Transcript 2013 - Canadian Diabetes Guidelines

Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Essentials
(Updated November 2016)
2016
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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 and, updates
2. Understand the rationale behind these changes
3. Apply the recommendations in clinical practice
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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
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Victor
59 years old
Type 2 Diabetes
ACS 2001
Bypass 2001
PAD 2002
CKD 2002
MI 2003
Neuropathy 2003
Retinopathy 2004
MI 2004
Ischemic Toes Amputation 2004
TIA 2005
Stroke 2006
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Victor
59 years old
Type 2 Diabetes
Reorganize his history
He has EVERY complication of Diabetes
That is what we need to avoid
Macrovascular
Microvascular
TIA 2005
Stroke 2006
Retinopathy 2004
ACS 2001
Bypass 2001
MI 2003
MI 2004
CKD 2002
Neuropathy 2003
PAD 2002
Ischemic Toes Amputation 2004
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www.guidelines.diabetes.ca
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What is new in making the
diagnosis of diabetes?
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Diagnosis of Diabetes
2013
FPG ≥7.0 mmol/L
Fasting = 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 diabetes
or
2hPG in a 75-g OGTT ≥11.1 mmol/L
or
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
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Diagnosis of Prediabetes*
2013
Test
Result
Prediabetes Category
Fasting Plasma
Glucose
(mmol/L)
6.1 - 6.9
Impaired fasting glucose
(IFG)
7.8 – 11.0
Impaired glucose tolerance
(IGT)
6.0 - 6.4
Prediabetes
2-hr Plasma Glucose in
a 75-g Oral Glucose
Tolerance Test (mmol/L)
Glycated
Hemoglobin
(A1C) (%)
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM
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Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia
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Self-Monitoring of
Blood Glucose (SMBG)
What should
we tell patients to do?
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Regular SMBG is Required for:
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Increased frequency of SMBG may be required:
Daily SMBG is not usually required if patient:
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Medications for glycemia
How do we choose?
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Pharmacotherapy in T2DM checklist
2013

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
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AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
Symptomatic hyperglycemia with
metabolic decompensation
A1C 8.5%
A1C <8.5%
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
Add another agent best suited to the individual by prioritizing patient characteristics:
PATIENT CHARACTERISTIC
CHOICE OF AGENT
Antihyperglycemic agent with
demonstrated CV outcome benefit
(empagliflozin, liraglutide)
PRIORITY:
Clinical Cardiovascular Disease
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Cardiovascular disease or multiple risk factors
Comorbidities (renal, CHF, hepatic)
Preferences & access to treatment
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See next
Consider relative A1C lowering
Rare hypoglycemia
Weight loss or weight neutral
Effect on cardiovascular outcome
See therapeutic considerations, consider eGFR
See cost column; consider access
page…
11/2016
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
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MakeDiabetes
timelyAssociation
adjustments to attain
Copyright © 2016 Canadian
target A1C within 3-6 months
Add another class of agent best suited to the individual (agents listed in alphabetical order):
Class
Relative
A1C
Lowering
Hypoglycemi
a
Weight
-glucosidase
inhibitor (acarbose)

Rare
Neutral to


Rare
Neutral to

GLP-1R agonists
 to 
Rare

lira: Superiority
in T2DM patients
with clinical CVD
lixi: Neutral
Insulin

Yes

Neutral (glar)
DPP-4 Inhibitors
Effect in
Cardiovascular
Outcome Trial
alo, saxa, sita:
Neutral
Insulin secretagogue:
Meglitinide

Yes

Sulfonylurea

Yes

SGLT2 inhibitors
 to 
Rare

empa:
Superiority in
T2DM patients
with clinical CVD
Thiazolidinediones

Rare

Neutral
Weight loss agent
(orlistat)

