guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials Canadian Diabetes Association 2013 Clinical Practice Guidelines (Updated July 2015) 2015

guidelines.diabetes.ca | BANTING ( ) | 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association TIA 2005 Stroke 2006 MI 2003 MI 2004 Bypass 2001 PAD 2002 Ischemic Toes Amputation 2004 Neuropathy 2003 CKD 2002 Retinopathy 2004 ACS 2001 Victor 59 years old Type 2 Diabetes

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Victor 59 years old Type 2 Diabetes Neuropathy 2002 TIA 2005 Stroke 2006 PAD 2002 Ischemic Toes Amputation 2004 MI 2003 MI 2004 Bypass 2001 ACS 2001 Macrovascular Neuropathy 2003 CKD 2002 Retinopathy 2004 Microvascular Reorganize his history He has EVERY complication of Diabetes That is what we need to avoid

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What is new in making the diagnosis of diabetes?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diagnosis of Prediabetes* TestResultPrediabetes Category Fasting Plasma Glucose (mmol/L) Impaired fasting glucose (IFG) 2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L) 7.8 – 11.0Impaired glucose tolerance (IGT) Glycated Hemoglobin (A1C) (%) Prediabetes * Prediabetes = IFG, IGT or A1C %  high risk of developing T2DM 2013

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Individualizing A1C Targets which must be balanced against the risk of hypoglycemia Consider % if: 2013

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Self-Monitoring of Blood Glucose (SMBG) What should we tell patients to do?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Regular SMBG is Required for:

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Increased frequency of SMBG may be required: Daily SMBG is not usually required if patient:

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Medications for glycemia How do we choose?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 LIFESTYLELIFESTYLE 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 2015

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 LIFESTYLELIFESTYLE 2015

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 LIFESTYLELIFESTYLE 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 2015

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2015

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Antihyperglycemic agents and Renal Function 2015 Adapted from: Product Monographs as of July 2015; Harper W et al. Can J Diab 2015;39: ; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What are the options for Insulin?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Types of Insulin 2015

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Types of Insulin (continued)

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Serum Insulin Level Time Analogue Bolus: Apidra, Humalog, NovoRapid Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Human Bolus: Humulin-R, Novolin ge Toronto

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Time Serum Insulin Level Human Premixed : Humulin 30/70, Novolin ge 30/70 Analogue Premixed: Humalog Mix25, NovoMix 30

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What about Hypoglycemia?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Macrovascular Disease Vascular Protection: Who and When?

guidelines.diabetes.ca | BANTING ( ) | 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 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ≥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 Who Should Receive Statins? (regardless of baseline LDL-C)

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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.

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 [p erindopril 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): HOPE study investigators. Lancet. 2000;355: ONTARGET study investigators. NEJM. 2008:358:

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | 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 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What if we did all the right things? How much could we protect our patients?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Gaede et al. NEJM. 2003: 348; STENO-2: Intensive Group Achieved Targets

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Intensive Group had Improved CV Outcomes P = Conventional therapy Intensive therapy Months of Follow-up RRR= relative risk reduction 53 % RRR Any CV event NNT = 5 Gaede et al. NEJM. 2003: 348;

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Gaede et al. NEJM. 2003: 348; STENO 2 – Microvascular Disease

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What about Microvascular Disease? Nephropathy Retinopathy Neuropathy

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Counsel all Patients About Sick Day Medication List 2015

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Neuropathy Checklist PREVENT with blood glucose control SCREEN with monofilament or tuning fork TREAT pain symptoms with anticonvulsants or antidepressants 2013

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 Recommendation 4

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Foot Care: What are the DO’s and DON’Ts of foot care?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Special populations …

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 CAUTION with renal dysfunction 2015

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 CDA diagnostic criteria for GDM PREFERRED APPROACH (2 steps) 1.50 gram glucose challenge test 2.75 gram oral glucose tolerance test –Using thresholds of OR 2.0 ALTERNATIVE APPROACH (1 step) 1.75 gram oral glucose tolerance test –Using thresholds of OR

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM diagnosis: Two approaches 2013

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association How can we keep track of all the parameters for our patients with Diabetes?

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Tools to help us keep track of our patients

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Tools to help us keep track of our patients

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Back Page: “Cheat Sheet” of Targets and Goals

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Back Page: “Cheat Sheet” of Targets and Goals

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association “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)

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines – for professionals BANTING ( ) – for patients