2013 Guideline Day Review of Diabetes Guidelines: (2008 CDA plus some new stuff)

1. 2013 Guideline DayReview of Diabetes Guidelines: (2008 CDA plus some new stuff) Ian Sempowski MD CCFP (EM) 2013

2. 2008 CDA • Highlighting long term recommendations in black • I will put any new recommendations or changes in red • I have included new med trends post 2008 CDA • New 2013 CDA guidelines – watch for them for knowledge purposes (not exam)

3. Diagnosis: • New screening guidelines Oct 2012 CMAJ • Use FINDRISC or Canrisk validated diabetes risk calculators- ugh • Low risk no screening • Med risk – Q 3-5 yrs • High risk - annual

4. FINDRISC calculator: CTFPHC website Watch for changes after the 2013 CDA guidelines come out Less emphasis on age alone

5. Prevention of progression from prediabetes to DM : • 5 % wt loss reduces progression by 60% • Acarbose 30% “should be considered” • Metformin 30% “should be considered” • Thiazolidinedione 60% - has really fallen out of favour

6. Metabolic Syndrome: ATP III criteria 3 or more of following: (3 or more) There are also other classification systems ie IDF, and WHO- see chart • elevated waist circumference males > 102 cm (40 in) females > 88 cm ( 34 in) • hypertension > 130/85 • high TG >1.7 • low HDL<1.0 men and < 1.3 women • FPG ≥ 5.6

7. Organization of Care: • Diabetes care should be systematic and should incorporate organizational interventions such as electronic databases, automatic reminders for the patient and DHC team, and adaptations for distance • Self-management education (SME) that incorporates knowledge and skills development, as well as cognitive behavioural interventions, should be implemented for all individuals with diabetes.

8. Targets glycemic control: • A1C<.07 • A target A1C of ≤6.5% may be considered in some patients with type 2 diabetes to further lower the risks but this must be balanced against the risk of hypoglycemia and increased mortality in patients who are at significantly elevated risk of cardio-vascular disease (ACCORD and ADVANCE trials)

9. Monitoring glycemic control: • Monitor A 1C every 3 months • Every 6 months once targets consistently achieved • Type 1 - blood ketone testing preferred over urine • Be aware on new technologies of continuous glucose monitoring ie sensors that attach to pump (CGMS)

10. Physical activity: • 150 minutes of mod to vigorous aerobic activity per week • No 2 consecutive days without • Resistance exercise 3 times per week

11. Nutritional therapy: • Consistency,meal spacing, snacks, low GI and high fiber carbs, low sat fats • Can improve A 1C by 1-2 % • Recommended distn as per Canada’s Food Guide- same as for people without diabetes –45-60% calories from CHO , < 35 % fat, protein 15-20% • Diabetes - <7% from sat fats and minimal trans fatty acids

12. Insulin for Type I diabetes: • multiple daily injections or continuous subcutaneous insulin infusion are the insulin regimens of choice for all adults with type 1 diabetes

13. Pharmacology Type 2: • If glycemic targets are not achieved within 2 to 3 months of lifestyle management, meds should be initiated • Attain target glycated hemoglobin (A1C) within 6 to 12 months • A1C ≥9.0% meds should be initiated concomitantly with lifestyle management, and consideration should be given to either initiating combination therapy with 2 agents or initiating insulin

14. Sulfonylureas: • Glyburide dose 2.5 mg od up to 10 mg BID • Diamicron is now ODB covered dose 80 mg BID to 160 mg BID –less hypoglycemia, diamicron MR is also covered • Amaryl still not ODB covered

15. New drug issues : • Januvia-Sitagliptin - DPP-4 inhibitor • Victosa - Liraglutide – GLP1 agonist • Diamicron full ODB coverage • Levemir and Lantus full ODB coverage

18. GLP-1 and DPP-4: • Glucagon-like Peptide-1 • Stimulates glucose-dependent insulin secretion from beta cells • Suppresses glucagon release from alpha cells • Slows gastric emptying & reduces food intake • Degraded by DPP-4 enzyme

19. How to use Januvia: • Usually add on to metformin esp if you are close to A1C already • Supplied as 25, 50, 100 mg od • Usual 100 mg once daily • Give without regard to meals • Lower dose to 50 mg daily if Cr Cl < 30

20. Adverse effects Januvia: • Headache, URI, UTI (≥ 5%) • Hypoglycemia • Peripheral edema • Pancreatitis • ? wt neutral

21. Victosa - Liraglutide : • Usually combined with metformin and a secretagogue (may consider lowering dose) • Use with insulin unclear at this time but many experts are starting to use it. • Pre-filled, multi-dose disposable pen • 0.6 mg, 1.2 mg, 1.8 mg • Theory – better glycemic control with more potential wt loss

22. Dosing Victosa: • Pre-filled, multi-dose disposable pen • 0.6 mg, 1.2 mg, 1.8 mg • Dosing/Administration: • Start 0.6 mg SQ once daily, anytime, independent of meals, increase weekly to max 1.8 mg if needed • Consider lowering dose of secretagogues • Lower insulin dose if using together

23. Concerns Victosa: • Nausea • Hypoglycemia • Pancreatitis • Thyroid C-cell tumors in rats and mice

24. Hypoglycemia: • important to prevent, recognize and treat hypoglycemic episodes secondary to the use of insulin or insulin secretagogues. • mild to mod 15 gm, severe conscious 20 gm, severe unconscious 1 mg glucagon sc or im or IV 20-50 ml D50W • avoid overtreatment, since this can result in rebound hyperglycemia and weight gain

