1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada Canadian Diabetes Association Steering and Expert Committees CMAJ;Oct.20,1998;159(8 Suppl)

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  Steering Committee co-chairs: Sara Meltzer, MDSara Meltzer, MD Lawrence Leiter, MDLawrence Leiter, MD  Steering Committee members: Keith Dawson, MD, PhDKeith Dawson, MD, PhD Jana Havrankova, MDJana Havrankova, MD Beverley Madrick, RD, CDEBeverley Madrick, RD, CDE Meng-Hee Tan, MDMeng-Hee Tan, MD Stewart Harris, MD, MPHStewart Harris, MD, MPH Donna Lillie, RN, BADonna Lillie, RN, BA Beryl Schultz, RN, CDEBeryl Schultz, RN, CDE  Steering Committee co-chairs: Sara Meltzer, MDSara Meltzer, MD Lawrence Leiter, MDLawrence Leiter, MD  Steering Committee members: Keith Dawson, MD, PhDKeith Dawson, MD, PhD Jana Havrankova, MDJana Havrankova, MD Beverley Madrick, RD, CDEBeverley Madrick, RD, CDE Meng-Hee Tan, MDMeng-Hee Tan, MD Stewart Harris, MD, MPHStewart Harris, MD, MPH Donna Lillie, RN, BADonna Lillie, RN, BA Beryl Schultz, RN, CDEBeryl Schultz, RN, CDE

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Introduction and Methodology

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 1998 Clinical Practice Guidelines What’s really changed? What does it mean in terms of practice changes? What’s really changed? What does it mean in terms of practice changes?

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Clinical Guidelines are... “ systematically developed statements which assist clinicians and patients in making decisions ” - KGMM Alberti

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Role of guidelines Promote optimal treatment and good medical practice (i.e.: quality control)Promote optimal treatment and good medical practice (i.e.: quality control) Facilitate development of education programs for those less familiarFacilitate development of education programs for those less familiar Provide justification for improvements to the health care systemProvide justification for improvements to the health care system -policy development -financial re-imbursement issues Promote optimal treatment and good medical practice (i.e.: quality control)Promote optimal treatment and good medical practice (i.e.: quality control) Facilitate development of education programs for those less familiarFacilitate development of education programs for those less familiar Provide justification for improvements to the health care systemProvide justification for improvements to the health care system -policy development -financial re-imbursement issues

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Process 1. Formation of team 2. Outline plan 3. Review literature 4. Production 5. External review 6. Amendments 7. Implementation 1. Formation of team 2. Outline plan 3. Review literature 4. Production 5. External review 6. Amendments 7. Implementation

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Evidence-Based Evaluation

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Evidence-Based Evaluation  Chair: Hertzel Gerstein, MD, MScHertzel Gerstein, MD, MSc  Members: Dereck Hunt, MDDereck Hunt, MD Anne Holbrook, MD, MScAnne Holbrook, MD, MSc  Chair: Hertzel Gerstein, MD, MScHertzel Gerstein, MD, MSc  Members: Dereck Hunt, MDDereck Hunt, MD Anne Holbrook, MD, MScAnne Holbrook, MD, MSc

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE “Evidence-Based”  = evidence - linked guidelines whose development requires the explicit linkage of the evidence with the recommendation Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Evidence-Based Guidelines Methodology Identify clinically important questions Search and review the literature Assign a level of evidence for key citations Identify clinically important questions Search and review the literature Assign a level of evidence for key citations Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Evidence-Based Guidelines Methodology Develop recommendations based on key citations Assign a grade to the recommendation Independent review of the recommendations and supporting citations Develop recommendations based on key citations Assign a grade to the recommendation Independent review of the recommendations and supporting citations Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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   A: supportive level 1 or 1+ evidence   B: supportive level 2 or 2+ evidence   C: supportive level 3 & consensus   D: any lower level & consensus Process

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Organization of Diabetes Care

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Organization of Diabetes Care   Chair: Sora Ludwig, MD   Members: André Bélanger, MD Peggy Dunbar, PTD, CDE James McSherry, MD Beryl Schultz, RN, CDE   Chair: Sora Ludwig, MD   Members: André Bélanger, MD Peggy Dunbar, PTD, CDE James McSherry, MD Beryl Schultz, RN, CDE

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Central Themes Organisation of Diabetes Care  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  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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Role of Primary Care Physician Organization of Diabetes Care   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...

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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  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 Organization of Diabetes Care

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Education Organization of Diabetes Care  Diabetes self - management is complex  Initial and ongoing education of the individual with diabetes is an integral part of diabetes management  Diabetes self - management is complex  Initial and ongoing education of the individual with diabetes is an integral part of diabetes management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Rights and Responsibilities Health Care System-1 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 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 Organization of Diabetes Care

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Rights and Responsibilities Health Care System-2 Rights and Responsibilities Health Care System-2 Organization of Diabetes Care -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 -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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE -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 -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 Rights and Responsibilities Health Care System-3 Rights and Responsibilities Health Care System-3 Organization of Diabetes Care

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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) 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) Rights and Responsibilities Individuals with Diabetes Organization of Diabetes Carea

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Definition, Classification, Diagnosis and Screening

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE   Chair: Denis Daneman, MD   Members: Jeff Mahon, MD Stuart Ross, MD Edward Ryan, MD Claude Catellier, MD   Chair: Denis Daneman, MD   Members: Jeff Mahon, MD Stuart Ross, MD Edward Ryan, MD Claude Catellier, MD Definition, Classification, Diagnosis and Screening

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 > age 45 or risk factors present... Promote preventive lifestyle changes in those “at risk” 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 > age 45 or risk factors present... Promote preventive lifestyle changes in those “at risk”

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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   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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Recommendations Classification and Diagnosis 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 < 11.1 mmol/L) [Grade D]  primarily used for post-partum testing and research 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 < 11.1 mmol/L) [Grade D]  primarily used for post-partum testing and research

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Classification and Diagnosis The term Impaired Fasting Glucose (IFG) should be established to identify another intermediate stage of abnormal glucose homeostasis < 6.1 and < 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] The term Impaired Fasting Glucose (IFG) should be established to identify another intermediate stage of abnormal glucose homeostasis < 6.1 and < 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]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Classification and Diagnosis > > > Symptoms of diabetes plus a casual plasma glucose value > 11.1 mmol/L A fasting plasma glucose (FPG) > 7.0 mmol/L A plasma glucose value in the 2-h sample (2hPG) of the oral glucose tolerance test (OGTT) > 11.1 mmol/L Diagnosis of diabetes mellitus 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.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Glucose levels for diagnosis in non-pregnant adults Category Fasting plasma glucose; mmol/L Plasma glucose 2 hours after 75-g glucose load; mmol/L Impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) Diabetes mellitus (DM) Impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) Diabetes mellitus (DM) 6.1 – 6.9 < 7.0 > > 7.0 6.1 – 6.9 < 7.0 > > 7.0 N/A 7.8 – 11.0 > > 11.1 N/A 7.8 – 11.0 > > 11.1 N/A = not applicable. Classification and Diagnosis

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Approximately 3% to 5% of the general adult population has unrecognized type 2 diabetes. Screening for type 2 diabetes Classification and Diagnosis 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] 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]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE More frequent or earlier testing if : Annual screening if : Member of high risk population (Aboriginal, Hispanic, Asian, African descent) Diabetes in a first-degree relative Obesity Low HDL chol.( 2.8) Member of high risk population (Aboriginal, Hispanic, Asian, African descent) Diabetes in a first-degree relative Obesity Low HDL chol.( 2.8) History of GDM or delivery of neonate > 4kg History IGT or IFG Coronary artery disease Hypertension Presence of complications associated with diabetes History of GDM or delivery of neonate > 4kg History IGT or IFG Coronary artery disease Hypertension Presence of complications associated with diabetes [Grade D] Classification and Diagnosis Screening for type 2 diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Prevention Classification and Diagnosis 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] 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]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management of Diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE   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   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 Management of Diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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) 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) Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE History to be taken during initial visit Management   Past history Endocrine disorders Infections Cardiovascular disease Surgery (e.g.: pancreatic) Obstetric (if relevant)   Past history Endocrine disorders Infections Cardiovascular disease Surgery (e.g.: pancreatic) Obstetric (if relevant)

