Provider Algorithm for Managing Diabetes

Submitted by Nelly Maybee, MD, Augusta Health Diabetes & Endocrinology Clinic

Type II diabetes has become one of the most prevalent, costly and time-consuming medical conditions that physicians have to deal with. Based on Augusta Health’s recent Community Health Needs Assessment, diabetes is one of the top three health issues that our health system has to address. The other two are mental health and obesity, both of which are inexplicably linked to diabetes.

As endocrinologists, we try to stay up-to-date on all the new developments in diabetes. In the last 10 years there have been new developments in both medications and technology. Continuous glucose sensors are becoming more prevalent and more accessible to both type I and type II diabetics. FreeStyle libre continuous glucose sensor is one of the more recent developments on the market. It is covered by private insurances and Medicare, costs less than $200 for the initial package, and ranges from $15-$30 per sensor, which are replaced every 10-14 days. Compare that to Dexcom sensor, which is still available and is superior to FreeStyle libre, but costs about a thousand dollars for the initial package and about $60 per sensor, which are replaced every 7-10 days. Sometimes it is hard to know which sensor is appropriate for which patient, how much it will cost and how to best get it covered by insurance.

Medications are becoming more complex and more expensive. Within the same classes of medications, there may be different side effects and warnings. For example, in SGLT 2 blockers, canagliflozin has been linked to lower extremity amputations, whereas dapagliflozin has shown some cardiac protection. As for GLP-1 agonists, liraglutide has some cardiac benefits, whereas other GLP-1 agonists do not or have not been specifically tested.

To make things more complicated, insurances will often decide for you which medication they will cover, you have to fill out paperwork, and go through prior authorizations and peer to peer reviews to get medications approved.

With so much (often confusing) information out there, it is often difficult to know what is the right course of action to follow. Augusta Health is fortunate that we have 4 Board certified endocrinologists and a physician’s assistant.

Any diabetes referral is welcome, but patients that really need to see us are those with A1c greater than 8% on initial medication regimen, which usually involves metformin, sulfonylurea and/or basal insulin. If a patient has type 1 diabetes or adult onset autoimmune diabetes, they are usually better served at the endocrinology clinic. 

Below is a very basic algorithm from the American Association of Clinical Endocrinologists on how to manage a type II diabetic, depending on the severity of their diabetes. A printable version can be found here.

The Diabetes & Endocrinology Clinic is always open to referrals via email, phone at (540) 245-7180, or Athena text messages (for AMG providers).