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The Essentials
Canadian Diabetes Association 2013 Clinical Practice Guidelines
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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
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www.guidelines.diabetes.ca
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What is new in making the diagnosis of diabetes?
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FPG ≥7.0 mmol/L Fasting = 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 diabetes
or 2hPG in a 75-g OGTT ≥11.1 mmol/L
or 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
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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)
Glycated Hemoglobin (A1C) (%)
6.0 - 6.4
Prediabetes
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM
2013
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Individualizing A1C Targets
which must be balanced against the risk of hypoglycemia
Consider 7.1-8.5% if:
2013
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Self-Monitoring of Blood Glucose (SMBG)
What should
we tell patients to do?
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Regular SMBG is Required for:
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Increased frequency of SMBG may be required:
Daily SMBG is not usually required if patient:
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Individualize frequency of SMBG
• CDA SMBG tool - provides guidance on appropriate situations for SMBG utilization
http://guidelines.diabetes.ca
2013
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Medications for glycemia How do we choose?
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Pharmacotherapy in T2DM checklist
CHOOSE initial therapy based on glycemia
START with Metformin +/- others
INDIVIDUALIZE your therapy choice based on
characteristics of the patient and the agent
REACH TARGET within 3-6 months of
diagnosis
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 decompensation A1C ≥8.5%
Initiate insulin +/- metformin
If not at glycemic target (2-3 mos)
Start / Increase metformin
If not at glycemic targets
L I F E S T Y L E
Add an agent best suited to the individual:
Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other
See next page…
AT DIAGNOSIS OF TYPE 2 DIABETES
Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other
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
L I F E S T Y L E
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 decompensation A1C ≥ 8.5%
Initiate insulin +/- metformin
If not at glycemic target (2-3 mos)
Start / Increase metformin
If not at glycemic targets
L I F E S T Y L E
Add an agent best suited to the individual:
Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other
See next page…
AT DIAGNOSIS OF TYPE 2 DIABETES
Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other
2013
2013
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Adapted from: Product Monographs as of March 1, 2013; CDA Guidelines 2008; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.
Antihyperglycemic agents and Renal Function
Not recommended / contraindicated Safe Caution and/or dose reduction
Repaglinide
Metformin 30 60
Saxagliptin
Linagliptin
Glyburide 30 50
Thiazolidinediones 30
GFR (mL/min): < 15 15-29 30-59 60-89 ≥ 90 CKD Stage: 5 4 3 2 1
Gliclazide/Glimepiride 15 30 Liraglutide 50
Exenatide 30 50
Acarbose 25
Sitagliptin 50
50 15 2.5 mg
15
30 50 mg 25 mg
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What are the options for Insulin?
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Insulin Type (trade name) Onset Peak Duration
Bolus (prandial) Insulins Rapid-acting insulin analogues (clear): • Insulin aspart (NovoRapid®) • Insulin glulisine (Apidra™) • Insulin lispro (Humalog®)
10 - 15 min 10 - 15 min 10 - 15 min
1 - 1.5 h 1 - 1.5 h 1 - 2 h
3 - 5 h 3 - 5 h
3.5 - 4.75 h
Short-acting insulins (clear): • Insulin regular (Humulin®-R) • Insulin regular (Novolin®geToronto)
30 min
2 - 3 h
6.5 h
Basal Insulins Intermediate-acting insulins (cloudy): • Insulin NPH (Humulin®-N) • Insulin NPH (Novolin®ge NPH)
1 - 3 h 5 - 8 h Up to 18 h
Long-acting basal insulin analogues (clear) • Insulin detemir (Levemir®) • Insulin glargine (Lantus®)
90 min Not applicable
Up to 24 h (glargine 24 h,
detemir 16 - 24 h)
Types of Insulin
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Insulin Type (trade name) Time action profile
Premixed Insulins Premixed regular insulin – NPH (cloudy): • 30% insulin regular/ 70% insulin NPH (Humulin® 30/70) • 30% insulin regular/ 70% insulin NPH (Novolin®ge 30/70) • 40% insulin regular/ 60% insulin NPH (Novolin®ge 40/60) • 50% insulin regular/ 50% insulin NPH (Novolin®ge 50/50)
A single vial or cartridge contains a fixed ratio of insulin
(% of rapid-acting or short-acting insulin to % of intermediate-acting
insulin)
Premixed insulin analogues (cloudy): • 30% Insulin aspart/70% insulin aspart protamine crystals (NovoMix® 30) • 25% insulin lispro / 75% insulin lispro protamine (Humalog® Mix25®) • 50% insulin lispro / 50% insulin lispro protamine (Humalog® Mix50®)
Types of Insulin (continued)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
Seru
m In
sulin
Lev
el
Time
Analogue Bolus: Apidra, Humalog, NovoRapid
Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir
Human Bolus: Humulin-R, Novolin ge Toronto
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Time
Seru
m In
sulin
Lev
el
Human Premixed: Humulin 30/70, Novolin ge 30/70 Analogue Premixed: Humalog Mix25, NovoMix 30
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What about Hypoglycemia?
