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Transcript of Guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes...
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
The Essentials
5th Annual CE LHIN CME
Canadian Diabetes Association 2013 Clinical Practice Guidelines
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Dr. John SigalasEndocrinologistRouge Valley Health SystemToronto
May 15 , 2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
TIA 2005
Stroke 2006
MI 2003
MI 2004
Bypass 2001
PAD 2002
Ischemic Toes Amputation 2004
Neuropathy 2003
CKD 2002
Retinopathy 2004
ACS 2001Victor59 years oldType 2 Diabetes
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Victor59 years oldType 2 Diabetes
TIA 2005
Stroke 2006
PAD 2002Ischemic Toes Amputation 2004
MI 2003
MI 2004
Bypass 2001ACS 2001
Macrovascular
Neuropathy 2003
CKD 2002
Retinopathy 2004
Microvascular
Reorganize his history
He has EVERY complication of DiabetesThat is what we need to avoid
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
www.guidelines.diabetes.ca
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
What is new in making the diagnosis of diabetes?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
FPG ≥7.0 mmol/LFasting = 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 diabetesor
2hPG in a 75-g OGTT ≥11.1 mmol/Lor
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Diagnosis of Prediabetes*
Test Result Prediabetes 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 – 11.0 Impaired glucose tolerance (IGT)
GlycatedHemoglobin(A1C) (%)
6.0 - 6.4 Prediabetes
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association 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.
NL6.5%
ON 6.0%
QC 5.1%
PE5.6%
NB5.9%
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.
Prevalence of diagnosed diabetes among individuals aged ≥ 1 year, by age group and sex, 2008/09
Diabetes in Canada: Prevalence of Diagnosed Diabetes by age and sex
Prevalence increased with age. The sharpest increase occurred after age 40 years. The highest prevalence was in the 75-79 year age group.
Pre
va
len
ce
(%
)
0
10
15
25
30
1-19
5
20
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥85 CanadaAge group (years)
Females
Males
Total
Overall Prevalence
6.4%
7.2%
6.8%
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Patients with DM are more likely to be hospitalized for many conditions
Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Guideline Targets Achieved %
of
pat
ien
ts
Leiter LA et al. Can J Diabetes 2013; in press
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Self-Monitoring of Blood Glucose (SMBG)
What should we tell patients to do?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Regular SMBG is Required for:
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Increased frequency of SMBG may be required:
Daily SMBG is not usually required if patient:
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Pharmacotherapy in T2DM checklist
CHOOSE initial therapy based on glycemia
START with Metformin +/- others
INDIVIDUALIZE your therapy choice based on
characteristics of the patient and the agent
REACH TARGET within 3-6 months of
diagnosis
2013
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 decompensationA1C 8.5%
Initiate insulin +/-metformin
If not at glycemic target (2-3 mos)
Start / Increase metformin
If not at glycemic targets
LIFESTYLE
Add an agent best suited to the individual:
Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOther
See next page…
AT DIAGNOSIS OF TYPE 2 DIABETES
Agent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOther
2013
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
LIFESTYLE
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 decompensationA1C 8.5%
Initiate insulin +/-metformin
If not at glycemic target (2-3 mos)
Start / Increase metformin
If not at glycemic targets
LIFESTYLE
Add an agent best suited to the individual:
Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOther
See next page…
AT DIAGNOSIS OF TYPE 2 DIABETES
Agent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOther
2013
2013
Adapted from: Product Monographs as of March 1, 2013; CDA Guidelines 2008; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.
