Type II Diabetes Mellitus

Academic Half Day

Objectives
 Define and identify the various types of diabetes mellitus disease.
 Discuss the pathophysiology, risk factors, and clinical presentations of
the disease.
 Highlight the screening and diagnostic criteria of type 2 diabetes
mellitus disease.
 Identify the diabetic complications and prognosis of the disease.
 Review ADA 2024 guideline
 Introduction
 Diabetes is a chronic condition caused by an absolute lack of insulin or
relative lack of insulin as a result of impaired insulin secretion and
action.
 The two most common classifications of diabetes mellitus are
 Type 1 diabetes
 Absolute insulin deficiency
 Type 2 diabetes
 Relative insulin deficiency due to β-cell dysfunction coupled with insulin resistance.
 Others: Gestational diabetes, and post-transplantation diabetes mellitus.

Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed November
28, 2021.
Deborah J Wexler, MD, MSc. Insulin therapy in type 2 diabetes mellitus. David M Nathan, MD, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on November 28th, 2021.)
 Pathophysiology

Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed
November 28, 2021.
 Pathophysiology, cont.

Brian K. Alldredge, Robin L. Corelli, Michael E. Ernst, B. Joseph Guglielmo, Pamala A. Jacobson, Wayne A. Kradjan, and Bradley R. Williams. Applied Therapeutics The Clinical Use of Drugs. 10e. Philadelphia,
PA 19103 USA; 2012.
 Clinical Presentation

Fatigue Polyuria Polydipsia

Unexplained
Ketonuria
weight loss
• Symptoms are mild in their onset, and patients will rarely complain.
• Many patients are incidentally discovered to have type 2 DM based on the results of a routine laboratory test or
development of complications (e.g., myocardial infarction, stroke, renal impairment).

Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed November 28, 2021.
Brian K. Alldredge, Robin L. Corelli, Michael E. Ernst, B. Joseph Guglielmo, Pamala A. Jacobson, Wayne A. Kradjan, and Bradley R. Williams. Applied Therapeutics The Clinical Use of Drugs. 10e. Philadelphia, PA 19103 USA; 2012.
 Risk Factors
 Age ≥ 45 years old.  Hypertension
 Family history of type 2 diabetes.
 Dyslipidemia
 Overweight or obese
 Sedentary lifestyle  History of vascular diseases
 History of impaired glucose tolerance or elevated A1C.  Polycystic ovary disease
 History of gestational diabetes mellitus (GDM).
 Presence of acanthosis nigricans

Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed
November 28, 2021.
 Diagnosis

FBG A1C OGTT

Normal <100 mg/dL ≤ 5.6% <140 mg/dL

100-125 mg/dL (5.6-6.9 5.7-6.4% (39-47 140-199 mg/dL (7.8-11

Prediabetes mmol/L) mmol/mol) mmol)

≥ 200 mg/dL (11.1

≥ 126 mg/dL (7 mmol/L) ≥ 6.5% (48 mmol/mol)
mmol/L)
Diabetes
OR Syptomatic patient with RBG> 200 mg/dL (11.1 mmol/L)

American Diabetes Association. Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S111-S124. doi: 10.2337/dc21-S009. PMID: 33298420.
Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed
November 28, 2021.
 Screening
 Adult with overweight or obesity who have one of the risk factors:
 First degree relative with diabetes.
 History of cardiovascular disease (CVD).
 Hypertension
 HDL cholestrol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level >
250 mg/dL (2.82 mmol/L).
 Physical inactivity.
 Women with polycystic ovarian syndrome.

American Diabetes Association. Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S111-S124. doi: 10.2337/dc21-S009. PMID: 33298420.
 Screening, cont.
 Patients with prediabetes should be tested yearly.
 Women who are diagnosed with Gestational diabetes mellitus (GDM)
should have lifelong testing at least every 3 years.
 HIV
 For all other patients, testing should begin at age 45 years.
 If results are normal, testing should be repeated at a minimum of 3
years interval.

