2013 - The Canadian Family Practice Nurses Association

Report
Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Essentials
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Copyright © 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
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Copyright © 2013 Canadian Diabetes Association
Faculty for slide deck development
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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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Copyright © 2013 Canadian Diabetes Association
www.guidelines.diabetes.ca
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Copyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca
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Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia
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| 1-800-BANTING
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Copyright
© 2013 Canadian
Diabetes Association
AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
A1C <8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C 8.5%
Symptomatic hyperglycemia with
metabolic decompensation
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/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…
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
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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Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
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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Copyright © 2013 Canadian Diabetes Association
Counsel all
Patients
About
Sick Day
Medication
List
2013
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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| 1-800-BANTING
(226-8464)
| diabetes.ca
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Need a preconception checklist for
women with pre-existing diabetes
2013

1. Attain a preconception A1C of ≤ 7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 mo pre-conception to 12
weeks post-conception

5. Discontinue potential embryopathic meds:


Ace-inhibitors/ARB (prior to or upon detection of pregnancy)
Statin therapy
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Tools to help us
keep track of our
patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Tools to help us
keep track of our
patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Back Page:
“Cheat Sheet” of
Targets and Goals
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Back Page:
“Cheat Sheet” of
Targets and Goals
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
New resources
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Download the App Today!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 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.ca
Copyright © 2013 Canadian Diabetes Association

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