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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   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 Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 History to be obtained at initial and follow-up visits Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 History to be obtained at initial and follow-up visits Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Social and psychological factors -support of family and friends -economic abilities -medical insurance -medic alert Social and psychological factors -support of family and friends -economic abilities -medical insurance -medic alert History to be obtained at initial and follow-up visits Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Initial and follow-up physical examination Management 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 Cardiovascular system Signs of congestive heart failure, pulses, bruits 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 Cardiovascular system Signs of congestive heart failure, pulses, bruits * BMI = body mass index (body weight in kg divided by height in m 2 )

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 Inspection for cutaneous infections, problems with injection sites and signs of dyslipidemias 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 Inspection for cutaneous infections, problems with injection sites and signs of dyslipidemias Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 Nutritional and physical activity counselling -dietitian visits -goals for lifestyle change Monitoring -frequency of testing -meter knowledge and laboratory correlation Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Follow-up visits Routine clinical care -routine visit at 2–4 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 Routine clinical care -routine visit at 2–4 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 Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Follow-up visits Glycemic control -glycated hemoglobin every 2–4 months -laboratory-meter glucose correlation at least annually -FPG level (preferred for correlation), as needed Glycemic control -glycated hemoglobin every 2–4 months -laboratory-meter glucose correlation at least annually -FPG level (preferred for correlation), as needed Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 > 35yr)   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 > 35yr) Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management 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 RationaleRationale

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Level Ideal (normal nondiabetic) Glycated Hb (% of upper limit) e.g., HbA 1c assay Fasting or premeal glucose level (mmol/L) Glucose level 1–2 h after meal (mmol/L) < 100 (0.04–0.06) 3.8–6.1 4.4–7 < 100 (0.04–0.06) 3.8–6.1 4.4–7 < 115 (<0.07) 4–7 5.0–11 < 115 (<0.07) 4–7 5.0–11 116–140 (0.07–0.084) 7.1–10 11.1–14 116–140 (0.07–0.084) 7.1–10 11.1–14 > 140 (> 0.084) > 10 > 14 > 140 (> 0.084) > 10 > 14 Optimal (target goal) Suboptimal (action may be required) Inadequate (action required) Levels of glucose control for adults and adolescents with diabetes mellitus Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management Lipids > 40%< 2.5+< 4.0+< 2.0 20-40%< 3.5+< 5.0+< 2.0 10-20%< 4.0+< 6.0+< 2.0 0-10%< 5.0+< 7.0+< 3.0 > 40%< 2.5+< 4.0+< 2.0 20-40%< 3.5+< 5.0+< 2.0 10-20%< 4.0+< 6.0+< 2.0 0-10%< 5.0+< 7.0+< 3.0 # of risk factors in addition to diabetes 10 yr risk Target values LDL-C (mmol/L) LDL-C (mmol/L) TC/HDL-C ratio TC/HDL-C ratio TG (mmol/L) TG (mmol/L) CHD present or 3 other risk factors 2 other risk factors 1 other risk factor no other risk factor CHD present or 3 other risk factors 2 other risk factors 1 other risk factor no other risk factor

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Essential All insulin-treated people (Type 1 or 2 diabetes) [Grade B] All pregnant women with pre-existing diabetes or gestational diabetes [Grade A] Integral Component Majority of people with Type 2 diabetes treated with oral hypoglycemic agents [Grade D] Useful People with Type 2 diabetes controlled by diet therapy alone [Grade D] Essential All insulin-treated people (Type 1 or 2 diabetes) [Grade B] All pregnant women with pre-existing diabetes or gestational diabetes [Grade A] Integral Component Majority of people with Type 2 diabetes treated with oral hypoglycemic agents [Grade D] Useful People with Type 2 diabetes controlled by diet therapy alone [Grade D] Self-Monitoring Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE All people with diabetes should receive individual advice on nutrition from a registered dietitian. [Grade D] Management Nutritional approaches

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 [Grade B] This can result in improved metabolic control and weight loss.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management  -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  -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 Nutritional approaches Nutritional recommendations are the same as those of Health and Welfare Canada for the general population :

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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] Management Nutritional approaches

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE [Grade B] 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. Management Nutritional approaches

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  cardiovascular fitness and well-being  increased insulin sensitivity  lower blood pressure, and  a healthy lipoprotein profile in all people with diabetes  cardiovascular fitness and well-being  increased insulin sensitivity  lower blood pressure, and  a healthy lipoprotein profile in all people with diabetes Management Physical activity and exercise An active lifestyle promotes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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  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] Management Physical activity and exercise