American Diabetes Association. Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S111-S124. doi: 10.2337/dc21-S009. PMID: 33298420.
 Complications

 Acute complications:
 Diabetic ketoacidosis (DKA).
 Hyperosmolar hyperglycemic syndrome (HHS).
 Chronic complications:
 Microvascular including diabetic nephropathy, retinopathy, and neuropathy.
 Macrovascular including peripheral vascular disease, coronary heart disease,
and stroke.

Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed November
28, 2021.
 Prognosis

 Diabetes mellitus (DM) has been found to be related to high mortality,

morbidity and vascular complications, accompanied by poor general
health and lower quality of life.
 Diabetes is the seventh leading cause of death in the United States,
although deaths attributed to diabetes and its complications are likely to
be underreported.
 The mortality rate for people with diabetes is about twice that for people
without diabetes.

Brian K. Alldredge, Robin L. Corelli, Michael E. Ernst, B. Joseph Guglielmo, Pamala A. Jacobson, Wayne A. Kradjan, and Bradley R. Williams. Applied Therapeutics The Clinical Use of Drugs. 10e. Philadelphia, PA 19103 USA; 2012.
Al Dawish MA, Robert AA, Braham R, Al Hayek AA, Al Saeed A, Ahmed RA, Al Sabaan FS. Diabetes Mellitus in Saudi Arabia: A Review of the Recent Literature. Curr Diabetes Rev. 2016;12(4):359-368. doi: 10.2174/1573399811666150724095130. PMID:
26206092.
Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed November 28, 2021.
 Prognosis, cont
 People with DM are at far greater risk for CV disease (eg, myocardial
infarction, ischemic stroke).
 Optimal management of DM substantially
 Lowers the risk of complications.
 Increases life expectancy.
 Improves the quality of life.

Brian K. Alldredge, Robin L. Corelli, Michael E. Ernst, B. Joseph Guglielmo, Pamala A. Jacobson, Wayne A. Kradjan, and Bradley R. Williams. Applied Therapeutics The Clinical Use of Drugs. 10e. Philadelphia, PA 19103 USA; 2012.
Al Dawish MA, Robert AA, Braham R, Al Hayek AA, Al Saeed A, Ahmed RA, Al Sabaan FS. Diabetes Mellitus in Saudi Arabia: A Review of the Recent Literature. Curr Diabetes Rev. 2016;12(4):359-368. doi: 10.2174/1573399811666150724095130. PMID:
26206092.
Joseph T. DiPiro, Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod. Diabetes Mellitus. Pharmacotherapy: A Pathophysiologic Approach, 11e. New York, NY: McGraw-Hill; 2020. Accessed November 28, 2021.
 Glycemic Targets

Pre-prandial plasma Postprandial plasma

A1C <6.5% glucose 80–130 mg/dL glucose <180 mg/dL
(4.4–7.2 mmol/L) (<10 mmol/L)

Less stringent A1C

goals (E.g., <8%).

Limited life
expectancy.

The harms of
treatments are
greater than benefits.
Management
Section 9
Pharmacologic Approaches to Glycemic Treatment:
Standards of Care in Diabetes—2024
Type 2 Diabetes Mellitus Management

 Metformin is the preferred initial pharmacologic agent for the

treatment of type 2 diabetes. A
 Early combination therapy can be considered in some patients at
treatment initiation to extend the time to treatment failure. A
Pharmacologic Approaches to Glycemic
Treatment
• Metformin is effective and safe, is inexpensive, may reduce risk of cardiovascular
events and death.
• Available in an IR form for twice-daily dosing or as an ER form that can be given once
daily. Compared with sulfonylureas, metformin as first- line therapy has beneficial
effects on A1C, is weight neutral, does not cause hypoglycemia, and reduces
cardiovascular mortality.
• The principal side effects of metformin are gastrointestinal intolerance due to
bloating, abdominal discomfort, and diarrhea; these can be mitigated by gradual dose
titration and/or using ER.
• The drug is cleared by renal filtration, and very high circulating levels (e.g., as a result
of overdose or acute renal failure) have been associated with lactic acidosis. However,
the occurrence of this complication is now known to be very rare, and metformin may
be safely used in people with estimated glomerular filtration rate <30 mL/min/1.73 m2.
• When A1C is >1.5% above the individualized glycemic goal, many individuals will
require dual-combination therapy or a more potent glucose-lowering agent to achieve
and maintain their goal A1C level
Type 2 Diabetes Mellitus Management, cont.
 Many patients with type 2 diabetes eventually require and benefit from insulin
therapy.
 The early introduction of insulin should be considered if
 There is evidence of ongoing catabolism (weight loss),
 Symptoms of hyperglycemia are present,
 When A1C levels >10% [86 mmol/mol]
 Blood glucose levels ≥ 300 mg/dL [16.7 mmol/L]. E

• there is evidence that people with poorly managed hyperglycemia associated with
type 2 diabetes can also be effectively treated with a sulfonylurea, GLP-1 RA, or dual
GIP and GLP-1 RA.
• GLP-1 RAs and tirzepatide have additional benefits over insulin and sulfonylureas,
specifically lower risk for hypoglycemia (both) and favorable weight (both),
cardiovascular (GLP-1 RAs), and kidney (GLP-1 RAs) end points.
Type 2 Diabetes Mellitus Management, cont.
 Basal insulin alone is the most convenient initial insulin regimen and
can be added to metformin and other oral agents.
 Many individuals with type 2 diabetes require doses of insulin before
meals, in addition to basal insulin, to reach glycemic targets.
 In clinical trials, long-acting basal

Insulin Therapy
analogs (U-100 glargine or
detemir) have been demonstrated
to reduce the risk of level 2
hypoglycemia and nocturnal
hypoglycemia compared with NPH
insulin (126). Longer-acting basal
Basal Insulin
ana- logs (U-300 glargine or
• Basal insulin alone is the most convenient initial insulin treatment and can
degludec) be added
convey to nocturn
a lower
metformin hypoglycemia risk com- pared with
• Starting doses can be estimated based on body weight (0.1–0.2 U-100 glargine and the
units/kg/day)
degree of hyperglycemia, with individualized titration over days to weeks as needed.
• The principal action of basal insulin is to restrain hepatic glucose production and limit
hyperglycemia overnight and between meals
• Clinical signals that may prompt evaluation of overbasalization include basal dose
greater than 0.5 units/kg, high bedtime-to-morning or preprandial-to- postprandial
glucose differential (e.g., bedtime-to-morning glucose differential >50 mg/dL [>2.8
mmol/L]), hypoglycemia (aware or unaware), and high variability. Indication of
overbasalization should prompt reevaluation to further individualize therapy.
Insulin Therapy
Prandial Insulin