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Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
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Macrovascular Disease
Vascular Protection: Who and When?
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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
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• ≥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.
2013 Who Should Receive Statins? (regardless of baseline LDL-C)
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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
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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
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Summary of Pharmacotherapy for Hypertension in Patients with Diabetes Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
With Nephropathy, CVD or CV risk factors
ACE Inhibitor or ARB
Diabetes
Without the above
1. ACE Inhibitor or ARB or
2. Thiazide diuretic or DHP-CCB
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria More than 3 drugs may be needed to reach target values
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired
Combination of 2 first line drugs may be considered
as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above
target
> 2-drug combinations
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What about Microvascular Disease? • Nephropathy
• Retinopathy • Neuropathy
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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
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Retinopathy Checklist
SCREEN regularly
DELAY onset and progression with glycemic and blood pressure control ± fibrate
TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery
2013
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Delaying Retinopathy
1. Glycemic control: target A1C ≤7%
2. Blood pressure control: target BP <130/80
3. Lipid-lowering therapy: fibrates have been shown to decrease progression and may be considered 2013
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Neuropathy Checklist
PREVENT with blood glucose control
SCREEN with monofilament or tuning fork
TREAT pain symptoms with anticonvulsants or antidepressants
2013
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4. The following agents may be used alone or in combination for relief of painful peripheral neuropathy:
– Anticonvulsants (pregabalin [Grade A, Level 1], gabapentin‡, valproate‡) [Grade B, Level 2]
– Antidepressants (amitriptyline‡, duloxetine, venlafaxine‡) [Grade B, Level 2]
– Opioid analgesics (tapentadol ER, oxycodone ER, tramadol) [Grade B, Level 2]
– Topical nitrate spray [Grade B, Level 2]
‡This drug is not currently approved by Health Canada for the management of neuropathic pain associated with diabetic peripheral neuropathy.
2013 Recommendation 4
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Foot Care: What are the
DO’s and DON’Ts of foot care?
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Educate patients on proper foot care – The “DO’s” DO …
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet – seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. Wipe off excess.
Change your socks every day
Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
See a foot care specialist if you need advice or treatment
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Educate patients on proper foot care – The “DON’Ts” DO NOT …
Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your doctor or foot care specialist Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak your feet
Take very hot baths
Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
Smoke
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Special populations …
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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
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Add an agent best suited to the individual (agents listed in alphabetical order):
Class Relative A1C
Lowering
Hypo-glycemia
Weight Other therapeutic considerations Cost
α-glucosidase inhibitor (acarbose)
↓ Rare Neutral to ↓
Improved postprandial control, GI side-effects
$$
Incretin agents: DPP-4 Inhibitors GLP-1 receptor agonists
↓↓
↓↓ to↓↓↓
Rare Rare
neutral
↓
GI side-effects
$$$
$$$$
Insulin ↓↓↓ Yes ↑↑ No dose ceiling, flexible regimens $-$$$$
Insulin secretagogue: Meglitinide Sulfonylurea
↓↓ ↓↓
Yes* Yes
↑ ↑
*Less hypoglycemia in context of missed meals but usually requires TID to QID dosing Gliclazide and glimepiride associated with less hypoglycemia than glyburide
$$ $
Thiazolidinediones ↓↓ Rare ↑↑ CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect
$$
Weight loss agent (orlistat)
↓ None ↓ GI side effects $$$
• CAUTION in the elderly • Initial doses = HALF of usual dose • Avoid glyburide • Use gliclazide, gliclazide MR,
glimepiride, nateglinide or repaglinide instead
• CAUTION in the elderly • Increased risk of fractures • Increased risk of heart failure
• May use detemir or glargine instead of NPH or human 30/70 for less hypos
• Premixed insulins and prefilled insulin pens instead of mixing insulin to reduce dosing errors
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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
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How can we keep track of all the parameters for our patients with Diabetes?
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Tools to help us keep track of our patients
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Tools to help us keep track of our patients
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Back Page: “Cheat Sheet” of Targets and Goals
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Back Page: “Cheat Sheet” of Targets and Goals
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“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)
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CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca – for patients