Article Figures & Data
Figures
- Figure 1.
Prioritization of key messages from the Diabetes Canada 2018 clinical practice guidelines8
D&I—dissemination and implementation.
*Consisting of primary care practitioners, endocrinologists, diabetes educators, other specialists, and people living with diabetes.
- Figure 2.
Individualizing HbA1c targets for patients with diabetes
CKD—chronic kidney disease, HbA1c—hemoglobin A1c.
*Lower limit applies only if the patient is taking antihyperglycemic agents with the risk of hypoglycemia.
†At the end of life, HbA1c measurement is not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.
Adapted from the Diabetes Canada Clinical Practice Guidelines Expert Committee.8
- Figure 3.
The ABCDES3 of routine diabetes visits
ACEI—angiotensin-converting enzyme inhibitor, ARB—angiotensin receptor blocker, ASA—acetylsalicylic acid, GLP1RA—glucagon like peptide 1 receptor agonist, SGLT2I—sodium glucose transporter 2 inhibitor.
Adapted from the Diabetes Canada Clinical Practice Guidelines Expert Committee.8
Tables
- Table 1.
Selected high-priority type 2 diabetes recommendations and relevant tools for FPs: Highlighted recommendations were prioritized for dissemination by those involved in preparing this review. They are not presented in any particular order and are not necessarily the most important recommendations for a given practice or patient; the full guideline is available at guidelines.diabetes.ca.
KEY MESSAGE GUIDELINE RECOMMENDATION RELEVANT TOOLS Discuss opportunities to reduce the risk of diabetes complications If glycemic targets are not achieved with existing antihyperglycemic medications, other classes of agents should be added to improve glycemic control. The choice should be individualized taking into account the information below and in Figure 28 (grade B, level II)
In people without clinical CVD in whom glycemic targets are not achieved with existing antihyperglycemic medication, incretin agents (DPP4Is or GLP1RAs) or SGLT2Is should be considered as add-on medication over insulin secretagogues, insulin, and TZDs to improve glycemic control, if lower risk of hypoglycemia or weight gain are priorities (grade A, level IA). Acarbose and orlistat can also be considered as add-on medication to improve glycemic control with a low risk of hypoglycemia and weight gain (grade D, consensus)
In people with clinical CVD in whom glycemic targets are not achieved with existing antihyperglycemic medication, an antihyperglycemic agent with demonstrated CV outcome benefit should be added to reduce the risk of major CV events (grade A, level IA for empagliflozin; grade A, level IA for liraglutide; grade C, level II for canagliflozin)Interactive tool for selecting agents for glycemic control:
guidelines.diabetes.ca/bloodglucoselowering/pharmacologyt2Insulin can be used at any time in the course of type 2 diabetes (grade D, consensus) (see link in Relevant Tools column for examples of insulin initiation and titration in people with type 2 diabetes). In people not achieving glycemic targets with existing non-insulin antihyperglycemic medication, the addition of a once-daily basal insulin regimen should be considered over premixed insulin or bolus-only regimens to reduce weight gain and hypoglycemia (grade B, level II)
Long-acting insulin analogues should be considered over NPH insulin to reduce the risk of nocturnal and symptomatic hypoglycemia (grade A, level IA)
In people receiving insulin, doses should be adjusted or additional antihyperglycemic medication (non-insulin or bolus insulin) should be added if glycemic targets are not achieved (grade D, consensus)A GLP1RA should be considered as add-on therapy to improve glycemic control with weight loss (grade A, level IA) before initiating bolus insulin or intensifying insulin to improve glycemic control with weight loss and a lower hypoglycemia risk compared with single or multiple bolus-insulin injections (grade A, level IA)
An SGLT2I should be considered as add-on therapy to improve glycemic control with weight loss and lower hypoglycemic risk compared with additional insulin (grade A, level IA)
A DPP4I could be considered as add-on therapy to improve glycemic control without weight gain or increased hypoglycemia risk compared with additional insulin (grade B, level II)
Insulin prescription tool:
guidelines.diabetes.ca/reduce-complications/insulin-prescription-tool
Examples of insulin initiation and titration in people with type 2 diabetes:
guidelines.diabetes.ca/docs/cpg/Appendix-9.pdfAll individuals with diabetes should follow a comprehensive, multifaceted approach to reducing CV risk, including the following: HbA1c target ≤ 7.0% implemented early in the course of diabetes (grade C, level III)
systolic BP of < 130 mm Hg (grade C, level III) and diastolic BP of < 80 mm Hg (grade B, level I)
additional vascular protective medications in most adult people with diabetes (see recommendations below) (grade A, level I for those with type 2 diabetes aged > 40 y with albuminuria; grade D, consensus for those with type 1 diabetes)
achievement and maintenance of healthy weight goals (grade D, consensus)
healthy eating
regular physical activity (grade D, consensus)
smoking cessation (grade C, level III)
clinical CVD (grade A, level I)
age ≥ 40 y (grade A, level I, for type 2 diabetes; grade D, consensus for type 1 diabetes)
age < 40 y and 1 of the following ...
-diabetes duration > 15 y and age > 30 y (grade D, consensus)
-microvascular complications (grade D, consensus)
-warrants therapy based on the presence of other risk factors according to the “2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult”16 (grade D, consensus)
ACEIs or ARBs, at doses that have demonstrated vascular protection, should be used to reduce CV risk in adults with type 1 or type 2 diabetes with any of the following:clinical CVD (grade A, level I)
age > 55 y with an additional CV risk factor or end organ damage (albuminuria, retinopathy, left ventricular hypertrophy) (grade A, level I)
microvascular complications (grade D, consensus)
In people with established CVD, low-dose ASA therapy (81–162 mg) should be used to prevent CV events (grade B, level II)
ASA should not be used routinely for the primary prevention of CVD in people with diabetes (grade A, level IA). ASA can be used in the presence of additional CV risk factors (grade D, consensus)
Clopidogrel 75 mg can be used in people unable to tolerate ASA (grade D, consensus)
In adults with type 2 diabetes with clinical CVD in whom glycemic targets are not achieved with existing antihyperglycemic medication, an antihyperglycemic agent with demonstrated CV outcome benefit should be added to reduce the risk of major CV events (grade A, level IA for empagliflozin; grade A, level IA for liraglutide; grade C, level II for canagliflozin)Flow sheets:
guidelines.diabetes.ca/docs/cpg/Appendix-3.pdf
Interactive tool for selecting agents for vascular protection:
guidelines.diabetes.ca/vascularprotection/riskassessmentDiscuss opportunities to ensure safety and prevent hypoglycemia Drivers with diabetes treated with insulin secretagogues or insulin ... should maintain a log of their SMBG measurements either by using a memory-equipped BG meter or an electronic record of BG measurement performed at a frequency deemed appropriate by the person with diabetes and his or her health care team. For commercial drivers, for initial commercial license application, the record should include the last 6 mo (or since the diagnosis of diabetes if < 6 mo). BG logs should be verifiable on request (grade D, consensus)
should always have BG monitoring equipment and supplies of rapidly absorbable carbohydrate within easy reach (eg, attached to the driver’s side visor or in the centre console) (grade D, consensus)
should consider measuring their BG level immediately before and at least every 4 h while driving or wear a real-time CGM device (grade D, consensus)
should not drive when their BG level is < 4.0 mmol/L (grade C, level III for type 1 diabetes; grade D, consensus for type 2 diabetes). If the BG level is < 4.0 mmol/L, they should not drive until at least 40 min after successful treatment of hypoglycemia has increased their BG level to at least 5.0 mmol/L (grade C, level III for type 1 diabetes; grade D, consensus for type 2 diabetes)
must refrain from driving immediately if they experience severe hypoglycemia while driving and notify their health care provider as soon as possible (no longer than 72 h) (grade D, consensus)
If any of the following occur, health care professionals should inform people with diabetes treated with insulin secretagogues or insulin to no longer drive, and should report their concerns about the person’s fitness to drive to the appropriate driving licensing body:any episode of severe hypoglycemia while driving in the past 12 mo (grade D, consensus)
> 1 episode of severe hypoglycemia while awake but not driving in the past 12 mo (grade D, consensus)
Educational handout for safe driving:
guidelines.diabetes.ca/docs/patient-resources/drive-safe-with-diabetes.pdfBP targets should be individualized for older adults who are functionally dependent, or who have orthostasis, or who have a limited life expectancy (grade D, consensus)
In older patients with diabetes and multiple comorbidities or frailty, strategies should be used to strictly prevent hypoglycemia, which include the choice of antihyperglycemic therapy and less-stringent HbA1c targets (grade D, consensus). Antihyperglycemic agents that increase the risk of hypoglycemia or have other side effects should be discontinued in these people (grade C, level III)
A higher HbA1ctarget can be considered in older people with diabetes taking antihyperglycemic agents with risk of hypoglycemia, with any of the following (grade D, consensus for all) ...functionally dependent: 7.1%–8.0%
frail or with dementia: 7.1%–8.5%
end of life: HbA1c measurement is not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia
DPP4Is should be used over sulfonylureas as second-line therapy to metformin because of a lower risk of hypoglycemia (grade B, level II)
In general, initial doses of sulfonylureas in older people should be half of those used for younger people, and doses should be increased more slowly (grade D, consensus)
Gliclazide and gliclazide MR (grade B, level II) and glimepiride (grade C, level III) should be used instead of glyburide, as they are associated with a reduced frequency of hypoglycemic events
Meglitinides can be used instead of glyburide to reduce the risk of hypoglycemia (grade C, level II for repaglinide; grade C, level III for nateglinide), particularly in individuals with irregular eating habits (grade D, consensus)
In older people with type 2 diabetes with no other complex comorbidities but with clinical CVD and in whom glycemic targets are not achieved with existing antihyperglycemic medications, an antihyperglycemic agent with demonstrated CV outcome benefit could be added to reduce the risk of major CV events (grade A, level IA for empagliflozin; grade A, level IA for liraglutide; grade C, level II for canagliflozin)Interactive tool for individualizing HbA1c target:
guidelines.diabetes.ca/reduce-complications/a1ctarget
Interactive tool for selecting agents for glycemic control:
guidelines.diabetes.ca/bloodglucoselowering/pharmacologyt2
Therapeutic considerations for renal impairment:
guidelines.diabetes.ca/docs/cpg/Appendix-7.pdfAdults with diabetes and CKD should be given a “sick-day” medication list that outlines which medications should be held during times of acute illness (grade D, consensus) Sick-day planning handout:
guidelines.diabetes.ca/docs/cpg/Appendix-8.pdfDiscuss progress on self-management goals and address barriers Individuals with diabetes should be regularly screened for diabetes-related psychological distress (eg, diabetes distress, psychological insulin resistance, fear of hypoglycemia) and psychiatric disorders (eg, depression, anxiety disorders) by validated self-report questionnaire or clinical interview (grade D, consensus). Plans for self-harm should be asked about regularly as well (grade C, level III) Handouts about self-management:
guidelines.diabetes.ca/patientresourcesCollaborative care by interprofessional teams should be provided for individuals with diabetes and depression to improve the following: depressive symptoms (grade A, level I)
adherence to antidepressant and non-insulin antihyperglycemic medications (grade A, level I)
glycemic control (grade A, level I)
motivational interventions (grade D, consensus)
stress management strategies (grade C, level III)
coping skills training (grade A, level IA for type 2 diabetes; grade B, level II for type 1 diabetes)
family therapy (grade A, level IB)
case management (grade B, level II)
Handouts about identifying and managing diabetes-related distress:
guidelines.diabetes.ca/selfmanagementeducation/psychosocialPeople with diabetes should ideally accumulate a minimum of 150 min of moderate- to vigorous-intensity aerobic exercise each wk, spread over at least 3 d of the wk, with no more than 2 consecutive d without exercise, to improve glycemic control (grade B, level II) and to reduce risk of CVD and overall mortality (grade C, level III). Smaller amounts (90–140 min/wk) of exercise or planned physical activity can also be beneficial for glycemic control but to a lesser extent (grade B, level II)
Interval training (short periods of vigorous exercise alternating with short recovery periods at low to moderate intensity or rest from 30 s to 3 min each) can be recommended to people willing and able to perform such training to increase gains in cardiorespiratory fitness in type 2 diabetes (grade B, level II)
People with diabetes (including elderly people) should perform resistance exercise at least twice a wk and preferably 3 times/wk (grade B, level II) in addition to aerobic exercise (grade B, level II). Initial instruction and periodic supervision by an exercise specialist can be recommended (grade C, level III)
Setting specific exercise goals, problem solving potential barriers to physical activity, providing information on where and when to exercise, and self-monitoring should be performed collaboratively between the person with diabetes and the health care provider to increase physical activity and improve HbA1c levels (grade B, level II)
In addition to achieving physical activity goals, people with diabetes should minimize the amount of time spent in sedentary activities and periodically break up long periods of sitting (grade C, level III)
People with diabetes should be offered timely self-management education that is tailored to enhancing self-care practices and behaviour (grade A, level IA)
Technologies, such as Internet-based computer programs and glucose monitoring systems, brief text messages, and mobile applications can be used to support self-management in order to improve glycemic control (grade A, level IA)Interactive tool to provide specific exercise advice:
guidelines.diabetes.ca/selfmanagementeducation/patool
Sample exercise prescriptions for patients with diabetes:
guidelines.diabetes.ca/docs/resources/diabetes-and-physical-activity-your-exercise-prescription.pdfACEI—angiotensin-converting enzyme inhibitor, ARB—angiotensin receptor blocker, ASA—acetylsalicylic acid, BG—blood glucose, BP—blood pressure, CGM—continuous glucose monitoring, CKD—chronic kidney disease, CV—cardiovascular, CVD—cardiovascular disease, DPP4I—dipeptidyl peptidase 4 inhibitor, GLP1RA—glucagonlike peptide 1 receptor agonist, HbA1c—hemoglobin A1c, LDL-C—low-density lipoprotein cholesterol, MR—modified release, NPH—neutral protamine Hagedorn, PCSK9—proprotein convertase subtilisin-kexin type 9, SGLT2I—sodium glucose transporter 2 inhibitor, SMBG—self-monitoring of blood glucose, TZD—thiazolidinedione.
Grades and levels of evidence are defined in the methods chapter of the guidelines (guidelines.diabetes.ca/browse/chapter2). Briefly, grade A and level I evidence is the strongest and most relevant. Level IV evidence is the weakest, and grade D recommendations are supported by level IV evidence or consensus.8
Data from the Diabetes Canada Clinical Practice Guidelines Expert Committee.8
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