• Many individuals with type 2 diabetes require doses of insulin before meals, in addition
to basal insulin, to reach glycemic goals.
• basal insulin, to reach glycemic goals. If an individual is not already being treated with
a GLP-1 RA or dual GIP and GLP-1 RA, a GLP-1 RA (either as an individual product or in a
fixed-ratio combination with a basal insulin product) or dual GIP and GLP-1 RA should
be considered prior to prandial insulin to further address prandial control and to
minimize the risks of hypoglycemia and weight gain associated with insulin therapy
• For individuals who advance to prandial insulin, a prandial insulin dose of 4 units or
10% of the amount of basal insulin at the largest meal or the meal with the greatest
postprandial excursion is a safe estimate for initiating therapy
Combination Therapy
• The VERIFY (Vilda- gliptin Efficacy in combination with met- formin For earlY treatment
of type 2 diabetes) trial demonstrated that initial combination therapy—in this case of
metformin and the dipeptidyl peptidase 4, (DPP-4) inhibitor vildagliptin—is superior to
sequential addition of medications for extending primary and secondary failure (100).
Initial combination therapy should be considered in people presenting with A1C levels
1.5–2.0% above goal.
• Finally, incorporation of high-glycemic-efficacy therapies or therapies for cardiovascular
and kidney disease risk reduction (e.g., GLP-1 RAs, dual GIP and GLP-1 RA, and SGLT2
inhibitors) may allow for weaning of the current medication plan, particularly of agents
that may increase the risk of hypoglycemia and weight gain.
Concentrated Insulins
• U-500 reg- ular insulin is, by definition, five times more concentrated than U-100
regular
• regular insulin vials are prescribed, the prescription should be accompanied by a
prescription for U-500 syringes to minimize the risk of dosing errors.
Pharmacologic Approaches to Glycemic
Treatment
Pharmacologic Approaches to Glycemic Treatment, Cont.
Pharmacologic approach to glycemic treatment
Cardiovascular disease and risk
management
 Cardiovascular disease and risk
management

Target
BP <130/80 mmHg
 Cardiovascular Disease and Risk Management

HYPERTENSION/BLOOD PRESSURE CONTROL

• 10.1 Blood pressure should be measured at every routine clinical visit. When possible,
individuals found to have elevated blood pressure (systolic blood pressure 120–129
mmHg and diastolic <80 mmHg) should have blood pressure confirmed using multiple
readings, including measurements on a separate day, to diagnose hypertension. A
Hypertension is defined as a systolic blood pressure >130 mmHg or a diastolic blood
pressure >80 mmHg based on an average of two or more measurements obtained on
two or more occasions. A Individuals with blood pressure >180/110 mmHg and
cardiovascular disease could be diagnosed with hypertension at a single visit. E
• 10.2 All people with hypertension and diabetes should be counseled to monitor their
blood pressure at home after appropriate education. A
 Cardiovascular Disease and Risk Management

Treatment Strategies/Pharmacologic Interventions

• 10.7 Individuals with confirmed office- based blood pressure >130/80 mmHg qualify for
initiation and titration of pharmacologic therapy to achieve the recommended blood
pressure goal of <130/80 mmHg. A
• 10.8 Individuals with confirmed office- based blood pressure >150/90 mmHg should, in
addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or
a single-pill com- bination of drugs demonstrated to reduce cardiovascular events in
people with diabetes. A
• 10.9 Treatment for hypertension should include drug classes demonstrated to reduce
cardiovascular events in people with diabetes. A ACE inhibitors or angiotensin receptor
blockers (ARBs) are recommended first-line therapy for hy- pertension in people with
diabetes and coronary artery disease. A
Cardiovascular Disease and Risk Management
Cardiovascular Disease and Risk Management
Cardiovascular disease and risk
management
 10.24 In people with diabetes
intolerant to statin therapy,
Cardiovascular Disease and Risk Management
treatment with bempedoic acid
is recommended to reduce
cardiovascular event rates as an
LIPID MANAGEMENT – Primary Prevention alternative cholesterol-lowering
plan. A
Age CV Risk Factors
40-75 Nil Moderate intensity sattin LDL< 100 mg/dl
40-75 1 or more
With multiple CV RF High intensity statin LDL< 70 mg/dl
Reduce LDL 50% from
reasonable to add baseline
ezetimibe or a PCSK9
20-39 inhibitor
+ to maximum Reasnoble to start statin
tolerated statin therapy.
>75 Nil Reasnoble to start moderate
innsiy statin

>75 + Continue statin therapy

 Cardiovascular Disease and Risk Management

LIPID MANAGEMENT – Secondary prevention

• 0.26 For people of all ages with diabetes and ASCVD, high-intensity statin therapy
should be added to lifestyle therapy. A
• 10.27 For people with diabetes and ASCVD, treatment with high-intensity statin therapy
is recommended to target an LDL cholesterol reduction of >50% from baseline and an
LDL cholesterol goal of <55 mg/dL (<1.4 mmol/L). ( add ezetimibe or a PCSK9 inhibitor
if target not achieved ). B
• 10.28a For individuals who do not tolerate the intended statin intensity, the maximum
tolerated statin dose should be used. E
• 10.28b For people with diabetes and ASCVD intolerant to statin therapy, PCSK9
inhibitor therapy with monoclonal antibody treatment, A bempedoic acid therapy, A or
PCSK9 inhibitor therapy with inclisiran siRNA E should be considered as an alternative
cholesterol-lowering therapy.
Cardiovascular disease and risk
management
Cardiovascular Disease and Risk Management

ANTIPLATELET AGENTS

• Combination therapy with aspirin plus low-dose

Secondary rivaroxaban should be considered for individuals
Prevention with stable coronary and/or peripheral artery
disease (PAD) and low bleeding risk to prevent major
adverse limb and cardiovascular events

• HTN
Primary • Dyslipidemia
Prevention • Smocking
• Family h/o CAD
• Albuminuria
 Cardiovascular Disease and Risk Management

ANTIPLATELET AGENTS

• 10.34 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in

those with diabetes and a history of ASCVD. A
• 10.35a For individuals with ASCVD and documented aspirin allergy, clopidogrel (75
mg/day) should be used. B
 Cardiovascular Disease and Risk Management

ANTIPLATELET AGENTS, Cont.

• 10.36 Combination therapy with aspirin plus low-dose rivaroxaban should be

considered for individuals with stable coronary and/or peripheral artery disease (PAD)
and low bleeding risk to prevent major adverse limb and cardiovascular events. A
• 10.37 Aspirin therapy (75–162 mg/day) may be considered as a primary prevention
strategy in those with diabetes who are at increased cardiovascular risk, after a
comprehensive discussion with the individual on the benefits versus the comparable
increased risk of bleeding. A
 Cardiovascular Disease and Risk Management

CARDIOVASCULAR DISEASE – Treatment

• 10.41a In people with type 2 diabetes and established ASCVD, multiple ASCVD risk
factors, or diabetic kid- ney disease, an SGLT2 inhibitor with demonstrated
cardiovascular benefit is recommended to reduce the risk of major adverse
cardiovascular events and/or heart failure hospitalization. A
• 10.41b In people with type 2 diabetes and established ASCVD or multiple risk factors
for ASCVD, a GLP-1 recep- tor agonist with demonstrated cardio- vascular benefit is
recommended to reduce the risk of major adverse cardiovascular events. A
 Cardiovascular Disease and Risk Management

CARDIOVASCULAR DISEASE – Treatment, Cont.

• 10.41c In people with type 2 diabetes and established ASCVD or multiple risk factors
for ASCVD, combined therapy with an SGLT2 inhibitor with demonstrated
cardiovascular benefit and a GLP-1 receptor agonist with demonstrated cardiovascular
benefit may be considered for additive re- duction of the risk of adverse cardio-
vascular and kidney events. A
• 10.42a In people with type 2 diabetes and established heart failure with either
preserved or reduced ejection fraction, an SGLT2 inhibitor (including SGLT1/2 inhibitor)
with proven benefit in this patient popu- lation is recommended to reduce the risk of
worsening heart failure and cardiovascular death. A
• 10.42b In people with type 2 diabetes and established heart failure with either
preserved or reduced ejection fraction, an SGLT2 inhibitor with proven benefit in this
patient population is recommended to im- prove symptoms, physical limitations, and
quality of life. A
 Cardiovascular Disease and Risk Management

CARDIOVASCULAR DISEASE – Treatment, Cont.

