Diagnostic Criteria
Diagnose with any one of the following:
| Test | Cut-off |
|---|---|
| Fasting plasma glucose (FPG), ≥8h fast | ≥126 mg/dL |
| Random plasma glucose (with classic symptoms) | ≥200 mg/dL |
| 2-h plasma glucose, 75g OGTT | ≥200 mg/dL |
| HbA1c (NGSP-standardized) | ≥6.5% |
Confirmation rule —
- Diagnose immediately (no repeat): classic symptoms (polyuria/polydipsia/unexplained weight loss) + random glucose ≥200 mg/dL.
- Confirm before diagnosing if asymptomatic: repeat the same test on a different day, or two different tests from the same draw both abnormal (e.g. FPG + HbA1c) — either satisfies confirmation, no need to repeat both.
Glucose / A1c interpretation
| Status | Normal | IFG | IGT | Diabetes |
|---|---|---|---|---|
| FPG | <100 | 100–125 | — | ≥126 |
| 2h-PG (75g OGTT) | <140 | — | 140–199 | ≥200 |
| HbA1c | <5.7% | 5.7–6.4% | ≥6.5% | |
All values mg/dL unless stated. IFG/IGT = prediabetes. Type 1 DM: confirm with C-peptide + islet autoantibodies if clinical phenotype is atypical or age <30y without typical T2DM features.
Glycemic Targets
| Parameter | Intensive control | Standard control |
|---|---|---|
| Fasting / pre-meal glucose | 70–110 mg/dL | 80–130 mg/dL |
| 2h post-prandial glucose | <140 mg/dL | — |
| Peak post-prandial glucose | — | <180 mg/dL |
| HbA1c | <6.5% | <7.0% |
- A1c <7.0% — most non-pregnant adults, no/low hypoglycemia risk
- A1c <6.5% — acceptable if achieved without hypoglycemia/treatment burden
- A1c <8.0% — frequent/severe hypoglycemia, multiple comorbidities
- Healthy older adult (>65y), no comorbidity: A1c 7.0–7.5%
- Moderately complex older adult (functionally independent + comorbidity/mild-mod cognitive impairment): A1c <8%
- Highly complex / frail older adult (LTC, end-stage illness, mod-severe cognitive impairment): avoid hypo/hyperglycemic symptoms; no fixed A1c target
Complication & Risk Evaluation
Risk-stratify every patient at diagnosis and at follow-up to set referral urgency:
| Domain | Low risk | Moderate | High | Established complication |
|---|---|---|---|---|
| Glycemic control | A1c <7% | A1c 7.0–7.9% | A1c ≥8% or hypo >3×/wk | — |
| Kidney | No proteinuria, UACR <30 | UACR 30–300 | UACR >300 or eGFR 30–59 | eGFR <30 |
| Eye | No retinopathy | Mild NPDR | Moderate NPDR / VA abnormal | Severe NPDR / PDR / macular edema |
| Heart & vessels | No HTN/dyslipidemia | HTN/dyslipidemia present | HTN/dyslipidemia uncontrolled | Angina/CAD/MI/CABG/HF/CVA |
| Foot | Normal sensation & pulses | Peripheral neuropathy, ↓pulses | Prior ulcer/amputation, claudication | Rest pain / gangrene |
Annual / routine screening (no known complications)
- Full physical exam incl. foot exam — ≥1×/year
- Dilated eye exam — ≥1×/year
- Dental/oral health check — ≥1×/year
- Spot urine UACR + eGFR (CKD-EPI) — ≥1×/year
- Lipid profile — at diagnosis, then every 5y (or annually if on statin / abnormal baseline / age ≥40)
CKD referral triggers
- eGFR <30 mL/min/1.73m², or rapidly/persistently declining
- UACR ≥300 mg/g or UPCR ≥500 mg/g despite BP control
- >20 RBC/hpf unexplained
- eGFR drop ≥25% from baseline, or decline >5 mL/min/1.73m²/yr
Treatment — Drug Classes
| Class | ↓A1c | Key points |
|---|---|---|
| Metformin | 1–2% | Cheap, weight-neutral, low hypo risk. Reduce dose eGFR 30–45; avoid <30. |
| Sulfonylureas | 1–2% | Cheap, weight gain, hypoglycemia risk (avoid glibenclamide in elderly/renal impair); avoid eGFR <30 (except glipizide, caution). |
| SGLT2 inhibitors | 0.8% | Weight loss, ↓CV/HF/CKD progression. Avoid eGFR <20–30 (check label). ↑GU infection, DKA risk (euglycemic). |
| GLP-1 analogs | 1–1.5% | Weight loss, ↓CV events in established/high-risk ASCVD. Avoid eGFR <15. GI side effects. Avoid in MTC/MEN2, pancreatitis hx. |
| DPP-4 inhibitors | 0.8% | Weight-neutral, well tolerated, expensive. Avoid in pancreatitis hx. |
| TZD (pioglitazone) | 0.5–1.4% | Good for insulin resistance. Fluid retention, weight gain, CI in heart failure, ↑fracture risk. |
| Glinides | 1–1.5% | Fast onset, good for post-prandial control, irregular meals. |
| α-glucosidase inhibitors | 0.4–0.6% | Targets post-prandial glucose; GI side effects; avoid eGFR <30. |
| Insulin | 1.5–3.5%+ | No ceiling effect, highest hypo risk, weight gain. |
First-line / Second-line Algorithm
Step 1 — at diagnosisLifestyle modification (MNT + exercise) for up to 3 months. Start medication immediately if not at target.
↓
First-lineMetformin — unless contraindicated / cost-prohibitive
↓ if not at target
No CV/renal/HF diseaseAdd 2nd agent: SU, TZD, DPP-4i, SGLT2i, α-GI, GLP-1, or basal insulin — choose by patient profile
ASCVD / HF / CKD / severe obesitySGLT2i (HF, CKD) or GLP-1 analog (ASCVD, severe obesity) — preferred 2nd-line regardless of A1c, ± metformin
↓ if not at target
Triple therapy3 oral agents, or 2 oral + GLP-1, or oral agents + basal insulin
↓ if not at target
Insulin intensificationBasal insulin (NPH/LAA/ULAA at bedtime) ± GLP-1 → add prandial insulin (basal-plus → basal-bolus) if post-prandial / A1c still uncontrolled
Start dual therapy immediately if FPG ≥200 mg/dL or A1c ≥9%. Start insulin ± other agents if FPG ≥300 mg/dL or A1c ≥10% or symptomatic hyperglycemia.
Full Prescriptions
Oral agents (representative starting doses)
Metformin (Glucophage®)
500 mg PO OD–BID with meals, titrate weekly to 500–1000 mg BID–TID (max 2550 mg/day). XR form: 500–2000 mg OD with evening meal.
Tab: 500 mg, 850 mg, 1000 mg (IR); 500 mg, 750 mg, 1000 mg (XR)
Glipizide (Minidiab®)
2.5–5 mg PO OD before breakfast, titrate to max 20 mg/day (divide BID if >15 mg)
Tab: 5 mg
Gliclazide MR (Diamicron MR®)
30–60 mg PO OD with breakfast, max 120 mg/day
Tab: 30 mg, 60 mg (modified release)
Pioglitazone (Actos®)
15–30 mg PO OD, max 45 mg/day. Avoid in heart failure.
Tab: 15 mg, 30 mg, 45 mg
Sitagliptin (Januvia®)
100 mg PO OD (50 mg if eGFR 30–45; 25 mg if eGFR <30)
Tab: 25 mg, 50 mg, 100 mg
Vildagliptin (Galvus®)
50 mg PO OD–BID (max 100 mg/day; 50 mg OD if eGFR <50)
Tab: 50 mg
Empagliflozin (Jardiance®)
10 mg PO OD, may increase to 25 mg/day. Avoid initiation eGFR <20.
Tab: 10 mg, 25 mg
Dapagliflozin (Forxiga®)
5–10 mg PO OD. Avoid initiation eGFR <25 (glycemic indication).
Tab: 5 mg, 10 mg
Acarbose (Glucobay®)
25 mg PO TID with first bite of each meal, titrate to 50–100 mg TID
Tab: 50 mg, 100 mg
Injectable GLP-1 analogs
| Drug (brand) | Half-life | Dose | Frequency |
|---|---|---|---|
| Liraglutide (Victoza®) | 13h | 1.2–1.8 mg | OD |
| Dulaglutide (Trulicity®) | 4.5–4.7d | 1.5 mg (up to 3.0/4.5) | Weekly |
| Semaglutide SC (Ozempic®) | 7d | 0.5–1.0 mg | Weekly |
| Semaglutide oral (Rybelsus®) | ~152h | 7–14 mg | OD, fasting |
| Lixisenatide (in Soliqua® only) | 3h | 10–20 mcg | OD |
Insulin reference
| Type (brand) | Onset | Peak | Duration |
|---|---|---|---|
| Regular (Actrapid®, Humulin R®) | 30–45 min | 2–3h | 4–8h |
| NPH (Insulatard®, Humulin N®) | 2–4h | 4–8h | 10–16h |
| Lispro / Aspart / Glulisine (rapid) | 5–20 min | 1–2h | 3–4h |
| Glargine U100 (Lantus®) / Detemir (Levemir®) | 2h | none | 18–24h |
| Degludec (Tresiba®) / Glargine U300 (Toujeo®) | 6h | none | 24–36h |
| Premixed 30/70 (Mixtard 30®, Humulin 70/30®) | 30–60 min | 2h & 8h | 12–20h |
Basal insulin start: NPH/glargine/detemir/degludec 0.1–0.2 U/kg/day, titrate +2–4 U every 3–7 days to fasting target. T1DM total starting dose ≈0.4–0.6 U/kg/day (~30–40% basal, rest as prandial RI/rapid-acting split across meals).
Source: Clinical Practice Guideline for Diabetes 2023 (แนวทางเวชปฏิบัติสำหรับโรคเบาหวาน 2566), Diabetes Association of Thailand / Endocrine Society of Thailand / Department of Medical Services, MOPH, and National Health Security Office — September 2023.
ADA 2026 Standards — Additions
International guideline used to supplement areas not verified in the Thai DM CPG 2566. Where ADA differs from the Thai CPG, follow the Thai CPG.
