Www.diabetesclinic.ca 2003 CDA Clinical Practice Guidelines J. Robin Conway M.D. Diabetes Clinic - Smiths Falls, ON Diabetes Office Mgmt

www.diabetesclinic.ca

2003 CDA Clinical Practice Guidelines

J. Robin Conway M.D.Diabetes Clinic - Smiths Falls, ON

Diabetes Office Mgmt


TorontoMay 6 2004


80

70

60

50

40

30

20

10

0

Prevalence (millions)

North America

Europe SoutheastAsia

Year199520002025

World Health Organization. 1997.Canadian Diabetes Association, 1998 website.

Worldwide rates of diabetes mellitus: predictions


Frequency of diagnosed and undiagnosed diabetes and IGT, by age (U.S. data - Harris)

2 Million Canadians Have Diabetes Mellitus

0

5

10

15

20

25

30

35

40

20-34 35-44 45-54 55-64 65-74

% ofpopulation

IGTUndiagnosed diabetesDiagnosed diabetes

Harris. Diabetes Care 1993;16:642-52.

www.diabetesclinic.caHaffner Am J Cardiol 1999;84:11J-4J.

Framingham study: diabetes and CAD mortalityat 20-year follow-up

Cardiovascular Disease Risk is Increased 2 to 4 Times

17.4

8.5

17.0

3.602468

101214161820

Annual CAD Deaths per 1,000

Persons

Men Women

Diabetics Nondiabetics


What proportion of your office visits involve Diabetics?

1. <10%

2. 10-20%

3. 20-30%

4. 30-50%

5. >50%


The burden of Diabetes• 87% of Type 2 Diabetes is managed

in Primary Care

• Diascan Study: 23.5% of patients in our office have diabetes

• Quebec screening >2 Risk Factors 79% tested 7% Diabetes 13% IGT or IFG

74% No Treatment AdviceStrychar I et al. Cdn J Diab 2003(abs)

Leiter et al. Diabetes Care 2000


Glucose Monitoring

• Do you do A1c to follow glycemic control

1= YES

2= NO


Microvascular Complications

• Do you order urine microalbumen test

1= YES

2= NO


Microvascular Complications

• Do you use a 10 gm filament for testing sensation in the feet?

1= YES

2= NO


T2DM in Family Practice

• 84% of patients had A1c in past year

• Average A1c 7.9% (goal<7%)

• 88% had BP check

• 48% had lipid profiles

• 28% tested for microalbuminuria

• 15% had foot examsHarris S et al. Cdn Fam Phys 2003


Organization and Delivery of Care

• Diabetes should be organized using a DHC (Diabetes Healthcare) team approach

• People with diabetes should be offered initial and

ongoing needs-based diabetes education• The role of diabetes nurse educators and other

DHC team members should be enhanced in cooperation with the physician


Structured care

• ACLS

• ATLS

• Seattle Defibrillator Experience

• GREACE Study


Structured Care VS Usual Care

Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228.

• Patients received atorvastatin 10 mg/d (titrated up to 80 mg/d) to reach the NCEP LDL-C goal

• Specialist care unit with a strict protocol to achieve NCEP LDL-C target

• Treatment from a physician of pt’s choice• All patients had access to any necessary medications,

including statins• Included lifestyle modifications (diet and exercise) as well

as lipid-lowering medications

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Reduction in Relative Risk of Primary Endpoints

-43

-59-52 -51 -50

-47-47

-60

-50

-40

-30

-20

-10

0Total Mortality

CoronaryMortality Nonfatal MI

UnstableAngina PTCA/CABG CHF Stroke

Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228.

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Type 2 Diabetes

• Increasing Prevalence

• Primary Care Based

• Forms a large part of a practice

• Needs structured care approach

• Team Approach

• Multiple comorbidities

• Limited Time & Funding


How can we deal with this?

• Refer all Diabetic Patients?• Community Education Programs?• Guidelines Based Structured Care?• Identify the Diabetics in the practice?• Diabetes Day in Office?• Get some Diabetes CME?• Team Approach in Office?• Office Tools?


Diabetes Day in the Office

• Book Diabetic Patients for one day• Get office support staff to follow formula• Office staff do Wt, BMI, BP, Glucose, lab• Have educational material, consider 1 room• Follow Guideline Algorithms• Use Tools & Flowsheet• Extra Staff?• Follow up Appt & Lab


Educational Material

• Canadian Diabetes Assoc: www.diabetes.ca

• Pharma Companies; Lilly, Novo, Bayer

• Web Site list www.diabetesclinic.ca

• Hospital Diabetes Education Program

• Community Diabetes Education Program

http://www.diabetesclinic.ca/









Screening and Prevention - Type 2 Diabetes

• Screen all persons >40 years for type 2 diabetes, with a fasting blood glucose (FPG), every 3 years.

• For people with risk factors, screen earlier and /or more frequently, with either FPG or Oral Glucose Tolerance test (OGTT).

• If the FPG is 5.7 – 6.9mmol/L and suspicion of diabetes or IGT is high, recommend a 2hPG in a 75-g OGTT.

