1. Sohil Rangwala MDCM, CCFP Primrose Family Medicine Centre
Diabetes in a nutshell
Sohil Rangwala
MDCM, CCFP
Primrose Family Medicine Centre

2. Objectives Review screening and diagnostic criteria for DM2
Review management of DM2
Review the use of Diabetic Flow sheets
Review of CDA interactive website

3. Who do you screen for diabetes?
A) Everyone
B) Men and women over 50
C) Men and women over 40
D) It doesn’t really matter
E) Someone who scores moderate risk on the FINRISK or CANRISK calculator

4. How frequently do you screen?
A) yearly
B) every 2 years
C) Every 3 years
D) After the holiday season
E) Every 5 years

5. When do you screen earlier than 40 for DM2?
A) If they have metabolic syndrome
B) If they are very high risk using the FINRISK/CANRISK calculator
C)Family History of DM
D) history of GDM
E) all of the above

6. When do you screen more frequently than every 3 years?
If they request it
If they have additional risk factors for DM2
If they are high risk on FINRISK or CANRISK
If they are very high risk on FINRISK or CANRISK
B and D

7. How do you screen for DM2? A) Ask the patient B) using HBA1c
C) using Fasting Blood sugar
D) using HsCRP
E) B or C

8. How do you diagnose DM2?
A )HbA1c > 7% B) FBS > 7 C) HbA1c> 6.5% D) RBS > 11.1 with symptoms E) Always need second confirmatory test F) B, C, D, E

9. When do you do a 2 hour OgTT?
A) All of the below
B) if HbA1c is between %
C) if HbA1c is between % and have a risk factor
D) if FBS is between and have a risk factor
E) if FBS is between

13. Screening and Diagnosis review

15. Type 2 DM risk factors

16. CANRISK calculator

17. Management
1. Lowering Blood sugar
2. Lowering Vascular risk

18. What are the complications?

19. What is the target HbA1c? A) less than 6.5% B) less than 7 %
C) it depends on the day
D) less than 6%
E) if I’m on metformin who cares!

20. When should Hba1c less than 6.5%
A) to help reduce complications from retinopathy
B) to help reduce complications from neuropathy
C) to help reduce complications from nephropathy
D) A + C
E) A+ B

22. How much physical activity is recommended in diabetes?
A) as tolerated
B) 150 minutes of aerobic exercise
C) Resistance exercise 2-3 times a week
D) Daily weights at the gym
E) B and C

23. Physical Activity Checklist
2013
Physical Activity Checklist
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 multi-disciplinary team
ASSESS patient’s health before prescribing an exercise regimen

25. What dietary advice should be given in diabetes?
A) Patients should see a registered dietician
B)Dietary advice should emphasize low glycemic index foods
C) Canada Food guide should be followed
D) All of the above

26. By how much can dietary changes lower HbA1c?
C) it’ s a rumor
D) 2%
E) 1-2%

27. Nutrition Checklist www.guidelines.diabetes.ca
2013
REFER for nutrition counseling by a registered dietitian
FOLLOW Eating Well with Canada’s Food Guide
INDIVIDUALIZE dietary advice based on preferences and treatment goals
CHOOSE low glycemic index carbohydrate food sources

28. Choose low glycemic index carbohydrates

29. At diagnosis of Diabetes, I should:
A) Always start Metformin
B) Consider Metformin
C) Always recommend lifestyle changes
D) A +C
E) B + C

30. If the A1C is > 8.5 %, I should:
A) Refer to endocrinology
B) Start Metformin Immediately
C) Consider combination therapy
D) Start Glicazide Immediately
E) B and C

31. If HbA1c is < 8.5% but not at target, I should:
A) Make no changes
B) Start/Increase Metformin
C) Start Insulin
D) Run(away)

32. After diagnosis, how long should it take me to reach target HbA1c?
A) one year
B) 9 months
C) 3-6 months
D) one month
E) 2 years

33. Which of the following has the greatest effect in lowering HbA1c?
A) diet and exercise
B) insulin
C) DPP4 inhibitors
D) Glicazide
E) Metformin

34. What is the most common side effect of metformin?
A) Headaches
B) Hypoglycemia
C) Vomiting
D) Kidney Failure
E) Diarrhea