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE The initiation of a vigorous exercise program requires detailed history and physical examination and specific laboratory investigations (e.g.: a stress ECG if > 35 years). [Grade D] Management Physical activity and exercise

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE [Grade D, consensus]  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.  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. Management Physical activity and exercise

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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  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 Management Physical activity and exercise [Grade D, consensus]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Stepwise approach to Type 2 diabetes If individualized goals for glucose are not achieved within 2-4 months, reassess lifestyle interventions to maximize benefits Advance to next level of therapy Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Lifestyle modifications:nutrition therapy (consultation with a dietitian)physical activity avoidance of smoking Education: teach diabetes self-care, including self-monitoring of blood glucose level Stepwise approach to Type 2 diabetes Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Choice of agent should be tailored to the individual: if FPG > 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 Choice of agent should be tailored to the individual: if FPG > 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 Stepwise approach to Type 2 diabetes Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Agent or agents from other classes may be added until the maximum dose of an agent of each class is reached Stepwise approach to Type 2 diabetes Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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. Stepwise approach to Type 2 diabetes Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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. Nonpharmacologic therapy Oral agent monotherapy Oral combination therapy Bedtime insulin ± oral agents Insulin injections, 1-4/day Stepwise approach to Type 2 diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management Type 1 Children & Adolescents The target HbA 1c for pre-pubertal children is 120-140% of the upper limit of normal with graduated blood glucose and HbA 1c 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 The target HbA 1c for pre-pubertal children is 120-140% of the upper limit of normal with graduated blood glucose and HbA 1c 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

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Diabetes in the elderly Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Elderly people with diabetes should be referred to a DHC team. Interdisciplinary interventions have been shown to improve glycemic control in the elderly. Diabetes in the elderly Management  [Grade B]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Diabetes in the elderly: Lifestyle Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE comorbid conditions may prevent aerobic physical training [Grade D] any increase in activity levels may be difficult to achieve [Grade D] comorbid conditions may prevent aerobic physical training [Grade D] any increase in activity levels may be difficult to achieve [Grade D] Diabetes in the elderly Management Moderate exercise is beneficial for elderly people with type 2 diabetes:

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Diabetes in the elderly Management Oral agents

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Gliclazide may be the preferred sulfonylurea, as it is associated with a reduced frequency of hypoglycemic events compared with glyburide Diabetes in the elderly Management Oral agents  [Grade A]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Insulin In elderly people, the use of premixed insulins as an alternative to mixing insulins may minimize dosage errors. Insulin In elderly people, the use of premixed insulins as an alternative to mixing insulins may minimize dosage errors. Diabetes in the elderly Management  [Grade B]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Pregnancy - Pre-existing Diabetes Prior to pregnancy Pregnancy in women with diabetes should be planned Pregnancy in women with diabetes should be planned [Grade C] All women with diabetes should attempt to attain ideal or normal blood glucose control. HbA 1c levels above 140% of the upper limit of normal non pregnant values should be avoided All women with diabetes should attempt to attain ideal or normal blood glucose control. HbA 1c 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 Pregnancy in women with diabetes should be planned Pregnancy in women with diabetes should be planned [Grade C] All women with diabetes should attempt to attain ideal or normal blood glucose control. HbA 1c levels above 140% of the upper limit of normal non pregnant values should be avoided All women with diabetes should attempt to attain ideal or normal blood glucose control. HbA 1c 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 Management [Grade B]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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]  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] Pregnancy - Pre-existing Diabetes During pregnancy Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Management 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] 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] Pregnancy - Pre-existing Diabetes During pregnancy

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  Screening between 24 - 28 weeks  A 50-g glucose load given any time of day with a 1 hour plasma glucose - If 7.8 mmol/L - do OGTT - If 10.6 mmol/L - diagnose GDM  A 50-g glucose load given any time of day with a 1 hour plasma glucose - If >7.8 mmol/L - do OGTT - If >10.6 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)  Screening between 24 - 28 weeks  A 50-g glucose load given any time of day with a 1 hour plasma glucose - If 7.8 mmol/L - do OGTT - If 10.6 mmol/L - diagnose GDM  A 50-g glucose load given any time of day with a 1 hour plasma glucose - If >7.8 mmol/L - do OGTT - If >10.6 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) Screening Management Gestational Diabetes Mellitus:

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  Values post - 75g glucosw load:  FPG  FPG > 5.3 mmol/L  1 hour > 10.6 mmol/L  2 hours > 8.9 mmol/L  If 2 abnormal values = GDM  If only 1 abnormal value = Impaired  Glucose Tolerance of Pregnancy  Values post - 75g glucosw load:  FPG  FPG > 5.3 mmol/L  1 hour > 10.6 mmol/L  2 hours > 8.9 mmol/L  If 2 abnormal values = GDM  If only 1 abnormal value = Impaired  Glucose Tolerance of Pregnancy Diagnosis Management Gestational Diabetes Mellitus:  [Grade D]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] During pregnancy Gestational Diabetes Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Women with gestational diabetes should aim for normal glucose levels Goals associated with best neonatal outcome are:  FPG < 5.3 mmol/L [Grade C]  1 h post-prandial glucose < 7.8 mmol/L [Grade B]  2 h post-prandial glucose < 6.7 mmol/L [Grade D] Women with gestational diabetes should aim for normal glucose levels Goals associated with best neonatal outcome are:  FPG < 5.3 mmol/L [Grade C]  1 h post-prandial glucose < 7.8 mmol/L [Grade B]  2 h post-prandial glucose < 6.7 mmol/L [Grade D] During pregnancy Gestational Diabetes Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Gestational Diabetes 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] 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] Postpartum Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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. First Nations Management

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 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 First Nations Management  [Grade D]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Complications of Diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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  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 Complications of Diabetes

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Retinopathy screening Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 rehabilitation [Grade D] 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 rehabilitation [Grade D] Retinopathy care Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE If dipstick negative or trace... Annual albumin/creatinine ratio on random daytime urine sample Values  > 2.8 mg/mmol/L for women and > 2.0 mg/mmol/L for men should be repeated  if still elevated, confirm with a timed urine collection [Grade A] People > 15 years of age who have had > 5 years of Type 1 diabetes, or all individuals after diagnosis of Type 2 diabetes [Grade D] If dipstick negative or trace... Annual albumin/creatinine ratio on random daytime urine sample Values  > 2.8 mg/mmol/L for women and > 2.0 mg/mmol/L for men should be repeated  if still elevated, confirm with a timed urine collection [Grade A] People > 15 years of age who have had > 5 years of Type 1 diabetes, or all individuals after diagnosis of Type 2 diabetes [Grade D] Nephropathy Screening Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Definition of microalbuminuria Complications Normal Normoalbuminuria Microalbuminuria Macroalbuminuria Normal Normoalbuminuria Microalbuminuria Macroalbuminuria Standard urinalysis (protein) Urinary AER* (mg/24 h) Urinary AER* (µg/min) Albumin/creatinine ratio Male Female Negative Positive Negative Positive 10 ± 3 < 30 30 - 300 > 300 10 ± 3 < 30 30 - 300 > 300 7 ± 2 < 20 20 - 200 > 200 7 ± 2 < 20 20 - 200 > 200 < 2.0 > 2.0 – < 2.0 > 2.0 – < 2.8 > 2.8 – < 2.8 > 2.8 – * AER: albumin excretion rate

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 > 300 mg/24hrs) should be treated with an ACE inhibitor [Grade A] Refer if greater than 50% renal function is lost 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 > 300 mg/24hrs) should be treated with an ACE inhibitor [Grade A] Refer if greater than 50% renal function is lost Management of Nephropathy Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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]  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] Neuropathy Screening Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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) 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) Neuropathy Management Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  Foot examination should be performed at least annually in people > 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  Foot examination should be performed at least annually in people > 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 Foot Care Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Foot Care Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Prevention of foot ulceration requires foot care education, proper footwear, avoidance of foot trauma, smoking cessation, and early referral if problems occur Foot Care Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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] 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] Foot Care Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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 Cardiovascular - Lifestyle Complications [Grade D]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE 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) 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) Cardiovascular - Lipids Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Hypertension in people with diabetes (BP > 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) Hypertension in people with diabetes (BP > 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) Cardiovascular - Hypertension Complications

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE  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  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 Cardiovascular - Hypertension TX Complications [Grade D]

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE Team approach Screening New diagnostic criteria Better glycemic control Continuum of care Team approach Screening New diagnostic criteria Better glycemic control Continuum of care Summary

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE.

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1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE.

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Presentation on theme: "1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABÈTE."— Presentation transcript:

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