Drug choice by comorbidity
| Situation | Preferred | Key points |
|---|---|---|
| ASCVD or high CV risk* | GLP-1 RA or SGLT2i (may combine) | Independent of A1c. 2nd option: TZD (lower dose better tolerated) |
| Symptomatic HF, EF ≤40% | SGLT2i (eGFR ≥20) + HFrEF GDMT | ARNI (or ACEi/ARB), β-blocker, MRA (eGFR ≥30, K <5). No TZD, no saxagliptin |
| HF, EF >40% | SGLT2i | If obesity: GLP-1 RA or GIP/GLP-1 RA. Finerenone (eGFR ≥25, K <5). ACEi/ARB if HTN, prior MI or CKD |
| CKD (eGFR <60 and/or UACR ≥30) | SGLT2i (eGFR ≥20) or GLP-1 RA | Continue SGLT2i until dialysis/transplant; glycemic effect falls at eGFR <45. GLP-1 RA preferred for glycemia at eGFR <30; usable on dialysis. Finerenone if albuminuria (eGFR ≥25, K <5); SGLT2i + finerenone together can be considered if UACR ≥100 mg/g and eGFR 30–90 |
| MASLD + overweight/obesity | GLP-1 RA or GIP/GLP-1 RA | Biopsy-proven MASH / high fibrosis risk: GLP-1 RA, tirzepatide, pioglitazone (± GLP-1 RA). Decompensated cirrhosis: insulin |
| None of the above | Metformin, or any effective agent | Choose non-hypoglycemic agents if hypoglycemia risk is high |
*High CV risk: age ≥55 with ≥2 additional risk factors (HTN, smoking, dyslipidemia, obesity, albuminuria), or end-organ damage (LVH, retinopathy). Screen T2DM/prediabetes for MASH fibrosis with FIB-4, even if liver enzymes are normal.
Glucose-lowering rules
- Start drug therapy at diagnosis without delay. Initial combination if A1c is 1.5–2% above goal.
- Metformin in HF: continue in stable HF (eGFR >30); avoid in unstable or hospitalized HF.
- Metformin in CKD: do not initiate if eGFR <45; stop if <30; if stable at 30–45, continue at reduced dose. Hold around iodinated contrast if eGFR 30–60. Check vitamin B12 periodically.
- Do not combine DPP-4i with GLP-1 RA or GIP/GLP-1 RA.
- Injectable needed: GLP-1 RA or GIP/GLP-1 RA before insulin. If already on insulin, add GLP-1 RA/GIP-GLP-1 RA. Continue other agents after starting insulin if tolerated.
- Insulin first: glucose ≥300 mg/dL, A1c >10%, symptomatic hyperglycemia or catabolic features (weight loss, ketosis, hypertriglyceridemia); can step down to non-insulin agents once improved.
- Severe hyperglycemia: sulfonylurea, GLP-1 RA or tirzepatide are alternatives to insulin.
- Glycemic efficacy — very high: dulaglutide (high dose), semaglutide, tirzepatide, insulin. Weight loss — very high: semaglutide, tirzepatide. Weight gain: insulin, sulfonylureas, TZD.
A1c targets (ADA 2026)
| Patient | A1c | Fasting / pre-meal glucose |
|---|---|---|
| Age <65, most patients | <7% | 80–130 (peak post-prandial <180) |
| Age <65, good health, low treatment burden | <6.5% | — |
| Frailty, cognitive/functional limits, severe comorbidity | Less stringent | — |
| Age ≥65, healthy | <7–7.5% | 80–130 |
| Age ≥65, complex/intermediate health | <8% | 90–150 |
| Age ≥65, very complex/poor health, or limited life expectancy | Avoid reliance on A1c | 100–180; avoid hypoglycemia and symptomatic hyperglycemia |
Blood pressure in DM (ADA 2026)
- Diagnosis: average ≥130/80 on ≥2 measurements on ≥2 occasions, or one visit ≥180/110 with CVD. Start drugs at ≥130/80.
- Initial therapy: 1 drug if 130/80 to <150/90; 2 drugs if ≥150/90.
- Use ACEi, ARB, thiazide-like diuretic or dihydropyridine CCB. ACEi/ARB first-line with albuminuria (UACR 30–299 suggested; ≥300 strongly recommended; max tolerated dose) or CAD.
- Continue ACEi/ARB if creatinine rises ≤30% without hyperkalemia or volume depletion; may continue even at eGFR <30. Not for primary prevention of CKD with normal BP, UACR and eGFR.
- Resistant HTN (≥130/80 on 3 drugs including a diuretic): add MRA.
- Goal <130/80; SBP <120 encouraged in high CV or kidney risk; <140/90 for very complex/poor health older adults.
Conflict: the 2024 Thai HT guideline advises not aiming for office SBP <120 (Class III). Follow the Thai guideline.
Lipids in DM (ADA 2026)
| Group | Statin | Goal / add-on |
|---|---|---|
| Age 20–39 + ASCVD risk factor | Moderate-intensity | — |
| Age 40–75, no risk factor | Moderate-intensity | — |
| Age 40–75, ≥1 risk factor | High-intensity | LDL-C <70 and ≥50% reduction; add ezetimibe or PCSK9i if ≥70 |
| Age >75; T1DM + risk factor | Moderate-intensity | — |
| Secondary prevention, any age | High-intensity | LDL-C <55 and ≥50% reduction; add ezetimibe or PCSK9i |
| Statin-intolerant | Bempedoic acid (primary prevention); in secondary prevention PCSK9 mAb, bempedoic acid or inclisiran | |
- ASCVD risk factors: older age, HTN, dyslipidemia, smoking, CKD, obesity.
- Pregnancy: stop lipid-lowering drugs before conception; may continue in FH, familial hypertriglyceridemia, prior ASCVD event or pancreatitis if benefit outweighs risk.
- Statins are safe in compensated cirrhosis; use with caution and close monitoring in decompensated cirrhosis.
- HDL <40 with TG >200: fibrate not recommended for CV risk reduction (PROMINENT).
Conflict: ADA uses LDL-C <70 for age 40–75 with ≥1 risk factor and <55 for all secondary prevention. The Thai CPG uses <70 for ≥2 risk factors and, in secondary prevention, <55 for ACS and <70 for chronic coronary syndrome (see the LDL table above). Follow the Thai CPG.
Low-dose aspirin, primary prevention (75–162 mg/day)
- May be considered after risk–benefit discussion: age ≥50 with ≥1 major risk factor (obesity, HTN, smoking, dyslipidemia, CKD) and no increased bleeding risk (age >70, anemia, renal disease).
- Not recommended: age <50 with no other major risk factor.
- Intermediate risk (age <50 with ≥1 risk factor, or ≥50 without): clinical judgement. Coronary calcium score can help.
- Age <21: do not give (Reye syndrome).
Source: ADA Standards of Care in Diabetes — 2026 (published Dec 2025), taken from a Thai-language summary supplied by JJ. Cross-checked against the ADA 2026 factsheet: SBP <120 for high CV/renal risk, GLP-1 RA in CKD and HFpEF, finerenone in HF EF >40%, SGLT2i + finerenone with UACR ≥100 and eGFR 30–90, no add-on fibrate/niacin/n-3 to statin, BP <130/80 and <140/90 in older adults. Other items are from the summary only.
Follow-up & Monitoring
Visit frequency
- New diagnosis / medication change: review every 1–4 weeks until glucose controlled → then every 1–3 months until at target
- Stable on treatment: every 3 months; check A1c every 2–6 months (3-monthly if not at goal; 6-monthly if stable at goal)
- Check glucose in-person each visit; review BGM/CGM logs; assess injection site if on insulin
Annual screening checklist
| Parameter | Test | Frequency |
|---|---|---|
| Glycemic control | HbA1c | Every 3 months if not at goal; every 6 months if stable |
| Kidney | Spot urine UACR + eGFR (CKD-EPI) | Annually (more frequently if abnormal) |
| Eye | Dilated fundoscopy / retinal photo | Annually |
| Foot | Full foot exam incl. sensation, pulses | Annually (every visit if high-risk) |
| BP | Office BP | Every visit |
| Lipids | Fasting lipid profile | At diagnosis; then every 5y if normal; annually if on statin or abnormal |
| Weight/BMI | BMI + waist circumference | Every visit |
| Liver/renal (if on metformin) | eGFR | Annually; before dose changes |
| Dental/oral | Dental exam | Annually |
| Vaccinations | Influenza, pneumococcal, Hep B | Per immunization schedule |
CV risk factor targets in DM (Thai DM CPG 2023 Ch. 14; LDL-C per RCPT 2024)
| Parameter | Target |
|---|---|
| BP (systolic) | <130 mmHg |
| BP (diastolic) | <80 mmHg |
| LDL-C (age ≥40, 0–1 risk factor*) | <100 mg/dL and ≥30% reduction (LDL-C ≥190: titrate for ≥50%; add ezetimibe if statin cannot be increased) |
| LDL-C (age ≥40, ≥2 risk factors*) | <70 mg/dL and ≥50% reduction; add ezetimibe, then refer for PCSK9 inhibitor if still above goal |
| LDL-C (established ASCVD) | ACS <55 · chronic coronary syndrome <70 mg/dL (both ≥50% reduction) — see Dyslipidemia tab |
| BMI | 18.5–22.9 kg/m² (Thai standard); ≥5% weight loss if overweight |
| Waist circumference | <90 cm (M) / <80 cm (F) |
| Smoking | Cessation |
| Exercise | ≥150 min/week moderate aerobic |
*Risk factors: DM duration >10y, obesity, smoking, hypertension, premature family CVD, CKD, albuminuria. DM age <40y: target not verified in the text reviewed — refer to RCPT 2024.
Escalation / treatment adjustment triggers
- A1c not at target after 3 months on current regimen → add agent or escalate dose
- ASCVD/HF/CKD identified at any point → add SGLT2i or GLP-1 regardless of A1c level
- eGFR 30–45 → reduce metformin dose; eGFR <30 → stop metformin, review SGLT2i (most contraindicated), titrate insulin
- UACR ≥30 mg/g → start ACEI/ARB; UACR ≥300 or eGFR <30 → refer nephrology
- Moderate/severe NPDR or PDR → refer ophthalmology urgently
- Severe NPDR, PDR, macular edema, eGFR <30, CAD/HF/CVA, gangrene → refer respective specialist
A1c that is falsely low (hemolytic anemia, iron deficiency, hemoglobinopathy) or falsely high (chronic kidney disease, B12/folate deficiency, erythropoietin use) — use fructosamine or glucose monitoring instead of A1c for primary monitoring in these patients.
