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Diabetes Medication Titration in Endocrine Diabetes Clinic/Health and Education Department – Adult – Ambulatory [88]

Diabetes Medication Titration in Endocrine Diabetes Clinic/Health and Education Department – Adult – Ambulatory [88] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 88

Delegation Protocol Title:
Diabetes Medication Titration in Endocrine Diabetes Clinic/Health and Education Department - Adult -
Ambulatory

Delegation Protocol Applies To:
UW Health Endocrine Diabetes Clinic
Health and Nutrition Education Department

Target Patient Population:
Adult patients with Type 2 diabetes

Delegation Protocol Champions:
Vanessa Rein, MD - Department of Medicine - Division of Endocrinology
Matt Anderson, MD - Department of Internal Medicine

Delegation Protocol Reviewers:
Cheryl Franz, RN, BSN – CDE, Clinical Staff Education
Shelly Van Note, PharmD – Pharmacy Department
Kristina Bennwitz, PharmD – Pharmacy Department
Jason Davis – Clinic Operations Manager

Responsible Departments:
Department of Medicine - Endocrinology

Purpose Statement:
To delegate authority from the endocrinology or primary care provider to Registered Nurses (RNs) and
Pharmacists (RPhs) in the UWHC Diabetes Clinic or UWMF Health and Nutrition Education Department
to titrate the diabetes medications listed in this protocol and to order the labs and supplies required to
monitor these medications.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) and Pharmacists (RPhs) experienced in managing diabetes and who have
successfully completed training in the use of this protocol.

Training and competency consists of the following:
1. Didactic instruction on all titratable medications in this protocol.
2. Successful completion of written competency.

Guidelines for Implementation:
1. This protocol is activated when a UW Health provider places the order in the Diabetes Education
Referral “Activate diabetes medication titration per protocol by RN CDE” or when the patient’s
diabetes is being managed by a UWHealth endocrinology provider with at least one diabetes
focused visit in the previous twelve months.
2. Contraindications. The RN/RPh will contact a provider for further direction if:
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2.1. The maximum dose (from Table 1) is reached and the patient has not met target
2.2. The patient experiences significant side effects/adverse reactions (see 6.3.2)
2.3. The patient is on metformin and has an eGFR <45 mL/min
2.4. The patient is on glyburide and has an eGFR <60 mL/min
2.5. The patient has an eGFR <30 mL/min
2.6. The patient is known to be pregnant
2.7. The patient is deemed incapable of or unwilling to comply to treatment plan
2.8. Other questions/issues arise
3. Only medications listed in this protocol (see Table 1) are authorized for delegated action. The
provider will order the medication and starting dose, but RN/RPh will enter orders to account for
changes in dose. The RN/RPh may also convert patients between regular-release and extended
release formulations as needed to improve compliance or manage side effects. Orders should be
limited to a 30-day supply with 2 refills until the patient is on a stable dose. Once the patient has
reached a stable dose, the order can be written for a 90-day supply with 1 refill.
4. Laboratory Tests
4.1. Before beginning titration, the patient must have had an A1C within the last 3 months and an
eGFR within the last 12 months.
4.2. The RN/RPh will enter orders for these laboratory tests if needed and await results before any
titration. Prior to placing any orders the RN/RPh will review the chart for any outstanding
orders to avoid duplicates.
5. The RN/RPh will order a blood glucose meter and/or testing supplies as needed. The RN/RPh will
confirm that the patient is knowledgeable on the use of supplies and provide training when
necessary.
6. Titration Steps
6.1. Targets
6.1.1. Fasting and pre-meal blood glucose 80 – 130 mg/dL
6.1.2. Two-hour post meal blood glucose < 180 mg/dL
6.1.3. Bedtime blood glucose 100-140 mg/dL
6.2. Dose Adjustments
6.2.1. If 50% or more of blood glucose readings are above target medications will be titrated
as in Table 1.
6.2.2. If any dose modifications are made the RN/RPh will update the patient’s medical
record with any changes and notify the patient of the medication changes.
6.3. Prior to making any dose adjustments the RN/RPH will:
6.3.1. Check for adherence with medication and confirm all doses in past week have been taken
as scheduled. If all doses have not been taken, the RN/RPh will not proceed to dose
titration, but will work to increase adherence with current dosing regimen and reassess in
one week.
6.3.2. Check for adverse effects to the medications, such as nausea, diarrhea, rash, and
hypoglycemia.
6.3.3. If the patient reports any episodes of hypoglycemia (blood sugar < 70 mg/dL):
• The RN/RPh will interview the patient to determine the severity and potential cause.
• The RN/RPh will provide education on causes, signs/symptoms, treatment and ways to
avoid future episodes.
• If the patient has more than 3 episodes of hypoglycemia in a 7-day period or has a single
blood glucose reading < 50 mg/dL the provider will be notified and consulted for follow-
up action.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

