Download 2013

Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Essentials
Presentation by Dr. Tessa Laubscher
Clinical Associate Professor, Family Medicine
Saskatoon
Sept 2013
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:
1. Have knowledge of the major changes within the 2013
CDA clinical practice guidelines.
2. Be able to apply the recommendations in clinical
practice and be familiar with online resources/tools.
3. Understand the importance of comorbidities in
individualizing diabetes management.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Where do you find the Diabetes CPG and
additional clinically useful information?
www.guidelines.diabetes.ca
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Diagnosis of Diabetes
FPG ≥7.0 mmol/L
Fasting = no caloric intake for at least 8 hours
or
A1C ≥6.5% (in adults)
Using a standardized, validated lab 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 (with or without symptoms)
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Diagnosis of Diabetes – usually require >1 test result
•
If results of two different tests (e.g. FPG and A1C) are
available and both are above the diagnostic cut-points,
the diagnosis of diabetes is confirmed.
•
If patient is asymptomatic and a single test is abnormal, a
repeat test must be done on a different day to confirm
diagnosis. Preferable to repeat same test, but this is not
essential.
•
If patient has typical symptoms of hyperglycemia and the
initial diagnostic test is elevated, repeat testing is not
required.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
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%  higher risk of developing
T2DM
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
A1C Level and Future Risk of Diabetes:
Systematic Review
A1C Category (%)
5-year incidence of
diabetes
5.0-5.5
<5 to 9%
5.5-6.0
9 to 25%
6.0-6.5 (prediabetes)
25 to 50%
Zhang X et al. Diabetes Care. 2010;33:1665-1673.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Screening for Type 2 Diabetes - Checklist
 ASSESS all adults clinically every year for risk of type 2
diabetes (T2DM)
 SCREEN every 3 years if ≥ 40 years
 SCREEN earlier and more frequently if very high risk on
risk calculator or additional risk factors present
 USE fasting plasma glucose (FPG) and/or A1C as initial
screening tests
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Screening for T2DM – Recommendations 1
and 2
1.
2.
All individuals should be evaluated annually for type 2
diabetes risk on the basis of demographic and clinical
criteria [Grade D, Consensus].
Screening for diabetes using a FPG and/or A1C should be
performed every 3 years in individuals ≥40 years of age or
at high risk using a risk calculator [Grade D, Consensus].
More frequent and/or earlier testing with either a FPG
and/or A1c or a 2h PG in a 75 g OGTT should be
considered in those at very high risk using a risk calculator
or in people with additional risk factors for diabetes [Grade D,
Consensus]
.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Screening for T2DM - Recommendations 3
and 4
3. Testing with a 2hrPG in a 75-g OGTT* should be
undertaken in individuals with FPG of 6.1 to 6.9 mmol/L
2013 and/or A1C 6.0 to 6.4% in order to identify individuals
with IGT or diabetes [Grade D, Consensus]
4. Testing with a 2hPG in a 75-g OGTT* may be
2013 undertaken in individuals with a FPG of 5.6 to 6.0
mmol/L and/or A1C 5.5 to 5.9% and >1 risk factor for
T2DM in order to identify individuals with IGT or diabetes
[Grade D, Consensus]
* 75g OGTT – consider this to be a “pancreatic stress test”
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Risk Factors for T2DM
•
Personal factors
•
Presence of associated problems
•
Presence of secondary causes
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
If you choose to use a diabetes risk
calculator …
•
•
•
Public Health Agency of Canada CANRISK calculator
http://www.phac-aspc.gc.ca/cd-mc/diabetesdiabete/canrisk/index-eng.php
For people 40 - 74 years old
Components
–
–
–
–
•
Age, sex, BMI, waist circumference
Physical activity level, Diet - eating veg and fruits
Hypertension, history of dysglycemia (GDM, hyperglycemia
with acute illness), macrosomia
Family history, ethnicity, level of education
Calculates low, moderate or high risk groups
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Screening for Type 2 Diabetes in Adults
2013
Algorithm presented on next slides
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Screening for Type 2 Diabetes in Adults
(continued)
*If both FPG and A1C are available, but discordant, use the test that appears
furthest to the right side of the algorithm (i.e. most abnormal test result).
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Can we reduce the risk of
developing
Type 2 Diabetes?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
What can you do for your patients diagnosed
with prediabetes?
•
Lifestyle Goal: weight loss of 7% of body weight and ≥ 150
minutes moderate physical activity per week
•
•
•
•
Assess and treat other CVD risk factors (IGT is risk factor for CAD)
Metformin (most evidence for BMI>35, age <60yrs, women with prior GDM)
Monitor annually for progression to T2DM
Saskatoon Health Region Live Well CDM program – specifically
designed for people at high risk of developing T2DM
–
Half-day workshops
– Focus is on education and assistance with lifestyle change & weight loss,
including regular phone follow-up and assistance with exercise planning
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Glycemic Targets:
New Targets and why?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Targets Checklist
 A1C
≤ 7.0% for MOST people with diabetes
Preprandial capillary plasma glucose 4.0 – 7.2 mmol/L, and
Postprandial (1-2hrs) capillary plasma glucose <10.0 mmol/L

