1. Screening for Type 1 and Type 2 Diabetes Chapter 4 Jean-Marie Ekoé, Zubin Punthakee, Thomas Ransom, Ally PH Prebtani, Ron Goldenberg Canadian Diabetes Association 2013 Clinical Practice Guidelines

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Screening Checklist ASSESS all adults clinically every year for risk of type 2 diabetes (T2DM) SCREEN every 3 years if ≥ 40 years or high risk on risk calculator 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

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Canada: Prevalence by Province and Territory Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011. NL 6.5% ON 6.0% QC 5.1% PE 5.6% NB 5.9% NS 6.1% MB 5.9% SK 5.4% AB 4.9% BC 5.4% NT 5.5% YT 5.4% NU 4.4% † Age-standardized to the 1991 Canadian population. Age-standardized † prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09 NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest. < 5.0 5.0 < 5.5 5.5 < 6.0 6.0 < 6.5 ≥ 6.5

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association DIASCAN: Canadian Screening for T2DM in those age > 40 Years in Primary Care 5.7% undiagnosed glucose abnormalities Leiter LA et al. Diabetes Care 2001;24:1038-43.

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ADDITION-Cambridge: No Mortality Benefit of Screening for T2DM in United Kingdom Simmons RK et al. Lancet 2012;380:1741-48.

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ADDITION-Cambridge: Prevalence of Diabetes Prevalence of diabetes only 3.0-3.3% in this study Prevalence of diabetes in Canada 6.8% Can the results of ADDITION-Cambridge be applied to Canada? Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011. Simmons RK et al. Lancet 2012;380:1741-48.

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Assessing Risk: Risk Factors for T2DM Personal factors: First-degree relative with T2DM Member of high-risk population (e.g. Aboriginal, African, Asian, Hispanic or South Asian) History of prediabetes History of gestational diabetes (GDM) History of delivery of macrosomic infant

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Presence of associated problems: End organ damage complications associated with diabetes – Microvascular (retinopathy, neuropathy, nephropathy) – Macrovascular (coronary, cerebrovascular, peripheral arterial) Vascular risk factors – Low HDL-cholesterol (< 1.0 mmol/L males, 1.3 mmol/L females) – Triglycerides ≥ 1.7 mmol/L – Hypertension, overweight, abdominal obesity Assessing Risk: Risk Factors for T2DM

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Presence of associated problems (continued): Associated diseases – Polycystic ovarian syndrome, acanthosis nigricans, obstructive sleep apnea, psychiatric disorders (bipolar, depression, schizophrenia), HIV infection Presence of secondary causes: Use of drugs associated with diabetes – Glucocorticoids – Atypical antipsychotics – Highly active antiretroviral therapy (HAART) – Others (see Appendix 1 in CPG document) Other secondary causes (see Appendix 1 in CPG document) Assessing Risk: Risk Factors for T2DM

10. 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/diabetes- diabete/canrisk/index-eng.php http://www.phac-aspc.gc.ca/cd-mc/diabetes- diabete/canrisk/index-eng.php For people 40 - 74 years old Components – Age, sex, BMI, waist circumference – Physical activity level, eating veg and fruits – Hypertension, history of dysglycemia (GDM, acute illness etc.) macrosomia – Family history, ethnicity, level of education Calculates low, moderate or high risk groups

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

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Similar to CANRISK Does not include: – Macrosomia – Ethnicity – Level of education Risk categories differ: – Low-moderate – High – Very high http://canadiantaskforce.ca/ guidelines/2012-diabetes/ http://canadiantaskforce.ca/ guidelines/2012-diabetes/ FINRISK calculator

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 Screening for Type 2 Diabetes in Adults Algorithm presented on next slides

14. 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.

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

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

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ‡ In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed. ‡ Diabetes: In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.

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

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

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%

22. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Do we need to screen for Type 1 diabetes (T1DM)? NO There is insufficient evidence for interventions to prevent or delay T1DM.

23. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 1 1. All individuals should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria [Grade D, Consensus].

24. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.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].

25. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2.Risk factors include: – First-degree relative with T2DM – Member of high-risk population (e.g. Aboriginal, African, Asian, Hispanic, or South Asian) – History of prediabetes – History of gestational diabetes (GDM) – History of delivery of macrosomic infant Recommendation 2 (continued)

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Presence of associated problems – End organ damage complications associated with diabetes Microvascular (retinopathy, neuropathy, nephropathy) Macrovascular (coronary, cerebrovascular, peripheral arterial) – Vascular risk factors Low HDL-cholesterol (< 1.0 mmol/L males, 1.3 mmol/L females) Triglycerides ≥ 1.7 mmol/L Hypertension, overweight, abdominal obesity Recommendation 2 (continued)

27. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Presence of associated problems (continued) – Associated diseases Polycystic ovarian syndrome, acanthosis nigricans, obstructive sleep apnea, psychiatric disorders (bipolar, depression, schizophrenia), HIV infection – Use of drugs associated with diabetes Glucocorticoids Atypical antipsychotics Highly active antiretroviral therapy (HAART) Others (See Appendix 1 in the full document) – Other secondary causes (See Appendix 1 in the full document) Recommendation 2 (continued)

28. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 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 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 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(s) in order to identify individuals with IGT or diabetes [Grade D, Consensus] 2013

29. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients