Canadian Diabetes Association 2013 Clinical Practice Guidelines The Essentials Presentation by Dr. Tessa Laubscher Clinical Associate Professor, Family Medicine Saskatoon Sept 2013

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

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

Random PG ≥11.1 mmol/L (with or without symptoms) Diagnosis of Diabetes 2013 FPG ≥7.0 mmol/L Fasting = no caloric intake for at least 8 hours or A1C ≥6.5% (in adults) Using a standardized, validated lab assay, in the absence of factors that affect the accuracy of the A1C and not for suspected type 1 diabetes 2hPG in a 75-g OGTT ≥11.1 mmol/L Random PG ≥11.1 mmol/L (with or without symptoms) Random = any time of the day, without regard to the interval since the last meal Script: Diabetes can be diagnosed by many different cut-offs. The biggest change from the previous set of guidelines is that HbA1c > 6.5% is part of diagnostic cut-off if a standardized validated assay is used with absence of other factors that affect A1c and not suspecting Dm. So FBG >7, A1c >6.5%, or 2h PG > 11.1 or random PG >11.1 can be used to used to diagnose diabetes. Diagnosis of diabetes is based on thresholds of glycemia that are associated with microvascular disease 2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

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

Diagnosis of Prediabetes* 2013 Test Result Prediabetes Category Fasting Plasma Glucose (mmol/L) 6.1 - 6.9 Impaired fasting glucose (IFG) 2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L) 7.8 – 11.0 Impaired glucose tolerance (IGT) Glycated Hemoglobin (A1C) (%) 6.0 - 6.4 Prediabetes * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  higher risk of developing T2DM

A1C Level and Future Risk of Diabetes: Systematic Review A1C Category (%) 5-year incidence of diabetes 5.0-5.5 <5 to 9% 5.5-6.0 9 to 25% 6.0-6.5 (prediabetes) 25 to 50% Script: Zhang et al did a systematic review on A1c level and future risk of diabetes and you as the A1C increased from 6.0 to 6.5%, this converted to a 5-year incidence of diabetes across 25% -50%. Zhang X et al. Diabetes Care. 2010;33:1665-1673.

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

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

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

Risk Factors for T2DM Personal factors Presence of associated problems Presence of secondary causes Details in complete slide set

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

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

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

Emphasize role of OGTT

Can we reduce the risk of developing Type 2 Diabetes?

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

Glycemic Targets: New Targets and why?

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

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

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

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

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

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

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

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

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

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

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

Medications for glycemia How do we choose?

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

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

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

Pharmacotherapy in T2DM checklist 2013 CHOOSE initial therapy based on glycemia START with Metformin +/- others INDIVIDUALIZE your therapy choice based on characteristics of the patient and the agent REACH TARGET within 3-6 months of diagnosis

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

Make timely adjustments to attain target A1C within 3-6 months From prior page… L I F E S T Y Concept of RELATIVE A1c lowering – not absolute Concept of RELATIVE cost considerations Change to achieve target within 3-6 months. If not at glycemic target Add another agent from a different class Add/Intensify insulin regimen 2013 Make timely adjustments to attain target A1C within 3-6 months

Consider weight effects when selecting antihyperglycemic medications Weight Gain Weight Effect (kg) Insulin +4.5 to 5.0 Thiazolidenediones (TZDs) +4.2 to 4.8 Sulfonylureas +1.6 to 2.6 Meglitinides + 0.7 to 1.8 Weight Neutral or Decrease Weight Metformin -4.6 to 0.4 α-Glucosidase inhibitors +0.0 to 0.2 Dipeptidyl peptidase-4 (DPP-4) inhibitors +0.0 to 0.4 Glucagon-like peptide-1 (GLP-1) receptor agonists -1.3 to 3.0 Anti-Diabetes and Anti-Obesity Medications: Effects on Weight in People With Diabetes Priscilla Hollander, MD Abstract In Brief Choosing medications for people with diabetes involves consideration of a number of factors, including effects on weight. Improvements in glucose control are often linked to weight gain, but this does not have to be the inevitable result of diabetes treatment. Adding a drug that either promotes weight-loss or is weight neutral to one that promotes weight gain and providing medical nutrition therapy can be considered. Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

What are the options for Insulin? Mention basal vs prandial insulin

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

What about Hypoglycemia?