Antihyperglycemic agents and Renal Function
Not recommended / contraindicated SafeCaution and/or dose reduction
Repaglinide
Metformin 30 60
Saxagliptin
Linagliptin
Glyburide 30 50
Thiazolidinediones 30
GFR (mL/min): < 15 15-29 30-59 60-89 ≥ 90
CKD Stage: 5 4 3 2 1
Gliclazide/Glimepiride 15 30
Liraglutide 50
Exenatide 30 50
Acarbose 25
Sitagliptin 50
5015 2.5 mg
15
30 50 mg25 mg
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Wh
at are th
e o
ptio
ns fo
r In
sulin
?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Insulin Type (trade name) Onset Peak Duration
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):• Insulin aspart (NovoRapid®)• Insulin glulisine (Apidra™)• Insulin lispro (Humalog®)
10 - 15 min10 - 15 min10 - 15 min
1 - 1.5 h1 - 1.5 h1 - 2 h
3 - 5 h3 - 5 h
3.5 - 4.75 h
Short-acting insulins (clear):• Insulin regular (Humulin®-R)• Insulin regular (Novolin®geToronto)
30 min 2 - 3 h 6.5 h
Basal Insulins
Intermediate-acting insulins (cloudy):• Insulin NPH (Humulin®-N)• Insulin NPH (Novolin®ge NPH)
1 - 3 h 5 - 8 h Up to 18 h
Long-acting basal insulin analogues (clear)• Insulin detemir (Levemir®)• Insulin glargine (Lantus®)
90 min Not applicable
Up to 24 h(glargine 24 h,
detemir 16 - 24 h)
Types of Insulin
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Insulin Type (trade name) Time action profile
Premixed Insulins
Premixed regular insulin – NPH (cloudy):• 30% insulin regular/ 70% insulin NPH (Humulin® 30/70)• 30% insulin regular/ 70% insulin NPH (Novolin®ge 30/70) • 40% insulin regular/ 60% insulin NPH (Novolin®ge 40/60)• 50% insulin regular/ 50% insulin NPH (Novolin®ge 50/50)
A single vial or cartridge contains a fixed ratio of insulin
(% of rapid-acting or short-acting insulin to % of intermediate-acting
insulin)
Premixed insulin analogues (cloudy):• 30% Insulin aspart/70% insulin aspart protamine crystals (NovoMix® 30)• 25% insulin lispro / 75% insulin lispro protamine (Humalog® Mix25®)• 50% insulin lispro / 50% insulin lispro protamine (Humalog® Mix50®)
Types of Insulin (continued)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Ser
um
Insu
lin L
evel
Time
Analogue Bolus: Apidra, Humalog, NovoRapid
Human Basal: Humulin-N, Novolin ge NPH
Analogue Basal: Lantus, Levemir
Human Bolus: Humulin-R, Novolin ge Toronto
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Time
Ser
um
Insu
lin L
evel
Human Premixed: Humulin 30/70, Novolin ge 30/70
Analogue Premixed: Humalog Mix25, NovoMix 30
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Wh
at ab
ou
t H
ypo
glycem
ia?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
1.D
evelopment of neurogenic
or neuroglycopenic sym
ptoms
2.Low
blood glucose (<4
mm
ol/L if on insulin or secretagogue)
3.R
esponse to carbohydrate load Neurogenic
(autonomic)Neuroglycopenic
Trembling Difficulty Concentrating
Palpitations Confusion
Sweating Weakness
Anxiety Drowsiness
Hunger Vision Changes
Nausea Difficulty Speaking
Dizziness
Defin
itio
n
of
Hyp
og
lycem
ia
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Macrovascular Disease
Vascular Protection:Who and When?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
A – ACEi or ARB │ S – Statin │ A – ASA if indicated
E • Exercise – regular physical activity, healthy diet,
achieve and maintain healthy body weight
S • Smoking cessation
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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.
2013Who Should Receive Statins?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Who Should Receive ACEi or ARB Therapy?
• ≥55 years of age or • Macrovascular disease or • Microvascular disease
At doses that have shown vascular protection (ramipril 10 mg daily, perindopril 8 mg daily, telmisartan 80 mg daily)
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
JPAD = Japanese Primary Prevention of Atherosclerosis with Aspirin for DiabetesPOPADAD = Prevention of Progression of Arterial Disease and DiabetesPPP = Primary Prevention ProjectETDRS = Early Treatment Diabetic Retinopathy StudyPHS = Physicians’ Health StudyWHS = Women’s Health Study
De Beradis G, et al. BMJ 2009; 339:b4531.
ASA for 1⁰Prevention in DiabetesMeta analysis of 6 studies(n = 10,117)
No overall benefit for: • Major CV events • MI• Stroke• CV mortality• All-cause mortality
0.03 0.125 0.5 12
8Favors ASA Favors control/placebo
JPADPOPADADWHSPPPETDRSTotal
68/1262105/63858/51420/519
350/1856601/4789
86/1277108/63862/51322/512
379/1855657/4795
0.80 (0.59-1.09)0.97 (0.76-1.24)0.90 (0.63-1.29)0.90 (0.50-1.62)0.90 (0.78-1.04)0.90 (0.81-1.00)
Major CV events
No. of events/No. in group
ASA Control/placebo RR (95% CI) RR (95% CI)
JPADPOPADADWHSPPPETDRSPHSTotal
28/126290/63836/5145/519
241/185611/275
395/5064
14/127782/63824/51310/512
283/185526/258
439/5053
0.87 (0.40-1.87)1.10 (0.83-1.45)1.48 (0.88-2.49)0.49 (0.17-1.43)0.82 (0.69-0.98)0.40 (0.20-0.79)0.86 (0.61-1.21)
Myocardial infarction
JPADPOPADADWHSPPPETDRSTotal
12/126237/63815/5149/519
92/1856181/4789
32/127750/63831/51310/51278/1855
201/4795
0.89 (0.54-1.46)0.74 (0.49-1.12)0.46 (0.25-0.85)0.89 (0.36-2.17)1.17 (0.87-1.58)0.83 (0.60-1.14)
Stroke
JPADPOPADADPPPETDRSTotal
1/126243/63810/519
244/1856298/4275
10/127735/6388/512
275/1855328/4282
0.10 (0.01-0.79)1.23 (0.80-1.89)1.23 (0.49-3.10)0.87 (0.73-1.04)0.94 (0.72-1.23)
Death from CV causes
JPADPOPADADPPPETDRSTotal
34/126294/63825/519
340/1856493/4275
38/1277101/63820/512
366/1855525/4282
0.90 (0.57-1.14)0.93 (0.72-1.21)1.23 (0.69-2.19)0.91 (0.78-1.06)0.93 (0.82-1.05)
All-cause mortality
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Summary of Pharmacotherapy for Hypertension in Patients with Diabetes
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
With Nephropathy, CVD or CV risk factors
ACE Inhibitor or ARB
Diabetes
Withoutthe above
1. ACE Inhibitor or ARB or
2. Thiazide diureticor DHP-CCB
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria
More than 3 drugs may be needed to reach target values
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired
Combination of 2 first line drugs may be considered
as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above
target
> 2-drug combinations
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Vascular Protection Checklist
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
A – ACEi or ARB │ S – Statin │ A – ASA if indicated
E • Exercise – regular physical activity, healthy diet,
achieve and maintain healthy body weight
S • Smoking cessation
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
What if we did all the right things?