A1C ≤ 6.5% for SOME people with T2DM

A1C 7.1 - 8.5% in people with specific features

INDIVIDUALIZE
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Individualization of Glycemic Goals
•
Glycemic targets should be individualized based on
–
–
–
–
–
–
Age of person and life expectancy
Duration of diabetes
Type of diabetes
Comorbid conditions
Known CVD or advanced microvascular complications such as
neuropathy or nephropathy
Hypoglycemia frequency and unawareness
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
A1C ≤ 7.0%
•
Lowering A1C to below or around 7%
-
•
Large trials (DCCT, EDIC, UKPDS) supporting this with reduced
microvascular complications in type 1 and type 2 diabetes
If this goal A1C is achieved soon after diagnosis of DM there is
an association with reduced macrovascular complications
Can usually be achieved safely in both Type 1 and Type
2 diabetes.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
A1C ≤ 6.5%
•
•
•
•
This should be encouraged only if can be done safely
without increased hypoglycemia.
Consider in individuals with short duration of DM, long life
expectancy, and no significant CVD.
In T2DM some study evidence (ADVANCE) demonstrating reduced
kidney and eye microvascular complications.
No outcome evidence of reduced macrovascular complications.
Recurrent hypoglcemia (BG < 4.0mmol/L) associated with
detrimental effects on vasculature (in T1DM), increased risk of falls,
cardiac ischemia, cognitive effects/decline.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Consider higher A1C of 7.1- 8.5% if …
•
•
•
•
•
•
•
2013
Limited life expectancy
High level of functional dependency (e.g. frail elderly)
Extensive coronary artery disease at high risk of ischemic
events
Multiple co-morbidities
History of recurrent severe hypoglycemia – consider temporary increased A1c
Hypoglycemia unawareness - consider temporary increased A1c
Longstanding diabetes for whom is it difficult to achieve an A1C ≤ 7%,
despite effective doses of multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Self-Monitoring of
Blood Glucose (SMBG)
What should
we tell patients to do?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Exercise and Nutrition:
What should we
advise patients to do?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Physical Activity Checklist
2013
 DO a minimum of 150 minutes of moderate to vigorous
intensity aerobic exercise per week
 INCLUDE resistance exercise ≥ 2 times a week
 Set physical activity goals and INVOLVE a multidisciplinary team
 ASSESS patient’s health before prescribing an exercise
regimen
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Useful Resources on Exercise
http://guidelines.diabetes.ca/PatientResources.aspx
Includes pre-exercise checklist, and new handouts for
patients on aerobic and resistance training including
diagrams of how to do some exercises.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Nutrition: Useful Resources on Diet /
Medical Nutrition Therapy
http://guidelines.diabetes.ca/PatientResources.aspx
Every person with diabetes should be referred to a
registered dietitian for MNT.
Often beneficial to recommend this when advancing
therapy in T2DM, such as adding insulin.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Modest weight loss CAN make a difference
•
Goal is to prevent weight gain, promote weight
loss and prevent weight re-gain
•
Weight loss of only 5-10% of body weight
improves:
–
Insulin sensitivity
– Glycemic control
– Blood pressure
– Lipid levels
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Medications for glycemia
How do we choose?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Type 1 Diabetes
•
•
•
•
•
•
T1DM requires intensive insulin management – multidaily injections (MDI).
Ideally should be using basal-bolus insulin regimen, or
continuous insulin infusion.
Basal insulin (long acting insulin analogue or NPH) once
or twice daily
Rapid acting insulin analogue with meals
Hypoglycemia is main limiting factor to achieving “perfect”
glycemic control.
In some adults with T1DM obesity causes additional problem of
insulin resistance – can add Metformin.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Type 2 Diabetes – natural history

Type 2 diabetes is a progressive disease - the initial problem
is mostly insulin resistance, but blood glucose control will
deteriorate over years due to progressive failure of the
pancreas to secrete enough insulin.