35. What is Sitagliptin? A) DPP-4 inhibitor B) Sulfonylurea
C) GLP-1 receptor agonist
D) Meglitinide

36. Which sulfonylurea causes less hypoglycemia?
A) Glyburide
B) Glicazide

37. Initial Choice of Therapy Depends on Glycemia
2013
Start metformin OR
Reassess in 2-3 months then decide on starting metformin
Initial A1C <8.5%
Start metformin
AND
Consider combo therapy to achieve ≥1.5% A1C reduction
Initiation and emphasis on lifestyle modification at time of diagnosis but quickly re-assess efficacy of this and need for pharmacotherapy
The lag period to starting medications and escalating therapy should be kept to a minimum, with the maximum effect of OHA therapy seen at 3-6 months (therefore if not on target, act)
Initial A1C ≥8.5%

39. When starting insulin, should I use basal or bolus?
A) Basal insulin
B) Bolus Insulin

40. Generally, how many units of basal insulin should be started?
A) 5 units
B) 15 units
C) 10 units
D) pick out of a hat
E) 20 units

41. When bolus insulin is added to basal, should oral secretagogues be stopped?
A) Yes
B) No

42. Insulin pen

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

44. What is the definition of hypoglycemia?
A) Blood sugar < 6
B) Blood sugar < 4
C) Autonomic symptoms
D) Response to carbohydrate load
E) B, C, D

45. How do we treat mild-moderate hypoglycemia?
A) Equivalent of 15 g carbohydrate load
B) Equivalent of 30 g carbohydrate load
C) Insulin
D) Equivalent of 10 g carbohydrate load

46. Definition of Hypoglycemia
Development of neurogenic or neuroglycopenic symptoms
Low blood glucose (<4 mmol/L if on insulin or secretagogue)
Response to carbohydrate load
Neurogenic (autonomic)
Neuroglycopenic
Trembling
Difficulty Concentrating
Palpitations
Confusion
Sweating
Weakness
Anxiety
Drowsiness
Hunger
Vision Changes
Nausea
Difficulty Speaking
Dizziness
The CDA defines hypoglycemia as the development of autonomic (trembling, palpitations, sweating, anxiety, hunger, nausea, tingling) or neuroglycopenic (difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness) symptoms, a low plasma glucose, and symptoms responding to the administration of a carbohydrate. In mild to moderate hypoglycemia, blood glucose is <4 mmol/L, autonomic and/or neuroglycopenic symptoms are present, but the patient is able to self-treat. However, patients who maintain a higher blood glucose level may experience hypoglycemia at levels >4.0 mmol/L. Severe hypoglycemia indicates the patient is unable to treat the reaction without outside assistance. He/she may or may not be conscious.

47. Steps to Address Hypoglycemia
Recognize autonomic or neuroglycopenic symptoms
Confirm if possible (blood glucose <4.0 mmol/L)
Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms
Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed
Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
Teaching patients to recognize and treat hypoglycemia can be done in 3 steps
1) It is important to teach patients to recognize the common autonomic and neuroglycopenic symptoms associated with hypoglycemia including: Trembling, Palpitations, Sweating, Anxiety, Hunger, Nausea, Tingling which are common autonomic symptoms and Difficulty concentrating, Confusion, Weakness, Vision change, and Headache are common neuroglycopenic symptoms.

48. Examples of 15 g Simple Carbohydrate
15 g of glucose in the form of glucose tablets
15 mL (3 teaspoons) or 3 packets of sugar dissolved in water
175 mL (3/4 cup) of juice or regular soft drink
6 Lifesavers (1=2.5 g of carbohydrate)
15 mL (1 tablespoon) of honey
: Evidence suggests that 15 g of glucose (monosaccharide) is required to produce an increase in BG of approximately 2.1 mmol/L within 20 minutes, with adequate symptom relief for most people

49. Vascular protection

50. Which of the following people with DM 2 should receive a statin?
A) 28 year old male recently diagnosed with diabetes
B)Everyone
C) 38 year old male with recent diagnosis of diabetes and ACR of 7 mmol/L
D) 45 year old female with diabetes
E) C and D

