, ora l h yp ogl yc emi c a gen t s a re omi t t ed on t h e d a y o f t h e p roc ed u re. Some ora l med i c a ti on s n eed t o b e ad ju st ed or omi tt ed the day before t h e p roc edu re i f th e di et wi ll c h an ge, i . e. c lea r li q ui d s.
 Pa t i ent s u sin g i n su lin wi ll req u i re i n su li n p re-p roc edu re a s n ot ed b elo w. In su li n sh ou ld n ot b e st op p ed. Ket oa c i dosi s c an occu r even t h ou gh t h e p at i ent h a s t yp e 2 d iab et es.
MEDICATION PREP DAY PROCEDURE DAY RESTARTING DOSE
OR
AL

AG
EN
T
S
AN
D

NO
N-
IN
SU
L
IN

IN
J
E
CT
IB
L
E
S
Secretagogues : Su lfon ylu r ea (gli p i zid e, glyb u ri d e, gli mep i rid e);
n on - su lfa d ru gs (rep a gli ni d e, n at egl i n id e)
Alpha-glucosidase: Ac a rb ose (Prec o se ® ), M i glit ol (Gl yset ® )
Amylin Analog: Pra mli nt id e (Symli n ® )
Hold i f on c lea r li q uid s, NPO , or b owel p rep n eed ed Hold
Aft e r p roc ed u re wh en ea t in g
u sua l mea ls
Biguanides: M et formi n, M et formi n XR (ext en d ed relea se )
Hold i f on c lea r li q uid s, NPO, or b owel p rep n eed ed Hold
C on sid er ch ec ki n g eGFR i f
p at i ent rec ei ved c ont ra st AND
h a s hi st ory of ren a l d i sea se.
GLP-1 agonists: i . e. , e xen a tid e (B yet t a ®, B yd u reon ® ) , l i ra glu ti d e
(Vi c t oza
®
) , d u la glu t id e ( Tru li c it y
®
), a lb i glu t id e
Hold i f on c lea r li q uid s, NPO, or b owel p rep n eed ed Hold
Aft e r p roc ed u re wh en ea t in g
u sua l mea ls
DPP-4 Inhibitors: “gliptins” – i . e. s it a gli p ti n (Jan u via ® ),
s a xa gli p ti n (On glyza
®
), l i na gli p ti n (Tra dj en ta
®
) , a logli p t in
(Nesi n a
®
)
Hold i f on c lea r li q uid s, NPO, or b owel p rep n eed ed Hold
TZDs: p i ogli t a zon e (Ac t os ® ), r osi gli ta zon e (Ava n d ia ® )
No rest ri c t i on s Hold
SGLT-2 Inhibitors “flozins” – i . e., c a n a gli flozi n ( In vok a n a ® ) ,
d ap a gli flozi n ( Fa rxi ga
®
), emp a gli flozi n ( Jard ia nc e
®
)
No rest ri c t i on s Ho ld
IN
SU
L
IN

Rapid-acting insulin analogs: li sp ro (Hu malog ® , Hu ma log ® U -
2 00 ), a sp a rt (Novol og
®
), glu li si n e (Ap id ra
®
)
Hol d i f on c lea r li q uid s, NPO , or b ow el p rep n eed ed .
( If patient uses carbohydrate-based insulin dosing for meals, insulin can
be taken to cover the carbs in the liquids.)
Hold
( may use to correct
hyperglycemia if patient uses
correction scale at home ) Aft e r p roc ed u re wh en ea t in g
u sua l mea ls Regular Insulin
Hold i f on c lea r li q uid s, NPO, or b owel p rep n eed ed .
(use to correct hyperglycemia if correction scale used at home)
Hold
(use to correct hyperglycemia if
correction scale used at home)
Intermediate-acting insulin
ξ Isop h a n e (NPH)
Usu a l d ose th e night before p rep a ra tion da y. Prep day: i f on c lea r li qui d s,
NPO , or b owe l p rep n eed ed , ½ d ose in th e morni n g (i f ta ki n g) a nd ½ of
u sua l even i n g d ose.
½ d ose in th e morni n g
Aft e r p roc ed u re wh en ea t in g
u sua l mea ls
Long-acting
ξ Gla rgi n e ( La n t u s ® , B a sa gla r ® ) , Det emi r (Lev emi r ® ) , Deglu d ec
( Tr esi b a
®
U - 10 0 )
Usu a l d ose, n o ad ju st men t i s req ui red .
Use c a ut i on for t h ose wh o u se b a sal in su lin ONLY wi t h out ora l a gen t s or in su lin for mea l c overa ge. Th ese
p at i ent s ma y n eed 2 0 - 5 0% less th an usu a l d ose.
C on ti nu e wi t h u su a l d ose (or
resu me u sua l d ose i f d ec rea se
h ad b een mad e p re - p roc ed u re)
Pre-mixed/combination insulins (e.g., 70/30, 75/25)
Usu a l d ose th e night before p rep a ra tion da y. Prep day: i f on c lea r li qui d s,
NPO, or b owe l p rep n eed ed , ⅓ to ½ d ose i n morn in g & even i n g ⅓ d ose i n th e morn in g
Aft e r p roc ed u re wh en ea t in g
u sua l mea ls
Concentrated insulin
ξ U - 5 00 , Deglu d ec U - 200 (Tresi b a® U - 2 00 ) , Gla rgi n e U - 30 0
(Tou j eo®)
NPO a dj u st men t for c on c en t rat ed i n suli n t yp es va ry. Diabetes/endocrine specialists should be consulted to
determine adjustment . (Du ra t i on of a c ti on : U - 500 : 12 h ou rs, U - 20 0 : 3 6 hou rs, U - 30 0 : 42 + h ou rs)
Aft e r p roc ed u re wh en ea t in g
u sua l mea ls
INSULIN PUMP : Ra pi d - a ct in g in su li n an a lo gs (li sp ro, a sp a rt ,
glu li si n e) a re u sed in i n su lin p u mp s. On oc ca si on , R egu la r in su lin
i s u sed . If U-500 is used, contact patient’s e nd oc rin ologi st .
No c h an ge i n b a sal i n su lin or pa ti en t c a n use a t emp ora ry b a sal d ec rea se t o main ta in t a rget B G. B olu s in su lin i s
n ot gi ven un less for h yp er gl yc emi a . REMOVE PUMP b efore most p roc edu res (i . e. , MR I, C T),
p roc ed u re/ su rger y l on ger t h an 2 h ou rs, an d/ or ot h er c on t rain di ca t i on s. (See Policy 10.25) SQ or IV i n su lin
i n fu si on M UST b e gi ven b efore t h e pu mp i s removed .
R esu me u su a l p rogra mmin g
wh en ea t i n g (p t sh ou ld c orrec t
for h yp er gl yc emi a a s lon g a s
p at i ent ca n ind ep en d ent ly
mana ge p u mp .
Medication Adjustment for Patients who are NPO
Diabetes Medication Adjustment: Ambulatory Procedures
Association AD. Professional Practice Committee for the
Standards of Medical Care in Diabetes-2017. Diabetes Care.
Jan 2017;40 Suppl 1:S1-135. Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Key Recommendations for Outpatient Management of Type 1 Diabetes Mellitus in Children

Screening in Children Diagnosis

Blood glucose rather than A1C should be used to diagnose the acute onset of type 1
diabetes in individuals with symptoms of hyperglycemia. (grade E)

Type 1 Diabetes is defined by the presence of 1 or more autoimmune Markers.
ξ GAD 65
ξ IA-2
ξ IA-2B
ξ ZnT8

ξ A1C: > 6.5%
ξ Fasting plasma glucose*: > 126 mg/dL ( * Fasting is defined as no caloric intake for > 8 hrs. )
ξ Random plasma glucose: > 200 mg/dL

When to
Test

Risk Factors:
ξ Symptoms of Hyperglycemia
o Polyuria
o Polydipsia
ξ Presence of autoantibodies
Tests
Plasma glucose
Hemoglobin A1C
Urinalysis
Autoimmune Markers
ξ GAD 65
ξ IA-2
ξ IA-2B
ξ ZnT8
MANAGEMENT
Lifestyle
Interventions
Nutrition Physical Activity
All patients with type 1 diabetes need to be evaluated by a registered
dietitian with expertise in addressing the nutritional needs of children with
Type 1 diabetes. (ADA Grade A)

Individualized eating plan and education.
Children with diabetes should be encouraged to engage in at
least 60 minutes of daily physical activity (vigorous-intensity
aerobic activity, bone/muscle-strengthening 3 days/week).
(ADA Grade B)

All patients should be encouraged to reduce sedentary time,
particularly by breaking up extended amounts of time (> 90
min.) spent sitting. (ADA Grade B)
Pharmacologic
Interventions
ξ Multiple Daily Injections: Including Basal and Prandial Insulin or Continuous subcutaneous insulin infusion (grade A)
ξ Use Rapid-acting insulin to reduce hypoglycemia risk (grade A)
ξ Match prandial insulin doses to carbohydrate intake, premeal blood glucose levels and anticipated physical activity (grade A)



References:
Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017; 40 (Suppl 1).
Kroenke, K & Spitzer, R. The PHQ-9: A New Depression Diagnostic and Severity Measure – 2002. Psychiatric Annals. Sep 2002: 32 (9).



