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**[CLASSIFICATION OF BLOOD PRESSURE IN
DM](http://vaww.va.gov/health/diabetes/DiabetesAlgorithm.doc#Patientwith)
^(a)^**

  ------------------------ ------------------------- ---------------------
                           **Systolic**              **Diastolic**

  Optimal                  \< 120 mm Hg and          \<80 mm Hg

  Normal                   \< 130 mm Hg and          \< 85 mm Hg

  High-normal              130-139 mm Hg or          85-89 mm Hg

  Hypertension             \> 140 mm Hg or           \> 90 mm Hg
  ------------------------ ------------------------- ---------------------

Blood pressure goal should be less than \<140/85, with lower target
levels individualized .

**[TARGET VALUE FOR HEMOGLOBIN
A1c](http://vaww.va.gov/health/diabetes/DiabetesAlgorithm.doc#Determinerecommended)
(HbA~1c~**)

+----------------------+-------------+---------------+----------------+
| **Risk factor**      |             |               |                |
+----------------------+-------------+---------------+----------------+
| **Major              | **Mi        |               |                |
| Co-Morbidity**       | crovascular |               |                |
|                      | Disease**   |               |                |
| **or**               |             |               |                |
|                      |             |               |                |
| **Advanced           |             |               |                |
| Physiologic Age**    |             |               |                |
+----------------------+-------------+---------------+----------------+
|                      | **Absent**  | **Moderate**  | **Advanced     |
|                      |             | ^2^           | ^3^**          |
|                      | **or Mild** |               |                |
|                      | ^1^         |               |                |
+----------------------+-------------+---------------+----------------+
| Absence^4^           | **\< 7%**   | **\<8%**      | **\< 9%**      |
|                      | (\<1% above | (\<2% above   | (\<3% above    |
|                      | upper       | upper normal  | upper normal   |
|                      | normal      | range)        | range)         |
|                      | range)      |               |                |
+----------------------+-------------+---------------+----------------+
| Present^5^           | **\<8%**    | **\<8%**      | **\< 9%**      |
|                      | (\<2% above | (\<2% above   | (\<3% above    |
|                      | upper       | upper normal  | upper normal   |
|                      | normal      | range)        | range)         |
|                      | range)      |               |                |
+----------------------+-------------+---------------+----------------+
| Marked^6^            | **\< 9%**   | **\< 9%**     | **\< 9%**      |
|                      | (\<3% above | (\<3% above   | (\<3% above    |
|                      | upper       | upper normal  | upper normal   |
|                      | normal      | range)        | range)         |
|                      | range)      |               |                |
+----------------------+-------------+---------------+----------------+

Major co-morbidity includes, but is not limited to, any or several of
the following conditions: cardiovascular disease, chronic obstructive
pulmonary disease, chronic liver disease, stroke, malignancy, etc.\
^1^ Mild microvascular disease is defined by early background
retinopathy, and/or microalbuminuria and/or mild neuropathy

^2^ Moderate microvascular disease is defined by pre-proliferative
retinopathy,macroalbuminuria) and/or demonstrable peripheral neuropathy
(sensory loss)

^3^ Advanced microvascular disease is defined by severe
non-proliferative ,retinopathy and/or renal insufficiency (serum
creatinine \> 2.0 mg/dl) and/or  insensate extremities or severe
autonomic neuropathy (gastroparesis, impaired sweating, orthostatic
hypotension, etc.)

^4^ Surrogate for \> 15 years of life expectancy

^5^ Moderate degree of major co-morbid condition (surrogate for 5-15
years of life expectancy)

^6^ Severe degree or end-stage major co-morbid condition (surrogate for
\<5 years of life expectancy)

