The Essentials Presentation by Dr. Tessa Laubscher Clinical Associate Professor, Family Medicine Saskatoon Sept 2013

1. Canadian Diabetes Association 2013 Clinical Practice Guidelines The EssentialsPresentation by Dr. Tessa Laubscher Clinical Associate Professor, Family MedicineSaskatoonSept 2013

2. Learning Objectives By the end of this session, participants will: • Have knowledge of the major changes within the 2013 CDA clinical practice guidelines. • Be able to apply the recommendations in clinical practice and be familiar with online resources/tools. • Understand the importance of comorbidities in individualizing diabetes management.

3. Where do you find the Diabetes CPG and additional clinically useful information? www.guidelines.diabetes.ca

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

5. Diagnosis of Diabetes – usually require >1 test result • If results of two different tests (e.g. FPG and A1C) are available and both are above the diagnostic cut-points, the diagnosis of diabetes is confirmed. • If patient is asymptomatic and a single test is abnormal, a repeat test must be done on a different day to confirm diagnosis. Preferable to repeat same test, but this is not essential. • If patient has typical symptoms of hyperglycemia and the initial diagnostic test is elevated, repeat testing is not required.

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

7. A1C Level and Future Risk of Diabetes: Systematic Review Zhang X et al. Diabetes Care. 2010;33:1665-1673.

8. Screening for Type 2 Diabetes - Checklist • ASSESS all adults clinically every year for risk of type 2 diabetes (T2DM) • SCREEN every 3 years if ≥ 40 years • SCREEN earlier and more frequently if very high risk on risk calculator or additional risk factors present • USE fasting plasma glucose (FPG) and/or A1C as initial screening tests

9. Screening for T2DM – Recommendations 1 and 2 • All individuals should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria [Grade D, Consensus]. • Screening for diabetes using a FPG and/or A1C should be performed every 3 years in individuals ≥40 years of age or at high risk using a risk calculator [Grade D, Consensus]. More frequent and/or earlier testing with either a FPG and/or A1c or a 2h PG in a 75 g OGTT should be considered in those at very high risk using a risk calculator or in people with additional risk factors for diabetes [Grade D, Consensus].

10. Screening for T2DM - Recommendations 3 and 4 • Testing with a 2hrPG in a 75-g OGTT* should be undertaken in individuals with FPG of 6.1 to 6.9 mmol/L and/or A1C 6.0 to 6.4% in order to identify individuals with IGT or diabetes [Grade D, Consensus] • Testing with a 2hPG in a 75-g OGTT* may be undertaken in individuals with a FPG of 5.6 to 6.0 mmol/L and/or A1C 5.5 to 5.9% and >1 risk factor for T2DM in order to identify individuals with IGT or diabetes [Grade D, Consensus] * 75g OGTT – consider this to be a “pancreatic stress test” 2013 2013

11. Risk Factors for T2DM • Personal factors • Presence of associated problems • Presence of secondary causes

12. If you choose to use a diabetes risk calculator … • Public Health Agency of Canada CANRISK calculator http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/canrisk/index-eng.php • For people 40 - 74 years old • Components • Age, sex, BMI, waist circumference • Physical activity level, Diet - eating veg and fruits • Hypertension, history of dysglycemia (GDM, hyperglycemia with acute illness), macrosomia • Family history, ethnicity, level of education • Calculates low, moderate or high risk groups

13. Screening for Type 2 Diabetes in Adults 2013 Algorithm presented on next slides

14. Screening for Type 2 Diabetes in Adults (continued) *If both FPG and A1C are available, but discordant, use the test that appears furthest to the right side of the algorithm (i.e. most abnormal test result).

16. Can we reduce the risk of developing Type 2 Diabetes?

17. What can you do for your patients diagnosed with prediabetes? • Lifestyle Goal: weight loss of 7% of body weight and ≥ 150 minutes moderate physical activity per week • Assess and treat other CVD risk factors (IGT is risk factor for CAD) • Metformin (most evidence for BMI>35, age <60yrs, women with prior GDM) • Monitor annually for progression to T2DM • Saskatoon Health Region Live Well CDM program – specifically designed for people at high risk of developing T2DM • Half-day workshops • Focus is on education and assistance with lifestyle change & weight loss, including regular phone follow-up and assistance with exercise planning

18. Glycemic Targets:New Targets and why?

19. 2013 Targets Checklist • A1C ≤ 7.0% for MOST people with diabetes Preprandial capillary plasma glucose 4.0 – 7.2 mmol/L, and Postprandial (1-2hrs) capillary plasma glucose <10.0 mmol/L • A1C ≤ 6.5% for SOME people with T2DM • A1C 7.1 - 8.5% in people with specific features • INDIVIDUALIZE