Risk Factors

Age 40 years Vascular disease Abdominal obesity

1st degree relative with diabetes Previous GDM Overweight

High risk population Delivery of macrosomic infant Polycystic ovary disease

Previous IGT or IFG Hypertension Acanthosis nigricans

Complications present Dyslipidemia Schizophrenia


Every 3 Years in individuals 40 years of age with no other risk factors

Earlier and/or more frequently in individuals < 40 years of age with risk factors

FPG

< 5.7 mmol/L 5.7 - 6.9 mmol/L plus risk factor(s) for diabetes/IGT

6.1 - 6.9 mmol/L and not risk factors for diabetes/IGT

7.0 mmol/L

2hPG in 75-g OGTT

Classify patients as normal, IFG (isolated), IGT (isolated), IFG &

IGT or Diabetes

Isolated IFG, Isolated IGT OR IFG & IGT IFG DiabetesNormal

Rescreen as clinically indicated

Strategies for prevention and rescreen at appropriate intervals Treatment

Screening for Type 2 Diabetes, IFG and IGT


Diagnostic CriteriaDiagnosis of diabetes

FPG 7.0 mmol/L

or

Casual PG 11.1 mmol/L + symptoms of diabetes

or

2hPG in a 75g OGTT 11.1 mmol/L

•FPG = fasting plasma glucose, no caloric intake for at least 8 hours•OGTT = oral glucose tolerance test•2hPG = 2-hour plasma glucose•Casual PG = any time of the day, without regard to the interval since the last meal•Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss

• A confirmatory laboratory glucose test must be done on another day unless there is unequivocal hyperglycemia and acute metabolic decompensation


Physical Activity and Diabetes

• For people who have not previously exercised regularly and are at risk of CVD, an ECG stress test should be considered prior to starting an exercise program

Type Recommendation Example

Aerobic – especially type 2

150 minutes of moderate-intensity exercise each week

spread out over at least 3 non-consecutive days

gradually increase to 4 hours or more a week

sessions should be at least 10 minutes at a time

Brisk walking Biking Raking leaves Continuous swimming Dancing Water aerobics

Resistance – all persons with diabetes, including elderly

3 times a week start with 1 set of 10-15 repetitions progress to 2 sets of 10-15 then 3 sets of 8

Weight lifting Exercise with weight machines

Testing is particularly important before, during and for many hours after exercise.


Nutrition TherapyPeople with diabetes should:

• Receive nutrition counseling by a registered dietitian

• Receive individualized meal planning

• Follow Canada’s Guidelines for Healthy Eating

• People on intensive insulin should also be taught to adjust the insulin for the amount of carbohydrate consumed


Recommended targets for glycemic control*

A1C**(%)

FPG/preprandial PG(mmol/L)

2-hour postprandial PG(mmol/L)

Target for most patients 7.0 4.0-7.0 5.0-10.0

Normal range (considered for patients in whom it can beachieved safely)

6.0 4.0-6.0 5.0-8.0

*Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors.†Glycemic targets for children 12 years of age and pregnant women differ from these targets. Please refer to “Other Relevant Guidelines” for further details.**An A1C of 7.0% corresponds to a laboratory value of 0.070. Where possible, Canadian laboratories should standardize theirA1C values to DCCT levels (reference range: 0.040 to 0.060). However, as many laboratories continue to use a differentreference range, the target A1C value should be adjusted based on the specific reference range used by the laboratory thatperformed the test. As a useful guide: an A1C target of 7.0% refers to a threshold that is approximately 15% above the upper limit of normal.

A1C = glycosylated hemoglobinDCCT = Diabetes Control and Complications TrialFPG = fasting plasma glucosePG = plasma glucose


Clinical assessment and initiation of nutrition and physical activity

Mild to moderate hyperglycemia (A1C <9.0%)

Overweight(BMI 25 kg/m2)

Non-overweight(BMI 25 kg/m2)

Biguanide alone or incombination with 1 of:

• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor

1 or 2† antihyperglycemicagents from differentclasses

• biguanide• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor

Add a drug from a different class orUse insulin alone or in combination with:

• biguanide• insulin secretagogue• insulin sensitizer*• alpha-glucosidase inhibitor

Marked hyperglycemia (A1C 9.0%)

2 antihyperglycemic agentsfrom different classes †

• biguanide• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor

Basal and/orpreprandial insulin

Add an oral

antihyperglycemic agentfrom a differentclass of insulin*

Intensify insulinregimen or add

• biguanide• insulin secretagogue**• insulin sensitizer*• alpha-glucosidase inhibitor

If not at targetIf not at targetIf not at targetIf not at target

L

I

F

E

S

T

Y

L

E

Timely adjustments to and/or additions of oral antihyperglycemic agentsand/or insulin should be made to attain target A1C within 6 to 12 months


Economics

• Gen Ass A003 $54.10• Int Ass A007 $28.50• Counselling K013 $50.45 4x/yr• Insulin Rx K029 $50.45 6x/yr• Type 2 FlowK030 $30.00 3x/yr• Glucose G002 $ 1.97• Urine G009 $ 4.20• Venipuncture G489 $ 2.27


Economics

• A003 G002, G009, G489 $ 62.54

• G030 G002 G009 G489 x3 $105.32

• K013 G00s G009 G489 x4 $235.76

• A007 x4 $114.00

• TOTAL $517.62


FLOWSHEETS





ABC of Diabetes

• A1c <7

• Blood Pressure <130/80

• Chol/HDL <4, LDL <2.5, Trig <1.5• ACR <2 men, <2.5 women• ACE• ASA


INVOLVE THE PATIENT




In Conclusion• Prevalence of type 2 diabetes is increasing

dramatically• Majority of patients are diagnosed and treated by

the family physician• New paradigm: need to be much more aggressive

early in the treatment of these patients utilizing dual therapies

• Hypoglycemia can be managed through proper treatment choices and lifestyle management

• Glucose is a continuous progressive risk factor for cardiovascular disease


Questions?

Documents

Www.diabetesclinic.ca 2003 CDA Clinical Practice Guidelines J. Robin Conway M.D. Diabetes Clinic - Smiths Falls, ON Diabetes Office Mgmt