• 10.43 For individuals with type 2 diabetes and chronic kidney disease with albuminuria
treated with maxi- mum tolerated doses of ACE inhibitor or ARB, addition of finerenone
is recommended to improve cardiovascular outcomes and reduce the risk of chronic
kidney disease progression. A
• 10.44 In individuals with diabetes with established ASCVD or aged >55 years with
additional cardiovascular risk factors, ACE inhibitor or ARB therapy is recommended to
reduce the risk of cardiovascular events and mortality. A
• 10.45a In individuals with diabetes and asymptomatic stage B heart failure, an
interprofessional approach to optimize guideline-directed medical therapy, which
should include a cardiovascular disease specialist, is recommended to reduce the risk
for progression to symptomatic (stage C) heart failure. A
 Cardiovascular Disease and Risk Management

CARDIOVASCULAR DISEASE – Treatment, Cont.

• 10.45b In individuals with diabetes and asymptomatic stage B heart failure, ACE
inhibitors/ARBs and b-blockers are recommended to reduce the risk for progression to
symptomatic (stage C) heart failure. A
• 10.45c In individuals with type 2 diabetes and asymptomatic stage B heart failure or
with high risk of or
• established cardiovascular disease, treatment with an SGLT inhibitor (including SGLT2
or SGLT1/2 inhibitors) is recommended to reduce the risk of hospitalization for heart
failure. A
• 10.45d In individuals with type 2 diabetes and diabetic kidney disease, finerenone is
recommended to reduce the risk of hospitalization for heart failure. A
Cardiovascular Disease and Risk Management
Section 10
Chronic Kidney disease
and risk management
CKD and Risk Management
CKD and Risk Management
CKD and Risk Management
• ACEI/ARB
Recommended in moderate increase albuminurea (3—299 mg/g)
Strongly recommned in sever albuminurea(>300 mg/g)
• SGLT2i
In all patients with DKD, recommended to reduce CKD progression and
CV events in patients with e GFR >20 ml/min and urinary albumin >200
mg/g
CKD and Risk Management, Cont.
• FINERENONE
Used if e GFR >25 ml/min and K+< 5mEq/L
10 mg/ 20 mg one weekly
Section 12
Retinopathy, Neuropathy
and Foot Care
Neuropathy
• 12.20 Gabapentinoids, serotoninnorepinephrine reuptake inhibitors,
tricyclic antidepressants, and sodium channel blockers are
recommended as initial pharmacologic treatments for neuropathic
pain in diabetes. A Refer to neurologist or pain specialist when pain
control is not achieved within the scope of practice of the treating
physician. E
• SNRI - duloxetine Avenlafaxine , all selective SNRI
• TCA – amitriptyline
• Capsaicin - FDA approved for pain as 8% patch
Neuropathy

• Sodium channel blockers - lamotrigine , lacosamide,

oxcarbamazepine, and valproic acid
• Carbamazepine not approved
Section 16. Diabetes Care in the
Hospital
GLYCEMIC GOALS IN HOSPITALIZED ADULTS

• 16.4 Insulin A and/or other therapies B should be initiated or intensified for treatment
of persistent hyperglycemia starting at a threshold of >180 mg/dL (>10.0 mmol/L)
(confirmed on two occasions within 24 h) for noncritically ill (non-ICU) individuals. A
• 16.5a Once therapy is initiated, a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is
recommended for most critically ill (ICU) individuals with hyperglycemia. A
• 16.5b More stringent glycemic goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be
appropriate for selected crtically ill individuals and are accept- able if they can be
achieved without significant hypoglycemia
Insulin Therapy

• 16.8 Basal insulin or a basal plus bolus correction insulin plan is the preferred
treatment for noncritically ill hospitalized individuals with poor oral intake or those who
are taking nothing by mouth. A
• 16.9 An insulin plan with basal, prandial, and correction components is the preferred
treatment for most noncritically ill hospitalized individuals with adequate nutritional
intake. A
• 16.10 Sole use of a correction or supplemental insulin without basal insulin (formerly
referred to as a sliding scale) in the inpatient setting is discouraged. A
Thank you.