How much could we protect our patients?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Gaede et al. NEJM. 2003: 348;383-393
STENO-2: Intensive Group Achieved Targets
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Intensive Group had Improved CV Outcomes
12 24 36 48 60 72 84 960
10
20
30
40
50
60P = 0.007
Conventional therapy
Intensive therapy
Months of Follow-upRRR= relative risk reduction
53 % RRRAny CV event
NNT = 5
Gaede et al. NEJM. 2003: 348;383-393
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
STENO 2 Extended Follow-up: Effect of a multi- factorial vascular protective strategy on total mortality
60
50
40
30
20
10Tota
l mor
talit
y (%
)
3
Years of follow-up
0 1 2 4 5 6 7 8 9 10 11 12 13
Conventional therapy
Intensive therapy
END OF TRIAL
HR = 0.54 (0.32-0.88)p = 0.015HR = 0.54 (0.32-0.88)p = 0.015
Gaede et al. N Engl J Med. 2008; 358(6):580-91.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Gaede et al. NEJM. 2003: 348;383-393
STENO 2 – Microvascular Disease
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What about Microvascular Disease?
• Nephropathy• Retinopathy• Neuropathy
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
Counsel all Patients About
Sick Day Medication
List
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Retinopathy Checklist
SCREEN regularly
DELAY onset and progression with glycemic and blood pressure control ± fibrate
TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Delaying Retinopathy
1. Glycemic control: target A1C ≤7%
2. Blood pressure control: target BP <130/80
3. Lipid-lowering therapy: fibrates have been
shown to decrease progression and may be
considered 2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Neuropathy Checklist
PREVENT with blood glucose control
SCREEN with monofilament or tuning fork
TREAT pain symptoms with anticonvulsants or antidepressants
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
4. The following agents may be used alone or in
combination for relief of painful peripheral
neuropathy:
– Anticonvulsants (pregabalin [Grade A, Level 1],
gabapentin‡, valproate‡) [Grade B, Level 2]
– Antidepressants (amitriptyline‡, duloxetine,
venlafaxine‡) [Grade B, Level 2]
– Opioid analgesics (tapentadol ER, oxycodone
ER, tramadol) [Grade B, Level 2]
– Topical nitrate spray [Grade B, Level 2]
‡This drug is not currently approved by Health Canada for the management of neuropathic pain associated with diabetic peripheral neuropathy.
2013Recommendation 4
Why diagnose and treat GDM?
• Macrosomia• Shoulder dystocia
and nerve injury• Neonatal
hypoglycemia• Preterm delivery• Hyperbilirubinemia
• Caesarian section• Offspring obesity (?)• Offspring diabetes (?)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
2013 GDM diagnosis: Two approaches 2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
8. Women with pregestational diabetes may use
aspart or lispro in pregnancy instead of regular
insulin to improve glycemic control and reduce
hypoglycemia [Grade C level 2 for aspart , Grade C, Level 3 for lispro].
9. Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may
be used in women with pregestational diabetes as
an alternative to NPH.
Recommendation 8-9: Management in Pregnancy for pre-gestational diabetes
2013
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
What about insulin analogues and oral agents among patients with GDM?
• May use rapid-acting analog insulin for
postprandial glucose control – no difference
in perinatal outcomes
• May use glyburide or metformin for women
who are non-adherent to or who refuse
insulin– Likely safe BUT it is OFF- Label no long-term
data, need discussion with patient
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 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)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
www.diabetes.ca – for patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca