Management of Diabetes
Federal Bureau of Prisons
Clinical Practice Guideline

April 2009

What’s New in this Document?
This is a targeted update of the February 2008 version of “Management of Diabetes”, which
has been issued to make the guideline consistent with the updated BOP guideline on
“Preventive Health Care.” Both guidelines have been adapted to be consistent with the
following U.S. Preventive Services Task Force recommendation:
There is only one group of asymptomatic, otherwise low-risk individuals for whom routine
diabetes screening is warranted. Those with a blood pressure greater than 135/80 (treated or
untreated) should be screened every 3 years.
Otherwise, glucose screening should be performed as clinically indicated, i.e., in association
with management of hyperlipidemia, cardiovascular disease, peripheral vascular disease,
history of gestational diabetes, or history of polycystic ovary disease.

Clinical guidelines are made available to the public for informational purposes only. The
Federal Bureau of Prisons (BOP) does not warrant these guidelines for any other purpose, and
assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper
medical practice necessitates that all cases are evaluated on an individual basis and that
treatment decisions are patient specific. Consult the BOP Clinical Practice Guideline Web page
to determine the date of the most recent update to this document:
http://www.bop.gov/news/medresources.jsp.

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Clinical Practice Guideline

Management of Diabetes
April 2009

What (Was) New in the Document?
(from the September 2002 version until the February 2008 major revision)
• The criteria for diagnosis of diabetes, impaired fasting glucose (IFG) and impaired glucose
tolerance (IGT) have been revised (Table 1, page 3). A new term, “pre-diabetes,” has been applied to
IFG and IGT.
• The screening criteria for diabetes have been revised (page 3). Obtaining a capillary blood glucose
from insulin dependent diabetics at intake is emphasized (page 4).
• Lifestyle interventions. The benefits of lifestyle intervention for inmates with IFG/IGT in preventing
or delaying the onset of type 2 diabetes are emphasized. The role of exercise as a diabetes treatment
intervention is more strongly emphasized. BOP institutions should consider implementing structured
exercise programs for diabetic inmates. The American Diabetes Association “Food Pyramid” is
included (Appendix 3).
• Treatment goals have been revised (Appendix 4), including an A1C goal of <7%.
• Early intervention for type 2 diabetes is emphasized. Recommendations for treatment of type 2
diabetes have changed (Section 6, starting on page 6).
• Drug treatment, in conjunction with lifestyle changes, is now recommended if the A1C
is >7% (making adjustments at least every three months until the A1C <7%).
• A new approach to the management of type 2 diabetes is presented in Appendix 5, BOP Treatment
Algorithm for Type 2 Diabetes.
• Initial therapy should generally consist of lifestyle intervention, plus metformin (unless
contraindicated). See new recommendations for titration of metformin (Table 3, page 10).
• Addition of insulin should not be delayed for type 2 diabetics who fail to meet glycemic goals on
oral medication. Insulin should be initiated and adjusted according to the flow chart in Appendix 6,
Initiation/Adjustment of Insulin Regimens in Type 2 Diabetes.
• Recommendations for insulin have been updated (Section 8, page 12). The use of intensive insulin
regimens is emphasized. Evening doses of NPH insulin should optimally be administered at bedtime or
as close to bedtime as feasible. Newly committed inmates who are on an insulin pump should
generally be maintained on a pump. Specific instructions for drawing up Regular and NPH insulin in
combination are provided.
• Infection control guidelines associated with diabetes management have been summarized
(Appendix 11). Finger stick devices must be issued for individual use only.
• Recommendations for blood glucose monitoring in the BOP are updated (Section 9, page 16).
Criteria for self-monitoring of blood glucose are provided.
• A glomerular filtration rate (GFR) should be calculated for all diabetic inmates at baseline and at
least annually. The calculation requires the following data: serum creatinine, age, sex, race. See GFR
calculator at: http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm.
• Recommendations for treatment of diabetic neuropathy have been added (Section 11, page 21).
• The following updated clinical tools are provided: Appendix 1, Components of the Comprehensive
Diabetes Evaluation and Appendix 2, Recommendations for Diabetes Clinic Chronic Care Monitoring.

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April 2009

Table of Contents
1. Purpose..................................................................................................................................... 1
2. Classification and Diagnosis .................................................................................................. 1
Table 1. Diagnostic criteria for diabetes and pre-diabetes (non-pregnant adults)....... 3
3. Screening.................................................................................................................................. 3
Preventive Health...................................................................................................................... 3
Previously Identified IFG or IGT ............................................................................................. 4
Pregnancy.................................................................................................................................. 4
4. Prevention/Delay of Type 2 Diabetes .................................................................................... 4
5. Baseline Evaluation and Initial Treatment Plan.................................................................. 4
Intake Blood Glucose Screening of Diabetics .......................................................................... 4
Baseline Evaluation .................................................................................................................. 4
Initial Treatment Plan ............................................................................................................... 5
Lifestyle Intervention................................................................................................................ 5
6. Type 2 Diabetes Treatment .................................................................................................... 6
Goals and Principles ................................................................................................................. 6
Medications for Type 2 Diabetes.............................................................................................. 6
Table 2. Summary of antidiabetic interventions as monotherapy for type 2 diabetes. 7
Metformin ........................................................................................................................... 7
Insulin ................................................................................................................................. 8
Sulfonylureas (SUs) ............................................................................................................ 8
BOP Treatment Algorithm for Type 2 Diabetes....................................................................... 9
Definite indications for insulin as initial therapy ............................................................. 10
Step 1: Lifestyle intervention and metformin .................................................................. 10
Table 3. Titration of metformin ................................................................................. 10
Step 2: Add a sulfonylurea or insulin .............................................................................. 10
Step 3: Add or intensify insulin ....................................................................................... 11
Rationale in selecting specific combinations.................................................................... 11

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7. Treatment of Type 1 Diabetes.............................................................................................. 11
8. Insulin and Insulin Administration..................................................................................... 12
Intensive vs. Conventional Insulin Therapy ........................................................................... 12
Insulin and Insulin Analogues ................................................................................................ 12
Table 4. Onset and Peak of Commonly Used Insulin Preparations........................... 13
Designing a Multiple-Dose Insulin Regimen ......................................................................... 13
Insulin Administration ............................................................................................................ 14
Coordination of Insulin and Food Intake................................................................................ 15
9. Blood Glucose Monitoring .................................................................................................... 16
10. Gestational Diabetes (GDM)............................................................................................... 17
Detection and Diagnosis ......................................................................................................... 17
Table 5. Gestational diabetes risk categories & related screening recommendations17
Table 6. Diagnostic criteria gestational diabetes mellitus ......................................... 17
Potential Complications of GDM ........................................................................................... 18
Monitoring and Treatment During Pregnancy........................................................................ 18
Postpartum Monitoring ........................................................................................................... 18
11. Medical Management of Diabetic Complications .............................................................. 19
Hypertension ........................................................................................................................... 19
Aspirin Therapy ...................................................................................................................... 19
Dyslipidemia ........................................................................................................................... 19
Diabetic Nephropathy ............................................................................................................. 20
Table 7. Stages of Chronic Kidney Disease .............................................................. 20
Diabetic Retinopathy .............................................................................................................. 21
Diabetic Neuropathy ............................................................................................................... 21
Dental Care ............................................................................................................................. 23
Medical Decompensation (Hospitalization Criteria) .............................................................. 24
12. Periodic Evaluations ............................................................................................................. 25
13. Health Care Provider Resources ......................................................................................... 28

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Definitions.................................................................................................................................... 29
References.................................................................................................................................... 31
Appendix 1: Components of the Comprehensive Diabetes Evaluation ................................ 32
Appendix 2: Recommendations for Diabetes Chronic Care Clinic Monitoring.................. 33
Appendix 3: The Diabetes Food Pyramid................................................................................ 34
Appendix 4. Treatment Goals for Nonpregnant Inmates with Diabetes .............................. 36
Appendix 5: BOP Treatment Algorithm for Type 2 Diabetes............................................... 37
Appendix 6: Initiation/Adjustment of Insulin Regimens in Type 2 Diabetes ...................... 38
Appendix 7: Oral Agents for Treatment of Type 2 Diabetes (Dosing/Side Effects) ............ 39
Appendix 8: Alternative Medications for Treatment of Type 2 Diabetes ............................ 42
Appendix 9: Keys to Controlling Diabetes .............................................................................. 44
Appendix 10: Inmate Fact Sheet on Diabetes ......................................................................... 45
Appendix 11. Infection Control for Diabetes Care Procedures............................................. 46
Appendix 12: Resources for Information on Diabetes ........................................................... 48

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April 2009

1. Purpose
The Federal Bureau of Prisons (BOP) Clinical Practice Guidelines for Management of Diabetes
provides recommendations for the medical management of Federal inmates with diabetes
mellitus.

2. Classification and Diagnosis
Classification
Diabetes is classified into four general categories, as listed below.
Note: Despite the general differences listed below for types 1 and 2, it is sometimes difficult to
determine whether an individual has type 1 or type 2 diabetes.
Type 1 diabetes is a disease resulting from absolute insulin deficiency, usually caused by
autoimmune destruction of pancreatic islet cells. The initial clinical presentation may be
ketoacidosis with an acute illness, or a more gradual presentation with symptoms of
hyperglycemia. Other autoimmune disorders may also be present such as Addison’s disease,
thyroiditis, and pernicious anemia. A small subset of patients with type 1 diabetes have a nonimmune mediated disease process with a waxing and waning clinical course. This form of type 1
diabetes is strongly inherited and most commonly affects persons of African and Asian descent.
The typical patient with type 1 diabetes:
•

Is often diagnosed as a child or young adult (although it can occur at any age).

•

Is lean (i.e., BMI less than 25 kg/m2).

•

Displays normal insulin sensitivity, i.e., insulin requirements do not exceed 0.7 units of
insulin/kilogram body weight/24 hours.

•

Displays evidence of anti-beta cell autoimmunity (i.e., anti-GAD, anti-IA-2, and/or antiinsulin antibodies).

•

Is more “ketosis prone” than individuals with type 2 diabetes (i.e., if the individual has a
history of repeated bouts of DKA, they are far more likely to have type 1).

Type 2 diabetes is a disease resulting from a relative, rather than an absolute, insulin deficiency
with an underlying insulin resistance. Type 2 diabetes is associated with obesity, age, and
physical inactivity. Patients with type 2 diabetes are not prone to ketoacidosis, frequently do not
require insulin, and may be asymptomatic, despite being hyperglycemic for many years.
The typical patient with type 2 diabetes:
•

Is more likely to be diagnosed as an adult.

•

Is overweight or obese (i.e., BMI >25 kg/m2, and often far exceeding that BMI).

•

Is more likely to have a family history of diabetes (>90% of those with type 2 diabetes will
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have a first degree relative with the disease).
•

If treated with insulin, is more likely to require very large doses to control the blood glucose
(e.g., >0.7 units/kg/day) due to insulin resistance. Such individuals frequently have
characteristics associated with insulin resistance, including abdominal obesity, hypertension,
lipid abnormalities, atherosclerosis, and hyperuricemia.

•

Does not have evidence of anti-beta cell specific antibodies. Those who do have such
circulating antibodies are sometimes referred to as having latent autoimmune diabetes of the
adult (LADA). Such individuals seem to have a slowly progressive beta cell destructive
process much like that occurring in children with typical type 1 diabetes, but the beta cell
destruction occurs more slowly.

•

Is much less likely to have a history of diabetic ketoacidosis (DKA), but may have a history
of hyperosmolar coma.

•

Is more likely to suffer other consequences of the “metabolic syndrome,” e.g. hypertension,
hyperlipidemia.

Gestational diabetes (GDM) is diabetes or any degree of glucose intolerance that is diagnosed
during pregnancy. Detection, diagnosis and treatment of gestational diabetes are discussed in
Section 10, Gestational Diabetes.
Other causes of diabetes that are not classified as either type 1 or type 2 include: genetic defects
of islet cell function; genetic defects in insulin action; endocrinopathies such as Cushing’s
disease or syndrome; drug- or chemical-induced hyperglycemia; infections; and insults to the
pancreas from a variety of causes such as pancreatic cancer, cystic fibrosis, trauma, and
pancreatitis.

Diagnosis
Inmates with any of the following should be evaluated for diabetes: symptoms of
hyperglycemia, symptoms that may represent complications of diabetes, or clinical presentations
that include diabetes in the differential diagnosis.
The American Diabetes Association (ADA) criteria for the diagnosis of diabetes in nonpregnant
adults are shown in Table 1 (next page). The diagnostic cut-points recommended by the ADA
are based on fasting plasma glucose values. Fasting serum glucose values run 10–15% lower
than fasting plasma glucose values. The BOP recommends fasting serum glucose tests for initial
screening and diagnosis. A fasting plasma glucose test should be obtained when fasting serum
glucose values are borderline high, or if a patient has impaired glucose tolerance (IFG or IGT).
(The BOP recommends the routine use of serum glucose testing because it does not require the
special collection methods used in plasma glucose testing, i.e., a separate gray-top tube
containing glycolytic inhibitor.)
The oral glucose tolerance test (OGTT) is not recommended for routine clinical use; however, it
may be required when evaluating patients with impaired fasting glucose (IFG), or when diabetes
is suspected despite a normal fasting plasma glucose test (as with postpartum evaluation of
women with GDM). Unless unequivocal symptoms of hyperglycemia are present, diagnosis of
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diabetes requires that test results be confirmed by repeating the test on a subsequent day. The
hemoglobin A1C should not be used for diagnostic purposes.
“Pre-diabetes” is a new term applied to hyperglycemia that does not meet the diagnostic criteria
for diabetes, i.e., impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Both
IFG and IGT are associated with a high risk for diabetes and cardiovascular disease.
Table 1. Diagnostic criteria for diabetes and pre-diabetes (non-pregnant adults)
Normal
Fasting plasma glucose <100 mg/dl or
Oral glucose tolerance test (OGTT) 2-hr plasma glucose <140 mg/dl

Pre-diabetes
Impaired fasting glucose (IFG) = fasting plasma glucose of 100–125 mg/dl or
Impaired glucose tolerance (IGT) = OGTT 2-hr plasma glucose of 140–199 mg/dl

Diabetes
1. Symptoms of diabetes and a casual plasma glucose >200 mg/dl.
“Casual” is defined as any time of day, without regard to the time since the last meal. The
classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.
or
2. Fasting plasma glucose >126 mg/dl.
Fasting is defined as no caloric intake for at least eight hours.
or
3. 2-h plasma glucose >200 mg/dl during an oral glucose tolerance test.
The test should be performed using a glucose load containing the equivalent of 75-g
anhydrous glucose dissolved in water.
Notes:
Serum glucose values run 10–15% lower than plasma glucose values. The BOP recommends the
use of serum glucose testing for initial screening and diagnosis. When fasting serum glucose values
are borderline high, or for patients with impaired glucose tolerance (IFG or IGT), a fasting plasma
glucose should be obtained.
To diagnose diabetes, lab results must be confirmed on a second test performed on a subsequent
day (unless there are unequivocal symptoms of hyperglycemia).

3. Screening
Preventive Health
Diabetes screening in the BOP should be instituted as part of the facility’s preventive health care
program. Utilize a fasting serum glucose test (confirming with a fasting plasma glucose test for
values that are borderline high). Routine universal screening for diabetes is not recommended.
There is only one group of asymptomatic, otherwise low-risk individuals for whom routine
diabetes screening is warranted. Those with a blood pressure greater than 135/80 (treated or
untreated) should be screened every 3 years. Otherwise, glucose screening should be performed
as clinically indicated, i.e., in association with management of hyperlipidemia, cardiovascular
disease, peripheral vascular disease, history of gestational diabetes, or history of polycystic

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ovary disease.

Previously Identified IFG or IGT
Inmates with impaired glucose homeostasis are at increased risk of developing diabetes.
Approximately one third of patients with IFG or IGT will develop diabetes within five years.
Annual screening by fasting plasma glucose is recommended for these patients.

Pregnancy
Risk-based screening of pregnant women should be conducted in accordance with
recommendations outlined in Section 10 of these guidelines.

4. Prevention/Delay of Type 2 Diabetes
Many studies have demonstrated that diabetes can be delayed, and sometimes prevented, in
individuals at high risk for developing diabetes (those with IFG, IGT, or both). All inmates with
IFG or IGT should be counseled on the importance of maintaining a healthy diet and a conscious
approach to meal planning. Such inmates should be counseled about the benefits of modest
weight loss and regular physical activity. They should be monitored annually for development
of diabetes. Inmates with IFG or IGT should be assessed for other cardiovascular disease risk
factors (e.g., hypertension and dyslipidemia) and provided treatment as indicated.

5. Baseline Evaluation and Initial Treatment Plan
Intake Blood Glucose Screening of Diabetics
It is essential to rapidly identify and evaluate insulin-treated inmates at intake to identify those at
highest risk for hypo- and hyperglycemia, and diabetic ketoacidosis. Inmates who report being
insulin-dependent at intake should have a capillary blood glucose (CBG) obtained upon
admission.

Baseline Evaluation
A complete medical evaluation should be performed to classify the patient, detect the presence
or absence of diabetes complications, assist in formulating a management plan, and provide a
basis for continuing care. If the diagnosis of diabetes has already been made, review the
previous treatment plan in light of past and present degrees of glycemic control. Appropriate
laboratory tests should be performed to evaluate the patient’s general medical condition. The
components of a comprehensive diabetes baseline evaluation are listed in Appendix 1,
Components of the Comprehensive Diabetes Evaluation and Appendix 2, Recommendations for
Diabetes Chronic Care Clinic Monitoring.

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April 2009

Initial Treatment Plan
The treating physician, with the assistance of other health care providers, should review the
initial diabetic treatment plan with the inmate. Involvement of the diabetic inmate in the
development of the treatment plan is pivotal to its success, including adequate training to
empower the patient to prevent and treat hypoglycemia.
The treatment plan should include the following basic components and recommendations:
•

•
•
•
•
•
•
•
•
•

Education on diabetes drug treatment options, self-monitoring, recognizing and treating
severe hypoglycemic and hyperglycemic episodes, and identifying the signs of diabetic
complications such as diseases of the eyes, kidneys, and nervous system.
Instruction on the inmate’s specific drug treatment regimen and methods for monitoring
glucose.
Necessary lifestyle modifications such as improving food selection, increasing physical
exercise, and smoking cessation.
Importance of annual eye exams (funduscopic) done by an optometrist or ophthalmologist.
Need for daily self-examination of the feet.
Need for daily self-examination of the skin, including insulin injection sites.
Importance of regular dental examinations and treatment.
Need for regular screenings: fasting blood glucose, A1C, lipid levels, and kidney monitoring
(BUN, creatinine, glomerular filtration rate calculation).
Need for daily aspirin therapy to prevent cardiovascular events.
Need for annual influenza vaccinations and tuberculosis screening.

Lifestyle Intervention
With rare exceptions, a lifestyle intervention program to increase activity levels and promote
weight loss (as indicated) should be included as part of diabetes management. Overweight and
lack of exercise are the most important environmental risk factors for type 2 diabetes. Losing
weight and increasing exercise have been shown to have a beneficial effect on controlling
glycemia in both type 1 and type 2 diabetics. Unfortunately, the high rate of weight regain has
limited the effectiveness of lifestyle intervention as a long-term means of controlling glycemia.

Food selection
Diabetic inmates should choose healthy foods from each of the food groups listed in Appendix 3,
The Diabetes Food Pyramid. They should also strive for day-to-day consistency in mealtimes
and in the amount of carbohydrates they eat. Eating appropriate foods at the right times balances
with the inmate’s insulin or medication to maintain the targeted blood glucose levels. Since
extra body fat makes it harder for type 2 diabetics to make and use their own insulin, achieving
and maintaining a reasonable body weight is particularly important. Dietary counseling should
include recommendations for a diet low in fat, especially saturated fat, and an emphasis on the
adequate intake of grains, fruits, vegetables, and low-fat milk. Serving sizes from the Food
Pyramid should serve as a guide for portion size. Diabetic inmates should be advised to use
sugar and salt sparingly.

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April 2009

Physical activity
Regular exercise can significantly improve glycemic control and contribute to weight reduction.
All inmates with diabetes should be counseled on the benefits of increased physical activity, as
well as the degree of exercise best suited to them. Sedentary diabetic inmates should be
medically evaluated prior to undertaking aerobic physical activity that goes beyond the intensity
of brisk walking. Institutions should consider implementing structured exercise programs for
diabetic inmates. Aerobic exercise plans should be developed individually, based on the
inmate’s interests, co-morbid conditions, and physical limitations.

6. Type 2 Diabetes Treatment
Goals and Principles
A recent consensus statement by the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes states that “an A1C of >7% should serve as a call to action
to initiate or change therapy.” For most inmates, the A1C should be decreased to <7%. It is
recognized, however, that such stringent goals may not be appropriate or practical for some
patients. Clinical judgment, based on the potential benefits and risks of a more intensified
regimen, should be applied for every patient. Factors such as life expectancy and risk for
hypoglycemia need to be considered before intensifying a patient’s therapeutic regimen.
Appendix 4 summarizes revised Treatment Goals for Nonpregnant Inmates with Diabetes. Early
treatment for diabetes (before the A1C is significantly elevated) is associated with improved
glycemic control and decreased diabetic complications. Further adjustments should be based on
the A1C result, aiming for levels as close to the nondiabetic range as possible. Until glycemic
goals are achieved, the patient should be seen at least monthly, and more frequently as indicated.
An A1C should be obtained no more frequently than every three months. Medications should be
adjusted according to blood glucose data, and the inmate should be counseled on diet and
exercise. An A1C >7% suggests the need for further intensification of diet, exercise, and
medication management.

Medications for Type 2 Diabetes
Selection of specific antihyperglycemic agents is based upon their effectiveness in lowering A1C
levels, extraglycemic effects (reducing CVD risks), safety profiles, and tolerability. Table 2
(next page) outlines the advantages and disadvantages of the different antidiabetic interventions,
when used as monotherapy, including the expected total decrease in A1C.

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April 2009

Table 2. Summary of antidiabetic interventions as monotherapy for type 2 diabetes
Interventions

Expected total
decrease in A1C
(%)

Advantages

Disadvantages

Step 1: Lifestyle intervention and metformin
Lifestyle to:
↓ weight & ↑ activity

1–2

Low cost, many benefits

Fails for most in the first year

Metformin

1.5

Weight-neutral, no
hypoglycemia, inexpensive

GI side effects, rare lactic acidosis

No dose limit, inexpensive,
improved lipid profile

Injections, requires frequent blood
glucose self-monitoring, hypoglycemia,
weight gain

Inexpensive

Weight gain, hypoglycemia

Step 2: Add a sulfonylurea or insulin
Insulin

Sulfonylureas

1.5–2.5

1.5

Alternative medications
Glitazones (TZDs-thiazolidinediones)

0.5–1.4

Improved lipid profile

Fluid retention, weight gain, expensive,
increased risk of congestive heart failure

Alpha-glucosidase
inhibitors

0.5–0.8

Weight-neutral

Frequent GI side effects, 3x/day dosing,
expensive

Exenatide

0.5-1.0

Weight loss

Infections, 3x/day dosing, frequent GI side
effects, expensive, little experience

Glinides
(meglitinides)

1–1.5

Short duration

three times/day dosing, expensive

Weight loss

Infections, 3x/day dosing, frequent GI side
effects, expensive, little experience

Pramlintide

0.5–1.0

Adapted from: Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus
algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29(8):1964.

For specific recommendations regarding the BOP recommended treatment algorithm for type 2
diabetes, refer to page 9 and the flow chart in Appendix 5.
The classes of medication used to treat type 2 diabetes are summarized below and in Appendix 7
(Oral Agents for the Treatment of Type 2 Diabetes). Refer to the BOP National Formulary for
the formulary status and non-formulary use criteria for specific medications.

Metformin
Metformin is the only biguanide available in most of the world. It reduces hepatic glucose
production in the presence of insulin and reduces hyperglycemia through other poorly defined
mechanisms. Metformin reduces A1C levels by 1–2%. In contrast to sulfonylureas, metformin
is associated with weight loss or no weight gain, and has a lower risk of hypoglycemia. Unless
contraindicated, metformin in combination with lifestyle changes is recommended as initial
treatment for type 2 diabetes (Appendix 5). Metformin can also be used in combination with
insulin, sulfonylureas, glitazones, and glinides. See Appendix 7 for general dosing
recommendations. See Table 3 (page 10) for recommendations for titrating metformin.

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April 2009

Clinical Precautions
1) Metformin should be discontinued during acute illnesses where dehydration is a significant risk or
where respiratory acidosis is possible, since metformin use in these situations may result in lifethreatening lactic acidosis. Inmates with acute myocardial infarction, with septicemia, on hunger
strikes, on a prolonged fast, or with any significant decrease in caloric intake are at risk of this
complication.
2) Metformin is not recommended in the elderly (age >80) unless renal sufficiency is proven with a
direct measure of GFR or for individuals with renal dysfunction (creatinine level >1.5 mg/dl in men
or >1.4 mg/dl in women), liver dysfunction, congestive heart failure, severe infection, or alcohol
abuse.
3) Metformin should be withheld 48 hours before and after surgery or IV contrast radiograph studies;
the inmate should be well hydrated both before and after these procedures. Before resuming
metformin, normal renal function should be confirmed by measuring serum creatinine 24–48 hours
after the procedure.
4) Metformin can cause vitamin B12 deficiency with an associated anemia and neuropathy. The
neuropathy may be misdiagnosed as a diabetic neuropathy.

Insulin
Insulin is the oldest of the currently available medications and, thereby, the one with the most
clinical experience. Although initially developed to treat insulin-deficient type 1 diabetes, it has
long been used to treat insulin-resistant type 2 diabetes. It is the most effective drug to decrease
glycemia. In adequate doses, insulin can decrease any level of elevated A1C to meet a
therapeutic goal. See Section 8 (page 12), “Insulin and Insulin Administration,” for a more
thorough discussion of insulin. See Appendix 6, Initiation/Adjustment of Insulin Regimens in
Type 2 Diabetes, for a recommended approach to insulin management in type 2 diabetics.
Unlike the other blood glucose-lowering medications, there is no maximum dose of insulin
beyond which a therapeutic effect will not occur. To overcome the insulin resistance of type 2
diabetes and lower the A1C to goal, relatively large doses of insulin (>1 unit/kg) may be
required. Initial therapy is aimed at increasing basal insulin supply. Patients may also require
pre-meal, regular insulin, as well. Insulin therapy has beneficial effects on triglyceride and HDL
cholesterol levels, but is associated with weight gain of about 2–4 kg. As with sulfonylurea
therapy, the weight gain may have an adverse effect on cardiovascular risk. Insulin therapy for
type 2 diabetes is also associated with hypoglycemia, albeit much less frequently than in type 1
diabetes.

Sulfonylureas (SUs)
Sulfonylureas stimulate insulin secretion and are most effective in treating non-obese, type 2
diabetics. The various sulfonylureas have equivalent efficacy, reducing A1C by 1–2%. Secondgeneration sulfonylureas, such as glyburide, glipizide, and glimepride, have more favorable
side effect profiles and fewer drug interactions than first-generation sulfonylureas, such as
chlorpropamide, tolazamide, and tolbutamide.

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Sulfonylureas can be prescribed as monotherapy, or they can be combined with other oral agents
or with insulin. (To achieve glycemic control with a sulfonylurea plus insulin, there must be
residual endogenous insulin production.) Sulfonylureas should not be used in combination with
the non-sulfonylurea secretagogues (repaglinide and nateglinide), due to the similarity in their
mechanisms of action.
Hypoglycemia (particularly in the elderly and in patients with renal insufficiency) and weight
gain are the two most common adverse effects of sulfonylurea therapy. All sulfonylureas are
metabolized by the liver and excreted in the urine; therefore, they should be used with caution in
inmates who suffer from either renal or hepatic insufficiency. Note that glipizide has less renal
toxicity than the other sulfonylureas and can be used in patient with renal insufficiency, only if
the creatinine clearance is >10 ml/min. Glyburide can only be used if the creatinine clearance is
>50 ml/min.
Sulfonylureas have a relatively high secondary failure rate (5–10% per year), most likely due to
the gradual decline of endogenous insulin production over time. Therefore, clinicians should
expect eventual loss of glycemic control with sulfonylureas and should counsel the inmate about
the eventual need to add another oral agent or insulin to the treatment regimen.
See Appendix 7 for general dosing recommendations for sulfonylureas.
Clinical Precaution:
Hypoglycemia caused by sulfonylureas can be prolonged or recurrent, due to the drugs’ long
duration of action. Symptomatic hypoglycemia that cannot be managed with frequent feedings over a
24-hour period should be treated in a hospital setting.

Alternative Medications
Other available medications to treat type 2 diabetes are all less effective than metformin, insulin,
and the sulfonylureas. Appendix 7 and Appendix 8 provide an overview of these medications,
including dosing information. In the BOP, their use should only be considered under special
circumstances, e.g., drug intolerance or contraindications.

BOP Treatment Algorithm for Type 2 Diabetes
Treatment should generally be initiated when the A1C is >7%. Except in rare circumstances,
hospitalization is not required to initiate or adjust therapy for type 2 diabetes. Until glycemic
goals are achieved, the patient should be seen at least monthly to adjust medications, based on
serum glucose data, and to counsel the inmate on diet and exercise. In order to achieve glycemic
goals, medications should be adjusted as frequently as titration allows (i.e., as often as every 3 to
4 days for insulin and every one to two weeks for metformin).
The A1C should not be obtained more frequently than every three months. An A1C level of
>7% suggests the need for further intensification of diet, exercise, and medication management.
Appendix 5, BOP Treatment Algorithm for Type 2 Diabetes, presents a flow chart of
recommended steps in the management of type 2 diabetes.

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April 2009

Definite indications for insulin as initial therapy
Insulin therapy in combination with lifestyle interventions is the initial treatment of choice for
severely uncontrolled diabetes (i.e., plasma glucose levels >250 mg/dl, random glucose levels
consistently >300 mg/dl, A1C >10%, or the presence of ketonuria or symptomatic diabetes with
polyuria, polydipsia, and weight loss). Some patients with these characteristics have
unrecognized type 1 diabetes; others have type 2 diabetes with severe insulin deficiency. Insulin
can be titrated often and is the drug most likely to rapidly bring glucose down to target levels.
After symptoms are relieved, oral agents can often be added and it may be possible to withdraw
insulin. In addition, type 2 diabetics with significant renal or liver dysfunction often require
insulin because they cannot take most oral agents.

Step 1: Lifestyle intervention and metformin
Throughout management of type 2 diabetes, lifestyle interventions (outlined in Section 5 above)
should be an underlying theme. However, lifestyle interventions alone rarely result in long-term
achievement of glycemic goals. Therefore it is recommended that drug treatment be initiated
along with lifestyle interventions at the time of type 2 diabetes diagnosis. Presuming there are
no contraindications, metformin is the initial drug of choice for the following reasons: effective
glycemic control, absence of weight gain, absence of hypoglycemia, low level of side effects,
and high level of acceptance.
Metformin should not be given to elderly patients (over age 80), unless renal sufficiency is
proven with a direct measure of GFR; to patients who have renal, hepatic, or cardiac disease; or
to patients who drink excess alcohol. If metformin is contraindicated, it is recommended that
either insulin or a sulfonylurea be used as the initial drug.
Careful titration of metformin is critical to minimize gastrointestinal side effects (Table 3):
Table 3. Titration of metformin
1.
2.

Begin with low-dose metformin (500 mg) once or twice daily with meals (breakfast and/or dinner).
After 5–7 days (if GI side effects have not occurred), advance dose to 850 or 1,000 mg before
breakfast and dinner.

3.

If GI side effects appear as doses are increased, decrease to previous lower dose and try to
advance dose at a later time.
The most efficacious dose is usually 850 mg twice per day. Modest improvements in effectiveness
can be achieved with doses up to a maximum daily dose of 2550 mg (administered 850 mg three
times a day or other combination). GI side effects are dose-related and may limit therapy.

4.

Adapted from: Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a
consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29(8):1969.

Step 2: Add a sulfonylurea or insulin
If lifestyle interventions plus a maximally tolerated dose of metformin fail to achieve or sustain
glycemic goals within two to three months, another medication should be added. Addition of
either a sulfonylurea or insulin is generally recommended. The A1C level will determine, in
part, which agent should be selected next.

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Insulin should be initiated for inmates with A1C >8.5% or who have symptoms of
hyperglycemia. See Appendix 6 (Initiation/Adjustment of Insulin Regimens in Type 2 Diabetes)
for suggested initial insulin regimens. Insulin is considered a fundamental tool for treating type
2 diabetes; initiation of insulin should not be delayed in patients who fail to meet glycemic goals.

Step 3: Add or intensify insulin
If lifestyle interventions plus metformin and a second medication fail to achieve glycemic goals,
the next step is to start or intensify insulin therapy. Usually, there is no benefit to prescribing
three oral agents. If plasma glucose and A1C goals are not met in a compliant patient on two
oral agents, i.e., metformin and a sulfonylurea, the most effective next step is to add NPH
insulin.
Intensification of insulin therapy usually consists of additional injections, often including regular
insulin prior to selected meals to reduce postprandial glucose excursions. In general, once
insulin has been started, sulfonylureas are discontinued.

Rationale in selecting specific combinations
The majority of patients with type 2 diabetes will require multiple medications over time. This
is because type 2 diabetics have both insulin resistance at the tissue level and declining
pancreatic insulin production. Drug selection should be based on glucose-lowering
effectiveness, mechanism of action, side effect profile, and other factors that may reduce
diabetes complications, e.g., weight loss or improvement in lipid profile. When adding
antihyperglycemic medications, the synergy of particular combinations and other interactions
should be considered. As a rule, antihyperglycemic drugs with different mechanisms of action
will have the greatest synergy.
The first-line oral agents utilized within the BOP are metformin and the sulfonylureas. If
metformin and/or sulfonylureas are contraindicated or not tolerated, the use of other oral
hypoglycemic agents should be considered on a case-by-case basis. Consult the National BOP
Formulary for nonformulary use criteria.

7. Treatment of Type 1 Diabetes
Type 1 diabetics generally present with both acute diabetes symptoms and significantly elevated
blood glucose levels. Given the acute onset of symptoms, type 1 diabetes is usually detected
soon after symptoms develop. Treatment goals for type 1 diabetes are the same as those for type
2 (Appendix 4). The A1C goal for type 1 diabetes is <7%.
For patients with type 1 diabetes, it has been clearly demonstrated that intensive insulin therapy
(outlined in Section 8 below) results in both improved glycemic control and reduction in
diabetes-related complications (including nephropathy, retinopathy, neuropathy, and
cardiovascular morbidity and mortality).

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8. Insulin and Insulin Administration
Intensive vs. Conventional Insulin Therapy
Intensive insulin therapy describes treatment with three or more injections per day, including
both basal and pre-meal insulin. Intensive therapy can also be accomplished with continuous
infusion of insulin via a pump. Conventional insulin therapy involves single daily injections or
two injections per day (usually twice-daily administration of a combination of short-acting and
NPH insulins). Intensive insulin therapy aims to provide a more physiologic profile of insulin; it
is now recommended for the majority of patients with type 1 diabetes and some type 2 diabetics.
Examples of intensive insulin therapy regimens are listed below.

Regimen
1
2
3
4

Examples of Intensive Insulin Therapy Regimens
Breakfast
Lunch
Dinner
Bedtime
Reg
Reg
Reg
NPH
Reg+ NPH
—
Reg
NPH
Reg + Glargine Reg
Reg
—
Reg
Reg
Reg
Glargine

Note: When NPH is used as part of either a conventional or an intensive insulin regimen,
evening doses should be administered at bedtime or as close to bedtime as feasible.
Although research findings strongly support the use of intensive insulin therapy, there are
associated drawbacks:
•
•
•
•

Greater effort is required on the part of the inmate to coordinate diet, activity, insulin
administration, and glucose monitoring.
Greater effort is required to assure that insulin and mealtimes are coordinated.
There is up to a three-fold increase in the incidence of hypoglycemia (a significant concern
for correctional facilities).
Weight gain is more likely, sometimes limiting patient compliance.

Insulin and Insulin Analogues
The recent introduction of insulin analogues has expanded options for management of diabetes.
The long-acting and rapid-acting insulin analogues are reviewed below. In general, rapid-acting
insulin is not utilized in the BOP because of the risks of hypoglycemia.
Long-acting insulins (insulin glargine and insulin detemir) are frequently utilized in the
community (i.e., outside the correctional setting) in place of intermediate-acting insulin (NPH).
Insulin glargine (Lantus) has virtually no peak and can often be administered once daily. A
disadvantage of insulin glargine is that it cannot be mixed with other insulins and thus requires a
separate injection. Insulin detemir has a shorter duration of action than that of insulin glargine,
but longer than NPH. Detemir is generally administered twice daily.
Studies comparing glargine and detemir with NPH have shown that the two longer acting agents
have no superiority over NPH in terms of glycemic control; A1C values are no lower with long-

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acting insulins than they are with NPH insulin. It is important to note that evening doses of NPH
insulin should be given at bedtime or as close to bedtime as feasible.
Rapid-acting insulins are often utilized in the community instead of short-acting (regular)
insulin. The advantages of rapid-acting insulin, over regular insulin, include a reduction in the
postprandial rise in blood glucose concentration and modest reductions in hypoglycemia. Rapidacting insulin must be injected immediately before or after meals (a potential advantage in the
community, but a disadvantage in the correctional setting). It may be necessary to increase the
dose of basal insulin when a patient is switched from regular to rapid-acting insulin. Rapidacting insulin can be especially useful in situations where unexpectedly high blood glucose
levels are encountered, i.e., in stressful situations or between meals, because it quickly lowers
glucose levels without a prolonged effect.
In terms of glycemic control, clinical trials have shown only minor benefits of rapid-acting
insulin over regular insulin. There is little difference in A1C values for patients on rapid-acting
insulin, as compared to regular insulin.
Recognizing that many diabetic inmates may have used insulin analogues prior to incarceration,
the action profiles of commonly utilized insulin analogues are outlined below in Table 4:
Table 4. Onset and Peak of Commonly Used Insulin Preparations
Insulin or Insulin Analogue

Action Profile
Onset

Peak

Ultra-rapid-acting
Insulin lispro (Humalog)
Insulin aspart (Novolog)
Insulin glulisine (Apidra)

12–30 min
12–30 min
12–30 min

30 min–2 hrs
30 min–2 hrs
30 min–2 hrs

Short-acting
Regular (human) Humulin R/Novolin R

30 min–1 hr

2–3 hrs

Intermediate-acting
NPH (human) Humulin N/Novolin N

1.5–4 hrs

4–10 hrs

Long-acting
Insulin glargine (Lantus)
Insulin detemir (Levemir)

1–3 hrs
1–3 hrs

No peak
9 hrs–unknown

Adapted from: Mooradian AD, Bernbaum M, Albert S. Narrative review: a rational approach to
starting insulin therapy. Ann Intern Med. 2006;145:125-134.

Designing a Multiple-Dose Insulin Regimen
Newly diagnosed type 1 diabetics ordinarily can be started on a total daily dose of 0.2 to 0.4
units of insulin per kg per day; most will eventually require 0.6 to 0.7 units per kg per day.
•

NPH: Approximately half the total dose should be NPH insulin, administered twice daily.
In general, two-thirds of the total NPH dose should be given in the morning and one-third at
bedtime (or as close to bedtime as feasible).

•

Regular: The second half of the total daily insulin dose should usually consist of pre-meal,
regular insulin. The dosing of pre-meal insulin is based upon the usual meal size and calorie

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count. Nutritional consistency is critical for maintaining adequate glycemic control. The
sliding scale for regular insulin is generally based upon the meal carbohydrate content and
the pre-meal blood glucose levels. When NPH insulin is utilized as part of the regimen, a
pre-lunch bolus of regular insulin may not be necessary.
Note the clinical precautions on the next page.
Clinical Precautions
• A disadvantage of glargine insulin (Lantus) is that it cannot be mixed with any other
insulins.
•

Fixed-dose insulin combinations (e.g., 70/30 insulin preparations), are generally not suitable for
insulin-dependent diabetics who need to achieve target A1C levels. Fixed-dose insulin formulations
are not flexible enough to match changes in caloric intake with appropriate doses of short-acting and
long-acting insulin.

•

Type 1 diabetics, and any type 2 diabetics who require short-acting insulin, must have access to
glucose monitoring on an as-needed basis (typically before each dose of short-acting insulin), in
order to achieve optimal control and to avoid hypoglycemia.

•

Rapid-acting insulin (lispro and aspart) should be avoided in most circumstances, because the
margin for error is too narrow in the correctional setting. Anything that keeps the inmate from
eating within 20–30 minutes after a rapid-acting insulin injection is very likely to induce symptomatic
hypoglycemia.
Note: If the rapid-acting insulin dose is not high enough to cause at least some symptoms of
hypoglycemia in the absence of food, then it is also not high enough to provide adequate
glucose control.

Insulin Administration
Diabetic inmates who require insulin should be educated on the appropriate and safe
administration of insulin.
Administration. Self-administration of insulin is recommended whenever feasible. Insulin
should be administered subcutaneously at a 45-to-90 degree angle at a clean injection site, using
clean hands. Absorption is fastest from injections into the abdominal wall (>2 inches from the
umbilicus), making this site preferable for pre-meal (regular) insulin therapy. Injections into the
leg or buttock result in slower absorption and are thereby appropriate for the evening dose of
intermediate-acting (NPH) insulin. Rotating injection sites is recommended to prevent
lipodystrophy.
Mixing Regular and NPH Insulin. The following procedure should be utilized when mixing
Regular and NPH insulin. Regular insulin should be drawn up first, followed by the NPH (being
careful not to inject the Regular insulin into the NPH vial). Administer the mixture of
Regular/NPH insulin within 15 minutes of drawing them up.
Infection Control Issues. Insulin syringes should be used only once; they should never be used
on more than one patient or reused in the same patient. Infection control procedures should be
established to prevent the recapping of insulin needles, or the handling of contaminated syringes

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by other inmates or health care providers, following injections. Used insulin syringes should be
promptly disposed of in puncture-resistant containers. Measures should be taken to avoid
contamination of insulin solution when using multi-dose vials. Individual (single-person) use of
multi-dose vials can be considered when inmates are permitted to draw up their own insulin.
Multi-dose vials should be discarded if their sterility has been compromised. See infection
control recommendations outlined in Appendix 11.
Insulin pumps are rarely necessary for type 2 diabetics. Newly incarcerated type 1 diabetics
who already on insulin pumps should usually be maintained on the pump. A physician with
expertise in treating diabetes should be consulted before initiating long-term use of an insulin
pump.
Inhaled Insulin (Exubra) was approved by the FDA in 2006 as an alternative to subcutaneous
rapid-acting insulin. The clinical indications are being evaluated. Given its higher cost,
constraints in dosage flexibility, and questionable efficacy in achieving tight glycemic control,
inhaled insulin is not indicated as a first-line treatment.

Coordination of Insulin and Food Intake
The correctional environment poses challenges for coordinating insulin administration with food
intake, particularly for inmates on short-acting (regular) insulin. The consequences of
insulin/food mismatch are, at best, suboptimal control of hyperglycemia; at worst, the result is
frequent and potentially severe hypoglycemic episodes. Because of the many factors in a
correctional environment that can interfere with the optimal timing of insulin and food, the
insulin regimen should be as “forgiving” as possible. The shorter the onset and peak of the
insulin, the more critical it is to coordinate food intake with insulin administration. For this
reason, rapid-acting insulin is generally not utilized within the BOP.
Short-acting (regular) insulin is typically administered two-to-three times per day; ideally, it
should be administered prior to a meal to allow some absorption of insulin prior to the rise in
blood glucose that occurs during a meal. However, if the timing of meals is uncertain, regular
insulin can be administered immediately after eating (rather than before). Although the inmate
will have a short period of postprandial hyperglycemia, this approach causes fewer long-term
consequences and good diabetic control can still be achieved.
Below are questions to consider when planning for optimal insulin/food coordination in BOP
facilities:
•

•
•

•

Depending on the size of the dining hall, the size of the inmate population, and the type of
meal being served, it may take anywhere from one-to-three hours to serve a meal. Is the pill
line open during this entire meal period to administer insulin?
Do inmates have free movement to go to the pill line before they go to the dining hall?
If insulin is given prior to a meal, and then an institution recall occurs (a lockdown, an
emergency count, a fog line, a severe weather incident, etc.), which of these situations would
prevent inmates from eating?
Are there contingency plans to provide food to prevent hypoglycemia?

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•

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April 2009

Are correctional staff trained to appropriately identify and respond to hypoglycemic
episodes in insulin-dependent inmates?
How quickly could a sack lunch or a snack be provided to inmates who had received their
insulin, but were then prevented from eating their usual meal?

9. Blood Glucose Monitoring
Glycemic control is the fundamental goal for managing patients with diabetes. Frequent
monitoring of blood glucose (three times per day) is optimal for most patients with type 1
diabetes, type 2 diabetics who are on insulin, and pregnant women taking insulin. The optimal
frequency of glucose monitoring for other patients with type 2 diabetes is uncertain and should
be determined on a case-by-case basis. Type 2 diabetics who are well-controlled on oral agents,
and are not taking insulin, generally have no need for a personal glucose monitor.
In the correctional setting, the methods and frequency of glucose monitoring must be determined
in light of the institution’s security concerns, as well as the relevant patient factors. The
following strategies permit adequate monitoring of blood or plasma glucose in inmates with
diabetes.
Self-monitoring of blood glucose is the preferred method for assessing glycemic control for most
diabetic inmates who require insulin. The following criteria should be used to determine if a
diabetic inmate should be issued a glucometer:
•

The inmate requires insulin on a chronic basis;

•

The inmate has arrived at his designated facility;

•

The inmate is highly motivated to monitor his or her blood glucose values; and

•

The inmate has no cognitive or sensory impairments that would prevent accurate and safe
self-monitoring.

Glucometers should be provided to inmates in accordance with the periodic guidance from the
Medical Director that addresses security, logistical, and infection control concerns.
Outbreaks of hepatitis B have been reported related to sharing of finger stick devices and glucose
monitors. Finger stick devices must be issued for individual use only. Glucometers generally
should be issued for individual use, as well. However, if a glucometer must be used by more
than one patient, it should be cleaned and disinfected after each use. See infection control
recommendations outlined in Appendix 11.

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10. Gestational Diabetes (GDM)
Detection and Diagnosis
All pregnant inmates should be assessed for risk for GDM at the first prenatal visit, according to
the risk categories outlined in Table 5 below.
Table 5. Gestational diabetes risk categories and related screening recommendations
Screening Recommendations

Risk Category

As soon as possible

At 24–28 weeks gestation

* Perform 50-g glucose load.
If threshold values exceed
140 mg/dl, perform 100-g
oral glucose tolerance test.

Repeat testing for women
not found to have GDM on
initial testing.

High Risk
If any of the following are true:
• Overweight/obese before pregnancy
(BMI >25)
• Personal history of GDM
• Delivery of a previous large-forgestation-age infant
• Glycosuria
• Polycystic ovary syndrome
• Strong family history of diabetes

* Perform 50-g glucose load.
If threshold values exceed
140 mg/dl, perform 100-g
oral glucose tolerance test.

Not-High Risk

* Perform an initial screening by measuring plasma or serum glucose concentration 1 hour after a 50-g
oral glucose load (glucose challenge test); for the subset of women who exceed the glucose threshold
value (140 mg/dl) on the glucose challenge test, perform a diagnostic 100-g oral glucose tolerance test
(OGTT).

The diagnostic criteria for gestational diabetes mellitus are outlined in Table 6 below.
Table 6. Diagnostic criteria gestational diabetes mellitus
• Oral Glucose Tolerance Test (OGTT). Two or more of the plasma glucose values must be exceeded
for a positive diagnosis:
>95 mg/dl fasting
>180 mg/dl at 1 hr
>155 mg/dl at 2 hr
>140 mg/dl at 3 hr

Note: To confirm diagnosis of GDM, confirm these results as soon as possible on a subsequent day.

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Potential Complications of GDM
Gestational diabetes (GDM) affects approximately 7% of all pregnant women. It is crucial that
women with GDM be monitored closely because the fetuses of mothers with hyperglycemia are
at greater risk for intrauterine death or neonatal mortality. GDM is also associated with fetal
macrosomia, as well as neonatal hypoglycemia, hypocalcemia, polycythemia, and
hyperbilirubinemia.

Monitoring and Treatment During Pregnancy
The following guidelines should be considered when managing inmates with GDM:
•

Close surveillance of the mother and fetus must be maintained throughout the pregnancy.
Self-monitoring of blood glucose should be done on a frequent (daily) basis. Use of postprandial monitoring is preferred. Monitoring of urinary glucose is not an adequate measure.

•

Screening for hypertension should include measurement of blood pressure and urine protein.

•

Clinical estimation of fetal size and asymmetric growth via serial ultrasounds, especially
early in the third trimester, may identify large infants who would benefit from maternal
insulin therapy.

•

All inmates with GDM should receive dietary counseling and be provided with adequate
calories and nutrients during pregnancy.

•

Insulin therapy should be considered if dietary management does not result in:
(1) the fasting whole blood glucose <95 mg/dL, or
(2) the fasting plasma glucose <105 mg/dL, or
(3) the two-hour postprandial whole blood glucose <120 mg/dL, or
(4) the-two hour postprandial plasma glucose <130 mg/dL.

•

Oral hypoglycemic agents should be considered in lieu of insulin on a case-by-case basis, but
only after careful consultation with an obstetrician; their efficacy and safety are still being
investigated.

•

Breast feeding should be encouraged in women with gestational diabetes mellitus.

•

Whenever possible, care should be coordinated with an obstetrician experienced in the
treatment of women with gestational diabetes.

Postpartum Monitoring
Women with GDM are at an increased risk for developing diabetes later in life and should be
educated on the importance of maintaining normal body weight, good nutrition, and physical
activity. If postpartum glucose levels are normal, a fasting serum glucose screening should be
obtained every three years in asymptomatic inmates. Inmates should be taught to recognize
symptoms of hyperglycemia so that they readily seek medical attention at the onset of diabetes.
Inmates with IFG or IGT (“pre-diabetes”) should be screened annually for diabetes with a fasting
plasma glucose test; at that time, they should also be counseled regarding diet and a plan for
aerobic exercise or increased physical activity.

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11. Medical Management of Diabetic Complications
Hypertension
Diabetic patients with hypertension should have their blood pressure (BP) lowered to targeted
levels, since serious microvascular and macrovascular diabetic complications are strongly linked
to hypertension. The optimal treatment goal for non-pregnant diabetics over age 18 is a systolic
BP of <130 and a diastolic <80 mmHg.
Patients with a systolic BP >140 or a diastolic BP >90 mmHg should receive drug therapy in
addition to recommended lifestyle interventions. Those with a systolic pressure of 130–139 or a
diastolic of 80–89 mmHg should be prescribed lifestyle interventions for up to three months. If
the inmate fails to achieve a systolic BP <130 or a diastolic BP <80 mmHg within three months,
drug therapy should be prescribed.
All diabetics with hypertension should ordinarily be treated with an ACE inhibitor. If an ACE
inhibitor is contraindicated, consider using an angiotensin receptor blocker (ARB). If targets are
not achieved, a thiazide diuretic should be added.
Note: ACE inhibitor therapy should also be considered for diabetic inmates, with or without
hypertension, who have other cardiovascular risk factors.

Aspirin Therapy
Clinical trials have demonstrated that aspirin therapy is a cheap and effective intervention for
preventing serious cardiovascular events such as myocardial infarctions and stroke among
diabetics. Enteric coated aspirin in dosages of 81–162 mg/day should be considered a standard
part of treatment for most diabetic patients. Aspirin is indicated for the following diabetic
inmates unless medically contraindicated, as follows:
•

If there is evidence of atherosclerosis (e.g., coronary artery disease, peripheral vascular
disease).

•

If the person is >40 years of age with one or more cardiovascular risk factors (hypertension,
smoking, dyslipidemia, albuminuria, or family history of CHD).

Other antiplatelet agents may offer reasonable alternatives for patients who are high-risk, but
have conditions that contraindicate aspirin therapy: an aspirin allergy, receiving anticoagulant
therapy, a bleeding tendency, recent gastrointestinal bleeding, or clinically active hepatic
disease.
Clinical Precaution:
Do not routinely use aspirin in inmates <21 years of age, due to the increased risk of Reye’s
syndrome.

Dyslipidemia
Type 1 and type 2 diabetes are considered coronary heart disease (CHD) risk equivalents, due to

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the strong association of diabetes and serious cardiovascular disease. Type 2 diabetes is
associated with other CHD risk factors such as elevated LDL cholesterol, low HDL cholesterol,
and elevated triglycerides. Lipid disorders should be managed aggressively in diabetic patients
to reduce the risk of serious cardiovascular events. The therapeutic LDL goal for diabetic
patients is <100 mg/dL; for diabetics with diagnosed CHD, an optional goal of <70 mg/dL
should be considered. If drug treated patients do not reach targets on maximal tolerated statin
therapy, a reduction in LDL cholesterol of ~40% of baseline is an alternative therapeutic goal.
Monitoring and treatment strategies for lipid disorders should be pursued in accordance with the
BOP Clinical Practice Guideline on Management of Lipid Disorders, which can be accessed at
http://bop.gov/news/medresources.jsp.

Diabetic Nephropathy
Microalbuminuria (30–300 mg/24 hour), the earliest stage of kidney disease associated with
diabetes, often progresses to clinical albuminuria (greater than 300 mg/24 hours) with a
subsequent decline in renal function over a period of years. Hypertension usually develops
during the onset of microalbuminuria and, if left untreated, can hasten progression of renal
disease. Prevention and treatment recommendations for diabetic nephropathy include:
•
•

•

•

Maximize glycemic control to delay onset of microalbuminuria.
Annually screen for microalbuminuria in all type 2 diabetics, in type 1 diabetics beginning
five years after diagnosis, and for gestational diabetes. The recommended method for
screening for microalbuminuria in the BOP is by measurement of the albumin-to-creatinine
ratio in a random spot collection. Clinical microalbuminuria is defined as the occurrence of
elevated albumin-to-creatinine ratio for two of three tests within a six-month period.
Measurement of spot urine for albumin only is not recommended.
Measure serum creatinine annually to calculate a glomerular filtration rate (GFR).
Serum creatinine alone is not an adequate measure of kidney function. Studies have found a
decreased GFR in the absence of increased urine albumin excretion in a substantial
percentage of adults with diabetes. All diabetic inmates should have a GFR calculated at
baseline and annually. The GFR can be calculated utilizing an internet calculator from the
National Kidney Foundation: http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm.
The stages of chronic kidney disease based on GFR are outlined in Table 7 below. A
nephrologist should be consulted if the GFR is <30 ml/min per 1.73 m2.
Table 7. Stages of Chronic Kidney Disease
Stage

GFR (mL/min/1.73 m2)

Description

1

Kidney damage with normal or elevated GFR

>90

2

Kidney damage with mildly decreased GFR

60–89

3

Moderately decreased GFR

30–59

4

Severely decreased GFR

15–29

5

Kidney failure

<15 (or dialysis)

Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for 3 months or more.
Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in
composition of blood or urine tests or abnormalities in imaging tests.

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•

•
•
•

Management of Diabetes
April 2009

Regardless of blood pressure status, treat diabetics with microalbuminuria with ACE
inhibitors (unless medically contraindicated). An ARB should be considered if ACE
inhibitors cannot be tolerated or are contraindicated. Monitor for hyperkalemia.
Lower blood pressure to <130/80, using multi-drug therapy if necessary.
Restrict protein intake for diabetic inmates with the onset of nephropathy.
Avoid metformin in patients with elevated creatinine levels (>1.5 mg/dl in men, or >1.4
mg/dl in women) because of increased risk of acidosis.

