2018 Clinical Practice Guidelines For The Prevention and Management of Diabetes in Canada

2018 Clinical Practice Guidelines for
the Prevention and Management of

Diabetes in Canada
Dr. Robyn Houlden
Professor and Chair, Division of Endocrinology
Queen’s University
Faculty/Presenter Disclosure
• Faculty: Dr. Robyn Houlden
• Relationships with commercial interests:
Clinical Trials (last 2 years): Astra Zeneca, Boehringer

Ingelheim, Eli Lilly, Novo Nordisk
Disclosure of Commercial
Support
• Potential for conflict(s) of interest:
• None
Mitigating Potential Bias
• The evidence presented and referenced in the program
materials was selected for inclusion in the program based
on consensus of the planning committee
• Data are published and recommendations are from
evidence-based guidelines – the Diabetes Canada
Clinical Practice Guidelines
• I will not make any off-label recommendations and will
identify when comments are from my own personal
opinion
Learning Objectives
• By the end of this session, participants will be
able to:
• Understand the major changes within the 2018
Diabetes Canada clinical practice guidelines
• Understand the rationale behind these changes
• Apply the recommendations in clinical practice
Chair: Dr.
Meng-Hee
Tan, Professor,
Department of
Medicine,
Dalhousie
• 16 pages published in
CMAJ
• Expert committee of 25
key stakeholders
• No grading of
recommendations
Co-Chair: Dr. Sara Co-Chair: Dr.
Meltzer, Associate Lawrence Leiter,
Professor, Professor, Department
Department of of Medicine,
Medicine, McGill University of Toronto
• 29 pages published as
supplement to CMAJ
key stakeholders
• 93 recommendations with
grading
Chair: Dr. Stewart Chair, Methods: Dr.
Harris, Professor Hertzel Gerstein,
Department of Family Professor Department
Medicine, Schulich of Medicine, McMaster
School of Medicine, University
UWO

Supplement to Canadian
Journal of Diabetes
key stakeholders
• 154 graded
recommendations +
practical paper tools
Chair: Dr. Vincent Chair, Methods: Dr. Chair, Dissemination
Woo, Division of Gillian Booth, Committee: Dr. Ian
Endocrinology, Associate Professor, Blumer, Lecturer,
University of Department of Department of
Manitoba Medicine, U. of T. Medicine, U. of T.

supplement to CJD
key stakeholders
grading + practical tools
• Dissemination Committee
Dr. Alice Cheng, Chair, Methods: Chair, Dissemination
Associate Professor, Dr. Gillian Booth, Committee: Dr.
Department of Associate Catherine Yu,
Medicine, U.of T. Professor, Assistant Professor,
Department of Department of
Medicine, U. of T. Medicine, U. of T.

supplement to CJD
key stakeholders
grading + practical tools +
website
• Dissemination&
Implementation Committee
Chair: Dr. Robyn Co-Chair, Methods: Co-Chair, Methods:
Houlden, Professor, Dr. Diana Sherifali, Dr. Doreen Rabi,
Department of Assistant Professor, Associate
Medicine, Queen’s School of Nursing Professor,
University Department of
Medicine,
University of
Calgary
Co-Chair,
Dissemination
Committee: Dr.
Catherine Yu,
Associate Professor,
Department of
Medicine, U. of T.
Co-Chair,
Dissemination
Committee: Dr. Noah
Ivers, Assistant
Professor,
Department of Family
• 325 pages Medicine, U. of T.
• Expert committee of 135 key

stakeholders
2018
2018
• 317 recommendations with grading +
practical tools + website
• The 2018 guidelines were released on April 9,
2018 and are housed on the Diabetes Canada
website at http://guidelines.diabetes.ca
• In addition to the full guidelines, various tools

and resources are present on the website and
are updated regularly
• Only medications with Health Canada Notice of

Compliance granted by September 15, 2017
were included
2018
Key Changes
• Expansion of the Expert Committee to include 135
healthcare professional volunteers
• Broader representation from more allied
health/interprofessional stakeholder groups
• Expertise from diverse practice settings across the
country
• Professionals from family medicine, endocrinology, internal
medicine, cardiology, neurology, nephrology, infectious
disease, urology, psychiatry, psychology, obstetrics,
ophthalmology, pediatrics, nursing, dietetics, pharmacy,
chiropractics, exercise physiology and others
2018
Key Changes
• Inclusion and active participation of informed
people with diabetes on the Expert Committee
• Key messages using lay terms directed at people
living with diabetes
Diabetes and Driving
2018
Key Changes
• Increased recognition of ethnocultural diversity in Canada
and its relationship with diabetes care
• Increased involvement of Indigenous authors and
organizations, and health-care providers working with
Indigenous populations and communities in the
development of recommendations related to type 2 diabetes
and Indigenous peoples
• Acknowledgement of the legacy of colonization and
residential schools and their ongoing effects on
Indigenous health, as well as the calls to action of the 2015
Truth and Reconciliation Commission
2018
Key Changes
• Addition of new material on diabetes and driving,
and post-transplant diabetes
• Introduction contains information related to
• Diabetes and Oral Health
• see a dental professional regularly
• enquire at least annually for symptoms of gum disease
• daily dental care is part of diabetes self-management
• Diabetes and Cancer Screening
• Appropriate screening recommended for age group and sex
2018
Key Changes
• Wider external review by specialists, community
primary care providers, all academic Departments of
Family Medicine across Canada, and specialty and
disease support organizations
• Additional efforts to manage and minimize conflict of
interest among all expert and steering committee
members
• Expanded harmonization of recommendations
through collaboration with other organizations,
including the Cardiovascular Society (CCS),
Hypertension Canada, and the Canadian
Cardiovascular Harmonization of National Guidelines
Endeavour (C-CHANGE)
2018
Key Changes
• More rigorous systematic review of literature with
the McMaster Evidence Review and Synthesis
Centre
2018 Diabetes Canada CPG – Chapter 2. Methods
2018
Literature Review Flow Diagram

2018
Key Changes
• Expanded dissemination and implementation
strategies to support all recommendations with
increased use of web-based technology
Visit guidelines.diabetes.ca
Or download the App
Key Message
• Throughout the guidelines remains the importance
of individualizing therapy for the person with
diabetes
Screening for and
Diagnosing Diabetes
Screening for Type 2 Diabetes in Adults
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults
2018
Screening for type 2 diabetes in
adults
Screen every 3 years in individuals ≥40 years of age or in individuals at high
risk using a risk calculator.
Screen earlier and/or more frequently (every 6 to 12 months) in people with
additional risk factors for diabetes or for those at very high risk using a risk
calculator
FPG <5.6 mmol/L FPG 5.6-6.0 mmol/L FPG 6.1-6.9 mmol/L FPG ≥7.0 mmol/L
and/or A1C <5.5% and/or A1C 5.5-5.9%* and/or A1C 6.0-6.4%** and/or A1C ≥6.5%
Normal
At Risk Prediabetes Diabetes
Rescreen as
Rescreen more often Rescreen more often
recommended
If both FPG and A1C are available, but discordant, use the test that appears furthest to the
right side of the algorithm.
*Consider 75-g OGTT if >1 risk factors; ** Consider 75-g OGTT

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome
Diagnosis of Diabetes
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
FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose
Confirmatory test required

• In the absence of symptoms of hyperglycemia, if a
single lab test result is in the diabetes range, a repeat
confirmatory lab test (FPG, A1C, 2hPG in a 75 g OGTT)
must be done on another day
• Repeat the same test (in a timely fashion) to confirm
• But a random PG in the diabetes range in an
asymptomatic individual should be confirmed with an
alternate test
• If results of two different tests are available and both
are above the diagnostic thresholds, the diagnosis of
diabetes is confirmed
2hPG, 2-hour plasma glucose; AlC, glycated hemoglobin; FPG, fasting plasma glucose;
OGTT, oral glucose tolerance test; PG, plasma glucose.
Diagnosis of prediabetes
Tests Result Prediabetes
category
FPG (mmol/L) 6.1-6.9 IFG
2h PG in a 75g 7.8-11.0 IGT

OGTT (mmol/L)
A1C (%) 6.0-6.4 Prediabetes
2hPG, 2-hour plasma glucose; AlC, glycated hemoglobin; FPG, fasting plasma glucose; IFG, impaired fasting
glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test.
2018 Diabetes Canada CPG – The Essentials
Approach to Management
2018
ABCDES3 of Diabetes Care

A • A1C – optimal glycemic control (usually ≤7%)
B • BP – optimal blood pressure control (<130/80)
C • Cholesterol – LDL <2.0 mmol/L or >50% reduction
D • Drugs to protect the heart
A – ACEi or ARB │ S – Statin │ A – ASA if indicated │SGLT2i/GLP-1 RA
with demonstrated CV benefit if type 2 DM with CVD and A1C not at target
E • Exercise / Healthy Eating

S • Screening for complications
S • Smoking cessation
S • Self-management, stress and other barriers
2018


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

Copyright © 2013 Canadian Diabetes Association
2018 Diabetes Canada CPG – Chapter 8. Targets for Glycemic Control
A1C Targets 2018
Adults with type 2 diabetes to reduce the risk of CKD

≤6.5 and retinopathy if at low risk of hypoglycemia*
≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2

DIABETES
7.1 7.1-8.0%: Functionally dependent*
7.1-8.5%:
• Recurrent severe hypoglycemia and/or hypoglycemia
unawareness
• Limited life expectancy
8.5 • Frail elderly and/or with dementia**
Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute and
chronic complications
A1C measurement not recommended. Avoid symptomatic
End of life hyperglycemia and any hypoglycemia
* Based on class of antihyperglycemic medication(s) utilized and person’s characteristics

** see Diabetes in Older People chapter
< 6.5%
ADVANCE
N = 11,140 T2DM
Intensive (A1C ≤6.5% with gliclazide MR)
vs.
Standard glycemic control
ADVANCE: Glucose Control

10.0
9.0
Standard control
8.0 7.3%
Mean
A1C (%) 7.0 p < 0.001
6.0 Intensive control

5.0
6.5%
0.0
0 6 12 18 24 30 36 42 48 54 60 66
Follow-up (months)
ADVANCE Collaborative Group. N Engl J Med 2008;358:24.

ADVANCE: Treatment Effect on the

Primary Microvascular Outcomes
25 • New/worsening nephropathy, retinopathy
20
HR 0.86 (0.77-0.97)
15 p = 0.01 Standard
Cumulative control
incidence (%) 10
5 Intensive
control
0
0 6 12 18 24 30 36 42 48 54 60 66
Follow-up (months)
Intensive Standard HR p
Nephropathy/retinopathy (%) 9.4 10.9 0.86 0.01

Nephropathy (%) 4.1 5.2 0.79 0.006
Retinopathy (%) 6.0 6.3 0.95 NS
ADVANCE Collaborative Group. N Engl J Med 2008;358:24.

The ACCORD Trial:
Mean A1C Levels at Each Study Visit
Within 4 months after randomization, A1C decreased to 6.7% in the
intensive-therapy group and to 7.5% in the standard-therapy group
9.0
8.5 Standard therapy
8.0
A1C (%)
7.5
Mean age:
62 yrs 7.0
Mean DM 6.5
duration: 10
years 6.0
Intensive therapy
0
0 1 2 3 4 5 6
Years
No. at Risk
Standard 5109 4774 4588 3186 1744 455 436
therapy
Intensive 5119 4768 4585 3165 1706 476 471
therapy
Mean duration of follow-up = mean, 3.5; median, 3.4 yrs
The ACCORD Study Group. N Engl J Med. 2008;358(24):2545-2559.
The ACCORD Trial: Primary
Outcome
No significant difference in primary outcome
P=0.16
8
7
7.2
6.9
6
Patients (%)
5
4
3
2
1
0
Intensive Therapy Standard Therapy
Primary outcome was the first occurrence of nonfatal myocardial infarction or nonfatal stroke or death from
cardiovascular causes.
The ACCORD Trial: Kaplan-Meier
Curves for Death From Any Cause
Rates of death in the 2 groups began to separate after 1 year and
the differences persisted throughout the follow-up period
25
Patients With Events (%)
20
15
10 Intensive therapy
5 Standard therapy
0
0 1 2 3 4 5 6
Years
No. at Risk
Intensive 5128 4972 4803 3250 1748 523 506
therapy
Standard 5123 4971 4700 3180 1642 499 480
therapy
The ACCORDION Trial: Kaplan-
Meier Curves for Primary
Outcome and Mortality
8601 people from ACCORD trial, monitored for additional 8.8

years. Neutral effect on outcomes.
Diabetes Care 2016;39:701
HYPO-
BENEFIT GLYCEMIA
7.1 – 8.5%
Moorhouse P, Rockwood K. J R Coll Physicians Edinb 2012;42:333-340.
A1C Targets 2018
Adults with type 2 diabetes to reduce the risk of CKD

≤6.5 and retinopathy if at low risk of hypoglycemia*
≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2