20. Individualization of Glycemic Goals • Glycemic targets should be individualized based on • Age of person and life expectancy • Duration of diabetes • Type of diabetes • Comorbid conditions • Known CVD or advanced microvascular complications such as neuropathy or nephropathy • Hypoglycemia frequency and unawareness

21. A1C ≤ 7.0% • Lowering A1C to below or around 7% • Large trials (DCCT, EDIC, UKPDS) supporting this with reduced microvascular complications in type 1 and type 2 diabetes • If this goal A1C is achieved soon after diagnosis of DM there is an association with reduced macrovascular complications • Can usually be achieved safely in both Type 1 and Type 2 diabetes.

22. A1C ≤ 6.5% • This should be encouraged only if can be done safely without increased hypoglycemia. • Consider in individuals with short duration of DM, long life expectancy, and no significant CVD. • In T2DM some study evidence (ADVANCE) demonstrating reduced kidney and eye microvascular complications. • No outcome evidence of reduced macrovascular complications. Recurrent hypoglcemia(BG < 4.0mmol/L) associated with detrimental effects on vasculature (in T1DM), increased risk of falls, cardiac ischemia, cognitive effects/decline.

23. 2013 Consider higher A1C of 7.1- 8.5% if … • Limited life expectancy • High level of functional dependency (e.g. frail elderly) • Extensive coronary artery disease at high risk of ischemic events • Multiple co-morbidities • History of recurrent severe hypoglycemia – consider temporary increased A1c • Hypoglycemia unawareness - consider temporary increased A1c • Longstanding diabetes for whom is it difficult to achieve an A1C ≤ 7%, despite effective doses of multiple antihyperglycemic agents, including intensified basal-bolus insulin therapy

24. Self-Monitoring of Blood Glucose (SMBG)What should we tell patients to do?

26. Exercise and Nutrition: What should we advise patients to do?

27. Physical Activity Checklist 2013 • DO a minimum of 150 minutes of moderate to vigorous intensity aerobic exercise per week • INCLUDE resistance exercise ≥ 2 times a week • Setphysical activity goals and INVOLVE a multi-disciplinary team • ASSESS patient’s health before prescribing an exercise regimen

28. Useful Resources on Exercise http://guidelines.diabetes.ca/PatientResources.aspx Includes pre-exercise checklist, and new handouts for patients on aerobic and resistance training including diagrams of how to do some exercises.

29. Nutrition: Useful Resources on Diet / Medical Nutrition Therapy http://guidelines.diabetes.ca/PatientResources.aspx Every person with diabetes should be referred to a registered dietitian for MNT. Often beneficial to recommend this when advancing therapy in T2DM, such as adding insulin.

30. Modest weight loss CAN make a difference • Goal is to prevent weight gain, promote weight loss and prevent weight re-gain • Weight loss of only 5-10% of body weight improves: • Insulin sensitivity • Glycemic control • Blood pressure • Lipid levels

31. Medications for glycemiaHow do we choose?

32. Type 1 Diabetes • T1DM requires intensive insulin management – multi-daily injections (MDI). • Ideally should be using basal-bolus insulin regimen, or continuous insulin infusion. • Basal insulin (long acting insulin analogue or NPH) once or twice daily • Rapid acting insulin analogue with meals • Hypoglycemia is main limiting factor to achieving “perfect” glycemic control. • In some adults with T1DM obesity causes additional problem of insulin resistance – can add Metformin.

33. Type 2 Diabetes – natural history Type 2 diabetes is a progressive disease- the initial problem is mostly insulin resistance, but blood glucose control will deteriorate over years due to progressive failure of the pancreas to secrete enough insulin. This progressive failure of insulin production occurs more rapidly in people with poor glycemic control. At the time of diagnosis (if symptoms of hyperglycemia), majority of people with T2DM have already lost 50% of pancreatic β-cell production of insulin. Regardless of management, β-cell destruction continues, and with time patients will require insulin to achieve normal fasting and post-prandial blood glucose levels. In many people with T2DM – insulin production is only 15-20% by 8 -10 years after diagnosis. Exogenous insulin is required to achieve glycemic targets.