Definition of Hypoglycemia Development of neurogenic or neuroglycopenic symptoms Low blood glucose (< 4 mmol/L if on insulin or secretagogue) Response to carbohydrate load. Emerging importance of Hypoglycemia Increasing evidence that hypoglycemia is associated with increased morbidity and mortality in both T1DM and T2DM. Hypoglycemia-related outcomes include: increased risk of falls; CNS consequences including cognitive effects/decline and decreased memory/retention; autonomic failure; cardiac effects – rhythm disturbances, ischemia; and accelerated atherosclerosis with recurrent hypoglycemia in T1DM.) The CDA defines hypoglycemia as the development of autonomic (trembling, palpitations, sweating, anxiety, hunger, nausea, tingling) or neuroglycopenic (difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness) symptoms, a low plasma glucose, and symptoms responding to the administration of a carbohydrate. In mild to moderate hypoglycemia, blood glucose is <4 mmol/L, autonomic and/or neuroglycopenic symptoms are present, but the patient is able to self-treat. However, patients who maintain a higher blood glucose level may experience hypoglycemia at levels >4.0 mmol/L. Severe hypoglycemia indicates the patient is unable to treat the reaction without outside assistance. He/she may or may not be conscious.

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

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

Macrovascular Disease Vascular Protection: Why? Who and When?

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

Vascular Protection Checklist 2013 A • A1C – optimal glycemic control (usually ≤7%) B • BP – optimal blood pressure control (<130/80) C • Cholesterol – LDL ≤2.0 mmol/L if decide to treat D • Drugs to protect the heart A – ACEi or ARB │ S – Statin │ A – ASA (only if established CVD) E • Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weight S • Smoking cessation

Who Should be Screened for CAD with ECG? Age >40 years Duration of DM >15years + Age >30 years End organ damage Microvascular Macrovascular Cardiac risk factors Symptoms of “silent CAD” – decreased exercise capacity, unexplained dyspnea, new onset HF Baseline resting ECG Repeat every 2 years Older people with T2DM commonly have silent MI – 40%; more common in people with albuminuria (65%).

Who Should Receive Statins? 2013 Who Should Receive Statins? Clinical Macrovascular disease [grade A, level A] or ≥40 yrs old [grade A, level A for T2DM; grade D, consensus for T1DM] or Microvascular disease [grade D, consensus] or DM >15 yrs duration and age >30 years [grade D, consensus] or Warrants therapy based on the 2012 Canadian Cardiovascular Society Lipid Guidelines Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception.

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

Who Should Receive ACEi or ARB Therapy? 2013 Who Should Receive ACEi or ARB Therapy? Clinical Macrovascular disease [grade A, level A] or ≥55 years of age [grade A, level A for those with additional CVD risk factors or end organ damage; grade D, consensus for all others] or Microvascular disease [grade D, consensus] At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily (HOPE), telmisartan 80 mg daily (ONTARGET)] ACE inhiibitor or ARB therapy should be offered to people with diabetes age ≥55 years, or in the presence of macrovasular disease or microvascular disease. This recommendation is regardless of blood pressure. It is important that the ACEi or ARB be titrated to the doses that have been shown to provide vascular protection since low dose ACE-inhibitor or ARB may not result in any benefit (DIABHYCAR study). These vascular protection benefits have been shown to be present irrespective of baseline blood pressure. Since it is not proven that low dose ACEi or ARB confers the same vascular protection, it is recommended that the ACEi or ARB dose be increased to the vascular protective doses (peripdopril 8mg, ramipril 10 mg, telmisartan 80 mg daily). Given that not all ACEi or ARB have conducted “vascular protection” type of studies and of those that have, not all have been positive, it is justified to titrate to doses shown to have vascular protection. Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy EUROPA Investigators, Lancet 2003;362(9386):782-788. HOPE study investigators. Lancet. 2000;355:253-59. ONTARGET study investigators. NEJM. 2008:358:1547-59