Diabetic Retinopathy
Patients with type 1 diabetes do not usually have vision-threatening retinopathy in the first five
years of their disease. Over the next 20 years, however, nearly all type 1 diabetics develop some
retinopathy. A significant percentage of patients with type 2 diabetes have retinopathy at the
time of diagnosis, and many will develop some degree of retinopathy over subsequent years.
Retinopathy progresses in a predictable manner, advancing from mild background abnormalities
to pre-proliferative retinopathy, and then to proliferative retinopathy. Vision loss occurs when
macular edema or capillary non-perfusion cause the loss of central vision, or from proliferative
retinopathy, which can lead to retinal detachment and irreversible vision loss. The proliferative
vessels may also bleed, leading to pre-retinal or vitreous hemorrhage. Prevention and treatment
recommendations for diabetic retinopathy include the following:
•

Maximize glycemic control, since this reduces the risk of progression to clinically significant
retinopathy.

•

Maximize blood pressure control.

•

Annual funduscopic eye exam. Screen diabetic patients for retinopathy, since proliferative
retinopathy and macular edema may occur in completely asymptomatic patients,

•

Monitor pregnant diabetic patients closely, since pregnancy may aggravate retinopathy.

•

Continue aspirin therapy. It neither prevents retinopathy nor increases the risk of retinal
hemorrhage.

•

Refer patients for laser photocoagulation surgery when indicated. Photocoagulation reduces
the risk of further vision loss in patients with retinopathy, but does not ordinarily reverse
established vision loss.

Diabetic Neuropathy
Peripheral diabetic neuropathy may result in pain, loss of sensation, and muscle weakness.
Autonomic neuropathy may involve the gastrointestinal, cardiovascular, and genitourinary
systems, resulting in related symptoms and complications. Diabetic neuropathy is treated by
maximizing glycemic control and addressing related symptoms.
Pain related to diabetic neuropathy is treated with tricyclic amines and anticonvulsant
medications. Titrated doses of nortryptline or carbamazepine are most effective in treating

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chronic nerve pain associated with diabetic neuropathy. Opioid therapy is not recommended as
it is an acute pain management therapy, and NSAIDS (ibuprofen) have no therapeutic benefit
with neuropathic pain.
Foot ulcers and amputations are complications of diabetes that are frequently related to
neuropathy. The risk of amputation is associated with the following conditions: peripheral
neuropathy with a loss of sensation, evidence of increased pressure (erythema, hemorrhage under
a callus), peripheral vascular disease (absent distal pulses), severe nail disease, and a history of
foot ulcers.
Screening for diabetic neuropathy should include monofilament testing. For a thorough
description of how to conduct a diabetes foot screen including monofilament testing, consult the
following website: Department of Health and Human Services, Health Resources and Services
Administration, Lower Extremity Amputation Prevention (LEAP) Program:
http://www.hrsa.gov/leap/.
Footwear recommendations for diabetic inmates should consider the following:
•

The current version of the BOP standard-issue work shoe addresses most concerns of
diabetic and non-diabetic inmates.

•

The institution is required to provide an inmate with a properly fitting work shoe. Tennis
shoes and other recreational footwear are solely the responsibility of the inmate.

•

Inmates with severe neuropathy are best served with protective footwear, such as steel-toed
work shoes or boots, that minimize the chance of an incidental foot trauma that could cause a
diabetic ulcer. Extra-wide, extra-deep toe boxes will reduce the risk of irritation to feet with
deformities and/or impaired sensation. Only rarely will a tennis shoe be the most appropriate
choice for a diabetic inmate.

•

Medically ordered footwear should be considered in certain circumstances, including the
following:
•

•

•

Inmates with symptomatic foot deformities (e.g., large bunions, pronounced hammertoes,
etc.) where regular-issue shoes of the appropriate size and width are causing significant
skin irritation or ulceration.
Inmates with Risk Category 2 or 3 (as determined by the LEAP Diabetes Foot Screen).
This includes those with a loss of protective sensation with either high pressure
(callous/deformity), or poor circulation; or history of plantar ulceration, neuropathic
fracture (Charcot foot) or amputation.
Inmates with significant vascular disease as suggested by claudication, absent dorsalis
pedis or tibialis posterior pulses, or other studies.

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April 2009

Dental Care
Diabetes is associated with an increase in the incidence and severity of gingival inflammation,
periodontal abscesses, and chronic periodontal disease. The increased prevalence of dental
caries in young diabetic patients is related to reduced salivary flow. Individuals with
uncontrolled diabetes often heal more slowly from oral surgery, making them more susceptible
to infection. The primary concern for diabetic inmates requiring dental treatment is the need to
avoid metabolic imbalances during treatment interventions.

Dental procedures
Dental practitioners should confirm that diabetic inmates have eaten breakfast and have received
morning medications before they provide dental care. Special attention should be given to
patients with severe periodontal disease, since this may be an indicator of poor glycemic control.
If possible, the inmate’s blood glucose should be assessed the day of the dental appointment
through glucometer testing or another available method. Adequately controlled diabetic inmates
can receive dental care much the same as non-diabetic patients.
Dental care should be provided to diabetic inmates early in the day. Blood glucose and
endogenous corticosteroid levels are usually higher in the morning, resulting in improved patient
outcomes. Patient encounters should be brief. If the dental procedure extends into a scheduled
meal, clinicians should provide a break for an appropriate snack. If this is not feasible, patient
care should be concluded and continued at another appointment.
Clinicians should make sure that the dental staff are aware of an inmate’s diabetic condition, and
the inmate should be instructed to tell dental staff when they feel the onset of an insulin reaction.
Dental practitioners should always be prepared for a hypoglycemic episode. A source of sucrose
(or glucose/glucagon, if the inmate is taking acarbose) should be kept in the dental clinic for
such emergencies.
Prior to performing invasive procedures (e.g., surgery or exodontia), dentists should consider
antibiotic coverage for patients with poorly controlled diabetes. Patients with uncontrolled
hyperglycemia are susceptible to post-operative infections and associated sequelae. The
administration of antibiotics may improve post-operative healing.
After all dental procedures, diabetic patients should be should be screened carefully for occult
dental infections. Special attention should be given to the post-surgery dietary needs of patients
undergoing extensive periodontal or oral surgical procedures. The inmate’s primary physician
should be consulted for dietary recommendations.

Oral complications of diabetes
Oral pathology in patients with uncontrolled diabetes mellitus is caused by a combination of
factors: excessive loss of fluids, an altered response to infections, microvascular changes, and
possibly the increase in salivary glucose concentrations. The combined effect of hyperglycemia
and the related polyuria is to deplete extracellular fluids and reduce salivary secretion, causing a
dry mouth (xerostomia). Oral complications most commonly associated with diabetes are

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April 2009

xerostomia, oral lesions, burning and/or enlargement of the tongue, denture sore mouth,
candidiasis, cheilosis, and periodontal disease; as well as orofacial neurosensory disorders
manifesting as hypogeusia (taste impairment), stomatopyrosis, glossodynia, and dysesthesia.
Diabetes is associated with an increase in the incidence and severity of dental caries, gingival
inflammation, periodontal abscesses, and chronic periodontal disease. Individuals with
uncontrolled diabetes often heal more slowly from oral surgery, making them more susceptible
to infection.
Dentists should consider the following when treating diabetic inmates with periodontitis:
•

Informing the inmate’s physician about the presence of periodontal infection and the
proposed treatment.

•

Providing periodontal therapy and motivating the inmate to establish and maintain
periodontal health.

•

Prescribing systemic antibiotics in conjunction with mechanical therapy.

•

Educating the inmate regarding the possible impact of periodontal infection on glycemic
control.

Medical Decompensation (Hospitalization Criteria)
The decision to admit inmates to an inpatient hospital unit should be made on a case-by-case
basis, but the following indications generally warrant hospitalization for diabetics:
•

Diabetic ketoacidosis that is characterized by a plasma glucose >300 mg/dL with an arterial
pH <7.30, an increased anion gap, and serum bicarbonate level <15 mEq/L, along with
moderate ketones in the urine or blood. Low sodium, elevated potassium, and elevated BUN
may also occur. Total body intracellular potassium may be significantly depleted, regardless
of serum potassium levels.

•

Hyperglycemic hyperosmolar state that is characterized by an elevated serum osmolality
(>320 mOsm/kg), usually with severe hyperglycemia (plasma glucose >600 mg/dL) and
associated with an altered mental status that may progress to coma.

•

Severe hypoglycemia with a blood glucose <50 mg/dL and an altered mental status that does
not readily improve with treatment or is associated with neurologic deficits. Hypoglycemia
caused by sulfonylureas can be prolonged or recurrent due to the drugs’ long duration of
action. Symptomatic hypoglycemia that cannot be managed with frequent feedings over a
24-hour period should be treated in a hospital setting.

•

Uncontrolled hyperglycemia diagnosed during pregnancy.

•

Moderate to severe hyperglycemia that is unresponsive to standard therapies or is associated
with an acute illness.

•

Severe complications of diabetes that warrant inpatient evaluation and treatment.

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April 2009

12. Periodic Evaluations
Overview
Diabetes management requires dedicated clinicians, as well as the expertise of other treatment
professionals, including pharmacists, nurses, optometrists or ophthalmologists, dieticians,
physical therapists, and recreation specialists. Inmate treatment plans should be individualized,
have measurable goals, and emphasize self-management. Regularly scheduled evaluations help
maximize glycemic control, reduce diabetic complications, and enhance educational efforts. A
one-page summary of recommended periodic evaluations is attached in Appendix 2,
Recommendations for Diabetic Chronic Care Clinic Monitoring.
The frequency of chronic care clinic visits for diabetic inmates should be individualized,
depending on a number of factors: the degree of glycemic control, the complexity of the
medication regimen, the frequency of changes to the regimen, the presence of complications of
diabetes and co-morbid conditions, and the inmate’s understanding of the disease and his or her
self-motivation. Inmates with uncomplicated diabetes that is controlled by diet and exercise
alone can be monitored predominantly by mid-level providers. Inmates with poorly controlled
diabetes or with other serious complications such as heart or kidney disease should be monitored
closely by a physician, along with the patient’s mid-level provider(s). Weekly or monthly
clinician evaluations may be necessary for brittle diabetics.
Inmates with IFG or IGT (“pre-diabetes”) should be monitored for the development of diabetes
with annual fasting plasma glucose measurements. One-third of these patients will be diagnosed
with diabetes within five years.

Medical History
The periodic patient interview should target the following concerns:
•

Results of glucose monitoring and review of medication and/or insulin compliance.

•

Frequency, causes, and severity of any hypoglycemic symptoms experienced since the last
visit.

•

Changes in the treatment regimen or any lifestyle changes made by the inmate between clinic
visits (including level of participation in exercise, diet, and smoking cessation programs).

•

Symptoms of concurrent illnesses such as untreated infections (e.g., tinea pedis, tinea cruris,
ear infections, and urinary tract infections).

•

Symptoms that suggest evolving complications such as paresthesias, weakness, angina,
visual disturbances, skin infections, or foot problems.

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April 2009

Physical Examination
The periodic examination should target the following (a more comprehensive physical should be
conducted annually and whenever clinically necessary):
•

Vital signs and weight.

•

Foot exam (inspection, palpation of pulses, and an annual sensory exam--using a
monofilament and documented on Diabetes Foot Screen form obtained from:
http://www.hrsa.gov/leap/).

•

Focused exam of organ systems, triggered by positive responses to questions on the interim
history or the presence of diabetic complications.

Glucose Monitoring
•

Diabetic inmates should have their fasting or random glucose (by finger stick or
venipuncture) evaluated frequently by the clinicians, nurses, and pharmacists they encounter,
with notation as to the number of hours the sample is obtained postprandially. (If recent
laboratory data are not available, at the very minimum, a random finger stick glucose should
be measured as an indication of the degree of glucose control.)

•

Inmates initiating insulin therapy, or making a major change in their insulin program, may
need to be seen by a health care provider as frequently as daily until glucose control is
achieved, the risk of hypoglycemia is low, and the inmate is competent and comfortable
implementing the treatment plan.

•

Inmates beginning treatment by diet or with oral glucose-lowering agents may need to be
seen as often as weekly until reasonable glucose control is achieved, and the inmate is
competent to conduct the treatment program.

•

The frequency of blood glucose monitoring by the clinic should be based on factors that
affect glycemic control:
• Whether or not the inmate is self-monitoring.
• Variations and degree of glycemic control, as documented by A1C levels.
• Whether the inmate is being treated with insulin or oral agents.
• Frequency of symptoms of hypoglycemia.
• Frequency of prior adjustments in therapy.
• Inmate motivation for self-care and the presence of limitations such as language barriers
or mental illness.
• Presence of diabetic complications. For example, diabetic inmates with retinopathy
should be more closely monitored to protect them from wide fluctuations in blood
glucose, which is thought to accelerate proliferative retinopathy.

•

At minimum, a fasting or random glucose should be obtained at all routine patient encounters
with diabetic inmates, along with routine vital signs.

•

Periodic measurement of A1C levels is essential for assessing glucose control and

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April 2009

compliance with therapy. Quarterly measurements are recommended if treatment changes
are made or if glucose goals are not met; otherwise, measurements two times per year are
ordinarily adequate.
Note: A1C measurements should be obtained just prior to a scheduled appointment to
review glycemic control. Medication adjustments should never be made based on
A1C levels that were obtained more than 30 days prior to the appointment.
•

Urine glucose monitoring has limited value; it should only be considered as an alternative
assessment of glucose control if inmates are unable or unwilling to perform blood glucose
testing.

Monitoring for Diabetic Complications
Inmates should receive the following evaluations to screen for diabetic complications:
•

Annual serum electrolytes.

•

Annual creatinine used to calculate a GFR.

•

An annual screening test for microalbuminuria (for inmates who have had type 1 diabetes for
more than five years and all inmates with type 2 diabetes), unless proteinuria has already
developed).

•

An annual fasting lipid profile to screen for hypercholesterolemia.

•

An annual, comprehensive, dilated-eye and vision examination, by an ophthalmologist or
optometrist (for all type 1 diabetics who have had the disease for five or more years and all
inmates with type 2 diabetes). If an optometrist identifies ocular complications of diabetes or
other serious problems, he or she should refer the inmate to an ophthalmologist.

•

At each periodic visit, conduct a foot examination (inspection and palpation) to identify risk
factors for amputation. Assess sensory loss through monofilament testing annually.

Inmate Education
All inmates with diabetes should receive education from a health care provider at the time of
diagnosis, and then periodically during subsequent evaluations and treatments. Inmates should
be counseled on a range of issues related to their disease: the symptoms of hyperglycemia and
hypoglycemia, how complications of diabetes progress, the importance of glycemic control, the
benefits of healthy dietary selections and regular exercise, the importance of modifying heart
disease risk factors, and the benefits and side effects of different medications. Inmates with poor
glycemic control require more intensive educational efforts, either one-on-one or in groups.
Educational materials are attached in Appendix 3, The Diabetes Food Pyramid, Appendix 9,
Keys to Diabetes Control, and Appendix 10, Inmate Fact Sheet on Diabetes.

Documentation
Periodic clinician evaluations should be documented in the inmate’s medical record. The
Chronic Care Flow Sheet for Diabetes (BP S670.060) is recommended for inmates who will be

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April 2009

monitored for more than one year.

13. Health Care Provider Resources
Provider resources for managing diabetes are listed in Appendix 12, Resources for Information
on Diabetes.

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April 2009

Definitions
Clinician is a physician or mid-level provider.
Conventional insulin therapy describes the more simple insulin regimens, such as single
injections of regular insulin given once daily, or two injections per day of regular and NPH
insulin mixed together in fixed amounts in the same syringe (see intensive insulin therapy
below).
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that results
from defects in insulin secretion, insulin action, or both.
Fasting plasma glucose is a blood glucose that is obtained after no caloric intake for at least
eight hours. It should be collected in a grey-top tube with glycolytic inhibitor and submitted for
no other testing.
HbA1C or A1C (glycated hemoglobin) reflects the mean glycemia over the preceding two to
three months. Values are free of day-to-day glucose fluctuations and are unaffected by exercise
or recent food ingestion. The interpretation of this test depends on the red blood cells having a
normal life span, the average being 120 days. Persons with hemolytic disease, or other
conditions with a shortened red blood cell survival, exhibit a significant reduction in A1C. A1C
can still be used to monitor inmates with such conditions, but the values must be compared with
previous values from the same inmate, not from published reference values. High A1C levels
have been reported in iron deficiency anemia, probably due to the high proportion of old,
circulating erythrocytes.
Gestational diabetes mellitus (GDM) is any degree of glucose intolerance identified during
pregnancy.
Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are intermediate stages
between normal glucose homeostasis and diabetes, which have recently been termed “prediabetes.” Persons with either IGT or IFG are at risk for future diabetes and cardiovascular
disease.
Intensive insulin therapy describes more complex regimens that provide basal insulin delivery
(given as one or two daily injections of intermediate- or long-acting insulin) together with
superimposed doses of short-, rapid-, or very rapid-acting insulin, three or more times daily.
Lower Extremity Amputation Prevention (LEAP) Program is a screening tool for peripheral
neuropathy designed by the Hansen’s Disease Center; it uses a 10-gram monofilament to assess
sensation of the soles of the feet. Refer to: http://www.hrsa.gov/leap/.
Oral glucose tolerance test (OGTT) is a supplemental test for diagnosing diabetes in certain
patients. It involves an overnight fast after consuming an unrestricted diet for three days; then,
an oral glucose load, followed by serial measurements of plasma glucose concentrations.
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April 2009

Pre-diabetes is a term applied to both impaired fasting glucose (IFG) and impaired glucose
tolerance (IGT). IFG and IGT are each risk factors for future diabetes and cardiovascular
disease.
Type 1 diabetes is caused by a deficiency of insulin secretion that is due to pancreatic islet βcell destruction, which is frequently associated with pancreatic autoantibodies. Individuals with
type 1 diabetes are usually dependent on exogenous insulin and are at risk for ketoacidosis.
Type 2 diabetes is caused by insulin resistance with a relative, but not absolute, deficiency of
insulin. The etiology of type 2 diabetes is uncertain. Individuals with type 2 diabetes are not
prone to ketoacidosis and may be asymptomatic.

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April 2009

References
American Diabetes Association. Standards of Medical Care in Diabetes—2008. Diabetes Care.
2008;31:S12-S54.
Available from: http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S12#T3
American Diabetes Association. Clinical practice recommendations – 2007. Diabetes Care.
2007;30(Supplement 1). Diabetes Management in Correctional Institutions: S77–84.
Available from: http://care.diabetesjournals.org/content/vol30/suppl_1/
Centers for Disease Control and Prevention. Transmission of hepatitis B virus among persons
undergoing blood glucose monitoring in long-term-care facilities – Mississippi, North Carolina,
and Los Angeles County, California, 2003–2004. MMWR. 2005;54:220-223. Available from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm
Federal Bureau of Prisons. Clinical practice guidelines: management of lipid disorders. Federal
Bureau of Prisons, Washington, DC: Federal Bureau of Prisons; 2006. Available from:
http://www.bop.gov/news/medresources.jsp
Federal Bureau of Prisons. Clinical practice guidelines: preventive health care. Federal Bureau
of Prisons, Washington, DC: Federal Bureau of Prisons; 2007. Available from:
http://www.bop.gov/news/medresources.jsp
Health Resources & Services Administration (HRSA). Lower Extremity Amputation Prevention Program

[homepage on the internet]. Available from: http://www.hrsa.gov/leap/. Accessed February 25,
2009.
Mattson JS, Cerutis RD. Diabetes mellitus: a review of the literature and dental implications.
Compendium of Continuing Education in Dentistry. 2001;22(9):757–770.
Mokdad, AH. The continuing epidemics of obesity and diabetes in the United States. JAMA.
2001;286:1195–1200.
Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a
consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 2006;29(8):
1963–1972. Available from: http://care.diabetesjournals.org/cgi/content/full/29/8/1963

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April 2009

Appendix 1: Components of the Comprehensive Diabetes Evaluation
Medical History
• Age and characteristics of onset of diabetes
(e.g., diabetes ketoacidosis, routine screening)
• Prior A1C records
• Symptom review
• Eating patterns, nutritional status, weight history;
exercise history
• Diabetes education history
• Review of previous diabetes treatment
• Current treatment of diabetes: medications, meal
plan, results of glucose monitoring
• Hypoglycemic episodes (any severe
hypoglycemia – frequency, severity, cause)
• History of diabetes-related complications:
• Microvascular (eye, kidney, nerve)
• Macrovascular (CHD, PAD)
• Other (sexual dysfunction, gastroparesis)

• Diabetic ketoacidosis: frequency, severity, cause
• Risk factors for atherosclerosis, i.e., smoking,
hypertension, obesity, dyslipidemia, family history
• Review of concurrent medications that may affect
blood glucose levels or precipitate diabetes, i.e.,
HIV protease inhibitors, atypical antipsychotic
agents, corticosteroids, pentamidine, high-dose
thiazide diuretics
• Review of prior/current infections, particularly of
the skin, feet, dentition, genitourinary system
• Female patients: gestational history including
hyperglycemia, delivery of infant weighing more
than 9 lbs., toxemia, stillbirth, polyhydramnios, or
otherwise complicated pregnancy
• Tuberculin (TST) skin test history and history of
treatment of latent TB infection (LTBI)

Immunization History
• Influenza vaccine (indicated annually for diabetic inmates, unless contraindicated)
• Pneumococcal vaccine (at diagnosis; or at age 65, one-time revaccination if >5 yrs since initial vaccine)

Physical Examination
• Cardiac exam; auscultation/palpation of DP and
PT pulses
• Presence/absence of patellar and Achilles
reflexes
• Determination of proprioception, vibration, and
monofilament sensation
• Signs of other conditions that can cause
secondary diabetes: bronzed skin color with
hemochromatosis; GI malignancy (acanthosis
nigricans); and endocrine disorders such as
acromegaly, Addison’s disease,
pheochromocytoma, and Cushing’s syndrome

• Vital signs: height, weight, blood pressure
(including orthostatic)
• Funduscopic examination (preferably with
pupillary dilation)
• Thyroid palpation (Type I diabetes)
• Skin examination (insulin injection site)
• Oral exam
• Hand and finger examination
• Abdominal examination to rule out hepatomegaly,
bruits, or enlargement of the abdominal aorta
• Examination of the feet for infections or skin
breakdown; testing for neuropathy

Laboratory Examination
• Testing for microalbuminuria in type 1 diabetic
inmates who have had the disease at least five
years, and in all type 2 diabetics. (If routine
urinalysis on two or more occasions detects
protein, and other causes such as infection and
menses are ruled out, then microalbumin
determinations are not necessary because the
nephropathy has already progressed to overt
proteinuria.)
• Urine culture, if symptoms of a urinary tract
infection are present
• Electrocardiogram (ECG) – baseline
• TST (if not previously tested)

• Fasting plasma or serum glucose (if not already
obtained)
• Hemoglobin A1C (HbA1C or A1C)
• Fasting lipid profile (including total, LDL and HDL
cholesterol, triglycerides)
• Liver function tests
• Urinalysis, as clinically warranted
• Serum creatinine and calculated glomerular
filtration rate (GFR)
• Thyroid stimulating hormone
• Screening for celiac disease in type 1 diabetes
and as indicated in type 2 diabetes

Referrals
• Baseline optometry or ophthalmology exam
• Dental care (including hard/soft tissue exam, periodontal assessment, and follow-up exam if indicated)
• Diabetes education and medical nutrition therapy

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April 2009

Appendix 2: Recommendations for Diabetes Chronic Care Clinic Monitoring
Recommendations for Diabetic Chronic Care Clinic Monitoring
Patient Evaluation / Routine Exam – SOAP Format
S:

-Observations and patient complaints
-Compliance with lifestyle changes and medications
-Side effects of medications
-Symptoms of diabetic complications

O:

-Vital signs: blood pressure, pulse, respiration rate, temperature, weight, height
-HEENT (include funduscopic exam and neck evaluation)
-Lungs/heart
-Abdomen
-Extremities / peripheral pulses / neuropathy / visual foot examination
-Labs, x-rays, other studies

A:

Assessment, analysis of data, diagnosis, degree to which glycemic goals are met

P:

-Therapeutic regimen
-Diagnostic studies
-Education – adherence to all self-care aspects, exercise evaluation, follow-up of referrals,
smoking cessation

Baseline
Visit

Quarterly
Visit

SemiAnnual Visit

Annual
Visit

Routine physical exam

X

(X)
as needed

(X)
as needed

X

Fasting blood sugar*(record results of selfmonitoring where applicable)

X

X

Fasting complete metabolic panel (electrolytes,
creatinine, total cholesterol)

X

X

Calculate glomerular filtration rate

X

X

Fasting lipid profile (obtain more often if
managing a lipid disorder, less often if low risk)

X

X

HbA1C

X

Procedure, Test, Examination

http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

(X)

X

X

if treatment
changes, or if
clinically
indicated

Screen for microalbuminuria (albumin to
creatinine ratio in a random spot collection)

X

X

Comprehensive, dilated-eye and vision exam,
by an ophthalmologist or optometrist

X

X

Funduscopic exam (by primary care doctor)

X

Foot Exam:

X
X

Visual
Monofilament

EKG

(X)

(X)

if not reaching
target goals

if reaching
target goals

X

* Fasting or random glucose (finger stick) monitoring: Methods and times must be determined on a
case-by-case basis, depending on the medical needs of the inmate and the severity of the condition.

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April 2009

Appendix 3: The Diabetes Food Pyramid
Adapted from Using the Diabetes Food Pyramid, available at the American Diabetes Association website
at: http://www.diabetes.org/nutrition-and-recipes/nutrition/foodpyramid.jsp

The Diabetes Food Pyramid divides food into six groups. These groups (shown as sections on the
pyramid) vary in size. The largest group—grains, beans, and starchy vegetables—is on the bottom. This
means that you should eat more servings of grains, beans, and starchy vegetables than of any of the other
foods. The smallest group—fats, sweets, and alcohol—is at the top, the narrowest part of the pyramid.
This tells you to eat very few servings from these food groups.
The Diabetes Food Pyramid gives a range of servings. If you follow the minimum number of servings
recommended in each group, you would eat about 1600 calories; if you were to eat the number of servings
at the upper end of the range, it would be about 2800 calories. Most women would eat at the lower end of
the range, and many men would eat in the middle to high end of the range if they are very active. The
exact number of servings you need depends on your diabetes goals, calorie and nutrition needs, lifestyle,
and the foods you like to eat. Divide the total number of servings you should eat among the meals and
snacks you eat each day.
Each of the six groups of food is described below, including the recommended range of servings for each.
Remember, not many people would eat the maximum number of servings. Most people aim towards the
lower end of each range.

Grains and Starches. Choose 6–11 servings per day.
At the base of the pyramid are bread, cereal, rice, and pasta. These foods contain mostly carbohydrates.
The foods in this group are made mostly of grains such as wheat, rye, and oats. Starchy vegetables like
potatoes, peas, and corn also belong to this group, along with dry beans such as black eyed peas and
pinto beans. Starchy vegetables and beans are in this group because they have about as many
carbohydrates in one serving as a slice of bread. Be sure to count them as carbohydrates in your meal
plan.