Diagnostic Criteria
Hypertension = repeated office BP ≥140/90 mmHg. Out-of-office measurement preferred to confirm and avoid white-coat / masked HTN.
| Category | SBP (mmHg) | DBP (mmHg) | |
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | <80 |
| BP at risk (new 2024 category) | 130–139 | and/or | 80–89 |
| Grade 1 HTN | 140–159 | and/or | 90–99 |
| Grade 2 HTN | 160–179 | and/or | 100–109 |
| Grade 3 HTN | ≥180 | and/or | ≥110 |
| Isolated systolic HTN | ≥140 | and | <90 |
| Isolated diastolic HTN | <140 | and | ≥90 |
Diagnostic thresholds by method
| Method | SBP | DBP | |
|---|---|---|---|
| Office | ≥140 | and/or | ≥90 |
| Home (HBPM) | ≥135 | and/or | ≥85 |
| ABPM daytime avg | ≥135 | and/or | ≥85 |
| ABPM nighttime avg | ≥120 | and/or | ≥70 |
| ABPM 24h avg | ≥130 | and/or | ≥80 |
BP 130–139/80–89 with normal out-of-office BP → diagnose HTN if HMOD, CVD, DM, or high CV risk is present.
Risk Evaluation
High CV risk = Thai CV Risk Score 10-yr risk ≥10%, or ≥3 of: male, age >55y, smoking, LVH, family hx CVD, albuminuria, DM, known ASCVD, total chol/HDL ratio >6.
Baseline work-up (every patient)
- 12-lead ECG — every patient
- Hb/Hct, FPG + HbA1c, lipid profile, creatinine/eGFR, K, Na, uric acid, urinalysis
- Urine albumin — every patient; urine microalbumin — every patient with DM
- Echocardiography — if ECG abnormal or suspected heart disease
- Retinal exam — Grade 3 HTN or DM
- Renal ultrasound/Doppler — CKD, albuminuria, or suspected renovascular HTN
Treatment initiation thresholds
| Population | Start drug at |
|---|---|
| Clinical CVD, DM, or 10-yr CV risk ≥10% | Office SBP ≥130 and/or DBP ≥80 |
| General adult | Office SBP ≥140 and/or DBP ≥90 |
BP Targets
| Age group | Office BP target |
|---|---|
| 18–64y | <130/80 mmHg |
| 65–79y | <140/90 initially → <130/80 if well tolerated |
| 65–79y with isolated systolic HTN | SBP 140–150 initially → 130–139 if tolerated (caution if DBP <70) |
| ≥80y | SBP 140–150, DBP <80 → SBP 130–139 if well tolerated |
Do not target office SBP <120 or DBP <70 mmHg (Class III — not recommended).
Home BP targets (average): <130/80 for all; consider <125/75 in age 18–65y with DM/CVD/high risk; age 65–79y or prior stroke <135/85; age ≥80y <140/80 acceptable (IIb, C).
First-line / Second-line Algorithm
5 major drug classes (any may be first-line): ACEI, ARB, beta-blocker, CCB, thiazide/thiazide-like diuretic (chlorthalidone, indapamide).
Most patientsStart 2-drug combination (preferably single-pill combination, SPC) — except advanced age/frailty, low starting BP (140–149/90–99) with low CV risk, or BP at risk (130–139/80–89) with very high CV risk → start 1 drug
↓
Preferred comboACEI or ARB + CCB (or + thiazide/thiazide-like diuretic)
↓ if not at target
3-drug combinationRAS blocker (ACEI/ARB) + CCB + thiazide/thiazide-like diuretic — one component must be a diuretic, preferably thiazide-like
↓ resistant HTN
Resistant HTNUncontrolled on 3 drugs at maximum tolerated doses including a diuretic. ARNI may replace the RAS blocker (IIb, B). The 2024 CPG algorithm does not name a 4th agent; spironolactone 12.5–25 mg OD is the usual add-on per Thai Hypertension Society resistant-HTN consensus (alternatives: eplerenone, beta-blocker, alpha-blocker).
Compelling indications
- DM: ACEI/ARB preferred (esp. with albuminuria)
- CAD: ACEI and/or beta-blocker first; ARB if ACEI not tolerated
- Heart failure: ACEI/ARB/ARNI + beta-blocker + MRA + diuretic (GDMT)
- CKD/diabetic nephropathy: ACEI preferred; ARB if ACEI not tolerated — monitor K+/creatinine after initiation
- Atrial fibrillation: beta-blocker or non-DHP CCB for rate control
Full Prescriptions
ACE inhibitors
Enalapril (Renitec®) 5 mg PO OD–BID, titrate to 10–20 mg BID (max 40 mg/day)
Tab: 5 mg, 20 mg
Perindopril (Coversyl®) 4 mg PO OD, max 8 mg/day
Tab: 4 mg, 8 mg
Ramipril (Tritace®) 2.5 mg PO OD, titrate to max 10 mg/day
Tab: 2.5 mg, 5 mg, 10 mg
ARBs
Losartan (Cozaar®) 50 mg PO OD, max 100 mg/day (single or divided)
Tab: 50 mg, 100 mg
Valsartan (Diovan®) 80 mg PO OD, max 320 mg/day
Tab: 80 mg, 160 mg
Telmisartan (Micardis®) 40 mg PO OD, max 80 mg/day
Tab: 40 mg, 80 mg
Calcium channel blockers (DHP)
Amlodipine (Norvasc®) 5 mg PO OD, max 10 mg/day
Tab: 5 mg, 10 mg
Thiazide / thiazide-like diuretics
Hydrochlorothiazide 12.5–25 mg PO OD
Tab: 25 mg
Chlorthalidone 12.5–25 mg PO OD
Tab: 25 mg (commonly split)
Indapamide SR (Natrilix SR®) 1.5 mg PO OD
Tab: 1.5 mg SR
Beta-blockers
Bisoprolol (Concor®) 2.5–5 mg PO OD, max 20 mg/day
Tab: 2.5 mg, 5 mg, 10 mg
Atenolol (Tenormin®) 25–50 mg PO OD, max 100 mg/day
Tab: 50 mg, 100 mg
Combination single-pill (examples)
Perindopril/Amlodipine (Coveram®) 4/5 mg – 8/10 mg PO OD
Tab: 4/5, 4/10, 8/5, 8/10 mg
Losartan/HCTZ (Cozaar Comp®) 50/12.5 mg PO OD, max 100/25
Tab: 50/12.5, 100/12.5, 100/25 mg
Resistant HTN add-on
Spironolactone 12.5–25 mg PO OD, max 50 mg/day (monitor K+)
Tab: 25 mg, 100 mg
Source: 2024 Thai Guidelines on the Treatment of Hypertension, Thai Hypertension Society (สมาคมความดันโลหิตสูงแห่งประเทศไทย), published in full Aug 2024; English summary: Kunanon S, et al. Asian Biomed 2025;19(6):316–357.
