Guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials Canadian Diabetes Association

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

The Essentials

Canadian Diabetes Association 2013 Clinical Practice Guidelines


Learning Objectives

By the end of this session, participants will be able to:

1. Understand the major changes within the 2013 CDA clinical practice guidelines

2. Understand the rationale behind these changes

3. Apply the recommendations in clinical practice


Faculty for slide deck development

• Jonathan Dawrant, BSc, MSc, MD, FRCPC• Zoe Lysy, MDCM, FRCPC• Geetha Mukerji, MD, FACP, FRCPC• Dina Reiss, MD, FACP, FRCPC• Steven Sovran, BSc, MD, MA, FRCPC

• Alice Y.Y. Cheng, MD, FRCPC• Peter J. Lin, MD, CCFP• Catherine Yu, MD, FRCPC, MHSc


www.guidelines.diabetes.ca


guidelines.diabetes.ca


FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hours

or

A1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the

accuracy of the A1C and not for suspected type 1 diabetesor

2hPG in a 75-g OGTT ≥11.1 mmol/Lor

Random PG ≥11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal

2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

Diagnosis of Diabetes 2013


Diagnosis of Prediabetes*

Test Result Prediabetes Category

Fasting Plasma Glucose(mmol/L)

6.1 - 6.9

Impaired fasting glucose (IFG)

2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)

7.8 – 11.0 Impaired glucose tolerance (IGT)

GlycatedHemoglobin(A1C) (%)

6.0 - 6.4 Prediabetes

* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

2013

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

Individualizing A1C Targets

which must be balanced against the risk of hypoglycemia

Consider 7.1-8.5% if:

2013

Start metformin immediately

Consider initial combination with another antihyperglycemic agent

Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin

A1C <8.5%Symptomatic hyperglycemia with

metabolic decompensationA1C 8.5%

Initiate insulin +/-metformin

If not at glycemic target (2-3 mos)

Start / Increase metformin

If not at glycemic targets

LIFESTYLE

Add an agent best suited to the individual:

Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOther

See next page…

AT DIAGNOSIS OF TYPE 2 DIABETES

Agent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOther

2013

If not at glycemic target

From prior page…

• Add another agent from a different class

• Add/Intensify insulin regimen

Make timely adjustments to attain target A1C within 3-6 months 2013

LIFESTYLE


Vascular Protection Checklist 2013

A • A1C – optimal glycemic control (usually ≤7%)

B • BP – optimal blood pressure control (<130/80)

C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat

D • Drugs to protect the heart (regardless of baseline BP or LDL)

A – ACEi or ARB │ S – Statin │ A – ASA if indicated

E • Exercise / Eating healthily – regular physical

activity, achieve and maintain healthy body weight

S • Smoking cessation


• ≥40 yrs old or • Macrovascular disease or• Microvascular disease or• DM >15 yrs duration and age >30 years or• Warrants therapy based on the 2012 Canadian

Cardiovascular Society lipid guidelines

Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling &

reliable contraception. Stop statins prior to conception.

2013Who Should Receive Statins? (regardless of baseline LDL-C)


What if baseline LDL-C ≤2.0 mmol/L?

• Within CARDS and HPS, the subgroups that started

with lower baseline LDL-C still benefited to the same

degree as the whole population

• If the patient qualifies for statin therapy based on the

algorithm, use the statin regardless of the baseline

LDL-C and then target an LDL reduction of ≥50%

HPS Lancet 2002;360:7-22 Colhoun HM, et al. Lancet 2004;364:685.


Who Should Receive ACEi or ARB Therapy?(regardless of baseline blood pressure)

• ≥55 years of age or • Macrovascular disease or • Microvascular disease

At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily

(HOPE), telmisartan 80 mg daily (ONTARGET)]

Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception

counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy

2013

EUROPA Investigators, Lancet 2003;362(9386):782-788.HOPE study investigators. Lancet. 2000;355:253-59.

ONTARGET study investigators. NEJM. 2008:358:1547-59


Recommendation

ASA should not be routinely used for the primary

prevention of cardiovascular disease in people with

diabetes [Grade B, Level 2]

ASA may be used in the presence of additional cardiovascular risk factors [Grade D, Consensus]

2013


Chronic Kidney Disease (CKD) Checklist

SCREEN regularly with random urine albumin creatinine ratio

(ACR) and serum creatinine for estimated glomerular filtration

rate (eGFR)

DIAGNOSE with repeat confirmed ACR ≥ 2.0 mg/mmol and/or

eGFR < 60 mL/min

DELAY onset and/or progression with glycemic and blood

pressure control and ACE inhibitor or angiotensin receptor

blocker (ARB)

PREVENT complications with “sick day management”

counselling and referral when appropriate

2013

Counsel all Patients About

Sick Day Medication

List

2013


Diabetes in the Elderly Checklist ASSESS for level of functional dependency (frailty)

INDIVIDUALIZE glycemic targets based on the above (A1C ≤ 8.5% for frail elderly) but if otherwise healthy, use the same targets as younger people

AVOID hypoglycemia in cognitive impairment

SELECT antihyperglycemic therapy carefully caution with sulfonylureas or thiazolidinediones Basal analogues instead of NPH or human 30/70

insulin Premixed insulins instead of mixing insulins separately

GIVE regular diets instead of “diabetic diets” or nutritional formulas in nursing homes

2013


Need a preconception checklist for women with pre-existing diabetes

1. Attain a preconception A1C of ≤ 7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 mo pre-conception to 12 weeks post-conception

5. Discontinue potential embryopathic meds: Ace-inhibitors/ARB (prior to or upon detection of pregnancy) Statin therapy

2013

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Tools to help us keep track of our patients


Tools to help us keep track of our patients


Back Page:“Cheat Sheet” of Targets and Goals


Back Page:“Cheat Sheet” of Targets and Goals


New resources


Download the App Today!


“Neither evidence nor clinical judgment alone is sufficient.

Evidence without judgment can be applied by a technician.

Judgment without evidence can be applied by a friend.

But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best clinical care.”

(Hertzel Gerstein, 2012)

Documents

Guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials Canadian Diabetes Association