1998 Clinical Practice Guidelines for the Management of Diabetes in Canada

1
1998 Clinical PracticeGuidelines for the
Management of Diabetes in Canada
Canadian Diabetes Association Steering and Expert
Committees CMAJOct.20,1998159(8 Suppl)
2

• Steering Committee co-chairs
• Sara Meltzer, MD
• Lawrence Leiter, MD
• Steering Committee members
• Keith Dawson, MD, PhD
• Jana Havrankova, MD
• Beverley Madrick, RD, CDE
• Meng-Hee Tan, MD
• Stewart Harris, MD, MPH
• Donna Lillie, RN, BA
• Beryl Schultz, RN, CDE

3
CANADIANDIABETES ASSOCIATION
ASSOCIATIONCANADIENNEDU DIABÈTE
Introduction and Methodology
1998 Clinical Practice Guidelines for
the Management of Diabetes in Canada
January 1999
4
1998 Clinical Practice Guidelines

• Whats really changed?
• What does it mean in terms of practice
  changes?

5
Rationale

• Diabetes is a serious and growing public
  health problem in Canada
• Complications of diabetes can be minimised if
  not prevented with quality diabetes care
• Previous guidelines 6 years old and required
  update

6
Clinical Guidelines are...

• systematically developed statements which
  assist clinicians and patients in making
  decisions

- KGMM Alberti
7
Objectives

• Provide evidence-based guidelines for
  outpatient management and treatment of
  diabetes
• Directed to professionals (team) involved in
  the care of diabetes
• To optimise care of those with diabetes and
  those at risk of developing diabetes in Canada

8
Role of guidelines

• Promote optimal treatment and good medical
  practice (i.e. quality control)
• Facilitate development of education programs
  for those less familiar
• Provide justification for improvements to the
  health care system
• - policy development
• - financial re-imbursement issues

9
Process

• 1. Formation of team
• 2. Outline plan
• 3. Review literature
• 4. Production
• 5. External review
• 6. Amendments
• 7. Implementation

10
Process

• 1. Formation of team
• - Steering Committee established in January 1996
• - Subcommittee Chairs and Expert Committee
  determined by Spring of 1997
• 2. Outline Plan
• - specific details on methodology and process
  developed in Spring 1996
• - letter requesting input and details sent out
  to expert committee in May - June of 1996

11
Process

• 3. Review Literature
• - review of literature with assessment of levels
  of evidence and formulation of initial draft...
  process began in the Fall of 1996
• 4. Production
• - initial draft reviewed by Steering Committee
  in March 1997
• - June 1997 meeting of Expert Committee
• - numerous meetings of Chairs of subcommittees
  with drafting and editing

12
Process

• 5. Production
• - preambles to contain pertinent but known
  information
• - recommendations to address basic issues or
  areas where controversy may exist
• - not a textbook!
• - supportive evidence in technical documents to
  be published
• 6. External Review
• - sent to over 200 people within and outside of
  Canada for review and comment

13
Process

• 7. Amendments
• - incorporation of revision suggestions by
  Steering Committee, September 1997
• - review of amended document in October, 1997 by
  Expert Committee
• - public presentation for consensus and further
  input in October, 1997 at CDA Professional
  Conference in London, Ontario
• 8. Implementation
• - once penultimate draft completed, submitted for
  publication
• - development of implementation strategies

14
Evidence-Based Evaluation
15
Evidence-Based Evaluation

• Chair
• Hertzel Gerstein, MD, MSc
• Members
• Dereck Hunt, MD
• Anne Holbrook, MD, MSc

16
Process
Evidence-Based

• evidence - linked guidelines whose development
  requires the explicit linkage of the evidence
  with the recommendation

17
Process
Evidence-Based Guidelines Methodology

• Identify clinically important questions
• Search and review the literature
• Assign a level of evidence for key citations

18
Process
Evidence-Based Guidelines Methodology

• Develop recommendations based on key
  citations
• Assign a grade to the recommendation
• Independent review of the recommendations and
  supporting citations

19
Process
Grades of Recommendations

• A supportive level 1 or 1 evidence
• B supportive level 2 or 2 evidence
• C supportive level 3 consensus
• D any lower level consensus

20
Organization of Diabetes Care
21
Organization of Diabetes Care

• Chair
• Sora Ludwig, MD
• Members
• André Bélanger, MD
• Peggy Dunbar, PTD, CDE
• James McSherry, MD
• Beryl Schultz, RN, CDE

22
Organisation of Diabetes Care
Central Themes

• Interdisciplinary team for Diabetes Health
  Care with the individual with diabetes central
  to team
• Shared care (i.e. organized care with
  structured approach)
• Education focused on self-management
• Role of the Primary Care physician
• Rights and responsibilities of person with
  diabetes and society

23
Organization of Diabetes Care
Role of Primary Care Physician

• The primary care physician (who may be a
  diabetes specialist), as an essential member of
  the DHC team and in consultation with other
  members of the team, has the responsability
  to...