None

Other therapeutic considerations
Cost
Improved postprandial control, GI side-effects
$$
Caution with saxagliptin in heart failure
$$$
GI side-effects
$$$$
No dose ceiling, flexible regimens
$-$$$$
Less hypoglycemia in context of missed meals
but usually requires TID to QID dosing
Gliclazide and glimepiride associated with less
hypoglycemia than glyburide
$$
$
Genital infections, UTI, hypotension, doserelated changes in LDL-C, caution with renal
dysfunction and loop diuretics, dapagliflozin not
to be used if bladder cancer, rare diabetic
ketoacidosis (may occur with no hyperglycemia)
$$$
CHF, edema, fractures, rare bladder cancer
(pioglitazone), cardiovascular controversy
(rosiglitazone), 6-12 weeks required for
maximal effect
$$
GI side effects
$$$
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glar=glargine;
saxa=saxagliptin; sita=sitagliptin; lira=liraglutide; lixi=lixisenatide; empa=empagliflozin
Copyright © alo=alogliptin;
2016 Canadian
Diabetes Association
11/2016
Antihyperglycemic agents and Renal Function
CKD Stage:
5
eGFR (mL/min/1.73 m2):
<15
Alphaglucosidase
Inhibitor
4
3
2
1
15–29
30–59
60–89
≥ 90
Acarbose Not recommended
Biguanide
25
30
30
Metformin
Alogliptin Not recommended
6.25 mg
DPP-4
inhibitors
Linagliptin
Saxagliptin
Sitagliptin
15
15
60
12.5 mg
50
50 mg
50
50
2.5 mg
30
25 mg
Albiglutide
GLP-1R
agonists
50
50
Dulaglutide
Exenatide (BID/QW)
Liraglutide
Insulin
Secretagogues
Gliclazide/Glimepiride
15
Glyburide
30
30
50
50
30
30
50
Repaglinide
25
Canagliflozin
SGLT2
inhibitors
45
Dapagliflozin
45
Empagliflozin
60*
60
60*
30
Thiazolidinediones
Not recommended
Contraindicated
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* =guidelines.diabetes.ca
do not initiate if eGFR <60
ml/min
Copyright
© 2016
Canadian
Diabetes
Adapted
from: Product
Monographs
as of March
2016
Harper W et al. Can J Diabetes 2015;39:440.
100 mg
Association
Caution and/or reduce dose
Safe
No dose adjustment but close monitoring of renal function
11/2016
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What are the
options for Insulin?
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2016
Types of Insulin
Insulin Type (trade name)
Onset
Peak
Duration
10 - 15 min
10 - 15 min
10 - 15 min
10 - 15 min
1 - 1.5 h
1 - 1.5 h
1-2h
1-2h
3-5h
3-5h
3.5 - 4.75 h
3.5 - 4.75 h
30 min
2-3h
6.5 h
1-3h
5-8h
Up to 18 h
Not
applicable
Up to 24 h (detemir 16-24 h)
Up to 24 h (glargine 24 h)
Up to 30 h
Up to 24 h (glargine 24 h)
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):
• Insulin aspart (NovoRapid®)
• Insulin glulisine (Apidra™)
• Insulin lispro (Humalog®)
• Insulin lispro U200 (Humalog® 200 units/mL)
Short-acting insulins (clear):
• Insulin regular (Humulin®-R)
• Insulin regular (Novolin®geToronto)
Basal Insulins
Intermediate-acting insulins (cloudy):
• Insulin NPH (Humulin®-N)
• Insulin NPH (Novolin®ge NPH)
Long-acting basal insulin analogues (clear)
• Insulin detemir (Levemir®)
• Insulin glargine (Lantus®)
• Insulin glargine U300 (Toujeo®)
TM)
•guidelines.diabetes.ca
Insulin glargine (Basaglar
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90 min
90 min
Up to 6 h
90 min
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Types of Insulin (continued)
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)
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®)
A single vial or cartridge contains a
fixed ratio of insulin
(% of rapid-acting or short-acting
insulin to % of intermediate-acting
insulin)
Serum Insulin Level
Time
Human Basal
Analogue Basal
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Human Bolus
Analogue Bolus
Serum Insulin Level
Time
Human Premixed
Analogue Premixed
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What about Hypoglycemia?
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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
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Macrovascular Disease
Vascular Protection:
Who and When?
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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
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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.
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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.
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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), telmisartan 80 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
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EUROPA Investigators, Lancet 2003;362(9386):782-788.
HOPE study investigators. Lancet. 2000;355:253-59.
ONTARGET study investigators. NEJM. 2008:358:1547-59
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]
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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
Without
the above
1. ACE Inhibitor
or ARB or
2. Thiazide diuretic
or DHP-CCB
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
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
diuretic if control of volume is desired
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loop ©diuretic
should
be substituted
for a thiazide
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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 (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
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What if we did all the right
things?
How much could we protect
our patients?
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STENO-2: Intensive Group Achieved Targets
Gaede et al. NEJM. 2003: 348;383-393
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Intensive Group had Improved CV Outcomes
60
50
Any CV
event
P = 0.007
53 % RRR
Conventional therapy
40
Intensive therapy
30
NNT = 5
20
10
0
12
24 36
48 60
72
Months of Follow-up
RRR= relative risk reduction
Gaede et al. NEJM. 2003: 348;383-393
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84
96
STENO 2 – Microvascular Disease
Gaede et al. NEJM. 2003: 348;383-393
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What about Microvascular Disease?
• Nephropathy
• Retinopathy
• Neuropathy
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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
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Counsel all
Patients
About
Sick Day
Medication
List
2015
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Retinopathy Checklist
2013
 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
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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
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Neuropathy Checklist
2013

PREVENT with blood glucose control

SCREEN with monofilament or tuning fork

TREAT pain symptoms with anticonvulsants
or antidepressants
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Recommendation 4
2013
4. The following agents may be used alone or in
combination for relief of painful peripheral
neuropathy:
‡This
–
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]
drug is not currently approved by Health Canada for the management of neuropathic pain associated with
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diabetic
peripheral neuropathy.
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Foot Care:
What are the
DO’s and DON’Ts
of foot care?
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Educate patients on proper foot care – The “DO’s”
DO …
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual
markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet – seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. Wipe off excess.
Change your socks every day
Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
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See a foot care specialist if you need advice or treatment
Educate patients on proper foot care – The “DON’Ts”
DO NOT …
Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak your feet
Take very hot baths
Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
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Smoke
Special populations …
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Diabetes in the Elderly Checklist
2013
 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
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•
•
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May use detemir or glargine instead of NPH or
human 30/70 for less hypos
Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing errors
•
•
•
•
CAUTION in the elderly
Initial doses = HALF of usual dose
Avoid glyburide
Use gliclazide, gliclazide MR, glimepiride,
nateglinide or repaglinide instead
•
CAUTION with renal dysfunction
•
•
•
CAUTION in the elderly
Increased risk of fractures
Increased risk of heart failure
2016
2013
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
2013 CDA diagnostic criteria for GDM
PREFERRED APPROACH (2 steps)
1. 50 gram glucose challenge test
2. 75 gram oral glucose tolerance test
– Using thresholds of OR 2.0
ALTERNATIVE APPROACH (1 step)
1. 75 gram oral glucose tolerance test
– Using thresholds of OR 1.75
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
2013
2013 GDM diagnosis: Two approaches
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
2013
How can we keep track of all
the parameters for our
patients with Diabetes?
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
Tools to help us
keep track of our
patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
Tools to help us
keep track of our
patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
Back Page:
“Cheat Sheet” of
Targets and Goals
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 Canadian Diabetes Association
Back Page:
“Cheat Sheet” of
Targets and Goals
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2016 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.ca
Copyright © 2016 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
Copyright © 2016 Canadian Diabetes Association