DIABETES
7.1 7.1-8.0%: Functionally dependent*
7.1-8.5%:
• Recurrent severe hypoglycemia and/or hypoglycemia
unawareness
• Limited life expectancy
8.5 • Frail elderly and/or with dementia**
Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute and
chronic complications
A1C measurement not recommended. Avoid symptomatic
End of life hyperglycemia and any hypoglycemia
* Based on class of antihyperglycemic medication(s) utilized and person’s characteristics

** see Diabetes in Older People chapter
2018 Diabetes Canada CPG – Chapter 9. Monitoring Glycemic Control
Glycated Hemoglobin: A1C

• Reliable measure of mean plasma glucose over
the past 8 to 12 weeks
• Mean BG level in
• last 30 days contributes 50%
• prior 90 to 120 days contributes 10%
• Valuable indicator of treatment effectiveness

Glycated Hemoglobin: A1C

• Measure
• Every 3 months to ensure glycemic goals are met
or maintained
• More frequently when significant changes are

made to therapy, or during pregnancy
• Every 6 months during periods of glycemic

stability
Factors that can affect A1C

Factors Increased A1C Decreased A1C Variable Change in
affecting A1C A1C
Erythropoiesis B12/Fe deficiency Use of EPO, Fe, or B12
Decreased Reticulocytosis
erythropoiesis Chronic liver disease
Altered Fetal hemoglobin
hemoglobin Hemoglobinopathies
Methemoglobin
Altered glycation Chronic renal failure ASA, vitamin C/E
↓↓erythrocyte pH Hemoglobinopathies
↑ erythrocyte pH
Erythrocyte Splenectomy Hemoglobinopathies
destruction Chronic renal failure
Splenomegaly
Rheumatoid arthritis
HAART meds, Ribavirin
Dapsone
Assays Hyperbilirubinemia Hypertriglyceridemia

Carbamylated Hb
ETOH
Chronic opiates
To achieve A1C ≤7.0%

A1C (%) Preprandial 2 hour
PG (mmol/L) Postprandial
PG (mmol/L)
For most patients ≤7.0 4.0-7.0 5.0-10.0
If A1C ≤7.0% not 4.0-5.5 5.0-8.0

achieved despite
the above PG
targets
PG, plasma glucose


PG (mmol/L)
If A1C ≤7.0% not 4.0-5.5 5.0-8.0

achieved despite
the above PG
targets
Monnier L, et al. Diabetes Care 2007;30:263
PG, plasma glucose


PG (mmol/L)
If A1C ≤7.0% not 4.0-5.5 5.0-8.0

achieved despite
the above PG
targets
Woerle HJ, et al. Diabetes Res Clin Pract 2007;77:280
PG, plasma glucose

2018
Recommendation 5
5. In order to achieve an A1C ≤7.0%, people with diabetes should
aim for:
• Fasting plasma glucose (FPG) or preprandial PG target of
4.0–7.0 mmol/L and a 2h PPG target of 5.0–10.0 mmol/L
[Grade B, Level 2 for type 1; Grade B, Level 2 for type 2 diabetes]
• If an A1C target ≤7.0% cannot be achieved with a FPG
target of 4.0-7.0 mmol/L and PPG target of 5.0–10.0 mmol/L,
further FPG lowering to 4.0 to 5.5 mmol/L and/or PPG
lowering to 5.0–8.0 mmol/L may be considered, but must be
balanced against the risk of hypoglycemia [Grade D, Level 4 for
FPG target for type 2 diabetes; Grade D, Consensus for FPG target for type
1 diabetes; Grade D, Level 4 for PPG target for type 2 diabetes; Grade D,
Consensus for PPG target for type 1 diabetes]
PPG, post-prandial plasma glucose

Monitoring with Meaning …

• SMBG accompanied by structured educational
program to facilitate behaviour change results in
improved outcomes
Teach patients
1. How and when to perform SMBG
2. How to record the results
3. Meaning of various BG levels
4. How behaviour and actions affect SMBG results
Parkin CG et al. J Diabetes Sci Technol. 2009;3:500-508.

Polonsky WH, et al. Diabetes Care. 2011;34:262-267.
BG, blood glucose; SMBG, self-monitoring of blood glucose
Individualize Frequency of
SMBG
• Diabetes Canada SMBG tool - provides
guidance on appropriate situations for SMBG
utilization
http://guidelines.diabetes.ca
SMBG, self-monitoring of blood glucose

Continuous Glucose
Monitoring (CGM) Systems
• Measure glucose concentration in interstitial fluid
• 2 types:
• Real time or personal: continuously displays BG levels
• Blinded or professional: captures BG levels that can be
downloaded later
• Real-time CGM has been shown to
• reduce A1C
• in adults and children with type 1 diabetes with and without CSII
• in adults with type 2 diabetes
• reduce time spent in hypoglycemia
• Successful use of CGM is dependent on adherence
with duration of time used
BG, blood glucose; CSII, continuous subcutaneous insulin infusion

2018
Recommendation 5
5. In people with type 1 diabetes who have not
achieved their glycemic target, real-time CGM may
be offered to improve glycemic control [Grade A, Level 1A
for non CSII users; Grade B, Level 2 for CSII users] and reduce
duration of hypoglycemia [Grade A, Level 1A] in individuals
who are willing and able to use these devices on a
nearly daily basis
CGM, continuous glucose monitoring; CSII, continuous subcutanenous insulin infusion

Flash Glucose Monitoring
• Measures plasma glucose in interstitial fluid
• BG values displayed when sensor is flashed with a
reader device on demand
• Also displays plot profile of last 8 hours
• Sensor can be worn for 14 days
• Has been shown to
• Decrease time spent in hypoglycemia in type 1 and type
2 diabetes
2018
Recommendation 6
6. Flash glucose monitoring may be offered to people
with diabetes to decrease time spent in
hypoglycemia [Grade B, Level 2 for type 1 diabetes ; Grade
B, Level 2 for type 2 diabetes]
2018 AT DIAGNOSIS OF TYPE 2 DIABETES
Start healthy behaviour interventions
HEALTHY BEHAVIOUR INTERVENTIONS (nutritional therapy, weight management, physical activity) +/- metformin
Symptomatic hyperglycemia
A1C <1.5% above target A1C ≥1.5% above target
and/or metabolic decompensation
Start metformin immediately Initiate insulin +/-

If not at glycemic target
within 3 months, metformin
Consider a second concurrent
start/increase metformin
antihyperglycemic agent
If not at glycemic target If not at glycemic target
Clinical CVD?
YES NO
Start antihyperglycemic agent with

demonstrated CV benefit
empagliflozin (Grade A, Level 1A)
liraglutide (Grade A, Level 1A)
canagliflozin* (Grade C, Level 2)
If not at glycemic target See next page

* Avoid in people with prior lower extremity amputation
2018 Diabetes Canada CPG – Chapter 13. Pharmacologic Glycemic Management of Type 2 Diabetes
Empagliflozin reduced CV events

CV death, non-fatal MI, or non-fatal stroke
PBO EMP HR P NNT3
A
CV death, MI, stroke (%) 12.1 10.5 0.86 0.04 63
CV deaths (%) 5.9 3.7 0.62 <0.001 46
Nonfatal MI (%) 5.2 4.5 0.87 0.22
Nonfatal stroke (%) 2.6 3.2 1.24 0.16 Placebo

Hosp. heart failure (%) 4.1 2.7 0.65 0.002 72
Empagliflozin
Patients with event (%)
All-cause mortality (%) 8.3 5.7 0.68 <0.001 39
HR 0.86
95.02% CI (0.74, 0.99)
P < 0.001 for non-inferiority
p=0.04 for superiority
Months
No. of patients
Empagliflozin 4687 4580 4455 4328 3851 2821 2359 1534 370
Placebo 2333 2256 2194 2112 1875 1380 1161 741 166
Zinman B et al. N Engl J Med 2015; DOI: 10.1056/NEJMoa1504720

Liraglutide reduced CV events

PBO LIRA HR P NNT4
CV death, MI, stroke (%) 14.9 13.0 0.87 0.01 53

CV death (%) 6.0 4.7 0.78 0.007 77
Nonfatal MI (%) 6.8 6.0 0.88 0.11

Nonfatal stroke (%) 3.8 3.4 0.89 0.30
Patients with event (%)
Hosp. heart failure (%) 5.3 4.7 0.87 0.14

All-cause mortality (%) 9.6 8.2 0.85 0.02 72
Placebo
Liraglutide
HR 0.87
95.02% CI (0.78, 0.97)
Time from randomization (months)

Patients at risk
Liraglutide 4668 4593 4496 4400 4280 4172 4072 3982 1562 424
Placebo 4672 4588 4473 4352 4237 4123 4010 3914 1543 407
Marso SP et al. N Engl J Med 2016;375(4):311-22.

Canagliflozin reduced CV events

Outcome PBO CANA HR P or 95% CI NNT 5
(per 1000 pt-y)
CV death, MI, stroke 31.5 26.9 0.86 0.02 44
CV deaths 12.8 11.6 0.87 (0.72-1.06)
Nonfatal MI 11.6 9.7 0.85 (0.69-1.05)
Nonfatal stroke 8.4 7.1 0.90 (0.71-1.15) Placebo

Hosp. heart failure 8.7 5.5 0.67 (0.52-0.87) 63 Canagliflozin
All-cause mortality 19.5 17.3 0.87 (0.74-1.01)
HR 0.86
95% CI (0.75, 0.97)
No. of patients
Canagliflozin 5795 5566 4343 2555 2460 2363 1661
Placebo 4347 4153 2942 1240 1187 1120 789
Neal B et al. N Engl J Med 2017; DOI:10.1056/NEJMoa1611925

CANVAS PROGRAM
Adverse events
Placebo Canagliflozin
Event (n=4347) (n=5795)
P Value†
Event rate per 1000 patient-yr
Mycotic genital infection in women 17.5 68.8 0.001
Infection of male genitalia § 10.8 34.9 <0.001
Urinary tract infection 37.0 40.0 0.38
Osmotic diuresis 13.3 34.5 <0.001
Volume depletion 18.5 26.0 0.009
Acute kidney injury 4.1 3.0 0.33
Hyperkalemia 4.4 6.9 0.10
Amputation 3.4 6.3 <0.001
Fracture (adjudicated) ‡
All 11.9 15.5 0.02
Low-trauma 9.2 11.6 0.06
Diabetic
† P values ketoacidosis
were estimated from(adjudicated) 0.3 was the prespecified primary fracture
Cox regression models; ‡ Low-trauma fracture 0.6 outcome, and all fracture
0.14was a
secondary outcome; § Infection of male genitalia included balanitis, phimosis, and events leading to circumcision
Neal B., Perkovic V, Mahaffey KW et al, Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes, N Engl J Med Jun 12, 2017. doi:
10.1056/NEJMoa1611925
SUSTAIN-6: CV death, non-fatal MI or
stroke
(%) PBO SEMA HR P NNT2
CV death, MI, stroke 8.9 6.6 0.74 0.02 44
CV death 2.8 2.7 0.98 0.92
Nonfatal MI 3.9 2.9 0.74 0.12
Nonfatal stroke 2.7 1.6 0.61 0.04 91
Hosp. heart failure 3.3 3.6 1.11 0.57
All-cause mortality 3.6 3.8 1.05 0.79

Placebo, 8.9%
Semaglutide,
6.6%
HR, 0.74 (95% CI, 0.58; 0.95)

P<0.001 for non-inferiority
P=0.02 for superiority
109
Number of subjects at
risk
Semaglutide 1648 1619 1601 1584 1568 1543 1524 1513
Placebo 1649 1616 1586 11567 1534 1508 1479 1466
Figure 1A. Kaplan Meier plot for first event adjudication committee-confirmed CV death, non-fatal MI and non-fatal stroke using ‘in-trial’ data from subjects in the full
analysis set.
*Not prespecified. CI, confidence interval; CV, cardiovascular; HR, hazard ratio; MI, myocardial infarction. 71
Marso et al. NEJM, Published on September 16th, NEJM.org
2018 AT DIAGNOSIS OF TYPE 2 DIABETES
Start healthy behaviour interventions
HEALTHY BEHAVIOUR INTERVENTIONS (nutritional therapy, weight management, physical activity) +/- metformin
Symptomatic hyperglycemia
A1C <1.5% above target A1C ≥1.5% above target
and/or metabolic decompensation
Start metformin immediately Initiate insulin +/-

If not at glycemic target
within 3 months, metformin
Consider a second concurrent
start/increase metformin
antihyperglycemic agent
If not at glycemic target If not at glycemic target
Clinical CVD?
YES NO
Start antihyperglycemic agent with

demonstrated CV benefit
empagliflozin (Grade A, Level 1A)
liraglutide (Grade A, Level 1A)
canagliflozin* (Grade C, Level 2)
If not at glycemic target See next page

* Avoid in people with prior lower extremity amputation
2018 Clinical CVD?
NO
Add additional antihyperglycemic agent best suited to the individual based

on the following
CLINICAL CONSIDERATIONS CHOICE OF AGENT
Avoidance of hypoglycemia and/or DPP-4 inhibitor, GLP-1 receptor

weight gain with adequate glycemic agonist or SGLT2 inhibitor
efficacy
Other considerations:
Reduced eGFR and/or albuminuria see Renal Impairment Appendix
Clinical CVD or CV risk factors
Degree of hyperglycemia See Table Below
Other comorbidities (CHF, hepatic
disease)
Planning pregnancy
Cost/coverage
Patient preference
Add additional antihyperglycemic agent best suited to the individual by prioritizing patient characteristics (agents listed in alphabetical order by CV outcome data):
Class Effect on CVD Hypo- Weight Relative Other therapeutic considerations Cost
Outcomes glycemia A1C Lowering
when added to
metformin
GLP-1R agonists lira: Superiority Rare ↓↓ ↓↓ to ↓↓↓ GI side-effects, Gallstone disease $$$$
in T2DM with Contraindicated with personal / family history of medullary
clinical CVD thyroid cancer or MEN 2
exenatide LAR & Requires subcutaneous injection
lixi: Neutral
SGLT2 inhibitors Cana & empa: Rare ↓↓ ↓↓ to ↓↓↓ Genital infections, UTI, hypotension, dose-related changes in $$$
Superiority in LDL-C. Caution with renal dysfunction, loop diuretics, in the
T2DM patients elderly. Dapagliflozin not to be used if bladder cancer. Rare
with clinical CVD diabetic ketoacidosis (may occur with no hyperglycemia).
Increased risk of fractures and amputations with
canagliflozin. Reduced progression of nephropathy & CHF
hospitalizations with empagliflozin and canagliflozin in those
with clinical CVD
DPP-4 Inhibitors alo, saxa, sita: Rare Neutral ↓↓ Caution with saxagliptin in heart failure $$$
Neutral Rare joint pain
Insulin glar: Neutral Yes ↑↑ ↓↓↓↓ No dose ceiling, flexible regimens $-

degludec: Requires subcutaneous injection $$$$
noninferior to glar
Thiazolidinediones Neutral Rare ↑↑ ↓↓ CHF, edema, fractures, rare bladder cancer (pioglitazone), $$
cardiovascular controversy (rosiglitazone), 6-12 weeks for
maximal effect
α-glucosidase Rare Neutral ↓ GI side-effects common $$

inhibitor (acarbose) Requires 3 times daily dosing
Insulin secretagogue: More rapid BG-lowering response

Meglitinide Yes ↑ ↓↓ Reduced postprandial glycemia with meglitinides but usually $$
requires 3 to 4 times daily dosing.
Sulfonylurea Yes ↑ ↓↓ Gliclazide and glimepiride associated with less hypoglycemia $
than glyburide. Poor durability
Weight loss agent None ↓ ↓ GI side effects $$$

(orlistat) Requires 3 times daily dosing
when added to
metformin
lixi: Neutral
with clinical CVD

noninferior to glar
maximal effect



when added to
metformin
lixi: Neutral
with clinical CVD

noninferior to glar
maximal effect



Outcomes glycemia A1C lowering
when added to
metformin
lixi: Neutral
with clinical CVD

noninferior to glar
maximal effect



when added to
metformin
lixi: Neutral
with clinical CVD

noninferior to glar
maximal effect



when added to
metformin
lixi: Neutral
with clinical CVD

noninferior to glar
maximal effect



2018
If not at glycemic targets
Add another antihyperglycemic agent from a different class and/or add/intensify insulin regimen
Make timely adjustments to attain target A1C within 3-6 months
Antihyperglycemic Agents and Renal Function

CKD Stage 5 4 3b 3a 1 or 2
eGFR (mL/min/1.73 m2): <15 15–29 30–44 45-59 ≥ 60
Alpha-glucosidase
Inhibitors
Acarbose 30
Biguanides Metformin 30 500-1000 mg daily 45
Alogliptin 6.25 mg daily 30 12.5 mg daily 60
DPP-4
Linagliptin 15
Inhibitors Saxagliptin 15 2.5 mg daily 50
Sitagliptin 25 mg daily 30 50 mg daily 50
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
Receptor Exenatide QW
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Secretagogues Glyburide 60
Repaglinide 60
Canagliflozin* 25 45 100 mg daily 60
SGLT2 Dapagliflozin 60
Inhibitors
Empagliflozin 30 45
Pioglitazone 60
Thiazolidinediones
Rosiglitazone Fluid retention 60
Insulins 30
Use alternative agent Dose adjustment required Caution Do not initiate Dose adjustment not required
* May be used for cardiorenal benefits in those with clinical CVD, A1C above target and eGFR >30 mL/min/1.73m2

eGFR (mL/min/1.73 m2): <15 15–29 30–44 45-59 ≥ 60
Alpha-glucosidase
Inhibitors
Acarbose 30
DPP-4
Linagliptin 15
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Repaglinide 60
Inhibitors
Empagliflozin 30 45
Pioglitazone 60
Thiazolidinediones
Insulins 30

eGFR (mL/min/1.73 m2): <15 15–29 30–44 45-59 ≥ 60
Alpha-glucosidase
Inhibitors
Acarbose 30
DPP-4
Linagliptin 15
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Repaglinide 60
SGLT2
60
Inhibitors
Empagliflozin 30 45
Pioglitazone 60
Thiazolidinediones
Insulins 30

eGFR (mL/min/1.73 m2): <15 15–29 30–44 45-59 ≥ 60
Alpha-glucosidase
Inhibitors
Acarbose 30
DPP-4
Linagliptin 15
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Repaglinide 60
25 100 mg daily 60
SGLT2
60
Inhibitors
Empagliflozin 30 45
Pioglitazone 60
Thiazolidinediones
Insulins 30

eGFR (mL/min/1.73 m2): <15 15–29 30–44 45-59 ≥ 60
Alpha-glucosidase
Inhibitors
Acarbose 30
DPP-4
Linagliptin 15
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Repaglinide 60
Canagliflozin 25 45 100 mg daily 60*
30
Inhibitors
Empagliflozin 60
Pioglitazone 60
Thiazolidinediones
Insulins 30
*May be considered when indicated for CV and renal protection with eGFR< 60 but >30 ml/min/1.732
Antihyperglycemic Agents and Renal