Follow-up & Monitoring
Visit frequency
- After initiating or changing medication: recheck in 2–4 weeks; measure HBPM 7 consecutive days starting 2 weeks after change, and 3 days before next clinic visit
- Not yet at target: every 1–3 months until BP goal achieved
- At target (stable): every 3–6 months; HBPM 1–2×/week or 7 days before each clinic visit (≥1 week within each 3-month interval)
Routine monitoring checklist
| Parameter | Test | Frequency |
|---|---|---|
| BP control | Office BP + HBPM log review | Every visit |
| Electrolytes | K+, Na+, creatinine/eGFR | 1–4 weeks after starting ACEI/ARB/diuretic; then annually if stable |
| Kidney | eGFR + urine albumin | Annually (every 6m if CKD or DM) |
| Metabolic | FPG/HbA1c, lipid profile, uric acid | Annually |
| ECG | 12-lead ECG | At diagnosis; repeat if symptomatic or significant BP change |
| Weight | BMI + waist | Every visit |
| Adherence | Pill count / self-report | Every visit |
| Orthostatic screen | Lying → standing BP | Elderly, DM, symptomatic patients |
Resistant hypertension
Defined (2024 Thai CPG) as uncontrolled BP on a 3-drug regimen at maximum recommended/tolerated doses including a diuretic. (Thai Hypertension Society consensus also counts controlled BP requiring ≥4 drugs.) Rule out pseudo-resistance first (poor adherence, white-coat effect, incorrect measurement technique, suboptimal doses).
Step 1 — excludeConfirm adherence, correct technique, check for drug interactions, sodium excess, secondary causes (primary aldosteronism, renal artery stenosis, OSA, pheochromocytoma, Cushing's)
↓
Step 2 — optimizeEnsure diuretic is thiazide-like (chlorthalidone/indapamide) at adequate dose; optimize RAS blocker + CCB; reinforce lifestyle
↓
Step 3 — 4th agentAdd spironolactone 12.5–25 mg OD (most evidence in resistant HTN — check K+/eGFR); alternatives: eplerenone, beta-blocker, alpha-blocker (doxazosin), or ARNI (sacubitril/valsartan)
↓
ReferHypertension specialist if ≥4 drugs without control, suspected secondary HTN, or hypertensive emergency
Escalation triggers
- BP not at target after 1–3 months on current regimen → optimize dose or add agent
- Creatinine rise >30% after ACEI/ARB start → investigate renal artery stenosis; rise <30% is acceptable, continue and monitor
- K+ ≥5.5 on ACEI/ARB → reduce dose, review diet, consider switching to CCB/diuretic combination
- Hypertensive urgency (severe asymptomatic elevation) → oral antihypertensive, observe, avoid rapid drop
- Hypertensive emergency (end-organ damage) → IV agents, ICU admission, target 25% SBP reduction in first hour
HBPM protocol (from Thai HTN 2024): Morning measurement within 1h of waking, after urination, before medication/breakfast. Evening before sleep. 2 readings per session, 1 min apart. Average all readings — do not selectively discard readings.
Screening & Measurement
Screen all adults age ≥35y, plus anyone with ASCVD, DM, CKD, or suspected familial dyslipidemia. LDL-C is the primary target for risk assessment and treatment.
- Calculated LDL-C (Friedewald) = TC − HDL-C − TG/5 (mg/dL)
- Use direct LDL-C if TG ≥400 mg/dL or calculated LDL-C <50 mg/dL
- Calculate non-HDL-C (TC − HDL-C) in patients with high TG, DM, or obesity
- Risk assessment, age 35–70y without CVD: Thai CV Risk Score 10-yr risk — <10% low; ≥10% moderate–high
Clinical ASCVD: ACS, MI, stable CAD/angina, revascularization, ischemic stroke/TIA, PAD, atherosclerotic aortic disease. Subclinical ASCVD: plaque on imaging or high coronary calcium score.