7. Discontinuation of protocol-based management:
7.1. The RN/RPh will discontinue the protocol when the patient has reached and maintained greater
than 50% of blood glucose readings in target range for at least 2 weeks.

Order Mode: Meds: Protocol/Policy, Without Cosign
Labs: Cosign Required, Protocol/Policy

References:
1. Clinical Practice Recommendations, 2016, Diabetes Care, Vol. 39, Supplement 1, January, 2016.
2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of Hyperglycemia in Type 2 Diabetes: A
Patient-Centered Approach. Diabetes Care 2012; 35: 1364 – 1379.
3. Nathan DM, Buse JB, Davidson MB, et al. Medical Management of Hyperglycemia in Type 2
Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A Consensus
Statement of the American Diabetes Association and the European Association for the Study of
Diabetes. Diabetes Care 2009;32(13):193-203.

Collateral Documents/Tools:
1. UW Health Diabetes – Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline. 2016
2. Diabetes Supplies – Adult/Pediatric – Ambulatory [110] Delegation Protocol
3. Diabetes Medication Titration– Adult – Ambulatory – Primary Care [87] Delegation Protocol

Approved By:
UW Health Ambulatory Protocol Committee – April 2013, January 2017
UW Health Pharmacy and Therapeutics Committee – July 2013, April 2017
UW Health Medical Board – August 2013, May 2017
UW Health Chief Clinical Officer – August 2013, June 2017

Effective Date: June 2017

Scheduled for Review: June 2020

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Table 1. Diabetes Medications with Titration Parameters for Endo and Health Ed
Biguanides Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Metformin
(Glucophage)
At least 3 FBGs within past week
AND
50% or more FBGs exceed target
500 mg PO 1x/day
1000 mg/day PO divided in 2 doses
1500 mg/day PO divided in 2 doses
1000 mg PO 2x/day
7 days 2000 mg/day eGFR < 45 mL/min
Metformin ER
(Glucophage XR)
At least 3 FBGs within past week
AND
50% or more FBGs exceed target
500 mg PO 1x/day
1000 mg PO 1x/day
1500 mg PO 1x/day
2000 mg PO 1x/day

Note: may split dose 2x/day based
on patient preference or GI side
effects
7 days 2000 mg/day eGFR < 45 mL/min