3a
eGFR <15 Function
15–29 30–44
CKD Stage
45-59
(mL/min/1.73 ≥ 60
m2):
5 4 3b 1 or 2
Alpha-glucosidase
Inhibitors
Acarbose 30
DPP-4
Linagliptin 15
Sitagliptin 25 mg daily 25 mg daily 30 50 mg daily 50
Dulaglutide 15
Exenatide 30 50
30 50
GLP-1
15
Agonists
Liraglutide
Lixisenatide 30
Gliclazide 30 60
Insulin
Glimepiride 30 60
Repaglinide 60
Canagliflozin 25 45 100 mg daily 60*
30
Inhibitors
Empagliflozin 60
Pioglitazone 60
Thiazolidinediones
Insulins 30
*May be considered when indicated for CV and renal protection with eGFR< 60 but >30 ml/min/1.732
Types of insulin
Insulin type (trade name) Onset Peak Duration
BOLUS (prandial or mealtime) insulins
Rapid-acting insulin analogues (clear)
● Insulin aspart (NovoRapid®) 9–20min 1–1.5h 3–5h
● Insulin glulisine (Apidra®) 10–15min 1–1.5h 3.5–5h
● Insulin lispro (Humalog®) U-100 U-200 10–15min 1–2h 3–4.75h
● Faster-acting insulin aspart (Fiasp®) 4min 0.5-1.5h 3-5h
Short-acting insulins (clear)
• Insulin regular (Humulin®-R, Novolin® ge Toronto) 30min 2–3h 6.5h
• Insulin regular U-500 (Entuzity® (U-500) 15min 4-8h 17-24h
BASAL insulins
Intermediate-acting (cloudy)
• Insulin neutral protamine Hagedorn (Humulin® N, 1–3h 5–8h Up to 18h
Novolin® ge NPH)
Long-acting insulin (clear) 90min Not applicable U-100 glargine 24h,

• Insulin detemir (Levemir®) detemir 16–24h
• Insulin glargine U-100 (Lantus®) U-300 glargine >30h
• Insulin glargine U-300 (Toujeo®) degludec 42h
• Insulin glargine biosimilar (Basaglar®)
• Insulin degludec U-100, U-200 (Tresiba®)
PREMIXED insulins
Premixed regular insulin –NPH (cloudy) A single vial or cartridge contains a fixed ratio of insulin
• Humulin® 30/70 (% of rapid-acting or short-acting insulin to % of intermediate-acting insulin)
• Novolin® ge 30/70, 40/60, 50/50
Premixed insulin analogues (cloudy)

• Biphasic insulin aspart (NovoMix® 30)
• Insulin lispro/lispro protamine (Humalog® Mix25 and
Mix50)
2018
CHOOSE AN CHOOSE A DOSING
INSULIN TYPE BRAND SEE REVERSE FOR TIPS
SELECT PEN CHECK OFF QUANTITY &

DEVICE SUPPLIES REPEATS
SIGN AND DATE

guidelines.diabetes.ca/BloodGlucoseLowering/Insulin
PrescriptionTool
2018


2018 Diabetes Canada CPG – Chapter 26. Hypertension
Pharmacotherapy for Hypertension

in Patients with Diabetes – Summary
Threshold ≥130/80 mmHg and Target <130/80 mmHg
With ACE inhibitor

CKD or CVD or ARB
or CV risk ≥ 2-drug
Diabetes factors combinations
ACE inhibitor or
ARB or Most people with diabetes should
Without receive standard-dose
DHP-CCB or monotherapy for initial
CKD or CVD management; however, there is
Thiazide/thiazide- emerging evidence for supporting
or CV risk like diuretic earlier use of single pill
factors combination therapy
Check serum potassium and creatinine at baseline and within 1 to 2 weeks of initiation of an ACEI or ARB
Combinations of agents that block the RAAS (ACEi, ARB, DRI) should not be used
More than 3 drugs may be needed to reach target values for people with diabetes
CKD, chronic kidney disease; CV, cardiovascular, CVD, cardiovascular disease; DHP-CCB,
dihydropyridine calcium channel blocker; DRI, direct renin inhibitor
2018


2018 Diabetes Canada CPG – Chapter 25. Dyslipidemia
Who Should Receive Statins?

(regardless of baseline LDL-C)
• Clinical cardiovascular disease or

• Age ≥40 yrs or
• Microvascular complications or
• DM >15 yrs duration and age >30 yr or
• Warrants therapy based on the 2016 Canadian
Cardiovascular Society Guidelines for the Diagnosis
and Treatment of Dyslipidemia
Among women with childbearing potential, statins should only be

used in the presence of proper preconception counselling & reliable
contraception. Stop statins prior to conception.
2018


2018 Diabetes Canada CPG – Chapter 23. Cardiovascular Protection in People with Diabetes
2018
Who Should Receive ACEi or ARB Therapy?

(regardless of baseline blood pressure)
• Clinical CVD or
• Age >55 years with an additional CV risk factor or end
organ damage (albuminuria, retinopathy, left ventricular
hypertrophy) or
• Microvascular complications
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

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
Who Should Receive ACEi or ARB
Therapy? 2013
(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
EUROPA Investigators, Lancet 2003;362(9386):782-788.
HOPE study investigators. Lancet. 2000;355:253-59.
Copyright © 2013 Canadian Diabetes Association ONTARGET study investigators. NEJM. 2008:358:1547-59
RAAS blockade in diabetes

• Without hypertension or other CVD risk factors:
• Emerging uncertainty whether RAAS blockade is
beneficial1
• Importantly,
• Majority of persons with diabetes > age 55:
• Require > 1 BP medication to get below target
• Most will end up on a RAAS agent to achieve BP target
• Regularly evaluate CVD event risk and the need for ACE-inhibition
or ARB therapy
1. Bangalore S, et al. BMJ. 2016; 352:i438.
BP, blood pressure; CVD, cardiovascular disease, RAAS, renin angiotensin
aldosterone system
2018 Diabetes Canada CPG – Chapter 25. Dyslipidemia
Who Should Receive Statins?

(regardless of baseline LDL-C)
• Clinical cardiovascular disease or

• Age ≥40 yrs or
• Microvascular complications or
• DM >15 yrs duration and age >30 yr or
• Warrants therapy based on the 2016 Canadian
Cardiovascular Society Guidelines for the Diagnosis
and Treatment of Dyslipidemia
Among women with childbearing potential, statins should only be

contraception. Stop statins prior to conception.
Who should receive ASA?