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Monitoring
BLOOD GLUCOSE CONTROL
Test Frequency Notes
Blood Glucose
ξ Check blood
glucose levels
fasting, pre-
meal and at
bedtime until at
target level
ξ At diagnosis
ξ Review self-monitored blood
glucose (SMBG) at each visit
ξ Goal: 90-130 mg/dL pre-meals and 90-150 mg/dL at bedtime (individualize goals for
children < 6 years of age and/or hypoglycemia unawareness)

Hemoglobin A1C ξ A1C ξ At diagnosis
ξ Review A1C every 3 months
ξ Hemoglobin A1C goal < 7.5 % (< 7 % is reasonable if it can be achieved without
excessive hypoglycemia)
ξ Long term benefits of achieving lower A1C should be balanced against the risks of
hypoglycemia and developmental burdens of intensive regimens in children and
youth.
AUTOIMMUNE CONDITIONS

Thyroid Disease
TPO antibodies
TSH
ξ Consider testing antithyroid
peroxidase and antithyroglobulin
antibodies soon after
diagnosis.(grade E)
ξ Measure TSH at diagnosis and
after glucose control has been
established.
ξ Recheck TSH every 1-2 years
thereafter and sooner if patient
develops symptoms of thyroid
disorder.
ξ Thyroid disease occurs in 17-30% of patients with Type 1 Diabetes
ξ 25% of children with type 1 diabetes will have thyroid antibodies at the time of
diagnosis
ξ Thyroid function tests at diagnosis may be misleading (euthyroid sick
syndrome)

Celiac Disease TTG and IgA
ξ Screen tissue transglutaminase
and IgA levels soon after the
diagnosis (grade E)
ξ 1.6 % - 16.4 % of patients with type 1 diabetes will also be diagnosed with
celiac disease.
ξ Most cases of celiac disease are diagnosed within the first 5 years after the
diagnosis of type 1 diabetes. Consider repeat TTG and IgA at 2 years and 5
years after diagnosis and with symptoms
ξ If elevated a GI consult and small bowel biopsy is recommended to confirm
diagnosis
ξ In symptomatic children with confirmed celiac disease, gluten-free diets reduce
symptoms of rates of hypoglycemia.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

CARDIOVASCULAR RISK FACTORS
Tobacco Use Interview
patient/parent ξ Every visit (ADA Grade B)
ξ Discourage smoking in youth who do not smoke and encourage smoking
cessation in those who do.
ξ Consider secondhand smoke exposure and use of e-cigarettes
Hypertension Blood pressure ξ Every visit (ADA Grade B)
ξ Goal: < 90th percentile for age, sex and height (ADA Grade B)
ξ Confirm BP on 3 separate days.
ξ Consider Nephrology consult.
ξ Initial treatment of high/normal BP is diet and exercise. If target BP is not reached
within 3-6 months , pharmacologic treatment should be considered.(ADA Grade E)
ξ If HTN >95% tile is confirmed pharmacologic treatment is advised immediately in
addition to lifestyle modifications.
ξ Consider ACE Inhibitor following appropriate reproductive counseling. (ADA Grade E)
Dyslipidemia Fasting lipid profile
(ADA Grade E)
ξ Age 10
ξ For children with significant
family history of CVD, start at
age 2.
ξ If abnormal, repeat annually
(ADA Grade E)
ξ If LDL values are <100 mg/dL,
repeat every 3-5 years (ADA
Grade E)
ξ 14-45% of children with type 1 diabetes have two or more CVD risk factors and
prevalence increases with age, with girls having a higher risk burden than boys.
ξ Initial therapy consists of optimizing glucose control and medical nutrition therapy with
a registered dietician. (ADA Grade B)
ξ If patient 10 years old and LDL > 160 mg/dL after 6 months or LDL > 130 mg/dL and
one or more CVD risk factors, consider statins with goal of LDL < 100 mg/dL,
following reproductive education and implementation of effective birth control.
(ADA Grade E).
ξ Consider Pediatric Preventive Cardiology Clinic consult.
MICROVASCULAR COMPLICATIONS
Retinopathy Dilated eye exam
ξ Age 10 or after puberty has
started, once the youth has had
diabetes for 3-5 years.
ξ Annually thereafter (ADA Grade E)
Less frequent examinations (i.e., every 2 years) may be acceptable on the advice of an
eye care professional. (ADA Grade E)
Nephropathy
Random urine
sample for
microalbumin/
creatinine ratio
(UACR)

Creatinine
clearance/estimat
ed glomerular
filtration rate
ξ Annual urine screen (UACR)
once child has diabetes for 5
yrs. (ADA Grade B)
ξ Estimate glomerular filtration
rate at initial evaluation and then
based on age, diabetes
duration, and treatment.
ξ If initial positive screen, repeat on separate occasion
ξ When persistently elevated ratio (>30 mg/d) is documented in 2-3 urine samples:
treatment with an ACE inhibitor should be considered following appropriate
reproductive counseling. (ADA Grade C)
ξ Consider Nephrology consult.
Neuropathy Comprehensive
foot exam.
ξ Annually, starting at Age 10,
once the youth has had type 1
diabetes for 5 years.
ξ Comprehensive exam includes: inspection, palpation of pulses, reflexes,
proprioception, vibration and monofilament sensation and assessment of pain
symptoms.
ξ Include Foot Care Education



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

QUALITY OF LIFE
Self- Management
Education and
Support
ξ DSME/DSMS

ξ At diagnosis (B)
ξ With Routine Visits (B)
ξ Culturally sensitive
ξ Developmentally appropriate
ξ For both the patient and the caregivers
School and
childcare
ξ Interview
parent/child
ξ With Routine Visits ξ Assess the educational needs and skills of day care providers, school nurses or other
school personnel who participate I the care of the young child with diabetes.
Psychosocial
Issues:

ξ Depression

ξ Symptoms of
disordered
eating
ξ Interview
patient/parent
ξ Consider
screening for
diabetes distress
starting at 7-8
years of age.
ξ Depression
Screen (PHQ - 2,
with follow- up for
children > 12 yrs.)
ξ Consider
screening for
disordered eating
ξ At diagnosis (ADA Grade E)
ξ Every visit (ADA Grade E)
ξ Assess psychosocial issues and family stresses that could impact diabetes
management and provide appropriate referrals to trained mental health professionals,
preferably experienced in childhood diabetes. ( grade E)
ξ Provide developmentally appropriate family involvement in diabetes self-management
tasks in children and adolescents. (grade B)
ξ Mental health professionals should be considered integral part of pediatric
multidisciplinary team. (grade E)
ξ Youth and families with behavioral self-care difficulties, repeated hospitalizations for
DKA, significant family distress, consider referral to mental health provider for
evaluation and treatment.
ξ Adolescents should have time by themselves with their care provider starting at age
12. (grade E)
ξ Starting at puberty, preconception counseling should be incorporated into routine
diabetes care for all girls of childbearing potential. (grade A)
ξ Positive screen on PHQ - 2 ( > 3 points)
ξ Further assessment using PHQ - A or PHQ - 9 ( > 10 points)
Transition from
Pediatric to Adult
Care
ξ Prepare youth for
transition
ξ Early-mid adolescence and at
the least 1 year before transition
to adult health care (grade E)
ξ Both pediatric and adult HCP should provide support and links to resources for teen
and emerging adult
ξ Refer to UW Health Transition of Pediatric Patients with Special Health Care Needs to
Adult Health Care – Adult/Pediatric – Ambulatory Clinical Practice Guideline

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Key Recommendations for Outpatient Management of Type 2 Diabetes Mellitus in Children

Screening in Children (10- 18 years)
Diagnosis (ADA Grade B)

A diagnosis should be given when a positive
test result is exhibited on more than one
occasion.

ξ A1C: > 6.5%
ξ Fasting plasma glucose*: > 126 mg/dL
ξ 2-hr plasma glucose on 75-g oral glucose
tolerance test (OGTT): > 200 mg/dL
ξ Random plasma glucose: > 200 mg/dL
* Fasting is defined as no caloric intake for > 8 hrs.
When to
Test
Screen patients > 10 yrs. (or at onset of puberty if earlier) with BMI > 85th percentile for age
and sex, weight for height > 85th percentile, or weight > 120% of ideal for height AND two or
more additional risk factors. (ADA Grade E)

Risk Factors:
ξ First or second-degree relative with type 2 diabetes
ξ High risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific
Islander)
ξ Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, HTN, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth
weight)
ξ Maternal history of diabetes or GDM during pregnancy
Screening
Tests
A1C, fasting plasma glucose with insulin level, or oral glucose tolerance test (preferred with
fasting and 2-hour insulin levels) (ADA Grade B)
Frequency If results normal, repeat testing every 3 years. (ADA Grade C)
If results abnormal (prediabetes), repeat testing annually. (ADA Grade E)
First Line Therapy
Lifestyle
Interventions
Nutrition Physical Activity
All patients with type 2 diabetes need to be evaluated by a registered
dietitian at every visit with expertise in addressing the nutritional needs of
children with Type 2 diabetes and obesity. (ADA Grade A)

Healthy eating is encouraged with 3 meals and planned snacks, reducing
portion size (ADA Grade C), encouraging water consumption of water,
reducing juice intake, increasing consumption of fruits and vegetables.
(ADA Grade B)

Consider referral to Pediatric Fitness Clinic.
Children with diabetes should be encouraged to engage in at
least 60 minutes of daily physical activity (vigorous-intensity
aerobic activity, bone/muscle-strengthening 3 days/week).
(ADA Grade B)

All patients should be encouraged to reduce sedentary time,
particularly by breaking up extended amounts of time (> 90
min.) spent sitting. (ADA Grade B)
Pharmacologic
Interventions Metformin (ADA Grade A) Insulin (ADA Grade E)

References:
1. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017;40(Suppl 1):S6-127.
2. Springer SC, Silverstein J, Copeland K, et al. Management of type 2 diabetes mellitus in children and adolescents. Pediatrics. 2013;131(2):e648-664.
3. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
4. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247-2256.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Monitoring
Test Frequency Notes
Tobacco Use Interview patient/parent ξ Every visit (ADA Grade B) Consider secondhand smoke exposure and use of e-cigarettes
Blood
Glucose
Control
ξ Check blood glucose
levels fasting, pre-
meal and at bedtime
until at target level
ξ A1C
ξ At diagnosis
ξ Review self-monitored blood
glucose (SMBG) at each visit
ξ Repeat A1C every 3 months
Once at target level:
ξ Patients on metformin only: To be determined by individual provider
ξ Patients on basal insulin: Daily fasting blood sugars and 2-hour postprandial
ξ Patients on basal/bolus insulin therapy: Pre-meals and at bedtime.
Hypertension Blood pressure ξ Every visit (ADA Grade B)
ξ Goal: < 90th percentile for age, sex and height (ADA Grade E)
ξ If elevated, first line therapy is diet and exercise (ADA Grade E)
ξ If still elevated after 3-6 months, recommend further evaluation with laboratory
evaluation of sodium, potassium, chloride, bicarbonate, BUN, creatinine, urinalysis
without microscopy renal ultrasound and referral to Hypertension Clinic. Consider
ACE Inhibitor following appropriate reproductive counseling. (ADA Grade E)
Retinopathy Dilated eye exam ξ At diagnosis
ξ Annually thereafter (ADA Grade E)
Less frequent examinations (i.e., every 2 years) may be acceptable on the advice of an
eye care professional. (ADA Grade E)
Nephropathy
Random urine sample
for microalbumin/
creatinine ratio (UACR)

Creatinine
clearance/estimated
glomerular filtration rate
ξ At diagnosis
ξ Consider annual urine screen
(UACR) once patient has
diabetes for 5 yrs. (ADA Grade B)
ξ Measure creatinine clearance at
diagnosis, then based on age,
diabetes duration and treatment
thereafter (ADA Grade E)
ξ If initial positive screen, repeat on separate occasion
ξ If repeat screen is positive, recommend a 24 hour urine study for protein and
creatinine.
ξ If elevated (UACR > 30 mg/g) on 2/3 urine samples, consider renal consult and
initiation of an ACE inhibitor. (ADA Grade B)
Dyslipidemia Fasting lipid profile
(ADA Grade E)
ξ At diagnosis (ADA Grade E)
ξ If abnormal, repeat annually
(ADA Grade E)
ξ If normal, repeat every 5 years
(ADA Grade E)
ξ Initial therapy diet and exercise with counseling with a registered dietician (ADA Grade B)
ξ If patient 10 years old and LDL > 160 mg/dL after 6 months or LDL > 130 mg/dL and
one or more CVD risk factors, consider statins with goal of LDL < 100 mg/dL
(ADA Grade E)
ξ If triglycerides > 150 mg/dL and < 600 mg/dL, decrease simple carbohydrates, fat,
and increase exercise. If > 700 mg/dL, consider niacin therapy to prevent pancreatitis.
ξ Consider referral to Pediatric Preventive Cardiology Clinic
ξ Consider Omega 3 fatty acids.
Nonalcoholic
Fatty Liver
Disease
Liver Enzymes
(AST, ALT)
ξ At diagnosis
ξ Annually thereafter
Obstructive
Sleep Apnea Interview patient/parent ξ Every visit
Depression
ξ Interview
patient/parent
ξ PHQ-2, with follow-up
for children > 12 yrs.
ξ At diagnosis (ADA Grade E)
ξ Every visit (ADA Grade E)
ξ Positive screen on PHQ-2 (> 3 points)
ξ May further assessment using PHQ-A or PHQ-9 (> 10 points)

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Glycem ic Goals for
Hospitalized Patients
Last Updated 2/23/2017 I Last Reviewed 3/23/2017
Questions? Contact Inp atient Diabetes Quality Committee
Glycemic Goals
Adult Patients
Non-ICU and ICU Patient s:
 140 - 180 mg/dL
 <140 mg/dL may be appropriate for selected patients, as long as
this can be achieved without significant hypoglycemia.
Insuli n Infusi on Target :
 110 – 150 mg/dL
 Lower target
Pediatric Patients
Patient s wit h histor y of dia b etes:
 Ages 0-12: 100-180 mg/dL
 Ages 12-19: 90- 130 mg/dL
Newly dia gn os ed :
 100 - 180 mg/dL
Other Important Glycemic Values
Hypoglyc emia
 Glucose <70 mg/dL
 Refer to orders, adult/pediatric hypoglycemia treatment algorithms ,
and Patient Care Policy 13.24: Hypoglycemia, Care of the
Hospitalized Patient
Critical Values
 Critical Low: < 40 mg/dL
 Critical High: > 400 mg/dL
 See related policies: 11.26 Nova Stat Strip Blood Glucose Meter and
8.07 Communication of Critical Results and Critical Tests/Procedures
Reference: Association AD. Professional Practice Committee
for the Standards of Medical Care in Diabetes-2017. Diabetes
Care. Jan 2017;40 Suppl 1:S1-13 5.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Steps for Coordinating Glucos e Monitoring , Meals, and Medication s
for Inpatient Diabetes Care
Monitori ng
Check Blood Glucos e
9Check glucose no more
than 30 minutes before
insulin administration
Medicati ons
Insul i n
9 Lispro: Give within 0- 15
minutes of meal (after
meal if carb counting or
adjusting dose for intake)
9 Regular: Give 25- 35
minutes before meal
**Give PRN correction
insulin with meal dose if
possible to limit the
number of injections
Meals
9Ask patient to notify you
when ordering food or
when tray arrives
9Check glucose before
patient eats
9Document % meal eaten
and/or carb grams eaten
Last Revi sed 2/11/2016 | Last Reviewed 3/23/2017
Questions? Contac t Inpatient Diabetes Quali ty Committee
Association AD. Professional Practice Committee for
the Standards of Medical Care in Diabetes-201 7.
Diabetes Care. Jan 2017;40 Suppl 1:S1-135.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated January 2016 I Last Reviewed
3/23/2017 Inpatient Diabetes Quality Committee
Continuous Glucose Monitoring (CGM):
Information for Clinicians
C onti nuous Glucose Monitoring S ystems
(CGM) ar e devices th at c onti nuousl y
moni tor and record int e rs ti ti al flui d glucose
levels. P ati ents and fami li es ma y ref er to thi s
as “sensor the rap y. ”
How does a CGM (sensor) work?
C GM s ystems us e a ti n y sensor inserted
under the ski n to che ck glucose levels i n the
int erstit ial space . The sen sor sta ys in p la ce
for seve ral da ys to a wee k and then must be
replac ed. A transmitter is connected to the
sensor and sends i nfo rma ti on about glucose
levels vi a radio w aves fr om t he sensor to a
pager - li ke wireless monitor. The use r must
(cali brat e) ch eck blood s ampl e with a
glucose m eter to pro gra m t he device 2- 3
ti mes per da y.
What does a CGM look like?
Dexcom Medtronic
Can I use sensor glucose readings for
treatment?
ξ Glucose re adin gs obtaine d from t he
C GM are used to m onit or patt erns and
trends. T he y a re not i nte nded to replac e
standard blood glucose moni toring.
ξ An y diab etes int erv enti on (meal/ snack
insul in, correcti on ins uli n, or
h ypo gl yc emi a treatm ent) must be
preceded by POC blood glucose check.
Can anything alter sensor glucose values?
ξLag time: S ensor glucos e values a re
t ypicall y 10 - 15 mi nutes behind bl ood
glucose v alues.
ξCompression: If the s en sor is
compressed du e to pos it ioni ng , the
sensor glucose valu e can be dramatic all y
lower than the blood gluc ose value.
ξAcetaminophen: An y m edicati on with
acetaminophen wi ll false l y elev ate
sensor data fo r as much a s 8 hours.
How do I keep it safe if it needs to be
removed?
ξCGM transmitters are very expensive
and not disposable . I f y ou need to
remove the devi ce, c are f ull y li ft the tape
and pull the sensor out. P lace
sensor /t ransmi tt er (dr essi ng and all ) in a
pati ent belongin g container (ord er f rom
C S ) with a pati ent l abel on it for the
fami l y to t ake hom e.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Adult Hypoglycemia Treatme nt Algorithm
Patients
with
G-tubes
If
Bl
oo
d
Glu
co
se

is
b
et
wee
n


40
a
n
d
6
9 m
g/d
L
If
Bl
oo
d
Glu
co
se

is

le
ss
t
han
40 m
g/d
L
30 grams of car bohy dr ate =
6 to 8 oz. of juice or
8 glucose tablets
If patient has a G-tube being used for enteral nutrition and patient is conscious, 4-8 oz. juice may be used for initial treatment. If glucose is
less than 70 mg/dL after initial treatment, dextrose 50% or glucagon should be used as indicated below.
Other types of tubes (i.e., NG, Dobhoff, J -tubes) shoul d not be used for hypog l y c emi a treatm ent.
15 grams of car bohy dr ate =
3 to 4 oz. of juice or
4 glucose tablets
Rechec k glu c o se
with in 1 hour to
ensu r e glu c o se
rem ain s gr eate r th an
or equ al to 70 mg/dL
Consider rechecking
glucose within1 hour to
ensure glucose remains
greater than or equal to
70 mg/dL
Last updated: 2/23/2017 | Last reviewed: 03/2017
Questions? Contact Diabetes Quality Committee
Reference: Association AD. Professional Practice Committee
for the Standards of Medical Care in Diabetes-2017. Diabetes
Care. Jan 2017;40 Suppl 1:S1-1 35. Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

K+ <3 . 3 mE q /L K+ > 5 . 2 mE q /L
E stab lish ad eq uate ur ine o utp ut o f •5 0 ml/hr ,
then r ep lete, if nec essar y
P o tassium
E nsur e ad eq uate p o tassium level b efo r e
star ting insulin ther ap y
C he c k blood ga s e s , s e rum gluc os e , s odium, potas s ium, bic a rb, c hlor ide , a nion ga p, C BC with diffe re nt ia l, SC r, be ta -hydro xyb ut yra te, a nd a UA. Orde r a HbA1C , if not done in la s t 90 da ys . Start IV fluids : 1 L NS ove r 1 hour
‚
Fo r a p atient in HHS, use an I V so lutio n co ntaining 5 % d extr o se when b lo o d gluco se d ec lines to 300 mg/d L o r lo wer .
Ho ur ly gluco se mo nito r ing r eq uir ed ever y ho ur until gluco se within tar get r ange o f 1 1 0 -1 5 0 mg/d L fo r 3 ho ur s, then chec k ever y 2 ho ur s. Resume ho ur ly mo nito r ing if
b lo o d gluco se d eviates fr o m the tar get r ange. Chec k elec tr o lytes and p ho sp hate level ever y 2 ho ur s times two , then ever y 4 ho ur s. Chec k a b eta -hyd r o x yb ut yr at e level
ever y 8 ho ur s. I d entify and trea t the cause o f the DKA p r ecip itation.
Once the p atient is ab le to ea t a nd the DKA ep iso d e is r eso lved ( as d emo nstr ated b y p H >7 . 3 , b icar b o nate >1 8 mmo l/L, and b lo o d gluco se <2 0 0 mg/d L) , tr ansitio n the
p atient to sub cutaneo us ( SQ) insulin. Over lap the insulin d r ip with the SQ insulin b y 2 o r mo r e ho ur s. Fo r an insulin -naïve p atient, ca lculate the d aily insulin d o se
r ec eived via insulin infusio n in the last 2 4 ho ur s, d ec r ea se b y 2 0 %, and sp lit the r emaind er up as ½ b asal insulin and ½ mea l tim e insulin ( mea ltime d o se to b e d ivid ed
b etwee n all mea ls) . References: Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Research and Clinical Practice.
2011;94:340-351. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017;40 Suppl 1:S1-135.
K+ 3 . 3 to 5 . 2 mE q /L
B efo r e star ting insulin
ther ap y, give 1 0 -2 0 mE q
K+ p er ho ur in I V fluid s
until K+ >3 . 3 mE q /L
Á
Do no t sup p lement K+
b ut c hec k K+ level ever y
2 ho ur s
Give 1 0 -2 0 mE q /L o f K+ in I V fluid s to maintain
K+ level b etwee n 4 and 5 mE q /L
Á
Use an I V so lutio n co ntaining 5 %
d extr o se when b lo o d gluco se d ec lines
to 2 0 0 mg/d L
‚
o r lo wer
Give 0 . 9 % Na Cl
at r ate o f 1 L/hr
Hemo d yna mi c
mo nito r ing/p r esso r s
E valuate hyd r atio n status
Sever e
hyp o vo lemia
Mild
d ehyd r ation
Car d io genic sho ck
I nsulin
Use Stand ar d Do se I nsulin I nfusio n –
Ad ult – P r ac tice P r o to co l
I V Fluid s
E valuate co r r ec ted ser um Na+ co nce ntr atio n
Na+corrected = Na+ measured + [(glucose-100)/100]*1.6
No r mal o r high
ser um Na+
Lo w ser um
Na+
0 . 4 5 % NaCl at r ate
o f 2 5 0 -5 0 0 mL/hr
0 . 9 % NaCl at r ate
o f 2 5 0 -5 0 0 mL/hr
Á K� ,nfusion rates •�� m(T�hr reTuire a cardiac monitor.
Maximum r eco mmend ed r ate fo r p er ip her al K+ a d ministratio n is
no gr ea ter than 1 0 mE q /hr . Slid ing Scale p o tassium o nly allo wed
o n B 4 /3 , B 4 /5 , B 6 N3 , B 6 S3 , D4 /5 , D6 /5 I MC, F4 /5 , F4 M5 , F8 /4
UWHC DKA Man ag emen t Al g o ri thm (Ad u l t Pat i en t s )
Last updated: 2/23/2017 | Last Reviewed 3/23 /2017 Qu est i on s? C on t a c t In p a t i en t Di a b et e s Qu a li t y C ommi t t ee Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Insulin to Carbohydrate Ratios (ICRs)
(for Adult Inpatients)
1:4
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 4
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-1 0
2-5 1
6-9 2
10- 13 3
14- 17 4
18- 21 5
22- 25 6
26- 29 7
30- 33 8
34- 37 9
38- 41 10
42- 45 11
46- 49 12
50- 53 13
54- 57 14
58- 61 15
62- 65 16
66- 69 17
70- 73 18
74- 77 19
78- 81 20
82- 85 21
86- 89 22
90- 93 23
94- 97 24
98- 101 25
1:8
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 8
gram s of carbohydrat e)
Nutriti onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-3 0
4- 11 1
12- 19 2
20- 27 3
28- 35 4
36- 43 5
44- 51 6
52- 59 7
60- 67 8
68- 75 9
76-83 10
84- 91 11
92- 99 12
Patient who eat s 35 gram s
of carbs would recei v e 4
unit s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
See reverse side
for other ICRs
Custom Ratios
If provider orders a ratio that
is not 1:4, 1:5, 1:8, 1:10 ,
1:12, 1:15, or 1:20, you will
need to calculate the
appropriate insulin dose as
follows:
Total Grams of
Carbohydrates
Eaten
# grams per unit
insulin (1: x )
Exampl e :
 If ICR is 1: 3 and patient ate 30
grams of carbohydrate, you
would administer 10 units of
insulin
(30 ψ 3 = 10)
If dose needs to be rounded,
do so as fol l ow s :
‡˂ .5, round dow n
Example: If ICR is 1: 25 and
patient ate 30 grams of
carbohydrate, you would
administer 1 unit of insulin (30
ψ25 = 1.2 or 1 unit)
ೠ.5, round up
Example : If ICR is 1:8 and
patient ate 30 grams of
carbohydrate, you would
administer 4 units of insulin (30
ψ8 = 3.75 or 4 units)
= # units
insulin
1:5
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 5
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0 - 2 0
3-7 1
8- 12 2
13- 17 3
18 - 22 4
23 - 27 5
28 - 32 6
33- 37 7
38 - 42 8
43- 47 9
48 - 52 10
53- 57 11
58 - 62 12
63 - 67 13
68 - 72 14
73- 77 15
78 - 82 16
83 -87 17
88 - 92 18
93 - 97 19
98- 102 20
Patient who eat s 35 gram s
of carbs would recei v e 7
unit s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
Association AD. Profes s ional
Practice Comm itte e for the
Standards of Medical Care
in Diabete s - 2017. Diabete s
Care. Jan 2017;40 Suppl
1:S1-135.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

1:10
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 10
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-4 0
5- 14 1
15- 24 2
25- 34 3
35- 44 4
45- 54 5
55- 64 6
65- 74 7
75- 84 8
85- 94 9
95- 104 10
Patient who eat s 35 gram s
of carbs would recei v e 4
unit s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
1:15
Insuli n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 15
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-7 0
8- 22 1
23- 37 2
38- 52 3
53-67 4
68- 82 5
83- 97 6
Patient who eat s 35 gram s
of carbs would recei v e 2
uni t s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
Insulin to Carbohydrate Ratios (ICRs)
(for Adult Inpatients)
See reverse side
fo r other ICRs
1:20
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 20
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-9 0
10- 29 1
30- 49 2
50- 69 3
70- 89 4
90- 109 5
Patient who eat s 35 gram s
of carbs would recei v e 2
uni t s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
1:12
Insul i n to Carb Ratio (ICR)
(1 unit of insuli n cov ers 12
gram s of carbohydrat e)
Nutrit i onal Dose
Grams of
Carbs Eaten
Units of
Insuli n
0-5 0
6 -17 1
18- 29 2
30- 41 3
42- 53 4
54- 65 5
66- 77 6
78- 89 7
90- 101 8
102- 113 9
Patient who eat s 35 gram s
of carbs would recei v e 3
unit s of insuli n to cover
nut rit i onal needs (plus
more if correct i on insuli n
ordered for pre -m eal
hypergl y cem i a)
Step 1: Select ICR that corresponds with provider orders.
Step 2: Determine nutritional dose of insulin based on number of
carbohydrates patient ate.
Step 3: Determine if correction insulin is ordered/needed for pre-
meal hyperglycemia.
Step 4: Document carb grams eaten and insulin given.
Last Updated 2/12/2016 I Last Reviewed 3/23/2017
Questio n s? Contac t Inpatien t Diabete s Qu ali ty Committ e e
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 2/ 23/2017
Questions? Contact Inpatient Diabetes Quality Committee
Cautions �egar†ing �ral �gents for �ia„etes in tŠe
�os’ital �ettingȀIn’atient �ia„etes Management
Key Points about Oral Agents in Hospital Setti ngs :
ξ Oral medications are generally not recommended in hospitalized patients due to multiple factors.
ξ Stop metformin for following conditions: renal insufficiency, acidosis, decompensated heart
failure, or received contrast dye.
ξ Stop thiazolidinediones (TZD) for following conditions: fluid overloaded, congestive heart failure,
or liver dysfunction.
ξ Sulfonylureas should never be used in a patient who is NPO/not eating consistently.
Key Points about Initi ati ng Insuli n:
ξ UW Health Formulary options include glargine for basal insulin and lispro for nutritional and
correction insulin.
ξ Regular and NPH insulin are also available but used less frequently.
ξ Combination insulins are not recommended during inpatient hospital stays due to inconsistent
PO intake and increased risk of hypoglycemia.
ξ Patients with type 1 DM and insulin-requiring type 2 DM must have some basal (long-acting)
insulin even when NPO.
ξ Refer to Initiation of Insulin in Non-Critically Ill Insulin-Naive Hyperglycemic Patients – Adult –
Inpatient Algorithm for guidance about starting insulin.
Americ an Diabetes Assoc iati on Guideli nes 1:
ξ The sole use of sliding scale insulin in the hospital settings is strongly discouraged.
ξ Glucose monitoring should be obtained every 4 to 6 hours according to nutrition or more
frequently when IV insulin is used.
ξ Hypoglycemia protocols should be available whenever POC glucose monitoring is ordered.
ξ Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a
threshold ш18 0 mg/dL. Once insulin therapy is started, a target glucose range of 140 –1 80 mg/dL
is recommended for the majority of critically ill and non-critically ill patien ts. More stringent
goals, such as ख़1 40mg/dL, may be appropriate for selected patients, as long as this can be
achieved without significant hypoglycemia.
ξ An insulin regimen with basal insulin, nutrition al (if patients are receiving nutrition), and
correction components is the preferred approach for non-critically ill patients.
Oral Agents and Non - Insulin Inje ctab les
 Hold all oral agent s and non - i nsul i n inject ables 
( Orders are required )
Me di ca t i on Cla ss/ Exa mp le s
Bigua n i d e s (metformin): consider re -checking SCr post -procedure if
patient has received contrast AND has history of renal disease.
S u l fonyl u re a s ( glipizide, glyburide, glimepiride)
Me gli t i n i d e s (repaglinide, nateglinide)
Th i a z oli d i n e di one s (“TZDs” – i.e., pioglitaz one, rosiglitazone)
DPP - 4 inhi bi t ors (“gliptins” – i.e., sitagliptin, saxagliptin, linagliptin,
alogliptin)
GLP - 1 agon i st s (exenatide, liraglutide , albiglutide, dulaglutide )
S GLT - 2 Inhi b i t ors (“flozins” – i.e., canagliflozin, dapagliflozin,
empagliflozin)
1 Association AD. Professional Practice Committee for the Standards of Medical Care
in Diabetes- 2017. Diabet es Care. Jan 2017;40 Suppl 1:S1 - 135 .
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 3/23/2 01 7 | Last Reviewed 3 /23/2017
Qu est io ns? Co n tact I np atien t Diab etes Q ual it y Co mmit te e
 Patients with type 1 DM & insulin-requiring type 2 DM must have some basal (long- act i ng) insuli n even when NPO.

Type of Insul i n Onset Peak Durat i on
Adjustment When NP O
 A wri t t e n/ ve rb a l orde r is nee d e d to adj u st insul i n .
Bolus
I
nsulin

Hum a l og

(lis p ro)
Novol og

(asp a rt )
Api d ra


( glul i si ne )
Hum a l og U - 200
5-��” 1-2 hours 4-6 hours  Hold scheduled dose
 Give correction insulin as ordered to cover elevated glucoses (i.e. >150 mg/dL)
Re gul a r 30-��” 2-4 hours 6 -10 hours
Basal
I
nsulin

NPH 1-2 hours 4-8 hours 10-20 hours  Take ½ of AM dose (Give entire PM or HS dose)
**If NPH is being given to cover prednisone, the full dose may be needed.
De t e mi r (Le ve mi r

) 1-2 hours 8 -12 hours 12-24 hours  Give u su a l dose . U se caution for those who use basal insulin ONLY without oral agents
or insulin for meal coverage. These patients may need 20 -50% less than usual dose.
 Given long duration of action for degludec, convert to alternative basal insulin while
hospitalized.
De glu d e c
(Tre si b a

U - 10 0 )
1 hour 12 hours 42+ hours
Gla rgin e
(La n t u s

/
Ba sa gla r

)
1-2 hours Flat ~24 hours
Combinations

Insulin combinations containing mixtures of intermediate -acting
and short-acting or rapid -acting insulins will have onset, peak
and duration of action similar to the individual components.
 Comb i n a t i on insu l in s shoul d not be use d whe n NPO since the short - a ct i n g or rapi d -
a ct i n g comp one n t of the comb i n a t i on wil l ca use hypoglyce mi a .
 Orders for NPH and Regular (or rapid -acting) should be obtained. Give ½ dose of NPH
and hold Regular (or rapid -acting). ( Example : 30 units of 70/30 = 21 units NPH and 9
units Regular. Give 10 units NPH; hold Regular.)
Concentrated

De glu d e c U - 20 0 (Tre si b a
®
U - 2 0 0) : duration of action – 42 hours
Gla rgin e U - 3 00 (Touj e o
®
) : duration of action – 36 hours
U - 500 : duration of action – 12 hours
 NPO adjustment for concentrated insulin types vary . Diabetes/endocrine specialists
should be consulted to determine adjustment.
 Given long duration of action for degludec U -200 and glargine U -300, convert to
alternative basal insulin while hospitalized.
Oral Agents and Non - Insulin Inje ctab les  Hold all oral agents and non - i nsul i n inject abl es  ( Orders are required )
Medi ca t i on Cla ss/ Exa mp le s
Bigua n i d e s (metformin): consider re -checking SCr post -procedure if patient has received contrast AND has history of renal disease.
S u l fonyl u re a s ( glipizide, glyburide, glimepiride)
Me gli t i n i d e s (repaglinide, nateglinide)
Th i a z oli d i n e di one s (“TZDs” – i.e., pioglitazone, rosiglitazone)
DPP - 4 inhi bi t ors (“gliptins” – i.e., sitagliptin, saxagliptin, linagliptin, alogliptin)
GLP - 1 agon i st s ( i.e., exenatide, liraglutide , albiglutide, dulaglutide )
S GLT - 2 Inhi b i t ors (“flozins” – i.e., canagliflozin, dapagliflozin, empagliflozin)
Medication Adjustment for Hospitalized Patients who are NPO
Association AD. Professional Practice
Committee for the Standards of Medical Care
in Diabetes-2017. Diabetes Care. Jan 2017;40
Suppl 1:S1-135. Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Intr aven ou s (IV) to Subcutaneou s (SQ) Insuli n Transi tion Algori th m - Adult - Inpati ent
















Full Nutr ition
Patient is eating > 50% of meals or is receiving
> 50% of continuous goal tube feeds
Minimal Nutr ition
Patient is NPO, eating ч 50% of meals
or is on a clear liquid diet
OR
Step 6: Calcu late dose of SQ insu lin for patien ts rec e ivin g f ull nutr ition
Step 6a : Order correction insulin for PRN hyperglycemia
Step 6: Calcu late dose of SQ insu lin for
patien ts rec e ivin g min im a l nutr ition
Step 6a : Give 100 % of TDD as glargine
insulin 4 hours prior to discontinuation of
the IV insulin infusion
Step 6b : Order correction insulin for PRN
hyperglycemia
Patien t eating Meals
Give 40 - 50% of TDD
as glargine insulin
4 hours prior to
discontinuation of
the IV insulin infusion
and give 50 - 60% of
TDD as rapid- acting
insulin in 3 divided
doses with meals
Patien t on Continu o u s Tube Feeds (TF)
ξ Give 30 - 4 0 % of TDD as glargine insulin 4 hours
prior to discontinuation of IV insulin and give 60 -
7 0% of TDD as regular insulin in 4 divided doses
every 6 hours
ξ Not all p atients on TF will require glargine insulin:
o No prior history of diabetes
o No medications or insulin for diabetes
G ive these patients 100% of TDD as regular insulin in 4
divided doses every 6 hours . Give first dose 30
minutes prior to discontinuation of IV insulin
Step 5: �ǀĂůƵĂƚĞ�ƚŚĞ�ƉĂƚŝĞŶƚ͛Ɛ�ĐƵƌƌĞŶƚ�ŶƵƚƌŝƚŝŽŶĂů�ŝŶƚĂŬĞ
Step 1: Does patien t meet the follo win g inc lu sio n cr ite r ia f or use of th e algo r ith m ?
ξ Maintained on IV insulin infusion for > 24 hours; AND
ξ Controlled blood glucose (ч 3 blood glucoses > 180 mg/dL in the past 8 hours)
Yes (go to step 2)
Step 2: Does patien t meet the follo win g exclusio n cr ite r ia for use of th e algo r ith m :
ξ R equiring vasopressors
ξ Acute MI with cardiogenic shock
ξ Unresolved Diabetic Ketoacidosis (DKA)
ξ Acute changes in renal function (an increase in serum creatinine of ш 0.3 mg/dL in the last 48 hours)
ξ High dose steroid use (ш 4 0 mg of prednisone or equivalent daily) or undergoing a steroid taper
ξ Receiving total parenteral nutrition (TPN )
ξ Receiving tube feeding and not at goal
Yes Continue insulin infusion
Consult DMS for transition guidance
No (go to step 3)
Step 3 : Does the patien t need sch e d u le d SQ insu lin ? Yes
ξ Type 1 diabetes
ξ Type 2 diabetes requiring insulin
ξ Patients with a mean insulin infusion rate of ш 1 unit/hr
Yes (go to step 4 )
No
Patients with no history of diabetes or wi th
diabetes managed witho ut insulin AND
with a mean infusion rate of < 1 unit/ hour
Step 4: Calcu late th e to tal daily dose (TDD) of insu l in
SQ transition dosing may be guided by previous home insulin dose in patients with well - controlled diabetes (A1c < 8%)
Step 4a: Determine the average rate (units/hour ) of insulin infusion over the previous 8 hours
Multiply this average rate by 24 hours to calculate the total average daily insulin dose
Step 4b: Multiply daily average calculated in step 4 a by 0.8 to account for a conversion safety factor

Do NOT exceed a TDD of 120 units/day or > 1 unit/kg/day (actual body weight) unless patient was stable on dose prior to
admission. If TDD is > 120 units/day or > 1 unit/kg/day consider a Diabetes Management Service consult
TDD (units/day) = average insulin infusion rate (units/hour) X 24 hours X conversion safety factor (0.8)
Order SQ
correction insulin
& discontinue IV
insulin
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Exampl e Calcu l ati on s for Transi ti on of IV to SQ Insul in
Exampl e Calcu l ati on: Patien t eati n g > 50% of meal s
Exampl e Calcu l ati on: Patien t receivi n g > 50% of goal tu be feed s

* Not all patients on TF will require glargine insulin: (No prior history of diabetes, no medications or insulin for diabetes)
Give these patients 100% of TDD as regular insulin in 4 divided doses every 6 hours. Give first dose 30 minutes prior to
discontinuation of IV insulin
Exampl e Calcu l ati on: Patien t is NPO (Minimal Nutrit ion)

Patient ZZ is receiving full nutrition and has an average insulin infusion rate of 2 units/hr over the previous 8 hours
1.) 2 units/hr X 24 hours = 48 units total average daily dose
2.) 4 8 units X 0.8 (safety factor) = ~38 units TDD insulin
3.) 3 8 X 0.5 ( 50% ) = 19 units of glargine insulin given 4 hours prior to discontinuation of insulin infusion
38 X 0.5 (50%) = 19 units; 19 units ÷ 3 meals = ~ 6 units of rapid- acting insulin given with each meal
4.) Order correction insulin for PRN hyperglycemia
Patient YY is receiving 30 ml/hr of tube feeds. The goal tube feed rate for YY is 45 ml/hr. The average rate of insulin
infusion over the previous 8 hours was 3 units/hr. YY has a history of Type 2 diabetes requiring insulin.
1.) 3 units/ hr X 24 hours = 72 units total average daily dose
2.) 72 units X 0.8 (safety factor) = ~58 units TDD insulin
3.) 58 X 0. 4 (40%) = ~23 units of glargine insulin given 4 hours prior to discontinuation of insulin infusion
58 X 0.6 (60%) = ~35 units; 35 units ÷ 4 doses = ~ 9 units of regular insulin given every 6 hours
4.) Order correction insulin for PRN hyperglycemia
Patient XX is NPO and has an average insulin infusion rate of 1.5 units/hr over the previous 8 hours
1.) 1.5 units/hr X 24 hours = 36 units total average daily dose
2.) 36 units X 0.8 (safety factor) = ~29 units TDD insulin
3.) 29 units x 100 % = 29 un its of glargine insulin given 4 hours prior to discontinuation of insulin infusion.
4.) Order correction insulin for PRN hyperglycemia
Last revised: 02/18/2016
Last reviewed: 03/23/2017
Contact the Center for Clinical Knowledge M anagement or Drug Policy Program for revisions.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Referenc es :
1. Avanzini F, Marelli G, Donzelli W, et al. Transition from intravenous to subcutaneous insulin: effectiveness and safety
of a standardized protocol and predictors of outcome in patients with acute coronary syndrome. Diabetes Care.
2011;34(7):1445-1450.
2. Bode BW, Braithwaite SS, Steed RD, Davidson PC. Intravenous insulin infusion therapy: indications, methods, and
transition to subcutaneous insulin therapy. Endocr Pract. 2004;10 Suppl 2:71-80.
3. Czosnowski QA, Swanson JM, Lobo BL, Broyles JE, Deaton PR, Finch CK. Evaluation of glycemic control following
discontinuation of an intensive insulin protocol. J Hosp Med. 2009;4(1):28-3 4.
4. Donaldson S, Villanuueva G, Rondinelli L, Baldwin D. Rush University guidelines and protocols for the management
of hyperglycemia in hospitalized patients: elimination of the sliding scale and improvement of glycemic control
throughout the hospital. Diabetes Educ. 2006;32(6):954-962.
5. Furnary AP, Braithwaite SS. Effects of outcome on in-hospital transition from intravenous insulin infusion to
subcutaneous therapy. Am J Cardiol. 2006;98(4):557-564.
6. Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin infusion protocol in a
medical intensive care unit. Diabetes Care. 2004;27(2):461-467.
7. Kidney Disease: Improving Global Outcomes (KDIGO). Acute Kidney Injury Work Group. KDIGO clinical practice
guidelines for acute kidney injury. Kidney Int Suppl 2012; 2:1.
8. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care.
2009;32(7):1335-1343.
9. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of
critically ill patients. Mayo Clin Proc. 2003;78(12):1471-1478.
10. Magaji V, Johnston J. Inpatient management of hyperglycemia and diabetes. Clinical Diabetes. 2011;29(1):3-9 .
11. Magee MF. Hospital protocols for targeted glycemic control: Development, implementation, and models for cost
justification. Am J Health Syst Pharm. 2007;64(10 Suppl 6):S15-20; quiz S21-13.
12. O'Malley CW, Emanuele M, Halasyamani L, Amin AN. Bridge over troubled waters: safe and effective transitions of
the inpatient with hyperglycemia. J Hosp Med. 2008;3(5 Suppl):55-65 .
13. Ramos P, Childers D, Maynard G, et al. Maintaining glycemic control when transitioning from infusion insulin: a
protocol-driven, multidisciplinary approach. J Hosp Med. 2010;5(8):446-451.
14. Schmeltz LR, DeSantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to subcutaneously
administered insulin glargine in patients with hyperglycemia. Endocr Pract. 2006;12(6):641-650.
15. University of Pittsburgh Medical Center. Transition from IV to SQ insulin. 2010;
http://inpatient.aace.com/sites/all/files/UPMC_Protocol_for_Transition_from_IV_to_SQ_Insulin.pdf
16. Weant KA, Ladha A. Conversion from continuous insulin infusions to subcutaneous insulin in critically ill patients.
Ann Pharmacother. 2009;43(4):629-634.
17. Yeldandi RR, Lurie A, Baldwin D. Comparison of once-daily glargine insulin with twice-daily NPH/regular insulin for
control of hyperglycemia in inpatients after cardiovascular surgery. Diabetes Technol Ther. 2006;8(6):609-616.
18. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-201 7. Diabetes Care.
Jan 2017;40 Suppl 1:S1-135.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 2/23/2017 I Last Reviewed 3/23/2017
Questions? Contact Inpatient Diabetes Quality Committee
Initiation of Insulin in Non-Critically Ill Insulin-Naive
Hyperglycemic Patients – Adult – Inpatient
Target Inpati ent Blood Glucos e for Non - c ri ti c ally Ill
1 40 - 18 0 mg/dL ; <14 0mg/dL may be appropriate for select patient if hypoglycemia can be avoided
Criteria for Algorithm U se
Inclus i on cri teri a:
ξ Patients who have > 3 blood glucose (BG)
readings > 180mg/dL in a 24 hour time
period
ξ Patients not previously on scheduled insulin
or an insulin drip
Exclusi on criteri a:
ξ Type 1 diabetes
ξ Steroid induced hyperglycemia
ξ Parenteral nutrition
ξ Severe hyperglycemia (insulin drip required)
ξ Postoperative patients using Normoglycemia
Delegation Protocol
Step 1: Us e the chart below to ĚĞƚĞƌŵŝŶĞ�ƚŚĞ�ƉĂƚŝĞŶƚ͛Ɛ�ŝŶŝƚŝĂů�dŽƚĂů��ĂŝůLJ��ŽƐĞ�;d��Ϳ�ŽĨ�ŝŶƐƵůŝŶ�ďLJ�ƚĂŬŝŶŐ�ƚŚĞ
baseline estimate and subtracting/adding for each risk factor. Actual body weight should be used for
TDD calculation. Stop all oral and non-insulin injectable diabetes medications if previously taking.
B as eli ne TDD estimate 0.4 units / kg / day
Age > 70 - 0.1 unit/kg/day
Renal insufficiency (CrCl<60ml/min) - 0.1 - 0.2 units/kg/day
End stage liver disease - 0.1 unit/kg/day
Using non- insulin diabetes medication prior
to admission AND all BG>200mg/dL in past
24 hours
+0.1 unit/kg/day
Final TDD esti mate =_ ____ ___ ___ __
Step 2: Split TDD of insulin into basal-nutritional regimen depending on diet.
If eati ng meals : If rec eiv i ng conti nuous tube feeds (TF): If NPO:
Basal : glargine = TDD x 0.5 daily
Nutritional : rapid- acting insulin
(i.e. lispro) =
TDD x 0.5 divided by 3 for 'set
meal' dosing or based on
insulin:carb ratio orders.
Correction: rapid- acting insulin
(i.e. lispro) TID prn & bedtime
prn
Diabetes meal plan
recommended
Not on DM meds pri or to admi ss i on:
Basal : none
Nutritional * : regular insulin =
TDD divided by 4, dosed q6hrs (hold if TF off
for >1 hour)
Correction: regular insulin every 6hrs prn
Basal : glargine = TDD x 0.5 daily
Nutritional : none
Correction: rapid- acting insulin
(i.e. lispro) every 6hrs prn
Consider low - dose dextrose
infusion (D5- 1/2NS at 75ml/hr)
to prevent hypoglycemia.
On DM meds pri or to admis s i on:
Basal : glargine = TDD x 0.4 daily
Nutritional * : regular insulin =
TDD x 0.6 divided by 4, dosed every 6hrs
(hold if TF off for >1 hour)
Correction: regular insulin every 6hrs prn
*If patient is not at goal tube feed rate, consider reducing initial nutritional dose by up to 50% and titrating dose up as
necessary.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 2/23/2017 I Last Reviewed 3/23/2017
Questions? Contact Inpatient Diabetes Q uality Committee
Step 3 : Choose correction scale insulin for blood glucose excursions TID PRN or every 6 hours prn. *May add
HS scale for glucose >200mg/dl for patients eating meals.
Lower intens i ty Higher intensi ty
Blood Glucose (mg/dL) Insulin (units) Blood Glucose (mg/dL) Insulin (units)
151 - 200 1 151 - 200 2
201 - 250 2 201 - 250 4
251 - 300 3 251 - 300 6
301 - 350 4 301 - 350 8
>350 5 >350 10
Generally used for:
ξ Insulin sensitive (TDD<40units)
ξ Renal failure
Generally used for:
ξ Insulin resistant (TDD> 40units)
ξ Obese patients
Refer en c e s
1. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-201 7.
Diabetes Care. Jan 2017;40 Suppl 1:S1-1 35.
2. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients
in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab.
2012;97(1):16-3 8.
3. Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced
hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an
insulin management algorithm. J Hosp Med. 2009;4(1):3-1 5.
4. Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or
steroid-induced diabetes. Curr Diab Rep. 2013;13:114-120.
5. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and
American Diabetes Association Consensus Statement on inpatient glycemic control. Diabetes Care.
2009;32(6):1119-1131.
6. tĞƐŽƌŝĐŬ��͕�K͛DĂůůĞLJ��͕�ZƵƐŚĂŬŽĨĨ�Z͕�Ğƚ�Ăů͘�DĂŶĂŐĞŵĞŶƚ�ŽĨ�ĚŝĂďĞƚĞƐ�ĂŶĚ�Śyperglycemia in the hospital: a
practical guide to subcutaneous insulin use in the non-critically ill, adult patient. J Hosp Med.
2008;3:17-2 8.
7. Umpierrez GE, Smiley D, Ariel Z, et al. Randomized study of basal-bolus insulin therapy in the inpatient
management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2007:30(9):2181-2186.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Hypoglycemia Treatment Algorithm
G
ly
cemic V
alues

Treatment
(P
er
p
ro
v
id
er
o
rd
er
s
ba
se
d
o
n
ag
e,
se
ve
ri
ty
o
f
hy
po
gl
yc
e
mi
a,
a
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c
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o
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it
io
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If patient has a NG/G-tube being used for enteral nutrition and patient is conscious, juice , formula, or breast milk may be
used for initial treatment. If still hypoglycemic after initial treatment, IV dextrose or glucagon should be used as indicated
above. Other type s of tu b e s (i.e., Dobhoff, J-tu b e s) shou ld not be used for hyp o glyc e m ia tr eatm e n t.
Consider rechecking
g lucose afte r 1 hour
to ensure glucose
remains in normal
range.
For critical lows (<40
mg/dL), reche ck
glucose 1 hour afte r
glucose nor malize s
to ensure glucose
remains in normal
range.
Last updated: 3/23/2017 | Last reviewed 3/23/2017
Questions ? Contac t Inpatient Diabetes Qualit y Committee
References: Association AD.
Professional Practice Committee for
the Standards of Medical Care in
Diabetes-2017. Diabetes Care. Jan
2017;40 Suppl 1:S1-135.
Is patie nt able to
eat/s wallow safely ?
Yes
Yes
No
Give 15- 30 gram s
carbohy dr ate s
Establis h IV
acces s
Reche ck glucos e
within 15 minute s
Reasons for delayed recheck
(>15 min) and/or ongoing
efforts to correct
hypoglycemia must be
documented (i.e., initiating
antiemetic treatment to
promote PO intake, breast
feeding, obtaining IV access,
dextrose infusing)
No Adminis te r glucagon SQ or IM
(see orders for weight-based
dose)
0.03 mg/kg, max dose 1 mg
Continue to follow
Hypogly cem ia
Treatm e nt Algorithm
until no long e r
hypog ly cemic
If meal or snack is not
planned within 1 hour,
consider giving a
snack with protein for
those with diabetes
Does patie nt have
intr av e ne ous acces s ?
Patients
with
NG/
G-tubes
Follow indi vidua li zed orders (when
given) to accommodate speci al nee ds or
popul at ions (i.e., neonates, ketogeni c
therapy, metab oli c cond it ion s)
Adminis te r IV dextr os e ove r 2 -3 min
0.25-1 g/kg
(See orde r s : appropr iate dex tr os e
conce ntr ation is bas e d on patie nt age
and clinical sce nario)
Oral carbohy dr ate Choice s :
15 gram s of carbohy dr ate = 3 to 4 oz. of juice or 4 glucose tablets
30 gram s of carbohy dr ate = 6 to 8 oz. of juice or 8 glucose tablets
For less than 1 year of age, breast milk or formula
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Emergency Dept. Diabetic Ketoacidosis (DKA) Algorithm
Patient presentation with suspected DKA
Diabetes – Pediatric/Adult – Inpatient/Ambulatory Guideline
Mild Moderate Severe
Severity of
Dehydration
Initial Lab
Tests and
Evaluation
IV Fluids
(1
st
Hour)
Lab Results
Initial Labs: Glucose, POC; Potassium, whole blood; Sodium, whole blood; BMP (sodium, potassium, chloride,
bicarbonate, anion gap, glucose, BUN, creatinine, calcium); pH; Magnesium; Phosphate; Urinalysis; Consider Hgb A1C if
not completed in the last 90 days
Evaluation:
ξ Perform hourly neurological exams and vital signs
ξ Evaluate hydration status
ξ Perform continuous electrocardiogram monitoring to assess for hyper- or hypokalemia and arrhythmias
ξ Stop patient’s insulin pump (if applicable)
Normal saline 10 mL/kg Normal saline 20 mL/kgNormal saline maintenance
pH > 7.25 and CO2 > 15
pH < 7.25 and CO2 < 15
If only one parameter abnormal, consider anion gap and clinical appearance.
Alert and oriented patients ONLY
If any mental status concerns, suspect cerebral
edema and intervene immediately
1. Consult Pediatric Endocrinology to discuss:
ξ Last insulin dose (long-acting and short-acting)
ξ Current lab values
ξ Correction factor and patient sick day plans
(see last clinic visit note)
2. Administer subcutaneous insulin lispro (once) based
on discussion with Pediatric Endocrinology. Consider
insulin glargine if patient reports missed dose of long-
acting insulin. Check blood sugar every 2-3 hours and
give correction insulin every 2-3 hours.
3. Administer further 0.9% NS boluses as needed
depending on degree of dehydration. If unable to take
orally, consider starting 0.9% NS with 5% dextrose at
maintenance rate with close attention to glycemic
control.
4. Evaluate disposition. Instruct patient and family to
check blood sugar every 2-3 hours and give correction
insulin every 2-3 hours. Consider providing contact
information for diabetes resources (608-263-6420 or
www.uwhealthkids.org/type1diabetes)
1. Consult PICU if pH < 7.25 and CO2 < 15 OR if one abnormal
parameter and anion gap > 15 mmol/L or clinically unwell.
A consult to Pediatric Endocrinology may be more appropriate if
anion gap < 15 mmol/L and/or patient is well-appearing.
2. Administer IV insulin regular (0.1 units/kg/hr).
Hold if K < 3 mmol/L.
3. Administer 2
nd
Hour IV fluids at 1.5 x maintenance IV fluid
rate according to 2-bag system:
ξ If K > 5.5 mmol/L, 0.9% NS (Bag A) and 0.9% NS with 10%
dextrose (Bag B) given in ratio dependent upon blood
glucose (see table below)
ξ If K < 5.5 mmol/L, 0.9% NS with 20 mEq/L KCl (Bag A) and
0.9% NS with 10 % dextrose and 20 mEq/L KCl (Bag B) given
in ratio dependent upon blood glucose (see table below)
DKA DiagnosedDKA Not Diagnosed
Admit to PICU ASAP
Admit to General Care
Do NOT administer insulin bolus.
Do NOT administer bicarb.
Discharge
References:
1. Wolfsdorf J, Glaser N, Sperling MA, Association AD. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement
from the American Diabetes Association. Diabetes Care. May 2006;29(5):1150-1159.
2. Kapellen T, Vogel C, Telleis D, Siekmeyer M, Kiess W. Treatment of diabetic ketoacidosis (DKA) with 2 different regimens regarding fluid
substitution and insulin dosage (0.025 vs. 0.1 units/kg/h). Exp Clin Endocrinol Diabetes. May 2012;120(5):273-276.
3. Nallasamy K, Jayashree M, Singhi S, Bansal A. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical
trial. JAMA Pediatr. Nov 2014;168(11):999-1005.
4. Koves IH, Leu MG, Spencer S, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics. Sep 2014;134(3):e848-856.
5. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2016. Diabetes Care. Jan 2016;39 Suppl 1:S107-108.
4. Consider 2
nd
IV for
hourly lab draws:
Glucose, POC; pH;
Electrolytes, whole blood
(sodium, potassium,
chloride, total carbon
dioxide, anion gap)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Emergency Dept. Diabet ic Ketoacid osi s Algorit hm -Suppl ement
Pediatric DKA - Calculation of Bag A and Bag B Rates
Weight/kg Maintenance Rate 1.5 x Maintenance Rate
(total amount in second hour)
4 kg 16 ml 24 ml
5 kg 20 ml 30 ml
6 kg 24 ml 36 ml
7 kg 28 ml 42 ml
8 kg 32 ml 48 ml
9 kg 36 ml 54 ml
10 kg 40 ml 60 ml
11 kg 42 ml 72 ml
12 kg 44 ml 66 ml
13 kg 46 ml 69 ml
14 kg 48 ml 72 ml
15 kg 50 ml 75 ml
16 kg 52 ml 78 ml
17 kg 54 ml 81 ml
18 kg 56 ml 84 ml
19 kg 58 ml 87 ml
20 kg 60 ml 90 ml
21 kg 61 ml 92 ml
22 kg 62 ml 93 ml
23 kg 63 ml 95 ml
24 k g 64 ml 96 ml
25 kg 65 ml 98 ml
26 kg 66 ml 99 ml
27 kg 67 ml 101 ml
28 kg 68 ml 102 ml
29 kg 69 ml 104 ml
30 kg 70 ml 105 ml
31 kg 71 ml 107 ml
32 kg 72 ml 108 ml
33 kg 73 ml 110 ml
34 kg 74 ml 111 ml
35 kg 75 ml 113 ml
36 kg 76 ml 114 ml
37 kg 77 ml 116 ml
38 kg 78 ml 117 ml
39 kg 79 ml 119 ml
40 kg 80 ml 120 ml
41 kg 81 ml 122 ml
42 kg 82 ml 123 ml
43 kg 83 ml 125 ml
44 kg 84 ml 126 ml
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Emergency Dept. Diabet ic Ketoacid osi s Algorit hm -Suppl ement
Weight/kg Maintenance Rate 1.5 x Maintenance Rate
(total amount in second hour)
45 kg 85 ml 128 ml
46 kg 86 ml 129 ml
47 kg 87 ml 131 ml
48 kg 88 ml 132 ml
49 kg 89 ml 134 ml
50 kg 90 ml 135 ml
51 kg 91 ml 137 ml
52 kg 92 ml 138 ml
53 kg 93 ml 140 ml
54 kg 94 ml 141 ml
55 kg 95 ml 143 ml
56 kg 96 ml 144 ml
57 kg 97 ml 146 ml
58 kg 98 ml 147 ml
59 kg 99 ml 149 ml
60 kg 100 ml 150 ml
61 kg 101 ml 152 ml
62 kg 102 ml 153 ml
63 kg 103 ml 155 ml
64 kg 104 ml 156 ml
65 kg 105 ml 158 ml
66 kg 106 ml 159 ml
67 kg 107 ml 161 ml
68 kg 108 ml 162 ml
69 kg 109 ml 164 ml
70 kg 110 ml 165 ml
71 kg 111 ml 167 ml
72 kg 112 ml 168 ml
73 kg 113 ml 170 ml
74 kg 114 ml 171 ml
75 kg 115 ml 173 ml
76 kg 116 ml 174 ml
77 kg 117 ml 176 ml
78 kg 118 ml 177 ml
79 kg 119 ml 179 ml
80 kg 120 ml 180 ml
81 kg 121 ml 182 ml
82 kg 122 ml 183 ml
83 kg 123 ml 185 ml
84 kg 124 ml 186 ml
85 kg 125 ml (adult rate) 188 ml
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org