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Grains and Starches Serving Sizes:
1 slice of bread
¼ of a bagel (1 ounce)
½ an English muffin or pita bread
1, 6-inch tortilla
¾ cup dry cereal

Management of Diabetes
April 2009

½ cup cooked cereal
½ cup potato, yam, peas, corn, or cooked beans
1 cup winter squash
1/3 cup of rice or pasta

Vegetables. Choose at least 3–5 servings per day.
All vegetables are naturally low in fat. Choose to include them often in your meals or as low calorie
snacks. Vegetables are full of vitamins, minerals, and fiber. They include spinach, chicory, sorrel, Swiss
chard, broccoli, cabbage, bok choy, brussel sprouts, cauliflower, kale, carrots, tomatoes, cucumbers,
lettuce, and many more. However, starchy vegetables such as potatoes, corn, peas, and lima beans are
counted in the starch and grain group for diabetes meal planning.
Vegetable Serving Sizes:
1 cup raw vegetables

½ cup cooked vegetables

Fruit. Choose 2–4 servings per day.
The next highest layer of the pyramid is fruits. While fruit contain carbohydrates, they also have plenty of
vitamins, minerals, and fiber. This group includes blackberries, cantaloupe, strawberries, oranges, apples,
bananas, peaches, pears, apricots, and grapes, among others.
Fruit Serving Sizes:
½ cup canned fruit
1 small fresh fruit
2 tablespoons dried fruit

1 cup of melon or raspberries
1 ¼ cup of whole strawberries

Milk. Choose 2–3 servings per day.
Milk products contain a lot of protein and calcium, as well as many other vitamins. Choose non-fat or lowfat dairy products for great taste and nutrition without the saturated fat.
Milk Serving Sizes:
1 cup non-fat or low-fat milk

1 cup of low-fat yogurt

Meat and Meat Substitutes. Eat 4–6 ounces per day.
The “meat” group includes beef, chicken, turkey, fish, eggs, tofu, dried beans, cheese, cottage cheese,
and peanut butter. Meat and meat substitutes are great sources of protein, vitamins, and minerals.
Choose lean meats, poultry, and fish, cutting off all the visible fat. Keep your portion sizes small. Three
ounces is about the size of a deck of cards. You only need 4–6 ounces from this group for the whole day.
Equal to One Ounce of Meat:
¼ cup cottage cheese
1 egg

1 tablespoon peanut butter
½ cup tofu

Fats and Sweets. Eat only occasionally.
Things like potato chips, candy, cookies, cakes, crackers, and fried foods contain a lot of fat or sugar.
They are not as nutritious as vegetables or grains. Keep your servings small and save them for a special
treat!
Fats and Sweets Serving Sizes:
½ cup ice cream
1 small cupcake or muffin

2 small cookies

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April 2009

Appendix 4. Treatment Goals for Nonpregnant Inmates with Diabetes
Glycemic control
A1C
Preprandial capillary plasma glucose*
Peak postprandial capillary plasma glucose†*

<7.0%
90–130 mg/dl
<180 mg/dl
<130 / <80 mmHg

Blood Pressure
Lipids‡
LDL
Triglycerides
HDL§

<100 mg/dl
<150 mg/dl
>40 mg/dl

Key concepts in setting glycemic goals
• A1C is the primary target for glycemic control.
• Goals should be individualized.
• Certain inmate populations, i.e., pregnant women and the elderly, require special
considerations.
• Less intensive glycemic goals may be indicated in patients with severe or frequent
hypoglycemia.
• Postprandial glucose may be targeted if A1C goals are not met despite reaching
preprandial glucose goals.
† Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal.
‡ Current NCEP/ATP III guidelines suggest that in patients with triglycerides <200 mg/dl, the “nonHDL cholesterol” (total cholesterol minus HDL) be utilized. The goal is <130 mg/dl.
§ For women, it has been suggested that the HDL goal be increased by 10 mg/dl.
* Many glucometers automatically convert capillary blood glucose values to plasma glucose values.
Check the glucometer. Blood glucose values are 10–15% lower than plasma glucose values.
Adapted from: American Diabetes Association. Standards of medical care in diabetes – 2007.
Diabetes Care 2007;30(Supplement 1):S10.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 5: BOP Treatment Algorithm for Type 2 Diabetes

Diagnosis of Type 2 Diabetes

Lifestyle Intervention + Metformin1,2

Step 1…

No

Step 2…

Add NPH Insulin

No

Step 3…

A1C >7

A1C >7

Add Sulfonylurea

Yes*

No

Intensify Insulin

No

A1C >7

Yes*

A1C >7

Yes*

Add NPH Insulin + D/C Sulfonylurea

Yes*

No

A1C >7

Yes*

Intensify Insulin

Intensive Insulin + Metformin
1

Exception: Insulin should be utilized if severely uncontrolled DM, i.e., plasma glucose >250 mg/dl, random
glucose consistently >300 mg/dl, A1C >10%, ketonuria, or symptomatic diabetes with polyuria, polydipsia, &
weight loss.

2

Use metformin unless contraindicated, i..e., in men with a serum creatinine >1.5 mg/dl, and in women with
a serum creatinine >1.4 mg/dl; if age >80 (unless renal sufficiency established); or chronic liver failure. A
sulfonylurea can often substitute for metformin if it is contraindicated.
* Check A1C every 3 months until <7%; then, every 6 months.
Notes:
• Refer to the BOP National Formulary for the formulary status and non-formulary use criteria for specific
medications.
• In order to achieve glycemic goals, medications should be adjusted as frequently as titration allows (i.e.,
as often as every 3 to 4 days for insulin and every one to two weeks for metformin).
Adapted from: American Diabetes Association. Standards of Medical Care in Diabetes – 2007. Diabetes
Care 2007;30 (Suppl 1):S11.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 6: Initiation/Adjustment of Insulin Regimens in Type 2 Diabetes
Initiation
Start with evening intermediate-acting (NPH)
insulin. Can initiate with 10 units or 0.2 U/kg.

Check fasting glucose (finger stick), usually daily.
• Increase dose (typically by 2 units every 3 days) until fasting
levels are in target range (70-139 mg/dl).
• Can increase dose in larger increments, e.g., by 4 units every 3
days, if fasting glucose >180 mg/dl.

If hypoglycemia occurs or
fasting glucose <70 mg/dl:
Reduce evening dose by >4
units, or 10% if dose >60.

A1C >7%
No

in 2-3 mos?

Yes*

If fasting blood glucose (bg) is in target
range (70-130 mg/dl), check bg at
pre-lunch, pre-dinner, and pre-bed.
• Depending on results, add 2nd injection.
• Can usually begin with ~4 units & adjust
by 2 units every 3 days until bg is in range

Continue regimen.
Check A1C every 3
months.

If pre-lunch bg out
of range: Add
regular insulin at
breakfast.

If evening bg out of
range: Add regular
insulin at dinner.

If pre-dinner bg out
of range: Add NPH
insulin at breakfast or
regular at lunch.

A1C >7%
No
Adapted from: Nathan DM, Buse JB,
Davidson MB, et al. Management of
hyperglycemia in type 2 diabetes: a
consensus algorithm for the initiation and
adjustment of therapy. Diabetes Care
2006;29(8): 1967

in 2-3 mos?

Yes*

• Recheck pre-meal bg levels. If out of range, may need
to add another injection.
• If A1C continues to be out of range, check 2-hr
postprandial levels & adjust preprandial regular insulin.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 7: Oral Agents for Treatment of Type 2 Diabetes (Dosing/Side Effects)
Oral Agents for Treatment of Type 2 Diabetes (Dosing and Side Effects)
Agent

Initial Dose
& Treatment

Maximum
Dose

Initial
Elderly
Dose

Side Effects

Drug Interaction

Biguanides
Note: Contraindications to metformin therapy: elevated creatinine (>1.4mg/dL in women or >1.5mg/dL in men), or a
creatinine clearance <60mL/min in the elderly; history of renal insufficiency, hepatic dysfunction, or serious
cardiovascular or pulmonary compromise.

Metformin

500 mg with a meal; on the

(Glucophage) basis of patient’s tolerance

to metformin and glycemic
response, increase dosage
by 500 mg/day at weekly
intervals, adding a dose to
another meal; tid dosing not
required for efficacy, but
may decrease GI
complaints; doses >1000
mg/day with meals will likely
be needed for therapeutic
effect as monotherapy;
doses >2000 mg/day have
little added benefit.

Nausea and
diarrhea, which
usually subside over
1 week; may limit
rate of dose
increase.
Hypoglycemia only if
metformin is given
with sulfonylurea or
insulin.

* Withhold 48 hours prior
to and following surgery or
IV contrast x-ray studies.

1.25 2.5 mg

Hypoglycemia &
weight gain

1.25 mg

Hypoglycemia &
weight gain

Alcohol; coumadin; zole
antifungals; asparaginase;
corticosteroids; thiazide
diuretics; lithium; beta
blockers; cimetidine;
ranitidine; cyclosporine;
quinolones; MAO
inhibitors;
chloramphenicol;
octreotide; pentamidine
Same as above

2.5 5 mg

Hypoglycemia &
weight gain

Same as above

2.5 mg

Hypoglycemia &
weight gain

Same as above

2550 mg/day
(850 mg tid)
OR
2500 mg/day

500 mg

20 mg

Alcohol; cimetidine;
amiloride; digoxin;
morphine; procainamide;
quinidine; ranitidine;
triamterene; trimethoprim;
vancomycin; furosemide;
calcium channel blocking
agents, especially
nifedipine

Sulfonylureas (second generation)
Glyburide
(DiaBeta,
Micronase)

2.5 - 5 mg/day; increase
dose by 2.5 - 5 mg no more
often than every 7 days.
Note: Use glyburide only if
creatinine clearance is >50
ml/min.

1.5 - 3 mg/day; increase by
12 mg
<1.5 mg weekly if needed.
Note: Use glyburide only if
creatinine clearance is >50
ml/min.
5 mg/day, 30 min before
40 mg
Give
Glipizide,
short-acting breakfast; increase dose by bid when dose
2.5 - 5 mg a week as
reaches 15 mg
(Glucotrol)
needed.
Note: Use glipizide only if
creatinine clearance is >10
ml/min.
5 mg/day at breakfast;
20 mg
Glipizide,
increase dose by 2.5 - 5 mg
extended
at 3-month intervals based
release
(Glucotrol XL) on A1C.
Note: Use glipizide only if
creatinine clearance is >10
ml/min.

Glyburide,
microcrystalline
(Glynase)

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Oral Agents for Treatment of Type 2 Diabetes (Dosing and Side Effects)
Agent

Initial Dose
& Treatment

Glimepiride 1-2 mg daily with breakfast
(Amaryl)

or first main meal; increase
at 1-2 mg increments every
1-2 weeks as needed.
Note: Use glimepiride only if
creatinine clearance is >30
ml/min.

Maximum
Dose
8 mg
once daily

Initial
Elderly
Dose
0.5 1 mg

Side Effects
Hypoglycemia &
weight gain

Drug Interaction
Same as above

Glitazones (Thiazolidinediones or TZDs)
Rosiglitazone 4 mg qd or 2 mg bid;

(Avandia)

Pioglitazone 15 or 30 mg qd; increase to
(Actos)

8 mg/day

2 mg

Edema; fluid
retention may
cause or
exacerbate CHF;
weight gain;
increased risk MI.
15 mg Edema, weight gain

increase to 8 mg qd or 4 mg
bid in 12 weeks as needed.

45 mg qd monotherapy or
30 mg qd as combo therapy.

45 mg/day
monotherapy;
30 mg/day
combo
therapy

Erythromycin; calcium channel
blocker; corticosteroids;
cyclosporine; HMB-CoA
reductase inhibitors; triazolam;
trimetrexate; ketoconazole;
itraconazole
Same as above

*Decreases oral
contraceptive
efficacy.

Alpha-Glucosidase Inhibitors
Acarbose
(Precose)

Miglitol
(Glyset)

100 mg tid
25 mg tid with first bite of
with meals
meals; lower dose may be
OR
needed if gastrointestinal
50 mg tid
distress is noted; increase
dose to 50 mg tid with meals with meals
(in patients
after 4-8 weeks.
<60 kg)

25 mg Diarrhea (33%),
abdominal pain
(12%),
flatulence (77%).

Absorbents; intestinal agents
such as activated charcoal;
digestive enzyme preparations
containing carbohydrate-splitting
enzymes such as amylase or
pancreatin

*Serum
transaminase
elevations may
occur at doses
>50 mg tid.
Digoxin, propranolol, ranitidine,
Flatulence,
diarrhea, abdominal GI enzymes
pain

25 mg tid at the start of each 100 mg tid
meal.

Glinides
0.5 mg Hypoglycemia &
4 mg
weight gain
A1C <8%; 1-2 mg with each with meals
(max 16 mg
meal if HbA1C >8%;
increase by 1 mg weekly as total per day)
needed.

Repaglinide 0.5 mg with each meal if
(Prandin)

Nateglinide 60 mg, 1-30 min before
(Starlix)

180 mg tid

60 mg Hypoglycemia &
weight gain

each meal if A1C <8%; 120
mg if A1C >8%.

40

* Contraindicated in moderate-tosevere hepatic dysfunction.
Beta-adrenergic blocking agents;
drugs metabolized by the
cytochrome p450 system;
erythromycin; ketoconazole;
miconazole; sulfonamides; MAO
inhibitors; NSAIDS;
anticoagulants (warfarin
derivatives)
Same as above

Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Oral Agents for Treatment of Type 2 Diabetes (Dosing and Side Effects)
Agent

Initial Dose
& Treatment

Maximum
Dose

Initial
Elderly
Dose

Side Effects

Drug Interaction

Dipeptidyl peptidase 4 (DPP-4) inhibitors
Sitagliptin
(Januvia)

None known
Nasopharyngitis,
headache, upper
respiratory infection

100 mg once daily. If CrCl
is 30-49 mL, min., dose is
50 mg daily. If CrCl <30 mL,
min. dose is 25 mg daily.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 8: Alternative Medications for Treatment of Type 2 Diabetes
Glitazones (thiazolidinediones--TZDs)
Agents in this drug category, pioglitazone and rosiglitazone, reduce insulin resistance in target tissues and enhance
insulin action, without directly stimulating insulin secretion from the pancreas. Glitazones can be prescribed as
monotherapy, or in combination therapy with insulin (pioglitazone only), sulfonylureas, or metformin.
Within the BOP, glitazones should ordinarily be restricted to patients who fail or cannot take metformin and/or
sulfonylurea. There is a lack of long-term data on both the adverse effects and the impact on occurrence of
microvascular and macrovascular diabetes complications. Recently reported data suggests that rosiglitazone may
increase the risk of myocardial infarction and death. The glitazones are associated with added benefits: slight
reductions in blood pressure, increases in HDL cholesterol, and decreases in triglycerides. Glitazones may cause
weight gain, but they do not increase the risk of hypoglycemia.
Clinical Precautions:
1) Glitazones may precipitate heart failure and peripheral edema, and therefore are contraindicated in patients
with congestive heart failure.
2) Increased risk of myocardial infarction and death have been associated with rosiglitazone.
3) Glitazones are contraindicated with moderate-to-severe liver disease. Liver function studies should be
monitored at baseline, every two months for one year, and then periodically thereafter.

Alpha glucosidase inhibitors (AGIs)
Agents in this category, acarbose and miglitol, decrease postprandial hyperglycemia by inhibiting carbohydrate
digestion and absorption. AGIs, which reduce A1C levels by only 0.5–1%, are somewhat less effective than
sulfonylureas and biguanides in controlling hyperglycemia. An AGI is best used in a combination regimen to treat
diabetes; they are particularly useful in patients with predominantly postprandial hyperglycemia (mild fasting
hyperglycemia with disproportionately elevated A1C). In order for these medications to be effective, they must be
taken 15 minutes before or after the start of a meal.
Significant gastrointestinal symptoms may occur with AGIs, including flatulence, diarrhea, and abdominal cramps.
Symptoms tend to diminish over time and are minimized if therapy is initiated gradually. AGIs are contraindicated
in patients with cirrhosis or inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis), or if creatinine
>2.0 mg/dl.
Clinical Precaution: Hypoglycemic reactions to acarbose or miglitol therapy must be treated with glucagon or
glucose (IV or oral), since oral treatment with sucrose will be blocked by the acarbose or miglitol.

Glinides – non-sulfonylurea secretagogues (non-SUSs) (AKA meglitinides)
Drugs in this category, including repaglinide and nateglinide, stimulate insulin secretion from the pancreas, but
they have shorter half-lives than the similar-acting sulfonylureas. Therapy with repaglinide reduces A1C levels,
comparable to monotherapy with sulfonylureas or metformin; nateglinide is somewhat less effective. Non-SUS
agents can cause weight gain and hypoglycemia, but these adverse effects may be less pronounced than with
sulfonylureas.
Because their long-term safety profile has not been determined, non-SUS agents ordinarily should not be used as
first-line agents.

Exenatide
Only one glucagon-like peptide (GLP)-1 agonist agent, exenatide (Byetta), is approved for use in the United States.
Exenatide acts as an incretin mimic, stimulating insulin production in response to high blood glucose levels,
inhibiting the release of glucagon after meals, and slowing the rate of gastric emptying. An A1C reduction of 0.5–

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

1% is expected with the use of exenatide. This medication is approved for use in combination with metformin or a
sulfonylurea. Exenatide is administered as a subcutaneous injection in the thigh, abdomen, or upper arm, twice daily
within one hour prior to the breakfast and evening meals; it should not be administered after meals. It is supplied in
pre-filled syringes that provide 60 doses, and must be kept refrigerated. The pen should be discarded 30 days after
the first use.
Administration of exenatide can cause significant nausea, vomiting, and diarrhea, which may lead to weight loss.
Hypoglycemia may occur when this medication is used with a sulfonylurea; therefore, the dose of the sulfonylurea
may need to be decreased when initiating exenatide. Since exenatide slows gastric emptying, the rate and extent of
absorption of orally administered medications may need to be altered. Other medications should be given at least
one hour before exenatide administration.
Clinical Precaution:
Exenatide should not be used in patients with creatinine clearance less than 30 ml/min or with end stage
renal disease. It should not be used in patients with severe gastrointestinal disease, including gastroparesis.
Stop medication in the event of severe abdominal pain.

Sitagliptin
Sitagliptin (Januvia) is the only dipeptidyl peptidase 4 (DPP-4) inhibitor currently approved; vildagliptin (Galvus) is
awaiting FDA approval. DPP-4 inhibitors work as incretin enhancers, stimulating the alpha and beta cells in the
pancreas to release insulin in response to a glucose load and signaling the liver to stop glucose production. The
expected reduction in A1C is only 0.6–0.8%. Sitagliptin is given by mouth, 100 mg once daily, and is approved for
use both as monotherapy and in combination with metformin and/or glitazones. Sitagliptin has not been shown to
cause weight gain or weight loss, and does not cause hypoglycemia.
Clinical Precaution:
The dose of sitagliptin must be modified in patients with renal disease. In patients with a creatinine clearance
that is between 30-50 ml per minute, the dose should be decreased to 50 mg once daily. With a creatinine
clearance of less than 30 ml per minute or for those who are on dialysis, the dose is 25 mg once daily.

Pramlintide
Pramlintide (Symlin) is an injectable amylin agonist that is only approved for use in patients using insulin.
Pramlintide acts by slowing gastric emptying, preventing an increase in serum glucagon and increasing the feeling of
fullness following a meal. Adding pramlintide to the treatment regimen of a patient who is using insulin is expected
to lower the A1C by 0.5–0.7%. Pramlintide is used as adjunctive treatment in type 1 patients who use mealtime
insulin, and in type 2 diabetics who use insulin with or without concurrent sulfonylureas and/or metformin.
Pramlintide is administered as a subcutaneous injection in the abdomen or thigh, prior to major meals containing at
least 250 calories and 30 gm of carbohydrates. Gastrointestinal adverse effects are common with pramlintinde.
Nausea, vomiting, and diarrhea may occur and can cause weight loss. Pramlintide alone does not cause
hypoglycemia, but it can cause hypoglycemia when used with insulin. The mealtime preprandial dose of insulin
should be reduced when pramlintide is initiated. Prescribing information for pramlintide suggests lowering the
mealtime preprandial dose of insulin by 50%.
Clinical Precaution:
Pramlintide has the following black box warning: Symlin is used with insulin and has been associated with
an increased risk of insulin-induced hypoglycemia, particularly in patients with type 1 diabetes. When severe
hypoglycemia associated with Symlin occurs, it is seen within three hours following a Symlin injection. If
severe hypoglycemia occurs while operating a motor vehicle, heavy machinery, or while engaging in other high
risk activities, serious injuries may occur. Appropriate patient selection, careful patient instruction, and insulin
dose adjustments are critical elements for reducing this risk.

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Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 9: Keys to Controlling Diabetes
Years ago, the diabetic diet was strict and boring. Today, you do not need special foods. In fact,
the foods that are good for you are actually good for everyone. Diabetes cannot be cured, but it
can be controlled so that you can lead a normal life. Keeping good control of your diabetes
helps to delay or even prevent potential complications.
There are three keys to controlling diabetes: diet, exercise, and medication. All three are
equally important. Eating the right foods and limiting how much you eat, together with regular
exercise, help you achieve and maintain a healthy weight. At the same time, keeping good
control of your blood glucose requires that your food intake and your level of activity balance
with the medication you are taking. Following the steps below will help you maintain both a
healthy weight and good blood glucose control.

Steps for Controlling Your Blood Glucose
• Eat a wide variety of foods every day. Increase high fiber foods such as grains, beans,
vegetables, and fruits to fill you up.
• Limit concentrated sweets such as sugar, honey, jelly, syrup, cakes, cookies, candy, ice
cream, pies, pastries, regular soda, and Kool-Aid. Concentrated sugars do not cause diabetes,
and you don’t need to avoid them totally. However, they are very high in calories—and the
more calories you eat, the higher your blood glucose!
• Limit fats such as butter, margarine, cheese, fried foods, cream soups, gravy, salad dressings,
mayonnaise, and breakfast meats (bacon, sausage, etc.).
• Control portion sizes. Too much of even the right foods can also cause high blood glucose.
If you want to lose weight, cut down on portion sizes.
• Never skip meals. Eat all three meals and include snacks as needed. Eat your meals at about
the same time every day.
• Exercise. Increase your activity level (as permitted by your doctor). This will decrease your
blood glucose level.
• Monitor your weight. Weigh yourself only once a week to determine if your diet is effective.
If you are overweight, a weight loss of 1–2 pounds per week is a good goal.
• Take medication as directed. If you take pills or insulin injections for your diabetes, always
take your medication as your doctor has recommended.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 10: Inmate Fact Sheet on Diabetes
1. What is diabetes?
Diabetes is a chronic disease for which there is no cure. It can be controlled by a combination of
diet, exercise, and medical care. Diabetes means having too much sugar (glucose) in the blood.
In people who have diabetes, sugar builds up in the blood instead of going into the cells.

2. What are the symptoms of diabetes?
Most people with diabetes do not notice any symptoms. However, some symptoms of diabetes
are:
• Frequent urination
• Weakness, fatigue, drowsiness
• Increased thirst and increased hunger
• Wounds and cuts that heal slowly
• Unexplained weight loss
• Blurred vision or changes in vision

3. What puts you at risk for diabetes?
• You are age 45 and older.
• You are a member of a high-risk ethnic group (African American, Hispanic/Latino, American
Indian, Asian American, Pacific Islander).
• You are overweight.
• You have high blood pressure (at or above 140/90).
• You have a family history of diabetes.
• You have a history of diabetes during pregnancy.
• You weighed more than nine pounds at birth.

4. What are the potential complications of diabetes?
•
•
•
•
•
•

Eye damage – poor vision, retina damage, cataracts, glaucoma, blindness.
Kidney damage – progressive failure, which may require hemodialysis or organ transplantation.
Heart problems – damaged blood vessels, which may lead to heart attacks and strokes.
Nerve damage – problems with nerve sensations and with moving muscles; loss of reflexes.
Decreased ability to fight infections.
Sores and ulcers of the legs and feet.

5. How is diabetes controlled?
Diabetes is controlled by a combination of diet, exercise, and medication. Treatment goals are to
keep blood sugar near normal, control blood pressure, lower cholesterol and fat levels, and lose
weight or maintain a healthy weight. Research shows that keeping blood sugar as near to normal
as possible means fewer complications from the disease. Strict control of blood sugar helps to
prevent kidney failure, amputations, blindness, heart attacks, and stroke.

6. What are the symptoms of hypoglycemia (low blood sugar)?
•
•
•
•

• Irritation or confusion
• Rapid heart rate
• Blurred vision

Shakiness
Sweating and clammy feeling
Extreme fatigue
Hunger

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 11. Infection Control for Diabetes Care Procedures
The potential for transmission of bloodborne pathogens exists with diabetes care procedures,
including insulin administration and capillary blood glucose monitoring. Outbreaks of hepatitis
B have been reported in association with blood glucose monitoring in nursing homes. The
following infection control procedures should be followed to prevent transmission of bloodborne
pathogens in BOP facilities during diabetes care procedures.

Diabetes care procedures and techniques
• Prepare medications such as insulin in a centralized medication area; multiple dose insulin
vials should be assigned only to individual patients and labeled appropriately.
• Never reuse needles, syringes, or lancets.
• Restrict use of fingerstick capillary blood sampling devices to individual patients. Consider
selecting single-use lancets that permanently retract upon puncture.
• Dispose of used fingerstick devices and lancets at the point of use in an approved sharps
container.
• Environmental surfaces such as glucometers should be decontaminated regularly and anytime
that contamination with blood or body fluids occurs or is suspected.
• Glucometers generally should be assigned to individual patients. If a glucometer that has
been used for one patient must be reused for another patient, the device must be cleaned and
disinfected. Local facilities should have procedures for decontamination based on the
manufacturer’s recommendations.
• Any trays or carts used to deliver medications or supplies to individual patients should remain
outside patient rooms. Do not carry supplies and medications in pockets.
• Because of possible inadvertent contamination, unused supplies and medications taken to a
patient’s bedside during fingerstick monitoring or insulin administration should not be used
for another patient.

Hand hygiene and gloves
• Wear gloves during fingerstick glucose monitoring, administration of insulin, and any other
procedure that involves potential exposure to blood or body fluids.
• Change gloves between patient contacts. Before touching clean surfaces, change gloves that
have touched potentially blood-contaminated objects or fingerstick wounds.
• Remove and discard gloves in appropriate receptacles after every procedure that involves
potential exposure to blood or body fluids, including fingerstick blood sampling.
• Perform hand hygiene (i.e., handwashing with soap and water or use of an alcohol-based hand
rub) immediately after removal of gloves and before touching other medical supplies intended
for use on other residents.

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Medical management
• Review regularly the individual patients’ schedules for fingerstick blood glucose sampling
and insulin administration and reduce the number of percutaneous procedures to the minimum
necessary for appropriate medical management of diabetes and its complications.
• Assure that adequate staffing levels are maintained to perform all scheduled diabetes care
procedures, including fingerstick blood glucose monitoring.
• Consider the diagnosis of acute viral hepatitis infection in diabetic inmates who develop an
illness that includes hepatic dysfunction or elevated aminotransaminase levels (AST or ALT).

Training and oversight
• Provide a full hepatitis B vaccination series to all previously unvaccinated correctional
facility health care workers.
• Establish responsibility for oversight of infection control activities. Investigate and report
any suspected case that may represent a newly acquired bloodborne infection.
• In accordance with BOP policy, maintain control of sharps and lancets in the work area.
• Have staff demonstrate knowledge of standard precautions guidelines, as well as proficiency
in the application of these guidelines during procedures that involve possible exposure to
blood or body fluid.
• For staff members who assume responsibilities involving percutaneous procedures, provide
infection control training that includes practical demonstration of aseptic techniques and
instruction regarding reporting exposures or breaches. Provide annual retraining to all staff
members who perform procedures that involve exposure to blood or body fluids.
• Assess compliance with infection control recommendations for fingerstick glucose
monitoring (such as hand hygiene and glove changes between patients) by periodically
observing personnel and tracking use of supplies.
Adapted from:
CDC. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in
long-term-care facilities — Mississippi, North Carolina, and Los Angeles County, California,
2003–2004. MMWR 2005;54(09):220-223. Available from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm

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Federal Bureau of Prisons
Clinical Practice Guideline

Management of Diabetes
April 2009

Appendix 12: Resources for Information on Diabetes
American Diabetes Association

http://www.diabetes.org

800-342-2383

American Dietetic Association

http://www.eatright.org

800-366-1655

Centers for Disease Control and
Prevention

http://www.cdc.gov/diabetes

877-232-3422

Diabetes Medication Supplement
National Diabetes Education Program

http://ndep.nih.gov/diabetes/p
ubs/Drug_tables_supplement.
pdf

Health Resources & Services
Administration (HRSA), Lower
Extremity Amputation Prevention
Program (LEAP)

http://www.hrsa.gov/leap/

National Diabetes Information
Clearinghouse

http://www.niddk.nih.gov/healt

National Institute of Diabetes and
Digestive and Kidney Diseases
(NIDDK)

http://www.niddk.nih.gov

800-860-8747

National Kidney Foundation

http://www.kidney.org

800-622-9010

800-860-8747

h/diabetes/ndic.htm

48