25. Hyperglycemic emergencies adults: • DKA and hyperosmolar hyperglycemic state (HHS) should be suspected in all ill patients with diabetes • DKA - NS 500ml/hr for 4 hrs, then 250 ml/hr for 4 hrs • Ketoacidosis requires insulin administration (0.1 U/kg/hour) for resolution until normalize AG • Once SBG >14 add IV dextrose

26. In hospital management diabetes: • diabetes in the hospitalized population is 2- to 3-fold higher than popn • severe, acute illnesses- intravenous insulin infusions may have significant advantage - use of “sliding scale” subcutaneous insulin therapy is considered suboptimal • hypoglycemia - diabetes education / management regimens to reduce the risk of hypoglycemia and the use of standardized treatment protocols

27. Obesity and diabetes: • 80 to 90% of type 2 diabetics • 5 to 10% of initial body weight can substantially improve insulin sensitivity and glycemic, blood pressure and lipid control • severe obesity may be considered for bariatric surgery ie BMI >40 or BMI 35-40 with comorbidities • Kingston getting a program….

28. Psychologic aspects: • multidisciplinary teams should include members with required expertise to offer cognitive behavioural interventions, such as stress management strategies and coping skills training

29. Influenza and pneumovax: • influenza vaccination can reduce hospitalizations by approximately 40% • pneumococcal revaccination is recommended for individuals >65 years of age if the original vaccine was administered when they were <65 years of age and >5 years earlier

30. Islet cell transplants: • Pancreas transplant can result in prolonged insulin independence and a possible reduction in the progression of secondary complications of diabetes • Risks of chronic immunosuppression must be carefully weighed against the potential benefits of pancreas or islet transplant for each individual

31. Alternative therapies: • 30% of patients with diabetes use complementary and alternative medicine • Be aware of side effects and interactions

32. Coronary disease and diabetes: • CAD approximately 2- to 3-fold • Consider pts to be “high 10-year risk” if ≥45 years and male, or ≥50 years and female • More likely to have asymptomatic CV disease • Less likely to be revascularized

33. Screening for CAD: • Baseline ECG, repeat every 2 yrs if “high risk” • High risk age over 40, DM > 15 yrs, hypertension, proteinuria, PVD, • Screening EST – see list of indications, DIAD trial • EST ischemia at <5 METS - cardiology

34. Vascular protection: • Lifestyle measures, optimized glycemic control and blood pressure control all patients • “High risk” CAD- recommended treatment is with either ACE inhibitors or ARB, antiplatelet therapy (usually ASA), and lipid lowering therapy (statin) • The decision to prescribe antiplatelet therapy for primary prevention of CV events, however, should be based on individual clinical judgment

35. Dyslipidemia and diabetes: • Goals LDL-C of ≤2.0 , Chol/ HDL < 4.0 • TGs are >10.0 mmol/L despite best efforts-a fibrate should be prescribed to reduce the risk of pancreatitis • Moderate TG (4.5 to 10.0 mmol/L)-a statin or a fibrate can be attempted as first-line therapy, with the addition of a second lipid-lowering agent of a different class if target lipid levels are not achieved after 4 to 6 months • Plasma apo B – better target than LDL esp in high TG patients - at the physician’s discretion to monitor adequacy of lipid-lowering therapy in the high-risk individual - target apo B <0.9 g/L

36. Hypertension and diabetes: • <130/80

37. Acute coronary syndrome: • Diabetes is an independent risk factor for mortality, recurrent MI and CHF following AMI • AMI- insulin-glucose infusion to maintain blood glucose 7.0 - 10.0 mmol/L for at least 24 hours, followed by multidose subcutaneous insulin for at least 3 months • They are less likely to receive recommended treatment such as revascularization, thrombolysis, beta blockers or acetylsalicylic acid – be aware and try to adhere to guidelines

38. CHF and diabetes: • heart failure is 2- to 4-fold higher in people with diabetes

39. Chronic Kidney Disease and diabetes: • Screen with annual ACR • Annual eGFR • Thiazide-like diuretics have been recommended for control of sodium and water retention, hypertension or hyperkalemia in people with diabetes and CKD • Stopping angiotensin-converting enzyme inhibitor and/or diuretic therapy during times of acute illness and in women before becoming pregnant have been added

40. Retinopathy: • Tight glycemic control reduces the onset and progression • Laser therapy reduces the risk of significant visual loss

41. Neuropathy: • higher levels of glucose, elevated triglycerides, high body mass index, smoking and hypertension are risk factors for neuropathy

42. Footcare: • foot ulceration requires an interdisciplinary approach that addresses glycemic control, infection, lower extremity vascular status and local wound care • Uncontrolled diabetes can result in immunopathy with a blunted cellular response to foot infection

43. Erectile dysfunction: • affects approximately 34 to 45% of adult men with diabetes • All adult men with diabetes should be regularly screened • phosphodiesterase type 5 inhibitors are first-line therapy

44. Type 1 Diabetes in children: • Children <6 years should aim for glycated hemoglobin A1C <8.5% • Poor control e.g. A1C >10% should be referred to a tertiary pediatric diabetes team and/or mental health professional • instructed in the use of mini-doses of glucagon at home • comprehensive education and support services and 24-hour telephone services should be available

45. Type 2 Diabetes in children: • Regular targeted screening for type 2 diabetes is recommended in children at risk- OGTT may be better than FPG in children – dx criteria are the same

46. Diabetes in pregnancy: • All women with pre-existing type 1 or type 2 diabetes should receive preconception care to optimize glycemic control, assess complications, review medications and begin folate supplementation • A recommendation has been added that glyburide or metformin may be considered in women with GDM who are non-adherent to or who refuse insulin

47. Summary • Read the full 2008 CDA guidelines • Learn more about Januvia, Victoza, Levemir, Lantus • Memorize the executive summary CDA website • Watch for 2013 guidelines • Good luck!!!