• In people with established CVD, low-dose ASA
therapy (81-162 mg) should be used to prevent CV
events [Grade B, Level 2]
• ASA should not be used routinely for the primary

prevention of CVD in people with diabetes [Grade A,
Level 1A]. ASA may be used in the presence of
additional CV risk factors [Grade D, Consensus]
2018
Antihyperglycemic therapy
selection
In adults with type 2 diabetes with clinical CVD in whom
glycemic targets are not achieved with existing
antihyperglycemic medication(s) and with eGFR >30
mL/min/1.73m2, an antihyperglycemic agent with
demonstrated CV outcome benefit should be added to
reduce the risk of major CV events [Grade A, Level 1A for
empagliflozin; Grade A, Level 1A for liraglutide; Grade C, Level 2 for
canagliflozin]
2018


2018 Diabetes Canada CPG – Chapter 10. Physical Activity
Physical Activity Checklist

 TRY TO 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 an

interprofessional team
 ASSESS patient’s health before prescribing a higher

intensity exercise regimen
Tools available at guidelines.diabetes.ca

Smarter Step Count Prescription
2018 Diabetes Canada CPG – Appendix 4

2018 Diabetes Canada CPG – Chapter 11. Nutrition
2018
Nutritional management of
hyperglycemia in type 2 diabetes
Clinical assessment
Health behaviour interventions by Registered Dietitan
Initiate intensive healthy behaviour interventions or energy restriction and

increased physical activity to achieve/maintain a healthy body weight
Provide counselling on a diet best suited to the individual based on values,

preferences, and treatment goals using the advantages/disadvantages listed in Table 1
If not at target
Continue healthy behaviour interventions and add pharmacotherapy
Timely adjustments to healthy behaviour interventions and/or pharmacotherapy

should be made to attain A1C within 2 to 3 months for healthy behaviour
interventions alone or 3 to 6 months for any combination with pharmacotherapy
Table 1. Properties of dietary interventions
Choose “healthy” dietary patterns

Mediterranean diet Vegetarian diet
https://oldwayspt.org/traditional-diets/mediterranean-diet https://oldwayspt.org/traditional-diets/vegetarian-vegan-diet
Patient resources available at guidelines.diabetes.ca/patientresources

Choose “healthy” dietary patterns

Portfolio diet DASH diet
http://guidelines.diabetes.ca/cdacpg/media/documents/patien
t-resources/high-blood-pressure-and-diabetes.pdf
https://www.ccs.ca/images/Images_2017/Portfolio_Diet_Scroll_eng.pdf
2018


Screening for complications
Eyes
Heart
Kidneys
Circulation
Nerves / Feet
2018 Diabetes Canada CPG – Chapter 30. Retinopathy
Screening for Retinopathy

2018 Diabetes Canada CPG – Chapter 30. Retinopathy
Retinopathy (cont’d)
2018 Diabetes Canada CPG – Chapter 29. Chronic Kidney Disease in Diabetes
Chronic Kidney Disease (CKD)

Checklist
SCREEN with random urine albumin creatinine ratio
(ACR) and serum creatinine for estimated glomerular
filtration rate (eGFR) at diagnosis then annually (T2D)
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 ACEi or ARB
PREVENT complications with dose adjustment, “sick day
management” counselling and referral when appropriate
ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker

Screening and
Diagnosis of CKD in
Diabetes
Counsel all
Patients About
Sick Day
Medication List
Visit
guidelines.diabetes.ca
for patient
handout
2018
Role of SGLT2 inhibitor in CKD

In adults with type 2 diabetes with clinical CVD in whom
glycemic targets are not achieved with existing
antihyperglycemic medication(s) and who have an eGFR
>30 mL/min/1.73 m2, an SGLT2 inhibitor with
proven renal benefit may be considered to reduce
progression of nephropathy [Grade B, Level 2 for
empagliflozin; Grade C, Level 3 for canagliflozin]
Empagliflozin reduced doubling of serum

creatinine*, initiation of renal replacement
therapy, or death due to renal disease
Hazard ratios are based on Cox regression analyses. *Accompanied by eGFR [MDRD] ≤45 ml/min/1.73m 2.
HR, hazard ratio; CI, confidence interval. Post-hoc analyses.
Wanner et al. N Engl J Med 2016; 75:323-334
Canagliflozin reduced composite endpoint of 40%

reduction in eGFR, requirement for renal
replacement therapy or death from renal causes
Neal B et al. N Engl J Med 2017; 377:644-657

2018 Diabetes Canada CPG – Chapter 32. Foot Care
Foot Care Checklist

EDUCATE about proper foot care
EXAMINE for structural, vascular, neuropathy
problems at diagnosis then annually
DO a 10 gram monofilament assessment
IDENTIFY those at high risk of foot ulcers and
educate, assess more frequently, consider
footwear
REFER persons with foot ulcers and other
complications to those specialized in foot care
Screening for Protective Sensation Using The
10 gram Monofilament
How to perform the sensory
examination:
• Conduct in a quiet and relaxed
setting.
• Begin by applying the
monofilament to the hands,
elbow or forehead so that
patient what to expect.
• Ensure that the patient can not
see whether or where the
monofilament is being applied.
• Test the three sites on both feet
shown in the figure.
Modified from: Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on the
Diabetic Foot. Prevention and management of foot problems in diabetes: A Summary Guidance for Daily Practice
2015, based on IWGDF Guidance Documents. Diabetes Metab Res Rev 2016;32 Suppl 1:7-15
Screening for Protective Sensation Using The
10 gram Monofilament
A B
How to Apply the monofilament:

•Repeat this application twice at the same site, but alternate this with at least one
‘mock’ application in which no filament is applied (total three questions per site).
Protective sensation is present at each site if the patient correctly answers two out
of three applications. Protective sensation is absent with two out of three incorrect
answers – the patient is then considered to be at risk of ulceration.
Modified from: Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on the
Diabetic Foot. Prevention and management of foot problems in diabetes: A Summary Guidance for Daily Practice
2015, based on IWGDF Guidance Documents. Diabetes Metab Res Rev 2016;32 Suppl 1:7-15
2018 Diabetes Canada CPG – Chapter 24. Screening for the Presence of Cardiovascular Disease
2018
Screening for CVD
Resting ECG, repeated every 3 to 5 years if
• Age >40 years
• Duration of diabetes >15 years and age >30 years
• End organ damage (microvascular, cardiovascular)
• >1 CVD risk factor(s)
• current smoking
• hypertension,
• family history of premature CVD in 1st degree relative (M<55 yrs, F<65 yrs)
• chronic kidney disease
• obesity (BMI > 30 kg/m2),
• erectile dysfunction
• Age >40 years and planning to undertake very vigorous or
prolonged exercise
2018 Diabetes Canada CPG – Chapter 33. Sexual Dysfunction & Hypogonadism in Men with Diabetes
Erectile Dysfunction (ED) Checklist
SCREEN all adult men regularly with sexual

function history
TREAT erectile dysfunction with PDE-5 inhibitor as

first-line therapy (if no contraindication)
INVESTIGATE for hypogonadism if men with ED

do not respond to PDE-5 inhibitor therapy
PDE-5, phosphodiesterase type 5

2018


2018


Formulate an
Action Plan to
support Self-
management
guidelines.diabetes.ca/selfm
anagementeducation/smeact
ionplan
2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health
Screening for depressive and anxious

symptoms is important in patients with
diabetes
Purpose Screening Tools
Diabetes-specific •Problem Areas in Diabetes (PAID) Scale
•Diabetes Distress Scale (DDS)
Quality of Life •WHO-5

