CDA Clinical Practice Guidelines J. Robin Conway M.D. Diabetes Clinic - Smiths Falls, ON Diabetes Office Mgmt Toronto May

Prevalence (millions) North America Europe Southeast Asia Year World Health Organization 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 Harris. Diabetes Care 1993;16:

Am J Cardiol 1999;84:11J-4J. Framingham study: diabetes and CAD mortality at 20-year follow-up Cardiovascular Disease Risk is Increased 2 to 4 Times

What proportion of your office visits involve Diabetics? 1.<10% % % % 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 Advice Strychar 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 exams Harris 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: 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 Structured Care: Usual Care:

Reduction in Relative Risk of Primary Endpoints Αthyros VG et al. Curr Med Res Opin. 2002;18: % Reduction P= P= P= P=0.034 P= P= P=0.021

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: Pharma Companies; Lilly, Novo, Bayer Web Site list Hospital Diabetes Education Program Community Diabetes Education Program

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.

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 mmol/L plus risk factor(s) for diabetes/IGT 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 & IGTIFG Diabetes Normal Rescreen as clinically indicated Strategies for prevention and rescreen at appropriate intervals Treatment Screening for Type 2 Diabetes, IFG and IGT

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

Nutrition Therapy People 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  Normal range (considered for patients in whom it can be achieved safely)  *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 Where possible, Canadian laboratories should standardize their A1C values to DCCT levels (reference range: to 0.060). However, as many laboratories continue to use a different reference range, the target A1C value should be adjusted based on the specific reference range used by the laboratory that performed 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 hemoglobin DCCT = Diabetes Control and Complications Trial FPG = fasting plasma glucose PG = plasma glucose

Clinical assessment and initiation of nutrition and physical activity Mild to moderate hyperglycemia (A1C <9.0%) Overweight (BMI  25 kg/m 2 ) Non-overweight (BMI  25 kg/m 2 ) Biguanide alone or in combination with 1 of: insulin sensitizer* insulin secretagogue insulin alpha-glucosidase inhibitor 1 or 2 † antihyperglycemic agents from different classes biguanide insulin sensitizer* insulin secretagogue insulin alpha-glucosidase inhibitor Add a drug from a different class or Use insulin alone or in combination with: biguanide insulin secretagogue insulin sensitizer* alpha-glucosidase inhibitor Marked hyperglycemia (A1C  9.0%) 2 antihyperglycemic agents from different classes † biguanide insulin sensitizer* insulin secretagogue insulin alpha-glucosidase inhibitor Basal and/or preprandial insulin Add an oral antihyperglycemic agent from a different class of insulin* Intensify insulin regimen or add biguanide insulin secretagogue** insulin sensitizer* alpha-glucosidase inhibitor If not at target L I F E S T Y L E Timely adjustments to and/or additions of oral antihyperglycemic agents and/or insulin should be made to attain target A1C within 6 to 12 months

Economics Gen AssA003$54.10 Int AssA007$28.50 CounsellingK013$ x/yr Insulin RxK029$ x/yr Type 2 FlowK030$ x/yr GlucoseG002$ 1.97 UrineG009$ 4.20 VenipunctureG489$ 2.27

Economics A003 G002, G009, G489$ G030 G002 G009 G489 x3$ K013 G00s G009 G489 x4$ A007 x4$ TOTAL $517.62

FLOWSHEETS

ABC of Diabetes A 1c <7 B lood Pressure <130/80 C hol/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?