**Every person with diabetes must have an annual documented foot risk
assessment**

**Visual inspection at routine primary care visit for high-risk
patient**

###### RECOMMENDED TREATMENT OPTIONS FOR TYPE 2 DM

+------------------------+-------------------+---+-----------------------+
| > **Therapy**          | > **Drugs**       | > |                       |
|                        |                   |   |                       |
|                        |                   | * |                       |
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|                        |                   | # |                       |
|                        |                   |   |                       |
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|                        |                   | p |                       |
+------------------------+-------------------+---+-----------------------+
| > Lifestyle            | > None            |   |                       |
| > modification, diet   |                   |   |                       |
| > and exercise         |                   |   |                       |
+------------------------+-------------------+---+-----------------------+
| > Lifestyle            | > Sulfonylurea or |   | > 1-2 percent         |
| > modification, diet   | > biguanide       |   |                       |
| > and exercise         |                   |   |                       |
| >                      |                   |   |                       |
| > Monotherapy with     |                   |   |                       |
| > oral agent           |                   |   |                       |
+------------------------+-------------------+---+-----------------------+
| > Lifestyle            | > Sulfonylurea +  |   | > 1-2 percent         |
| > modification diet    | > biguanide       |   | >                     |
| > and exercise         | >                 |   | > 0.5 to 1 percent    |
| >                      | > Sulfonylurea or |   | >                     |
| > Combination (add a   | > biguanide +     |   | > 0.7 to 1.75 percent |
| > second oral agent)   | >                 |   | >                     |
|                        | alpha-glucosidase |   | > 0.1 to .3 percent   |
|                        | > inhibitor       |   |                       |
|                        | >                 |   |                       |
|                        | > Sulfonylurea or |   |                       |
|                        | > biguanide +     |   |                       |
|                        | >                 |   |                       |
|                        | thiazolidenedione |   |                       |
|                        | >                 |   |                       |
|                        | > Biguanide +     |   |                       |
|                        | > repaglinide     |   |                       |
+------------------------+-------------------+---+-----------------------+
| > Insulin with oral    | > Biguanide +     |   |                       |
| > agent                | > insulin         |   |                       |
|                        | >                 |   |                       |
|                        | > th              |   |                       |
|                        | iazolidenedione + |   |                       |
|                        | > insulin         |   |                       |
|                        | >                 |   |                       |
|                        | > Sulfonylurea +  |   |                       |
|                        | > insulin         |   |                       |
+------------------------+-------------------+---+-----------------------+
| > Insulin              | > Insulin alone   |   |                       |
+------------------------+-------------------+---+-----------------------+

1.  Carefully selected individuals may benefit from three-drug oral
    hypoglycemic therapy. In general, such patients may benefit from
    referral to a diabetes care team.

Oral Hypoglycemic Agents

+-------------+---------------------------------+----------------------+
| # ORAL H    | # DOSING                        | # COMMENTS           |
| YPOGLYCEMIC |                                 |                      |
+-------------+---------------------------------+----------------------+
| # Su        |                                 |                      |
| lfonylureas |                                 |                      |
+-------------+---------------------------------+----------------------+
| 1^st^       |                                 |                      |
| generation  |                                 |                      |
+-------------+---------------------------------+----------------------+
| tolazamide  | Initial 100-250mg once daily    |                      |
|             |                                 |                      |
|             | Maintenance 250-500mg once      |                      |
|             | daily                           |                      |
|             |                                 |                      |
|             | Maximum 1000mg/d in 2 divided   |                      |
|             | doses                           |                      |
+-------------+---------------------------------+----------------------+
| tolbutamide | Initial 1000-2000mg in 1 or 2   |                      |
|             | divided doses                   |                      |
|             |                                 |                      |
|             | Maintenance 250-3000mg in 1 or  |                      |
|             | 2 divided doses                 |                      |
|             |                                 |                      |
|             | Maximum 3000mg in 1 or 2        |                      |
|             | divided doses                   |                      |
+-------------+---------------------------------+----------------------+
| 2^nd^       |                                 |                      |
| generation  |                                 |                      |
+-------------+---------------------------------+----------------------+
| glyburide   | Initial 1.25-5mg once daily     | Administer once      |
|             |                                 | daily doses with     |
|             | Maintenance 1.25-20mg in 1 or 2 | breakfast or first   |
|             | divided doses Maximum 20mg in 1 | main meal            |
|             | or 2 divided doses              |                      |
+-------------+---------------------------------+----------------------+
| glyburide   | Initial 0.75-3mg once daily     | Administer once      |
| micronized  |                                 | daily doses with     |
|             | Maintenance 0.75-12mg in 1 or 2 | breakfast or first   |
|             | divided doses                   | main meal            |
|             |                                 |                      |
|             | Maximum 12mg in 1 or 2 divided  |                      |
|             | doses                           |                      |
+-------------+---------------------------------+----------------------+
| glipizide   | ## Initial 2.5-5mg once daily   | Administer once      |
|             |                                 | daily doses with     |
|             | Maintenance 5-20mg once daily   | breakfast or first   |
|             |                                 | main meal            |
|             | Maximum 40mg in 2 divided doses |                      |
|             |                                 | Doses greater than   |
|             |                                 | 15mg/day should be   |
|             |                                 | divided and given    |
|             |                                 | twice daily          |
+-------------+---------------------------------+----------------------+
| glipizide   | ## Initial 5mg once daily       | Administer with      |
| extended    |                                 | breakfast            |
| release     | #                               |                      |
|             | # Maintenance 5-10mg once daily |                      |
|             |                                 |                      |
|             | Maximum 20mg once daily         |                      |
+-------------+---------------------------------+----------------------+
| g           | Initial 1-2 mg once daily       | Administer with      |
| limerperide |                                 | breakfast or first   |
|             | Maintenance 1-4 mg once daily   | main meal            |
|             |                                 |                      |
|             | Maximum 8mg once daily          |                      |
+-------------+---------------------------------+----------------------+
| Biguanides  |                                 |                      |
+-------------+---------------------------------+----------------------+
| metformin   | Initial 500mg bid or 850mg q am | Administer with      |
|             |                                 | meals                |
|             | Maintenance 850mg bid           |                      |
|             |                                 |                      |
|             | Maximum 2550mg in 3 divided     |                      |
|             | doses                           |                      |
+-------------+---------------------------------+----------------------+
| # Alpha-    |                                 |                      |
| glucosidase |                                 |                      |
|  inhibitors |                                 |                      |
+-------------+---------------------------------+----------------------+
| # acarbose  | Initial 25mg tid                | Administer with      |
|             |                                 | first bite of each   |
|             | Maintenance 50mg tid            | main meal            |
|             |                                 |                      |
|             | Maximum 100 mg tid; 50mg tid    |                      |
|             | ([\<]{.underline}60kg)          |                      |
+-------------+---------------------------------+----------------------+
| # miglitol  | Initial 25mg tid                | Administer with      |
|             |                                 | first bite of each   |
|             | Maintenance 50mg tid            | main meal            |
|             |                                 |                      |
|             | Maximum 100 mg tid              |                      |
+-------------+---------------------------------+----------------------+
| # Thiazol   |                                 |                      |
| idinediones |                                 |                      |
+-------------+---------------------------------+----------------------+
| # ro        | Initial 4mg qd or 2mg bid       | May be given without |
| siglitazone |                                 | regard to meals      |
|             | Maintenance                     |                      |
|             |                                 |                      |
|             | Maximum 8mg qd or 4mg bid       |                      |
+-------------+---------------------------------+----------------------+
| # p         | Initial 15 or 30mg qd           | May be given without |
| ioglitazone |                                 | regard to meals 45mg |
|             | Maintenance 30mg qd             | dose studied only as |
|             |                                 | monotherapy          |
|             | Maximum 45mg qd                 |                      |
+-------------+---------------------------------+----------------------+
| # M         |                                 |                      |
| eglitinides |                                 |                      |
+-------------+---------------------------------+----------------------+
| #           | Initial 0.5mg tid (for patients | Administer within    |
| repaglinide | who                             | 15-30 minutes of     |
|             |                                 | each meal            |
|             | are hypoglycemic agent naïve    |                      |
|             |                                 |                      |
|             | or have HbA1c \<8%). 1-2 tid    |                      |
|             |                                 |                      |
|             | mg (for patients previously     |                      |
|             |                                 |                      |
|             | treated with hypoglycemics      |                      |
|             |                                 |                      |
|             | or have HbA1c \>8%)             |                      |
|             |                                 |                      |
|             | Maintenance 0.5-4mg tid         |                      |
|             |                                 |                      |
|             | Maximum 16mg/day                |                      |
+-------------+---------------------------------+----------------------+