Download 2016 - Canadian Diabetes Guidelines

Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Essentials
(Updated November 2016)
2016
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Copyright © 2016 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 and, updates
2. Understand the rationale behind these changes
3. Apply the recommendations in clinical practice
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Copyright © 2016 Canadian Diabetes Association
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
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www.guidelines.diabetes.ca
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Copyright © 2016 Canadian Diabetes Association
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Diagnosis of Diabetes
2013
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
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Diagnosis of Prediabetes*
2013
Test
Result
Prediabetes Category
Fasting Plasma
Glucose
(mmol/L)
6.1 - 6.9
Impaired fasting glucose
(IFG)
7.8 – 11.0
Impaired glucose tolerance
(IGT)
6.0 - 6.4
Prediabetes
2-hr Plasma Glucose in
a 75-g Oral Glucose
Tolerance Test (mmol/L)
Glycated
Hemoglobin
(A1C) (%)
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM
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Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia
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AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
Symptomatic hyperglycemia with
metabolic decompensation
A1C 8.5%
A1C <8.5%
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
Add another agent best suited to the individual by prioritizing patient characteristics:
PATIENT CHARACTERISTIC
CHOICE OF AGENT
Antihyperglycemic agent with
demonstrated CV outcome benefit
(empagliflozin, liraglutide)
PRIORITY:
Clinical Cardiovascular Disease
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Cardiovascular disease or multiple risk factors
Comorbidities (renal, CHF, hepatic)
Preferences & access to treatment
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See next
Consider relative A1C lowering
Rare hypoglycemia
Weight loss or weight neutral
Effect on cardiovascular outcome
See therapeutic considerations, consider eGFR
See cost column; consider access
page…
11/2016
From prior page…
L
I
F
E
S
T
Y
L
E
If not at glycemic target
• Add another agent from a different class
• Add/Intensify insulin regimen
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MakeDiabetes
timelyAssociation
adjustments to attain
Copyright © 2016 Canadian
target A1C within 3-6 months
Add another class of agent best suited to the individual (agents listed in alphabetical order):
Class
Relative
A1C
Lowering
Hypoglycemi
a
Weight
-glucosidase
inhibitor (acarbose)

Rare
Neutral to


Rare
Neutral to

GLP-1R agonists
 to 
Rare

lira: Superiority
in T2DM patients
with clinical CVD
lixi: Neutral
Insulin

Yes

Neutral (glar)
DPP-4 Inhibitors
Effect in
Cardiovascular
Outcome Trial
alo, saxa, sita:
Neutral
Insulin secretagogue:
Meglitinide

Yes

Sulfonylurea

Yes

SGLT2 inhibitors
 to 
Rare

empa:
Superiority in
T2DM patients
with clinical CVD
Thiazolidinediones

Rare

Neutral
Weight loss agent
(orlistat)

None

Other therapeutic considerations
Cost
Improved postprandial control, GI side-effects
$$
Caution with saxagliptin in heart failure
$$$
GI side-effects
$$$$
No dose ceiling, flexible regimens
$-$$$$
Less hypoglycemia in context of missed meals
but usually requires TID to QID dosing
Gliclazide and glimepiride associated with less
hypoglycemia than glyburide
$$
$
Genital infections, UTI, hypotension, doserelated changes in LDL-C, caution with renal
dysfunction and loop diuretics, dapagliflozin not
to be used if bladder cancer, rare diabetic
ketoacidosis (may occur with no hyperglycemia)
$$$
CHF, edema, fractures, rare bladder cancer
(pioglitazone), cardiovascular controversy
(rosiglitazone), 6-12 weeks required for
maximal effect
$$
GI side effects
$$$
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
glar=glargine;
saxa=saxagliptin; sita=sitagliptin; lira=liraglutide; lixi=lixisenatide; empa=empagliflozin
Copyright © alo=alogliptin;
2016 Canadian
Diabetes Association
11/2016
2016
Types of Insulin
Insulin Type (trade name)
Onset
Peak
Duration
10 - 15 min
10 - 15 min
10 - 15 min
10 - 15 min
1 - 1.5 h
1 - 1.5 h
1-2h
1-2h
3-5h
3-5h
3.5 - 4.75 h
3.5 - 4.75 h
30 min
2-3h
6.5 h
1-3h
5-8h
Up to 18 h
Not
applicable
Up to 24 h (detemir 16-24 h)
Up to 24 h (glargine 24 h)
Up to 30 h
Up to 24 h (glargine 24 h)
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):
• Insulin aspart (NovoRapid®)
• Insulin glulisine (Apidra™)
• Insulin lispro (Humalog®)
• Insulin lispro U200 (Humalog® 200 units/mL)
Short-acting insulins (clear):
• Insulin regular (Humulin®-R)
• Insulin regular (Novolin®geToronto)
Basal Insulins
Intermediate-acting insulins (cloudy):
• Insulin NPH (Humulin®-N)
• Insulin NPH (Novolin®ge NPH)
Long-acting basal insulin analogues (clear)
• Insulin detemir (Levemir®)
• Insulin glargine (Lantus®)
• Insulin glargine U300 (Toujeo®)
• Insulin glargine (BasaglarTM)
90 min
90 min
Up to 6 h
90 min
Types of Insulin (continued)
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)
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®)
A single vial or cartridge contains a
fixed ratio of insulin
(% of rapid-acting or short-acting
insulin to % of intermediate-acting
insulin)
Antihyperglycemic agents and Renal Function
CKD Stage:
5
eGFR (mL/min/1.73 m2):
<15
Alphaglucosidase
Inhibitor
4
3
2
1
15–29
30–59
60–89
≥ 90
Acarbose Not recommended
Biguanide
25
30
30
Metformin
Alogliptin Not recommended
6.25 mg
DPP-4
inhibitors
Linagliptin
Saxagliptin
Sitagliptin
15
15
60
12.5 mg
50
50 mg
50
50
2.5 mg
30
25 mg
Albiglutide
GLP-1R
agonists
50
50
Dulaglutide
Exenatide (BID/QW)
Liraglutide
Insulin
Secretagogues
Gliclazide/Glimepiride
15
Glyburide
30
30
50
50
30
30
50
Repaglinide
25
Canagliflozin
SGLT2
inhibitors
45
Dapagliflozin
45
Empagliflozin
Adapted from: Product Monographs as of March 2016
Harper W et al. Can J Diabetes 2015;39:440.
60*
60
60*
30
Thiazolidinediones
* = do not initiate if eGFR <60 ml/min
100 mg
Contraindicated
Not recommended
Caution and/or reduce dose
Safe
No dose adjustment but close monitoring of renal function
11/2016
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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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Who Should Receive Statins?
(regardless of baseline LDL-C)
•
•
•
•
•
2013
≥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.
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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.
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2013
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
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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
2013
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]
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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
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Counsel all
Patients
About
Sick Day
Medication
List
2015
Diabetes in the Elderly Checklist
2013
 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
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Need a preconception checklist for
women with pre-existing diabetes
2013

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
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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
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
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