Table 1.
Hypertension (HTN) and Diabetes (DM) Care Management Medication Protocol
| HTN—First visit protocol | |
|---|---|
| Clinical Assessment | Plan |
| 140–159/90–99 not on drug treatment | Start diuretic; reinforce lifestyle modification. |
| 140–159/90–99 on 1–2 medications | Increase dose or add another medication. |
| Reinforce lifestyle modifications | |
| ≥160/≥100 not on drug treatment | Start combination of diuretic and second drug. |
| Reinforce lifestyle medications. | |
| ≥160/≥100 on 1 medication | Add combination of two drugs; reinforce lifestyle modification. |
| ≥180/≥110 on 3 medications | Consult PCP regarding reasons for resistant HTN. If already ruled out, make sure patient is adherent to regimen, add 4th drug. |
| Nonadherence to regimen | Address reasons for nonadherence, remove barriers, adjust regimen if necessary, monitor adherence. |
| At goal, no adherence barriers | Continue present treatment; reinforce lifestyle modifications. |
| HTN—Follow-up visit protocol | |
| At goal | Continue present treatment, reinforce lifestyle modifications. |
| BP <10 mmHg above goal | Increase dose or add another drug. |
| BP >10 mmHg above goal | Add another drug and increase doses or other agents. If other agent(s) at or above mid-dose, add a combination of 2 additional drugs. |
| Nonadherence to regimen | Address reasons for nonadherence, enlist family members and other social support, use pill counts, pill boxes to provide feedback and reinforcement. |
| >180/>110 mmHg on 3 BP medications | Address adherence, if secondary causes of hypertension ruled out add 4th medication and monitor every 2 weeks until at goal. |
| DM visit protocol | |
| Determine if patient experienced signs or symptoms of hyperglycemia or hypoglycemia in the last 2 weeks. | |
| Adjust current medications if A1c not at goal. | |
| • Increase oral antihyperglycemics to maximum effective dose provided no contraindications or adverse effects have been noted previously. | |
| • Recommend basal insulin for patients with symptoms of hyperglycemia and an A1C ≥10%. | |
| • Increase basal insulin incrementally until fasting plasma glucose (FPG) is 70–130 2 units every 3–5 days until FPG 70–130. If FPG is >180 may increase by 4 units per day. | |
| • Increase preprandial insulin incrementally until postprandial glucose is <180. Increase by 2 units according to which mealtime reading is elevated | |
BP, blood pressure.