24
Organization of Diabetes Care
Role of Primary Care Physician-2

• Incorporate current clinical practice
  guidelines for diabetes into daily management
  practices
• Coordinate and facilitate the care of the
  individual with diabetes and use a system of
  timely reminders for diabetes assessment and
  management
• Assure communication among all members of the
  DHC team

25
Organization of Diabetes Care
Education

• Diabetes self - management is complex
• Initial and ongoing education of the
  individual with diabetes is an integral part
  of diabetes management

26
Organization of Diabetes Care
Rights and Responsibilities Health Care System-1

• The health care system, governments, and society
  as a whole should recognize the rights of the
  person with diabetes by striving to
• - include the person with diabetes in the
  planning of health care delivery

27
Organization of Diabetes Care
Rights and Responsibilities Health Care System-2

• - provide equitable access to diabetes care and
  education which adheres to the Guidelines for
  the Management of Diabetes in Canada and
  Standards for Diabetes Education in Canada
• - eliminate diabetes as an unnecessary cause of
  workplace injury, illness and disability

28
Organization of Diabetes Care
Rights and Responsibilities Health Care System-3

• - eliminate diabetes as a source of blanket
  discrimination with respect to health care
  services, employment, insurance and other
  related individual rights
• - develop a comprehensive information system to
  support interdisciplinary delivery of diabetes
  care

29
Organization of Diabetes Carea
Rights and ResponsibilitiesIndividuals with
Diabetes

• Should strive to
• - actively participate in health care planning
  and delivery
• - follow recommended guidelines
• - become a full participant in the diabetes
  health care (DHC) team process
• - adhere to recommended guidelines where the
  public interest is at stake (e.g. motor vehicle
  licensing)

30
Definition, Classification, Diagnosis and
Screening
31
Definition, Classification, Diagnosis and
Screening

• Chair
• Denis Daneman, MD
• Members
• Jeff Mahon, MD
• Stuart Ross, MD
• Edward Ryan, MD
• Claude Catellier, MD

32
Classification and Diagnosis
Objectives

• Classification based on etiology
• eliminate the terms IDDM and NIDDM
• retain Type 1 and Type 2
• Facilitate diagnosis ie. FPG
• Introduce screening for Type 2
• if gt age 45 or risk factors present...
• Promote preventive lifestyle changes in those
  at risk

33
Classification and Diagnosis

• Type 1 result of pancreatic beta-cell
  destruction and prone to ketoacidosis
• Type 2 ranges from insulin resistance with
  relative insulin deficiency to predominantly
  secretory defect with insulin resistance
• Other variety of conditions which consist
  mainly of specific, genetic forms of
  diabetes, or diabetes associated with other
  diseases or drug use
• Gestational diabetes first recognized during
  pregnancy

34
Classification and Diagnosis
Recommendations
The specific fasting plasma glucose (FPG)
level used to diagnose diabetes should be
reduced from 7.8 to 7.0 mmol/L Grade A This
lowering of the FPG diagnostic level ensures
that both the FPG and 2hPG define a similar
degree of hyperglycemia and risk for
microvascular disease It also permits the
diagnosis of diabetes to be made on the basis of
a commonly available test the FPG
35
Classification and Diagnosis

• The term Impaired Glucose Tolerance (IGT) has
  been retained but now depends only on a
  measurement of plasma glucose 2 h after a 75-g
  glucose load (2hPG) (7.8 but lt 11.1 mmol/L)
  Grade D
• primarily used for post-partum testing and
  research

36
Classification and Diagnosis

• The term Impaired Fasting Glucose (IFG)
  should be established to identify another
  intermediate stage of abnormal glucose
  homeostasis lt 6.1 and lt 7.0 mmol/L Grade D
• Both IGT and IFG indicate a need for annual
  testing and attention to associated risk
  factors and lifestyle changes Grade D