LDL-C Targets by Indication
Primary prevention
| Group | LDL-C goal | Initial therapy / escalation |
|---|---|---|
| LDL-C ≥190 mg/dL (age ≥21y) | <100 and ≥50% reduction | Moderate-intensity statin; switch to high-intensity if not at goal at 4–12 wk |
| Familial hypercholesterolemia | <70 and ≥50% reduction | High-intensity statin → add ezetimibe at 4–12 wk → refer for PCSK9 inhibitor |
| Age ≥35y, LDL-C <190, Thai CV score ≥10% | <100 and ≥30% reduction | Low–moderate intensity statin, titrate to max tolerated |
| Age ≥35y, score <10% with subclinical atherosclerosis (CAC >100, ABI <0.9), premature family hx or chronic inflammation (psoriasis, RA, HIV) | <100 and ≥30% reduction | May consider low–moderate statin (Class IIb) |
| Age ≥35y, score <10%, no risk modifiers | — | Sustained lifestyle modification |
| DM age ≥40y, 0–1 risk factor | <100 and ≥30% reduction | Statin + lifestyle; LDL-C ≥190 → titrate for ≥50%; ezetimibe if statin cannot be increased |
| DM age ≥40y, ≥2 risk factors | <70 and ≥50% reduction | Statin → ezetimibe → refer for PCSK9 inhibitor |
| CKD eGFR <60 (non-dialysis), age ≥50y, LDL-C >100 | <100 or ≥30% reduction | Low–moderate statin or statin/ezetimibe; dialysis (5D): do not initiate statin |
Secondary prevention
| Condition | LDL-C goal |
|---|---|
| ACS | <55 and ≥50% reduction |
| Chronic coronary syndrome | <70 and ≥50% reduction |
| Ischemic stroke/TIA with intracranial or carotid atherosclerosis | <70 (if LDL-C ≥70) |
| Non-cardioembolic stroke/TIA without atherosclerosis | <100 if LDL-C ≥100; no target if <100 |
DM risk factors: duration >10y, obesity, smoking, hypertension, premature family CVD, CKD, albuminuria. Secondary-prevention targets are from a secondary summary of the RCPT 2024 flowcharts — confirm against the full guideline.
First-line / Second-line Treatment
All patientsLifestyle modification (diet, exercise, weight) — cornerstone regardless of drug therapy
↓
First-lineStatin — intensity selected by indication and LDL-C goal; reassess at 4–12 weeks, up-titrate to max tolerated dose
↓ if LDL-C goal not met on max tolerated statin
Second-line (add-on)Ezetimibe 10 mg/day added to statin
↓ if still not at goal (FH, DM with ≥2 risk factors, ASCVD)
Third-lineRefer for PCSK9 inhibitor (evolocumab/alirocumab) added to statin + ezetimibe
Statin Intensity & Full Prescriptions
| Intensity | LDL-C reduction | Examples & dose |
|---|---|---|
| High | ≥50% | Atorvastatin 40–80 mg/day · Rosuvastatin 20–40 mg/day |
| Moderate | 30–49% | Atorvastatin 10–20 mg · Rosuvastatin 5–10 mg · Simvastatin 20–40 mg · Pitavastatin 1–4 mg · Fluvastatin 80 mg · Lovastatin 40–80 mg |
| Low | <30% | Simvastatin 10 mg · Pravastatin 10–20 mg · Lovastatin 20 mg |
Intensity/dose classification is the standard scheme; the RCPT appendix dose table was not available for verification.
Atorvastatin (Lipitor®) 10–20 mg PO OD (moderate) or 40–80 mg PO OD (high intensity), any time of day
Tab: 10 mg, 20 mg, 40 mg, 80 mg
Rosuvastatin (Crestor®) 5–10 mg PO OD (moderate) or 20–40 mg PO OD (high intensity), evening
Tab: 5 mg, 10 mg, 20 mg
Simvastatin (Zocor®) 20–40 mg PO OD, evening. Do not use 80 mg/day.
Tab: 10 mg, 20 mg, 40 mg
Ezetimibe (Ezetrol®) 10 mg PO OD, any time, with or without statin
Tab: 10 mg
Ezetimibe/Atorvastatin (Atozet®) 10/10 – 10/80 mg PO OD
Tab: 10/10, 10/20, 10/40, 10/80 mg
Evolocumab (Repatha®) 140 mg SC every 2 weeks, or 420 mg SC once monthly
Pre-filled pen/syringe 140 mg/mL
Icosapent ethyl (Vascepa®) 2 g PO BID with food (4 g/day total) — ADA 2026: ASCVD/risk factors, LDL-C at goal, TG 150–499
Cap: 0.5 g, 1 g
Simvastatin interaction cautions: do not combine with azole antifungals, erythromycin, clarithromycin, HIV protease inhibitors, gemfibrozil, cyclosporine, or danazol. Max 10 mg/day with verapamil/diltiazem; max 20 mg/day with amiodarone/amlodipine/ranolazine.
Use high-intensity statins cautiously in age >75y, drug-interaction risk, prior non-traumatic cerebral hemorrhage, or CKD stage 3b–5 — start low/moderate intensity or statin+ezetimibe combination instead.
CKD-specific target (eGFR <60, non-dialysis, age ≥50y)
If LDL-C >100 mg/dL: target <100 mg/dL or ≥30% reduction from baseline, using low-to-moderate intensity statin or statin/ezetimibe combination. Dialysis (stage 5D): do not initiate a statin.
Source: 2024 RCPT Clinical Practice Guideline on Management of Dyslipidemia for Atherosclerotic Cardiovascular Disease Prevention (แนวทางเวชปฏิบัติการบำบัดภาวะไขมันผิดปกติในเลือดเพื่อป้องกันโรคหัวใจและหลอดเลือด พ.ศ. 2567), Royal College of Physicians of Thailand — Thai approval Apr 2024; English: Lolekha P, et al. Asian Biomed 2024;18(6):246–267.
Statin Comparison
| Drug | Intensity | Lipophilicity | CYP | Pros | Cons / cautions |
|---|---|---|---|---|---|
| Atorvastatin | High | Lipophilic | CYP3A4 | Most trial data; cheap generic; dose any time; no renal adjustment; safe in CKD | Interactions: azoles, macrolides, diltiazem/verapamil, HIV PIs; slightly ↑new-onset DM risk at high dose |
| Rosuvastatin | High | Hydrophilic | Minimal (CYP2C9) | Most potent per mg; fewer drug interactions; favorable in HIV/transplant; ↑HDL more than others | Partial renal elimination → cap dose at 10 mg in severe CKD; start low in Asian patients; interaction with Paxlovid (nirmatrelvir/ritonavir) |
| Simvastatin | Moderate | Lipophilic | CYP3A4 | Cheap; familiar; prodrug (less systemic exposure) | Worst interaction profile: 80 mg dose banned; hard caps with amiodarone (20 mg), amlodipine (20 mg), diltiazem/verapamil (10 mg); CI with azoles, macrolides, gemfibrozil, cyclosporine |
| Pravastatin | Low–Mod | Hydrophilic | Not CYP3A4 | Fewest interactions; preferred in HIV (on PIs), transplant (on cyclosporine); safe in pregnancy (relative) | Only low-moderate intensity; cannot achieve ≥50% LDL reduction |
| Pitavastatin | Moderate | Lipophilic | Minimal (CYP2C9) | Very few drug interactions; favorable TG/HDL effects; good option in HIV; minimal renal metabolism | No cheap generic (expensive); only moderate intensity; limited large-scale outcomes data vs atorvastatin/rosuvastatin |
Hydrophilic statins (rosuvastatin, pravastatin) are more hepatoselective with less extra-hepatic tissue penetration — generally fewer CNS/muscle side effects but less certain. Lipophilic statins (atorvastatin, simvastatin, pitavastatin) have higher extra-hepatic exposure, greater CYP interaction risk. Start all statins at low dose in Asian patients and titrate up.
Follow-up & Monitoring
Visit frequency & LDL recheck schedule
Start statinRecheck fasting lipid profile in 4–12 weeks to assess response and adherence
↓ if LDL-C goal not met
4–12 weeksUp-titrate statin to maximum tolerated dose, OR switch to higher-intensity statin
↓ still not at goal after max statin
4–12 weeks after max statinAdd ezetimibe 10 mg OD; recheck lipids in 4–12 weeks
↓ still not at goal (very high / high risk)
Refer / escalateRefer for PCSK9 inhibitor (evolocumab/alirocumab) added to statin ± ezetimibe
↓ once at LDL-C goal
Stable follow-upRecheck lipids every 6–12 months; continue same dose; annual safety labs
Safety monitoring
Monitoring thresholds below are standard practice; the CPG monitoring section was not available for verification.
| Test | When | Action threshold |
|---|---|---|
| Liver enzymes (AST/ALT) | Baseline; repeat at 3–6 months; then annually | Stop statin if ALT/AST >3× ULN (symptomatic) or >5× ULN (asymptomatic) |
| CK | Baseline; only recheck if myalgia/weakness develops — routine CK monitoring not required | Stop if CK >10× ULN or myopathy symptoms; investigate rhabdomyolysis if CK very high + myoglobinuria |
| Fasting lipid panel | 4–12 weeks after initiation or dose change; 6–12 monthly when stable | Escalate if LDL-C above target; consider dose reduction if LDL-C <40 mg/dL on 2 consecutive readings |
| FPG/HbA1c | Annually (statins mildly ↑DM risk at high intensity) | New-onset DM: continue statin (CV benefit >> DM risk); add glucose-lowering therapy |
| eGFR (rosuvastatin) | Annually; if CKD stage 3b+ → recheck before up-titrating | eGFR <30 → avoid rosuvastatin >10 mg; prefer atorvastatin (no renal adjustment) |
Statin intolerance management
- Myalgia without CK elevation: reduce dose → switch to alternate statin (rosuvastatin or pravastatin if was on simvastatin/atorvastatin) → or try every-other-day rosuvastatin 5–10 mg + ezetimibe 10 mg
- True statin intolerance (2+ statins tried): ezetimibe 10 mg OD + PCSK9 inhibitor; bempedoic acid (not widely available in Thailand)
- Exclusion before diagnosing statin myopathy: rule out hypothyroidism, vitamin D deficiency, strenuous exercise, drug interactions (CYP3A4 inhibitors)
Hypertriglyceridemia management
- Stop alcohol; reduce carbohydrate intake; added sugar ≤10% of energy (CPG Class I/IIa)
- Familial chylomicronemia: fat <10–15 g/day + MCT oil 30 g/day (IIa, C)
- The Thai CPG text reviewed gives no TG drug threshold. ADA 2026: fasting TG ≥500 → fibrate and/or fish oil to reduce pancreatitis risk; icosapent ethyl if ASCVD/risk factors, LDL-C at goal and TG 150–499; routine add-on of fibrate, niacin or n-3 supplements to a statin is not recommended
Do not combine dual RAS blockade: this is relevant across all three tabs — ACEI + ARB combination is contraindicated due to ↑AKI, hyperkalemia. Similarly, do not use ACEI/ARB + direct renin inhibitor (aliskiren) in DM or CKD patients.