This progressive failure of insulin production occurs more
rapidly in people with poor glycemic control.

At the time of diagnosis (if symptoms of hyperglycemia),
majority of people with T2DM have already lost 50% of
pancreatic β-cell production of insulin. Regardless of
management, β-cell destruction continues, and with time
patients will require insulin to achieve normal fasting and postprandial blood glucose levels.

In many people with T2DM – insulin production is only 15-20%
by 8 -10 years after diagnosis. Exogenous insulin is required
to achieve glycemic targets.
A healthcare provider needs to consider:
•
Type of diabetes
• Diabetes symptoms and variation in sugars
• Degree of hyperglycemia – A1C
• Duration of Type 2 diabetes – if >15 years insulin probably required
• Previous interventions – if not on metformin why not?
• Kidney and liver function
• Risk of hypoglycemia
• Cost of medications
• Potential weight gain from anti-hyperglycemic drugs
• Ability of patient or caregiver to implement therapy
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Pharmacotherapy in T2DM checklist
2013

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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
A1C <8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C 8.5%
Symptomatic hyperglycemia with
metabolic decompensation
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
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
Agent Characteristics
BG lowering efficacy and durability
Risk of inducing hypoglycemia
Effect on weight
Contraindications & side-effects
Cost and coverage
Other
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
See next
Copyright © 2013 Canadian Diabetes Association
page…
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
2013
guidelines.diabetes.ca
| 1-800-BANTING
(226-8464) | diabetes.ca
Make
timely adjustments
to attain
Copyright © 2013 Canadian Diabetes Association
target A1C within 3-6 months
Consider weight effects when selecting
antihyperglycemic medications
Weight Gain
Weight Effect (kg)
Insulin
+4.5 to 5.0
Thiazolidenediones (TZDs)
+4.2 to 4.8
Sulfonylureas
+1.6 to 2.6
Meglitinides
+ 0.7 to 1.8
Weight Neutral or Decrease Weight
Weight Effect (kg)
Metformin
-4.6 to 0.4
α-Glucosidase inhibitors
+0.0 to 0.2
Dipeptidyl peptidase-4 (DPP-4) inhibitors
+0.0 to 0.4
Glucagon-like peptide-1 (GLP-1) receptor
agonists
-1.3 to 3.0
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165
What are the
options for Insulin?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Serum Insulin Level
Time
Human Basal: Humulin-N, Novolin ge NPH
Analogue Basal: Lantus, Levemir
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Human Bolus: Humulin-R, Novolin ge Toronto
Analogue Bolus: Apidra, Humalog, NovoRapid
What about Hypoglycemia?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Definition of Hypoglycemia
1.
Development of neurogenic or neuroglycopenic symptoms
2.
Low blood glucose (< 4 mmol/L if on insulin or secretagogue)
3.
Response to carbohydrate load.
Emerging importance of Hypoglycemia
• Increasing evidence that hypoglycemia is associated with increased
morbidity and mortality in both T1DM and T2DM.
• Hypoglycemia-related outcomes include:
– increased risk of falls;
– CNS consequences including cognitive effects/decline and decreased
memory/retention;
– autonomic failure;
– cardiac effects – rhythm disturbances, ischemia; and accelerated atherosclerosis
with recurrent hypoglycemia in T1DM.)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Clinical relevance
•
•
•
•
Patients should be asked about frequency and severity
of hypoglycemia at every CDM visit, with appropriate
changes made to medical therapy if necessary.
Recurrent hypoglycemia may result in hypoglycemia
unawareness and more severe hypoglycemia.
People with frequent hypoglycemia (consider if A1C <
6.5% and patient on insulin) should have medical therapy
adjusted to raise glucose levels in an attempt to restore
the autonomic responses to hypoglycemia.
Frequent or severe hypoglycemia may impact fitness to
drive.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Hypoglycemia and Driving
Safe blood glucose (BG)
prior to driving
•
BG ≥ 5.0 mmol/L
If BG <5.0 mmol/L prior to driving:
–
Take 15 g carbohydrate
–
Re-check in 15 minutes
–
When BG >5 mmol/L for at least 45 minutes  safe to drive
•
Need to re-check BG every 4 hours of continuous
driving and carry simple carbohydrate snacks
HCP and Patient resources on guidelines website
Iain S. Begg et al . Canadian Journal of Diabetes. 2003;27(2):128-140.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Macrovascular Disease
Vascular Protection:
Why?
Who and When?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Why is vascular protection important?
•
•
•
•
Diabetes promotes both the development and adverse impact of
cardiovascular disease (CVD) risk factors (e.g. hypertension,
dyslipidemia, renal dysfunction) and, as a consequence, accelerates
cardiovascular age.
Persons with diabetes generally have a cardiovascular age 10 to 15 years
in advance of their chronological age.
Advanced cardiovascular age substantially increases both the
proximate and lifetime risk for CVD events, resulting in a reduced life
expectancy of approximately 12 years.
In young adults (aged 20 to 39 years), T1DM is an independent risk factor
for premature CVD and mortality. The presence of CVD in people with
T1DM is related to age, duration of diabetes, higher A1C levels and
presence of retinopathy and albuminuria, as well as traditional CVD risk
factors, such as elevated LDL-C, smoking and obesity.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
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 decide to treat

D • Drugs to protect the heart
A – ACEi or ARB │ S – Statin │ A – ASA (only if established CVD)

E • Exercise – regular physical activity, healthy diet, achieve and
maintain healthy body weight

S • Smoking cessation
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Who Should be Screened for CAD with
ECG?
Age >40 years
Duration of DM >15years
+
Age >30 years
End organ damage
–
–
Microvascular
Macrovascular
Cardiac risk factors
Symptoms of “silent CAD”
– decreased exercise capacity,
unexplained dyspnea, new onset HF
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Baseline resting
ECG
Repeat every 2 years
Who Should Receive Statins?
2013
•
Clinical Macrovascular disease [grade A, level A] or
•
≥40 yrs old [grade A, level A for T2DM; grade D, consensus for T1DM] or
•
Microvascular disease [grade D, consensus] or
•
DM >15 yrs duration and age >30 years [grade D, consensus] 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.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
If on statin – primary target is:
LDL ≤ 2.0 mmol/L or > 50% reduction in LDL
Alternate primary targets are: apo B <0.8g/L, or non-HDL-C <2.6
mmol/L.
If Triglycerides > 10.0 mmol/L –
•
•
•
Use a FIBRATE to reduce the risk of pancreatitis
Optimize glycemic control
Implement lifestyle interventions
– Weight loss
– Optimal dietary strategies
– Reduce alcohol
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Who Should Receive ACEi or ARB Therapy?
•
Clinical Macrovascular disease [grade A, level A] or
•
≥55 years of age [grade A, level A for those with additional CVD risk
factors or end organ damage; grade D, consensus for all others] or
•
Microvascular disease [grade D, consensus]
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
EUROPA Investigators, Lancet 2003;362(9386):782-788.
HOPE study investigators. Lancet. 2000;355:253-59.
ONTARGET study investigators. NEJM. 2008:358:1547-59
Who Should Receive Antiplatelet
Therapy?
•
Only patients with established cardiovascular disease –
secondary prevention [grade D, consensus]
•
No longer recommended for primary prevention in
people with diabetes [grade A, level 1]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Who requires vascular protection
medications?
•
http://guidelines.diabetes.ca/VascularProtection/RiskAssessment
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Hypertension / BP control
•
Screening and diagnosis
–
BP should be measured at every diabetes related visit and at least twice a
year.
– Patients found to have elevated BP should have high BP confirmed on a
separate day.
– Threshold for diagnosing hypertension in person with diabetes is BP ≥130/80
mmHg (may consider SBP up to 140 in elderly).
– Target for treating BP is <130/80.
•
Lifestyle therapy for elevated BP
–
Weight loss if overweight
– DASH-style diet with reduced sodium and increased potassium intake
– Moderation of alcohol intake
– Increased physical activity
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
What about Microvascular Disease?
• Nephropathy
• Retinopathy
• Neuropathy
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Chronic Kidney Disease (CKD)
2013
•
Diabetic Nephropathy - Progressive increase in proteinuria in people with
longstanding diabetes, followed by declining function which can
eventually lead to End-Stage Renal Disease (ESRD)
•
SCREEN regularly (annually) 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 of CKD by:
•
•
•
achieving glycemic and blood pressure control, and
using ACE inhibitor or angiotensin receptor blocker (ARB)
PREVENT additional renal complications with “sick day management”
counselling and referral when appropriate
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Urine ACR ≥ 2.0 mg/mmol
(for both males and females)
CKD
in diabetes
and / or
eGFR < 60 mL/min
Either test must be abnormal on ≥ 2
occasions tested over a 3 month
period
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Beware of Transient Albuminuria
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Reducing progression of diabetic nephropathy
•
Optimal glycemic control
•
Optimal blood pressure control – irrespective of type of drug used
•
Use of ACE-inhibitor or Angiotensin receptor blocker