37
Classification and Diagnosis
Diagnosis of diabetes mellitus
Symptoms of diabetes plus a casual plasma
glucose value gt 11.1 mmol/L A
fasting plasma glucose (FPG) gt 7.0 mmol/L
A plasma glucose value in the 2-h sample
(2hPG) of the oral glucose tolerance test
(OGTT) gt 11.1 mmol/L
Or
Or
A confirmatory test must be done on another day
in all cases in the absence of unequivocal
hyperglycemia accompanied by acute metabolic
decompensation. This must be based on
laboratory measurements of venous plasma
glucose.
38
Classification and Diagnosis
Glucose levels for diagnosis in non-pregnant
adults
Plasma glucose 2 hours after75-g glucose
loadmmol/L
Fasting plasma glucosemmol/L
Category
Impaired fasting glucose (IFG) Impaired
glucose tolerance (IGT) Diabetes mellitus (DM)
6.1 6.9 lt 7.0 gt 7.0
N/A 7.8 11.0 gt 11.1
N/A not applicable.
39
Classification and Diagnosis
Screening for type 2 diabetes
Approximately 3 to 5 of the general adult
population has unrecognized type 2 diabetes.
Recommendations
Mass screening for type 2 diabetes in the
general population is not recommended Grade
D Testing for diabetes using a FPG test
should be performed every 3 years in those over
45 years of age Grade D
40
Classification and Diagnosis
Screening for type 2 diabetes
More frequent or earlier testing if
Annual screening if
History of GDM or delivery of neonate gt
4kg History IGT or IFG Coronary artery
disease Hypertension Presence of
complications associated with diabetes
Member of high risk population (Aboriginal,
Hispanic, Asian, African descent) Diabetes in
a first-degree relative Obesity Low HDL
chol.(lt 0.9) or high triglycerides (gt 2.8)
Grade D
Grade D
41
Classification and Diagnosis
Prevention

• In those at increased risk for Type 2
  diabetes, a program of weight control
  throught diet and regular physical activity
  is recommended and may help prevent diabetes
  Grade B
• Attempts to prevent Type 1 diabetes are
  experimental and should be limited to
  research studies Grade D

42
Management of Diabetes
43
Management of Diabetes

• Chair
• Jean-François Yale, MD
• Members
• Heather Dean, MD
• Lynn Edwards, PDT
• François Gilbert, MD
• Jana Havrankova, MD
• Keith Dawson, MD, PhD
• Carol Joyce, MD
• Errol Marliss, MD
• Graydon Meneilly, MD
• Thomas Wolever, MD, PhD
• Stewart Harris, MD, MPH
• Irwin N. Antone, MD

44
Management
History to be taken during initial visit
Symptoms
Onset and progression of symptoms of
hyperglycemia Symptoms of acute and long-term
complications of diabetes (e.g. ophthalmologic,
renal, cardiovascular, neurologic, skin and foot
problems) Functional inquiry Status of organ
systems to determine other medical
disorders Eating habits (e.g., food choices,
meal plans, meal timing, ethnic and cultural
influences) Weight history, especially recent
changes Level of physical activity and limiting
factors (i.e., type, duration, intensity,
frequency and time of day of exercise) Risk
factors for diabetes (e.g., family history,
obesity, previous gestational diabetes)
45
Management
History to be taken during initial visit

• Past history
• Endocrine disorders
• Infections
• Cardiovascular disease
• Surgery (e.g. pancreatic)
• Obstetric (if relevant)

46
Management
History to be taken during initial visit

• Family history
• - diabetes mellitus
• - cardiovascular disease
• - dyslipidemia
• - hypertension, renal disease
• - syndrome of insulin resistance (metabolic
  syndrome)
• - infertility, hirsutism
• - autoimmune diseases

Hirsutism, obesity and fertility are
statistically associated with increased risk for
diabetes
47
Management
History to be taken during initial visit

• Risk factors
• - hypertension
• - dyslipidemia
• - central obesity
• - cigarette smoking
• Social factors
• - family dynamics
• - education
• - employment
• - lifestyle, coping skills
• Drug history
• - current medications
• - ethanol
• - possible drug interactions

48
Management
History to be obtained at initial and follow-up
visits

• Lifestyle
• Details of nutrition counselling
• meal plans, adherence to prescribed meal plans,
  ethnic and cultural influences and weight
  changes
• Diabetes education received in the past
• location and level of program, current
  understanding of diabetes and its management
• Level of physical activity
• i.e. type, duration, intensity, frequency and
  time of day of exercise

49
Management
History to be obtained at initial and follow-up
visits

• Monitoring
• - method used and technique
• - frequency, timing in relation to meals, records
• - quality control of meter (correlation with
  laboratory)
• Hypoglycemia
• - awareness, symptoms, frequency, time of
  occurrence, severity, precipitating causes,
  treatment and prevention

50
Management
History to be obtained at initial and follow-up
visits

• Antihyperglycemic medications
• - oral agents (type, dose, compliance), any
  adjustment in response to monitoring
• - insulin (type, source, dose, injection sites),
  understanding of dose adjustments in response to
  food, activity

51
Management
History to be obtained at initial and follow-up
visits

• Social and psychological factors
• - support of family and friends
• - economic abilities
• - medical insurance
• - medic alert

52
Management
Initial and follow-up physical examination
General Height, weight, waist circumference
(central obesity), BMI, blood pressure (lying
and standing), pulse Head and neck Eyes
(pupillary reactions, extraocular movements,
lens opacities and fundi), oral cavity (hygiene
and caries), thyroid assessment Chest Routine Ca
rdiovascular system Signs of congestive heart
failure, pulses, bruits
BMI body mass index (body weight in kg
divided by height in m2)
53
Management
Initial and follow-up physical examination
Abdomen Organomegaly Genitourinary system Rule
out fungal infections Musculoskeletal system Foot
inspections, signs of limited joint mobility and
arthropathy of the hands, colour and
temperature Central nervous system Routine
evaluation for dysesthesias, change in
proprioception, vibration, light touch
(monofilament) and reflexes. Evaluation for
autonomic neuropathy, if appropriate Skin Inspec
tion for cutaneous infections, problems with
injection sites and signs of dyslipidemias
54
Management
Management plan to be discussed during initial
visits

• Nutritional and physical activity counselling
• - dietitian visits
• - goals for lifestyle change
• Monitoring
• - frequency of testing
• - meter knowledge and laboratory correlation

55
Management
Management plan to be discussed during initial
visits

• Medication counselling (oral agents and/or
  insulin)
• - method of administration
• - dosage adjustments
• Diabetes knowledge
• - knowledge of value of glucose control
• - hypoglycemia (prevention, recognition and
  treatment)
• - determination of individual target goals
• - appreciation of lifestyle considerations
• - recognition of further educational or
  motivational needs

56
Management
Follow-up visits

• Routine clinical care
• - routine visit at 24 months with directed
  history for diabetes (table 7)
• - blood pressure, foot examination at each visit
• - evaluation of progress toward reduction of
  risks of long-term complications
• - adjustment of treatment plans

57
Management
Follow-up visits

• Glycemic control
• - glycated hemoglobin every 24 months
• - laboratory-meter glucose correlation at least
  annually
• - FPG level (preferred for correlation), as
  needed

58
Management
Follow-up visits

• Complication and risk evaluation
• Fasting lipid profile (including total, HDL,
  calculated LDL cholesterol and TG levels
  annually)
• Dipstick urinalysis to screen for gross
  proteinuria
• if negative, microalbuminuria screening with a
  random daytime urinary albumin creatinine
  ratio yearly in type 2 and yearly after 5 years
  of postpubertal type 1 diabetes
• if positive, a 24-h urine test for endogenous
  creatinine clearance rate and microalbuminuria
  every 6-12 mo
• Resting or exercise ECG if appropriate (age gt
  35yr)

59
Management
Rationale
For most people with diabetes, improving
metabolic control will achieve the primary goal
of preventing the onset or delaying the
progression of long-term micro and macro -
vascular complications
60
Management
Levels of glucose control for adults and
adolescents with diabetes mellitus
Level
Ideal (normal nondiabetic)
Optimal(target goal)
Suboptimal(action may be required)
Inadequate(action required)
Glycated Hb ( of upper limit) e.g., HbA1c
assay Fasting or premeal glucose
level (mmol/L)Glucose level 12 h after meal
(mmol/L)
lt 100(0.040.06) 3.86.1 4.47
lt 115(lt0.07) 47 5.011
116140(0.070.084) 7.110 11.114
gt 140(gt 0.084) gt 10 gt 14
61
Management
Lipids
of risk factors in addition to diabetes
10 yr risk
Target values
LDL-C (mmol/L)
TC/HDL-C ratio
TG (mmol/L)
gt 40 lt 2.5 lt 4.0 lt 2.0 20-40 lt
3.5 lt 5.0 lt 2.0 10-20 lt 4.0 lt 6.0 lt
2.0 0-10 lt 5.0 lt 7.0 lt 3.0
CHD present or 3 other risk factors 2 other
risk factors 1 other risk factor no other
risk factor
62
Management
Self-Monitoring
EssentialAll insulin-treated people (Type 1 or 2
diabetes) Grade BAll pregnant women with
pre-existing diabetes or gestational diabetes
Grade A Integral ComponentMajority of people
with Type 2 diabetes treated with oral
hypoglycemic agents Grade D UsefulPeople
with Type 2 diabetes controlled by diet therapy
alone Grade D
63
Management
Self-Monitoring
In order to ensure optimal performance of SMBG,
the person with diabetes must be educated on -
the use of the glucose meter - the interpretation
of the results - where possible, how to modify
treatment according to blood glucose levels
Grade B
64
Management
Nutritional approaches
All people with diabetes should receive
individual advice on nutrition from a registered
dietitian.
Grade D
65
Management
Nutritional approaches

• In type 2 diabetes, nutritional approaches
  are oriented toward improving glucose and
  lipid levels through diet modification and
  weight loss when appropriate
• In obese people with Type 2 diabetes,
  lifestyle changes (diet and increased
  physical activity) should be the initial
  therapy

This can result in improved metabolic control
and weight loss.
Grade B
66
Management
Nutritional approaches
Nutritional recommendations are the same as
those of Health and Welfare Canada for the
general population

• - choosing a variety of foods from the 4 food
  groups (grain products, vegetables and
  fruits, milk products, meat and alternatives)
• - attaining a healthy body weight
• - decreasing saturated fat intake to less than
  10 of calories
• - having an adequate intake of carbohydrate,
  protein, vitamins and minerals

67
Management
Nutritional approaches
The distribution of nutrients may be tailored
to the individual patient depending on needs and
personal preferences Meal-planning, using
approximately 55 carbohydrate and 30 fat
content often serves as a starting point in the
development of specific recommendations
Grade D
68
Management
Nutritional approaches
Sucrose and sucrose-containing foods can be
substituted for other carbohydrates as part of
mixed meals, up to a maximum of 10 of calories,
provided adequate control of blood glucose and
lipids is maintained .
Grade B
69
Management
Physical activity and exercise
An active lifestyle promotes

• cardiovascular fitness and well-being
• increased insulin sensitivity
• lower blood pressure, and
• a healthy lipoprotein profile in all people
  with diabetes

70
Management
Physical activity and exercise

• A stepwise increase in physical activity should
  be part of the therapeutic plan for everyone
  with type 2 diabetes who is able to increase
  activity, but prescribed with care for people
  with
• known occlusive vascular disease (or at high
  risk)
• significant sensory polyneuropathy
• advanced microvascular complications

Grade D, consensus
71
Management
Physical activity and exercise
The initiation of a vigorous exercise program
requires detailed history and physical
examination and specific laboratory
investigations (e.g. a stress ECG if gt 35
years).
Grade D
72
Management
Physical activity and exercise

• In anyone treated with insulin, recommendations
  regarding
• alterations of diet
• insulin regimen
• injection sites and
• self-monitoring should be appropriate for the
  general level of physical activity or specific
  types of exercise undertaken
• Oral agent doses may need to be decreased.

Grade D, consensus
73
Management
Physical activity and exercise

• General advice regarding physical activity for
  everyone with diabetes
• use proper footwear, inspect both feet daily and
  after each exercise session, if indicated, and
  use adequate protective devices
• avoid exercising during any period of poor
  metabolic control
• ingest rapidly absorbed carbohydrate if
  pre-exercise glucose level is under 5 mmol/L
• avoid exercise in extreme hot or cold conditions
• administer insulin into a site away from the
  most actively exercising extremities

