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The Essentials

Canadian Diabetes Association 2013 Clinical Practice Guidelines. The Essentials. Learning Objectives. By the end of this session, participants will be able to: Understand the major changes within the 2013 CDA clinical practice guidelines Understand the rationale behind these changes

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The Essentials

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  1. Canadian Diabetes Association 2013 Clinical Practice Guidelines The Essentials

  2. Learning Objectives By the end of this session, participants will be able to: • Understand the major changes within the 2013 CDA clinical practice guidelines • Understand the rationale behind these changes • Apply the recommendations in clinical practice 

  3. Faculty for slide deck development • Jonathan Dawrant, BSc, MSc, MD, FRCPC • Zoe Lysy, MDCM, FRCPC • GeethaMukerji, 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. www.guidelines.diabetes.ca

  5. guidelines.diabetes.ca

  6. Diagnosis of Diabetes 2013 2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

  7. Diagnosis of Prediabetes* 2013 * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM

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

  9. AT DIAGNOSIS OF TYPE 2 DIABETES L I F E S T Y L E Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C <8.5% A1C 8.5% Symptomatic hyperglycemia with metabolic decompensation If not at glycemic target (2-3 mos) Start metformin immediately Consider initial combination with another antihyperglycemic agent Initiate insulin +/- metformin Start / Increase metformin If not at glycemic targets 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 Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013 See next page…

  10. From prior page… L I F E S T Y L E If not at glycemic target • Add another agent from a different class • Add/Intensify insulin regimen 2013 Make timely adjustments to attain target A1C within 3-6 months

  11. 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. 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.

  13. 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. 2013 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 [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily (HOPE), telmisartan80 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 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. Recommendation 2013 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]

  16. 2013 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

  17. Counsel all Patients About Sick Day Medication List 2013

  18. 2013 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

  19. Need a preconception checklist for women with pre-existing diabetes 2013 • 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

  20. Tools to help us keep track of our patients

  21. Tools to help us keep track of our patients

  22. Back Page: “Cheat Sheet” of Targets and Goals

  23. Back Page: “Cheat Sheet” of Targets and Goals

  24. New resources

  25. Download the App Today!

  26. “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)

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