1. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials Canadian Diabetes Association 2013 Clinical Practice Guidelines

2. 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

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association www.guidelines.diabetes.ca

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diagnosis of Prediabetes* TestResultPrediabetes 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 – 11.0Impaired glucose tolerance (IGT) Glycated Hemoglobin (A1C) (%) 6.0 - 6.4Prediabetes * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM 2013

8. 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 Individualizing A1C Targets which must be balanced against the risk of hypoglycemia Consider 7.1-8.5% if: 2013

9. 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 2013

10. 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 LIFESTYLELIFESTYLE

11. 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 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

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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. 2013 Who Should Receive Statins? (regardless of baseline LDL-C)

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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.

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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):782-788. HOPE study investigators. Lancet. 2000;355:253-59. ONTARGET study investigators. NEJM. 2008:358:1547-59

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

18. Counsel all Patients About Sick Day Medication List 2013

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Tools to help us keep track of our patients

22. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Tools to help us keep track of our patients

23. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Back Page: “Cheat Sheet” of Targets and Goals

24. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Back Page: “Cheat Sheet” of Targets and Goals

25. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association New resources

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Download the App Today!

27. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | 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)