Grade D, consensus
74
Stepwise approach to Type 2 diabetes
Nonpharmacologic therapy
If individualized goals for glucose are not
achieved within 2-4 months, reassess lifestyle
interventions to maximize benefitsAdvance to
next level of therapy
Oral agent monotherapy
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
75
Stepwise approach to Type 2 diabetes
Nonpharmacologic therapy
Lifestyle modifications nutrition therapy
(consultation with a dietitian) physical
activity avoidance of smokingEducation
teach diabetes self-care, including
self-monitoring of blood glucose level
Oral agent monotherapy
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
76
Stepwise approach to Type 2 diabetes
Choice of agent should be tailored to the
individual if FPG gt 10 mmol/L, use
sulfonylurea or biguanide biguanides are
associated with less weight gain and lower
frequency of hypoglycemia than sulfonylureas,
but gastrointestinal side effects may be a
limiting factor in the elderly, initiate at a
lower dose, and choice of agent may differ it
there is renal or hepatic failure, biguanides
are contraindicated
Nonpharmacologic therapy
Oral agent monotherapy
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
77
Stepwise approach to Type 2 diabetes
Nonpharmacologic therapy
Oral agent monotherapy
Agent or agents from other classes may be added
until the maximum dose of an agent of each
class is reached
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
78
Stepwise approach to Type 2 diabetes
Nonpharmacologic therapy
When insulin therapy is initiated, the
concomitant use of oral agents is an acceptable
option. When insulin therapy is added to oral
agents, it may be in the form of a single
injection of intermediate-acting insulin at
bedtime. This approach may result in better
glucose control with a smaller insulin dose and
may induce less weight gain than the use of
insulin alone.
Oral agent monotherapy
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
79
Stepwise approach to Type 2 diabetes
Nonpharmacologic therapy
Once other modes of therapy no longer work,
insulin doses (frequently high) and the number
of injections (2-4) should be adjusted to
achieve target glucose levels. On occasion,
oral agents may be added to the insulin
regimen acarbose, metformin or troglitazone.
Oral agent monotherapy
Oral combination therapy
Bedtime insulin oral agents
Insulin injections, 1-4/day
80
Management
Oral Agents Alert
If lifestyle changes and/or oral agents are
unsuccessful, or in the presence of signs of
deterioration with symptoms within 2 - 4 weeks
of diagnosis, insulin may be required
immediately.
81
Management
Insulin Therapy Type 1

• Most individuals with Type 1 diabetes should
  aim for ideal glucose levels Grade A
• Multiple daily injections (3 or 4 per day) or
  the use of CSII as part of an intensified
  diabetes management regimen are usually
  required Grade A

82
Management
Insulin Therapy Type 1

• Lispro insulin can be used as a premeal
  insulin in intensified insulin therapy. It is
  associated with lower postprandial glucose
  levels and lower rates of nocturnal
  hypoglycemia Grade A
• Lispro is the preferred insulin for use in
  CSII Grade B

83
Management
Type 1 Children Adolescents

• The target HbA1c for pre-pubertal children is
  120-140 of the upper limit of normal with
  graduated blood glucose and HbA1c targets for
  age
• Extreme caution is required in children less
  than 5 years of age to avoid hypoglycemia
  because of the permanent cognitive deficit that
  may occur in this age group

84
Management
Type 1 Children Adolescents
All children with diabetes should have access to
an experienced DHC team. The complex physical,
developmental and emotional needs of children
and their families require specialized care to
optimize long-term outcome.
85
Management
Type 1 Children Adolescents
In children and adolescents with new-onset
diabetes, initial outpatient education and
management should be considered if the
appropriate personnel and a 24-h telephone
consultation service are available.
86
Management
Diabetes in the elderly

• The same glucose targets apply to otherwise
  healthy elderly as to younger people with
  diabetes
• In people with multiple comorbidity, the goal
  should be to avoid symptoms of hyperglycemia
  and prevent hypoglycemia Grade D
• Closer to normal glucose levels are
  associated with a lower risk of complications
  in elderly people with type 2 diabetes Grade
  A

87
Management
Diabetes in the elderly
Elderly people with diabetes should be referred
to a DHC team. Interdisciplinary interventions
have been shown to improve glycemic control in
the elderly.

• Grade B

88
Management
Diabetes in the elderly Lifestyle

• The recommended distribution of nutrients is
  as suggested for the general aging population
  Grade D
• In chronic care institutions, specific
  dietary restrictions may not be useful in
  improving glycemic control Grade D

89
Management
Diabetes in the elderly
Moderate exercise is beneficial for elderly
people with type 2 diabetes

• comorbid conditions may prevent aerobic
  physical training Grade D
• any increase in activity levels may be
  difficult to achieve Grade D

90
Management
Diabetes in the elderly
Oral agents

• In elderly people, sulfonylureas should be
  used with caution because the risk of
  hypoglycemia increases exponentially with age
  Grade D
• In general, initial doses should be half those
  for younger people, and doses should be
  increased more slowly Grade D

91
Management
Diabetes in the elderly
Oral agents

• Gliclazide may be the preferred sulfonylurea,
  as it is associated with a reduced frequency of
  hypoglycemic events compared with glyburide

• Grade A

92
Management
Diabetes in the elderly
Insulin In elderly people, the use of premixed
insulins as an alternative to mixing insulins
may minimize dosage errors.

• Grade B

93
Management
Pregnancy - Pre-existing Diabetes
Prior to pregnancy

• Pregnancy in women with diabetes should be
  planned Grade C
• All women with diabetes should attempt to
  attain ideal or normal blood glucose control.
  HbA1c levels above 140 of the upper limit of
  normal non pregnant values should be avoided
  Grade B
• Evaluation for possible complications
  (retinopathy, nephropathy, coronary heart
  disease) should be done prior to pregnancy

Grade B
94
Management
Pregnancy - Pre-existing Diabetes
During pregnancy

• All women with diabetes should aim for ideal
  glucose levels without significant hypoglycemia
  Grade D
• Any woman on diet alone who does not achieve
  target levels should be started on insulin
  Grade D

95
Management
Pregnancy - Pre-existing Diabetes
During pregnancy
Ketosis should be avoided Grade B - normal
weight gain should be the goal - weight gain
should be monitored - weight reducing diets
should be avoided Grade D Retinal
examination should be performed regularly,
especially if retinopathy was present before
pregnancy Grade B
96
Management
Gestational Diabetes Mellitus
Screening

• Screening between 24 - 28 weeks
• A 50-g glucose load given any time of day with a
  1 hour plasma glucose- If gt7.8 mmol/L - do
  OGTT- If gt10.6 mmol/L - diagnose GDM
• Done in all women unless they are in a very
  low-risk group (under 25 yr. old, lean,
  Caucasian, with negative family history)

97
Management
Gestational Diabetes Mellitus
Diagnosis

• Values post - 75g glucosw load
• FPG gt 5.3 mmol/L
• 1 hour gt 10.6 mmol/L
• 2 hours gt 8.9 mmol/L
• If 2 abnormal values GDM
• If only 1 abnormal value Impaired
• Glucose Tolerance of Pregnancy

• Grade D

98
Management
Gestational Diabetes
During pregnancy

• Dietary counseling should be given to ensure a
  well-balanced diet with a goal of achieving
  normal maternal and fetal weight gain, and
  normal maternal glucose values. Because of the
  risk of ketonemia, weight-reducing diets are not
  recommended. Grade D
• Regular and moderate exercise, particularly of
  the upper body, should be encouraged Grade A

99
Management
Gestational Diabetes
During pregnancy

• Women with gestational diabetes should aim for
  normal glucose levels
• Goals associated with best neonatal outcome are
• FPG lt 5.3 mmol/L Grade C
• 1 h post-prandial glucose lt 7.8 mmol/L Grade B
• 2 h post-prandial glucose lt 6.7 mmol/L Grade D

100
Management
Gestational Diabetes
Postpartum

• Women having had gestational diabetes should be
  advised to achieve a healthy body weight and
  exercise regularly Grade D
• Six weeks to 6 months after delivery, an OGTT
  (75 g/2-h) should be performed to rule out the
  presence of glucose intolerance or diabetes
  Grade D

101
Management
First Nations
There must be recognition, respect, and
sensitivity for the unique language, culture and
geographic issues as they relate to diabetes
care in First Nation communities across Canada.
102
Management
First Nations

• Community-based screening programs using blood
  glucose levels should be established in First
  Nations communities
• Urban people of First Nation origin should be
  screened for diabetes in primary care settings
• Primary prevention programs initiated by First
  Nation communities should be encouraged

• Grade D

103
Complications of Diabetes
104
Complications of Diabetes

• Co-chairs
• Bernard Zinman, MD
• David Lau, MD, PhD
• Members
• Timothy Benstead, MDC
• Iain Begg, MB
• Jean-Marie Ekoé, MD
• Andrew Steele, MDC
• Catharine Whiteside, MD, PhD

105
Complications
Retinopathy screening

• Screening done by a person highly trained and
  experienced in the use of the ophthalmoscope,
  using direct ophthalmoscopy through dilated
  pupils Grade A
• In Type 1, start annual screening for
  retinopathy at age 15 or 5 years after
  diagnosis Grade A
• In Type 2, screen at diagnosis and then tailor
  to findings, every 1 - 4 years Grade A

106
Complications
Retinopathy care

• Control of blood sugar Grade A, blood pressure
  and lipids Grade D all help to protect eyes
• Anyone with pre-proliferative or worse retinal
  changes should be followed by an ophthalmologist
  or retinal specialist Grade A
• Pre-pregnancy assessment important Grade A
• Refer for low vision rehabilitationGrade D

107
Complications
Nephropathy Screening

• If dipstick negative or trace...Annual
  albumin/creatinine ratio on random daytime urine
  sampleValues
• gt 2.8 mg/mmol/L for women and gt 2.0 mg/mmol/L
  for men should be repeated
• if still elevated, confirm with a timed urine
  collection Grade A
• People gt 15 years of age who have had gt 5 years
  of Type 1 diabetes, or all individuals after
  diagnosis of Type 2 diabetes Grade D

108
Complications
Definition of microalbuminuria
Standard urinalysis (protein)
UrinaryAER(mg/24 h)
UrinaryAER(µg/min)
Albumin/creatinine ratio
Male
Female
Normal Normoalbuminuria Microalbuminuria Macroalbu
minuria
Negative Negative Negative Positive
10 3 lt 30 30 - 300 gt 300
7 2 lt 20 20 - 200 gt 200
lt 2.0 lt 2.0 gt 2.0
lt 2.8 lt 2.8 gt 2.8
AER albumin excretion rate
109
Complications
Management of Nephropathy

• Intensive blood glucose control Grade A
• In Type 1 diabetes microalbuminuria should be
  treated with an ACE inhibitor even in the
  absence of hypertension Grade A
• In Type 2 diabetes, microalbuminuria may benefit
  from ACE inhibitor therapy Grade B
• Individuals with Type 1 diabetes and overt
  nephropathy (albuminuria gt 300 mg/24hrs) should
  be treated with an ACE inhibitor Grade A
• Refer if greater than 50 renal function is lost

110
Complications
Neuropathy Screening

• Annual screening to find feet at risk Grade A
• Detection of peripheral neuropathy should be
  assessed
• by a decrease or loss of vibration sense, and/or
  loss of sensitivity to a 10-g monofilament at
  the great toe
• and absent/decreased ankle reflexes Grade A

111
Complications
Neuropathy Management

• Intensive management of glucose control helps in
  both Type 1 and 2 diabetes
• Painful peripheral neuropathy can be treated
  with tricyclic antidepressants, carbamazepine or
  mexiletine
• Refer and assess autonomic dysfunction, ask
  about sexual dysfunction (people may be shy)

CANADIANDIABETES ASSOCIATION
ASSOCIATIONCANADIENNEDU DIABÈTE
1998 Clinical Practice Guidelines for
the Management of Diabetes in Canada
January 1999
112
Complications
Foot Care

• Foot examination should be performed at least
  annually in people gt 15 years of age and at more
  frequent intervals for those at high risk which
  includes
• previous ulceration
• age
• peripheral vascular disease (PVD)
• neuropathy
• structural deformity
• renal transplantation

113
Complications
Foot Care

• Foot examination in adults is an integral
  component of diabetes management and decreases
  risk for foot ulcer and amputation Grade A
• Foot examination should include assessment of
  structural abnormalities, neuropathy, vascular
  disease, ulcerations and evidence of infection
  Grade D

114
Complications
Foot Care

• Prevention of foot ulceration requires foot care
  education, proper footwear, avoidance of foot
  trauma, smoking cessation, and early referral if
  problems occur

115
Complications
Foot Care

• Individuals at high risk of foot ulceration
  should receive reinforcement of foot care
  education and management by individuals with
  expertise in diabetes foot care Grade A
• An individual with diabetes who develops a foot
  ulcer requires therapy by experienced health
  care providers Grade D

116
Complications
Cardiovascular - Lifestyle

• People with Type 1 and Type 2 diabetes should be
  encouraged to adopt a healthy lifestyle in order
  to lower their CVD risk by achieving and
  maintaining a healthy weight, regular physical
  activity and smoking cessation

Grade D
117
Complications
Cardiovascular - Lipids

• Fasting lipid profile (total cholesterol,
  triglycerides, HDL cholesterol, and calculated
  LDL cholesterol) should be performed in adults
  with diabetes and repeated every 1 to 3 years as
  clinically indicated (Grade D)
• Therapy with lipid modulating agents should be
  instituted if a 3-6 month trial of
  non-pharmacologic methods fails to achieve
  target lipid levels (Grade B)

118
Complications
Cardiovascular - Hypertension

• Hypertension in people with diabetes (BP gt
  140/90) should be treated to attain target blood
  pressure less than 130/85 mm/Hg (Grade D)
• Hypertension treatment goals in the elderly
  should be individualized (Grade D)

119
Complications
Cardiovascular - Hypertension TX

• First line drug therapies for hypertension in
  people with diabetes, without overt nephropathy,
  are (in alphabetical order)
• ACE inhibitors
• alpha blockade agents
• angiotensin II receptor antagonists
• calcium channel antagonists
• thiazide diuretics and beta - blockers are
  reserved as second-line agents

Grade D
120
Summary

• Team approach
• Screening
• New diagnostic criteria
• Better glycemic control
• Continuum of care