People with CKD are at increased risk of CV events
• Commence therapy as per vascular protection guidelines
•
Risk for CAD increases with combination of increasing
albuminuria and low eGFR
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
See
CPG Appendix 6
for therapeutic
considerations
for renal
impairment
2013
Counsel all
Patients
About
Sick Day
Medication
List
2013
2013
Retinopathy
• SCREEN every 1 – 2 years with dilated eye exam
by trained eye professional, or retinal photography.
• DELAY onset and progression of retinopathy with
– optimal glycemic and blood pressure control
• TREAT established disease with laser
photocoagulation, intra-ocular injection of
medications or vitreo-retinal surgery
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Neuropathy
2013
•
PREVENT with optimal blood glucose control
•
SCREEN annually by testing for loss of protective
sensation using a 10 gram monofilament or tuning
fork
•
TREAT pain symptoms with anticonvulsants or
antidepressants, and improved glycemic control
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
40-50% of People with Diabetes will have
Detectable Neuropathy within 10 years
• Sensorimotor poly- or mono-neuropathy
• Motor neuropathy
• Autonomic neuropathy
• Increased risk for:
–
–
–
–
Foot ulceration and amputation
Neuropathic pain
Hypoglycemia unawareness
Significant morbidity
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Special Populations:
Elderly
Women of child-bearing age
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Diabetes in the Elderly
2013
• ASSESS for level of functional dependency (frailty)
• INDIVIDUALIZE glycemic targets based on frailty and comorbid conditions (A1C ≤ 8.5% for frail elderly, limited life expectancy) but if
otherwise healthy, use the same targets as younger people
• AVOID hypoglycemia in cognitive impairment, frail elderly
• SELECT anti-hyperglycemic therapy carefully
• caution with sulfonylureas or thiazolidinediones
• Long-acting insulin analogues instead of NPH or human 30/70
insulin – lower risk of hypoglycemia
• Premixed insulins instead of mixing insulins separately
• GIVE regular diets instead of “diabetic diets” in nursing
homes
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Among frail elderly
Parameter
A1C
Target
≤ 8.5%
FPG or
preprandial
glucose
5.0-12.0 mmol/L
(depending on level of frailty)
AVOID HYPOGLYCEMIA
FPG= fasting plasma glucose
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
If choosing to use insulin …
•
Clock drawing test can be used to predict who is
likely to have problems with insulin therapy
•
“Write numbers on the blank clock face and draw
hands on the clock to show 10 minutes past 11
o’clock”
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright
Canadian
Diabetes 2005;29(2):102-104.
Association
Trimble
LA ©et2013
al. Can
J Diabetes
Women of child-bearing age Recommendations
2013
1. All women of reproductive age with type 1 or type 2
diabetes should receive advice on reliable birth control,
the importance of optimal glycemic control prior to
pregnancy, impact of BMI on pregnancy outcomes, need
for folic acid and the need to stop potentially
embyropathic drugs prior to pregnancy [Grade D, Level 4].
2. Women with type 2 diabetes and irregular
menses/PCOS who are started on metformin or a
thiazolidinedione should be advised that fertility may
improve and be warned about possible pregnancy [Grade D,
consensus].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
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 diabetic complications such
as retinopathy, nephropathy
3.
Switch to insulin if on oral agents; may continue on
metformin if T2DM
4.
Folic Acid 5 mg/day: 3 months pre-conception to 12
weeks post-conception
5.
Discontinue potentially embryopathic meds:
1.
2.
Ace-inhibitors/ARB (prior to or upon detection of pregnancy)
Statin therapy (prior to pregnancy)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Other Topics
•
•
•
•
•
•
•
Mental Health and Diabetes
Pregnant women - GDM
Children with Type 1 Diabetes
Children with Type 2 Diabetes
In-hospital therapy
Diabetic Foot
Immunizations
www.guidelines.diabetes.ca
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association