34. A healthcare provider needs to consider: • Type of diabetes • Diabetes symptoms and variation in sugars • Degree of hyperglycemia – A1C • Duration of Type 2 diabetes – if >15 years insulin probably required • Previous interventions – if not on metformin why not? • Kidney and liver function • Risk of hypoglycemia • Cost of medications • Potential weight gain from anti-hyperglycemic drugs • Ability of patient or caregiver to implement therapy

35. 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

36. AT DIAGNOSIS OF TYPE 2 DIABETES L I F E S T Y L E Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C <8.5% A1C 8.5% Symptomatic hyperglycemia with metabolic decompensation If not at glycemic target (2-3 mos) Start metformin immediately Consider initial combination with another antihyperglycemic agent Initiate insulin +/- metformin Start / Increase metformin If not at glycemic targets Add an agent best suited to the individual: Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013 See next page…

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

38. Consider weight effects when selecting antihyperglycemic medications Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

39. What are the options for Insulin?

40. Serum Insulin Level Time Human Bolus: Humulin-R, Novolin ge Toronto Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Analogue Bolus: Apidra, Humalog, NovoRapid

41. What about Hypoglycemia?

42. Definition of Hypoglycemia • Development of neurogenic or neuroglycopenic symptoms • Low blood glucose (< 4 mmol/L if on insulin or secretagogue) • Response to carbohydrate load. Emerging importance of Hypoglycemia • Increasing evidence that hypoglycemia is associated with increased morbidity and mortality in both T1DM and T2DM. • Hypoglycemia-related outcomes include: • increased risk of falls; • CNS consequences including cognitive effects/decline and decreased memory/retention; • autonomic failure; • cardiac effects – rhythm disturbances, ischemia; and accelerated atherosclerosis with recurrent hypoglycemia in T1DM.)

43. Clinical relevance • Patients should be asked about frequency and severity of hypoglycemia at every CDM visit, with appropriate changes made to medical therapy if necessary. • Recurrent hypoglycemia may result in hypoglycemia unawareness and more severe hypoglycemia. • People with frequent hypoglycemia (consider if A1C < 6.5% and patient on insulin) should have medical therapy adjusted to raise glucose levels in an attempt to restore the autonomic responses to hypoglycemia. • Frequent or severe hypoglycemia may impact fitness to drive.

44. Hypoglycemia and Driving Safe blood glucose (BG) prior to driving BG ≥ 5.0 mmol/L • If BG <5.0 mmol/L prior to driving: • Take 15 g carbohydrate • Re-check in 15 minutes • When BG >5 mmol/Lfor at least 45 minutes  safe to drive • Need to re-check BG every 4 hours of continuous driving and carry simple carbohydrate snacks HCP and Patient resources on guidelines website Iain S. Begg et al . Canadian Journal of Diabetes. 2003;27(2):128-140.

45. Macrovascular DiseaseVascular Protection:Why?Who and When?

46. Why is vascular protection important? • Diabetes promotes both the development and adverse impact of cardiovascular disease (CVD) risk factors (e.g. hypertension, dyslipidemia, renal dysfunction) and, as a consequence, accelerates cardiovascular age. • Persons with diabetes generally have a cardiovascular age 10 to 15 years in advance of their chronological age. • Advanced cardiovascular age substantially increases both the proximate and lifetime risk for CVD events, resulting in a reduced life expectancy of approximately 12 years. • In young adults (aged 20 to 39 years), T1DM is an independent risk factor for premature CVD and mortality. The presence of CVD in people with T1DM is related to age, duration of diabetes, higher A1C levels and presence of retinopathy and albuminuria, as well as traditional CVD risk factors, such as elevated LDL-C, smoking and obesity.

47. 2013 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 decide to treat • D•Drugs to protect the heart A – ACEi or ARB │S – Statin │A – ASA (only if established CVD) • E• Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weight • S•Smoking cessation

48. Who Should be Screened for CAD with ECG? Age >40 years Duration of DM >15years + Age >30 years End organ damage • Microvascular • Macrovascular Cardiac risk factors Symptoms of “silent CAD” – decreased exercise capacity, unexplained dyspnea, new onset HF Baseline resting ECG Repeat every 2 years

49. 2013 Who Should Receive Statins? • Clinical Macrovascular disease [grade A, level A] or • ≥40 yrs old [grade A, level A for T2DM; grade D, consensus for T1DM] or • Microvascular disease [grade D, consensus] or • DM >15 yrs duration and age >30 years[grade D, consensus]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.

50. 2013 If on statin –primarytarget is:LDL ≤ 2.0 mmol/L or > 50% reduction in LDLAlternate primary targets are: apo B <0.8g/L, or non-HDL-C <2.6 mmol/L. If Triglycerides > 10.0 mmol/L – • Use a FIBRATE to reduce the risk of pancreatitis • Optimize glycemic control • Implement lifestyle interventions • Weight loss • Optimal dietary strategies • Reduce alcohol