51. Which of the following people with DM2 should receive an ACE/ARB?
A) 48 year old male with Dm2
B) 52 year old female with DM2 and hx of retinopathy
C) 68 year old male
D) Everyone
E) B and C

52. Which of the following patients with Diabetes should receive ASA?
A) Everyone
B) All patients over 50 with diabetes
C) all patient over 40 with diabetes
D) all patients with diabetes who have had a vascular event
E) Nobody

53. Vascular Protection Checklist
2013
A • A1C – optimal glycemic control (usually ≤7%)
E • Exercise / Eating healthily – regular physical activity, achieve and maintain healthy body weight
B • BP – optimal blood pressure control (<130/80)
C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat
S • Smoking cessation
D • Drugs to protect the heart (regardless of baseline BP or LDL)
A – ACEi or ARB │ S – Statin │ A – ASA if indicated

54. Who Should Receive Statins? (regardless of baseline LDL-C)
2013
≥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.

55. Who Should Receive ACEi or ARB Therapy
Who Should Receive ACEi or ARB Therapy? (regardless of baseline blood pressure)
2013
≥55 years of age or
Macrovascular disease or
Microvascular disease
At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily (HOPE), telmisartan 80 mg daily (ONTARGET)]
ACE inhiibitor or ARB therapy should be offered to people with diabetes age ≥55 years, or in the presence of macrovasular disease or microvascular disease. This recommendation is regardless of blood pressure. It is important that the ACEi or ARB be titrated to the doses that have been shown to provide vascular protection since low dose ACE-inhibitor or ARB may not result in any benefit (DIABHYCAR study). These vascular protection benefits have been shown to be present irrespective of baseline blood pressure. Since it is not proven that low dose ACEi or ARB confers the same vascular protection, it is recommended that the ACEi or ARB dose be increased to the vascular protective doses (peripdopril 8mg, ramipril 10 mg, telmisartan 80 mg daily). Given that not all ACEi or ARB have conducted “vascular protection” type of studies and of those that have, not all have been positive, it is justified to titrate to doses shown to have vascular protection.
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
EUROPA Investigators, Lancet 2003;362(9386):
HOPE study investigators. Lancet. 2000;355:
ONTARGET study investigators. NEJM. 2008:358:

56. Insufficient evidence to support use of ASA for primary prevention
ASA Not Routinely Recommended for 1⁰ Prevention for CVD Among Patients with DM
Insufficient evidence to support use of ASA for primary prevention
Risk of bleeding CVD protection
2013
There is insufficient evidence at this time to support routine use of ASA in primary prevention
Need to balance the risk of bleeding vs CVD protection from ASA therapy
Will need to await until results of clinical trials such as Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes (ACCEPT-D) and ASCEND Collaborative Group to shed light on the role of ASA for primary prevention

58. How often should my patients with DM2 receive the pneumococcal vaccination?
A) Once over the age 50
B) Every 5 years
C) Over the age of 18
D)One time revaccination if > 65 and> 5 years between administration
E) C+ D

59. Immunization Checklist
2013
GIVE annual influenza immunization
OFFER pneumococcal immunization if >18 years of age
RE-VACCINATE for pneumococcal for those >65 years of age; ensure ≥5 years between administrations
Script
The key messages in the chapter are that: Influenza immunization is essential yearly among patients with diabetes to reduce hospitalizations, Pneumoccoccal immunization is desired in patients with diabetes as it is a chronic disease. For those > 65, a one time revaccination is essential if original vaccine adminstered < 65 y with at least 5 years in between to ensure adequate immunity. Finally, It is important to include immunization as part of the diabetic flowsheet as a reminder.
TTT:The purpose of slide is to provide the framework of key messages for the chapter

61. What to do when? A1c check- every 3 months ( less than 7%)
ACR check- Yearly( target less than 2.0)
Retinopathy check- Yearly
LDL check- yearly( LDL less than 2.0)
BP check- every visit( less than 130/80)
Neuropathy check- Yearly

62. Conclusions
Diabetes is very prevalent and having a grasp on diagnosis and management is key!
CDA guidelines are interactive and a great tool for health care providers and patients!

63. References