Depression/Anxiety •Hospital Anxiety and Depression Scale (HADS)
•Patient Health Questionnaire (PHQ-9)
•Beck Depression Inventory (BDI)
Websites with psychological / psychiatric scales:

www.phqscreeners.com
www.outcometracker.org/scales_library.php.
Other considerations
2018 Diabetes Canada CPG – Chapter 19. Vaccinations
Immunization Checklist
GIVE annual influenza vaccination
OFFER pneumococcal vaccination if

>18 years of age
RE-VACCINATE for pneumococcal for

those >65 years of age; ensure ≥5
years between administrations
2018 Diabetes Canada CPG – Chapter 21. Diabetes & Driving

• The fitness of people with diabetes to drive should be
assessed on an individual basis
• All drivers with diabetes should undergo a medical
examination at least every two years to assess
fitness to drive.
• People with diabetes should play an active role in
assessing their fitness to drive
• Should not drive when BG <4.0 mmol/L and should
wait at least 40 minutes after treatment of
hypoglycemia has increased their BG level to at least
5.0 mmol/L
2018 Diabetes Canada CPG – Chapter 21. Diabetes & Driving
2018
Stop driving and report concerns about the
person’s fitness to drive to the appropriate driving
licensing body if any of the following:
• Any episode of severe hypoglycemia while

driving in the past 12 months
• >1 episode of severe hypoglycemia while

awake but not driving
• Private driver: in the past 6 months
• Commercial driver: in the past 12 months
Visit guidelines.diabetes.ca for patient handout on Diabetes and Driving
Special Populations
2018 Diabetes Canada CPG – Chapter 37. Diabetes in Older People
2018
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 or ADJUST antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinediones
DPP-4 inhibitors should be used over sulfonylureas
Basal analogues instead of NPH or human 30/70 insulin
GIVE regular diets instead of “diabetic diets” or nutritional
formulas in long-term care
2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy
Preconception Checklist for 2018
Women with Pre-existing Diabetes

 Use reliable birth control until adequate glycemic control
 Attain a preconception A1C of ≤7.0% (≤ 6.5% if safe)
 May remain on metformin + glyburide until pregnancy, otherwise
switch to insulin
 Assess for and manage any diabetes complications
 Folic Acid 1 mg/d: 3 months pre-conception to at least 12
weeks gestation
 Discontinue potential embryopathic meds:
 ACE-inhibitors / ARB (prior to or upon detection of pregnancy
in those with significant proteinuria)
 Statin therapy
2018 Diabetes Canada CPG – Chapter 38. Type 2 Diabetes and Indigenous Peoples
Type 2 Diabetes and Indigenous 2018
Peoples
 Among the highest-risk populations
 Prevention strategies are essential
 Management targets should be no different from
general population
 Focus on building a therapeutic relationship
 Acknowledge the legacy of colonization and its ongoing
adverse effects on Indigenous health
 Use the Educating for Equity (E4E) framework to
address social barriers and identify strategies
for facilitating outcomes using a cultural approach
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2018 Clinical Practice Guidelines for

the Prevention and Management of

• Relationships with commercial interests:

Clinical Trials (last 2 years): Astra Zeneca, Boehringer

• 163 pages published as

• 201 pages published as

• 212 pages published as

• Expert committee of 135 key

• In addition to the full guidelines, various tools

• Only medications with Health Canada Notice of

Literature Review Flow Diagram

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

*Consider 75-g OGTT if >1 risk factors; ** Consider 75-g OGTT

Confirmatory test required

2h PG in a 75g 7.8-11.0 IGT

A1C (%) 6.0-6.4 Prediabetes

ABCDES3 of Diabetes Care

E • Exercise / Healthy Eating

ABCDES3 of Diabetes Care

E • Exercise / Healthy Eating

Consider 7.1-8.5% if:

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

A1C Targets 2018

Adults with type 2 diabetes to reduce the risk of CKD

≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2

* Based on class of antihyperglycemic medication(s) utilized and person’s characteristics

ADVANCE: Glucose Control

6.0 Intensive control

ADVANCE Collaborative Group. N Engl J Med 2008;358:24.

ADVANCE: Treatment Effect on the

Nephropathy/retinopathy (%) 9.4 10.9 0.86 0.01

ADVANCE Collaborative Group. N Engl J Med 2008;358:24.

8601 people from ACCORD trial, monitored for additional 8.8

A1C Targets 2018

Adults with type 2 diabetes to reduce the risk of CKD

≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2

* Based on class of antihyperglycemic medication(s) utilized and person’s characteristics

Glycated Hemoglobin: A1C

• Valuable indicator of treatment effectiveness

Glycated Hemoglobin: A1C

• More frequently when significant changes are

• Every 6 months during periods of glycemic

Factors that can affect A1C

Assays Hyperbilirubinemia Hypertriglyceridemia

To achieve A1C ≤7.0%

If A1C ≤7.0% not 4.0-5.5 5.0-8.0

PG, plasma glucose

To achieve A1C ≤7.0%

If A1C ≤7.0% not 4.0-5.5 5.0-8.0

Monnier L, et al. Diabetes Care 2007;30:263

PG, plasma glucose

To achieve A1C ≤7.0%

If A1C ≤7.0% not 4.0-5.5 5.0-8.0

Woerle HJ, et al. Diabetes Res Clin Pract 2007;77:280

PG, plasma glucose

PPG, post-prandial plasma glucose

Monitoring with Meaning …

Parkin CG et al. J Diabetes Sci Technol. 2009;3:500-508.

SMBG, self-monitoring of blood glucose

BG, blood glucose; CSII, continuous subcutaneous insulin infusion

CGM, continuous glucose monitoring; CSII, continuous subcutanenous insulin infusion

Start metformin immediately Initiate insulin +/-

If not at glycemic target If not at glycemic target