Sulfonylureas Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Glipizide
(Glucotrol)
At least 3 lunch and 3 supper BGs within past 2
weeks
AND
50% or more lunch and supper BGs exceed
target
5 mg PO each morning
10 mg PO each morning
7 days 10 mg/morning
dose
eGFR <30 mL/min
At least 3 FBGs and 3 bedtime BGs within past 2
weeks
AND
50% or more FBGs or bedtime BGs exceed target
5 mg PO each evening
10 mg PO each evening
7 days 10 mg/evening
dose
eGFR <30 mL/min
Glipizide ER
(Glucotrol XL)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
2.5 mg PO 1x/day
5 mg PO 1x/day
10 mg PO 1x/day
7 days 10 mg/day eGFR <30 mL/min
Glyburide
At least 3 lunch and 3 supper BGs within past 2
weeks
AND
50% or more lunch and supper BGs exceed
target
1.25 mg PO each morning
2.5 mg PO each morning
5 mg PO each morning
7 days 5 mg/morning
dose
eGFR < 60 mL/min
At least 3 FBGs and 3 bedtime BGs within past 2
weeks
AND
50% or more FBGs or bedtime BGs exceed target
1.25 mg PO each evening
2.5 mg PO each evening
5 mg PO each evening
7 days 5 mg/evening
dose
eGFR < 60 mL/min
Glimepiride
(Amaryl)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
1 mg PO 1x/day
2 mg PO 1x/day
7 days 4 mg/day eGFR <30 mL/min
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

AND
50% or more readings exceed target
4 mg PO 1x/day
Thiazolidinediones Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Pioglitazone
(Actos)
At least 3 FBGs within the past week
AND
50% or more readings exceed target
15 mg PO 1x/day
30 mg PO 1x/day
45 mg PO 1x/day
4 weeks 45 mg/day

If taking
gemfibrozil, max
is 15 mg/day
ALT > 3x upper
limit of normal
OR
eGFR <30 mL/min
Glucagon-Like Peptide-1
(GLP-1) Receptor Agonists
Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Albiglutide
(Tanzem)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
30 mg subq 1x/week
50 mg subq 1x/week
4 weeks 50 mg/week eGFR <30 mL/min
Dulaglutide
(Trulicity)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
0.75 mg subq 1x/week
1.5 mg subq 1x/week
4 weeks 1.5 mg/week eGFR <30 mL/min
Exenatide
(Byetta)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
5 mg subq 2x/day
10 mg subq 2x/day
4 weeks 10 mg 2x/day eGFR <30 mL/min
Liraglutide
(Victoza)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
0.6 mg subq 1x/day
1.2 mg subq 1x/day
1.8 mg subq 1x/day
7 days 1.8 mg/day eGFR <30 mL/min
Dipeptidyl Peptidase-4
(DPP-4) Inhibitors
Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Saxagliptin
(Onglyza)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
2.5 mg PO 1x/day
5 mg PO 1x/day
7 days 5 mg/day

If eGFR mL/min, max is
2.5 mg/day
eGFR <45 mL/min
Sodium Glucose Co-
Transporter 2 (SLGT2)
lnhibitors
Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Canagliflozin
(Invokana)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
100 mg PO 1x/day
200 mg PO 1x/day
300 mg PO 1x/day
7 days 300 mg/day

If eGFR <60
eGFR <60 mL/min
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

50% or more readings exceed target mL/min, max is
100 mg/day
Dapagliflozin
(Farxiga)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
5 mg PO 1x/day
10 mg PO 1x/day
7 days 10 mg/day eGFR <60 mL/min
Empagliflozin
(Jardiance)
At least 6 BGs (any combination of FBGs and
meal/bedtime) within past 2 weeks
AND
50% or more readings exceed target
10 mg PO 1x/day
25 mg PO 1x/day
7 days 25 mg/day eGFR < 45 mL/min
Meglitinides Titration Parameters Dose Adjustments Minimum Interval
Between Dose
Adjustments
Maximum
Protocol Dose
Consult Provider
Nateglinide
(Starlix)
At least 8 non-fasting BGs within past 2 weeks
AND
50% or more readings exceed target
60 mg PO before meals 3x/day
120 mg PO before meals 3x/day
7 days 120 mg 3x/day eGFR <30 mL/min
Repaglinide
(Prandin)
At least 8 non-fasting BGs within past 2 weeks
AND
50% or more readings exceed target
0.5-4 mg before meals up to 4x/day

Double preprandial dose until BGs
within target
7 days 4 mg 4x/day eGFR <30 mL/min
BG = Blood Glucose; FBG = Fasting Blood Glucose

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org