Who Should Receive Antiplatelet Therapy? Only patients with established cardiovascular disease – secondary prevention [grade D, consensus] No longer recommended for primary prevention in people with diabetes [grade A, level 1]

Who requires vascular protection medications? http://guidelines.diabetes.ca/VascularProtection/RiskAssessment For patients with DM we do not have CVD risk calculators – therefore assess risk for each individual based on diabetes, CV risk factors, family history, etc.

Hypertension / BP control Screening and diagnosis BP should be measured at every diabetes related visit and at least twice a year. Patients found to have elevated BP should have high BP confirmed on a separate day. Threshold for diagnosing hypertension in person with diabetes is BP ≥130/80 mmHg (may consider SBP up to 140 in elderly). Target for treating BP is <130/80. Lifestyle therapy for elevated BP Weight loss if overweight DASH-style diet with reduced sodium and increased potassium intake Moderation of alcohol intake Increased physical activity

What about Microvascular Disease? Nephropathy Retinopathy Neuropathy

Chronic Kidney Disease (CKD) 2013 Chronic Kidney Disease (CKD) Diabetic Nephropathy - Progressive increase in proteinuria in people with longstanding diabetes, followed by declining function which can eventually lead to End-Stage Renal Disease (ESRD) SCREEN regularly (annually) with random urine albumin creatinine ratio (ACR) and serum creatinine for estimated glomerular filtration rate (eGFR) DIAGNOSE with repeat confirmed ACR ≥ 2.0 mg/mmol and/or eGFR < 60 mL/min DELAY onset and/or progression of CKD by: achieving glycemic and blood pressure control, and using ACE inhibitor or angiotensin receptor blocker (ARB) PREVENT additional renal complications with “sick day management” counselling and referral when appropriate The random urine for albumin is insufficient, as the urinary albumin concentration can vary due to urine concentration (24). A random urine ACR predicts 24-hour urinary albumin excretion sufficiently well and is the test of choice for screening for albuminuria. There is substantial day-to-day variability in albuminuria. In addition, transient increases in albuminuria can be provoked by a number of factors. The eGFR is useful for assessing chronic changes in renal function but should not be used in situations where kidney function is changing rapidly. Dehydration and other conditions that lead to intravascular volume contraction can lead to a transient decline in renal function.

(for both males and females) 2013 CKD in diabetes Urine ACR ≥ 2.0 mg/mmol (for both males and females) and / or eGFR < 60 mL/min Either test must be abnormal on ≥ 2 occasions tested over a 3 month period An abnormal screening test should be confirmed by repeat testing of the eGFR within 3 months, and 2 more random urine ACRs ordered during that interval. If either the eGFR remains low or at least 2 of the 3 random urine ACRs are abnormal, then a diagnosis of CKD is confirmed.

Beware of Transient Albuminuria

Reducing progression of diabetic nephropathy Optimal glycemic control Optimal blood pressure control – irrespective of type of drug used Use of ACE-inhibitor or Angiotensin receptor blocker People with CKD are at increased risk of CV events Commence therapy as per vascular protection guidelines Risk for CAD increases with combination of increasing albuminuria and low eGFR All people with CKD are at risk for cardiovascular (CV) events and should be treated to reduce these risks. The degree of risk of CV events or progression to ESRD increases as albuminuria levels rise, and as eGFR falls, with the combination of albuminuria and low eGFR predicting a very high level of risk.

for therapeutic considerations for renal impairment See CPG Appendix 6 for therapeutic considerations for renal impairment 2013

Counsel all Patients About Sick Day Medication List 2013

2013 Retinopathy SCREEN every 1 – 2 years with dilated eye exam by trained eye professional, or retinal photography. DELAY onset and progression of retinopathy with optimal glycemic and blood pressure control TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreo-retinal surgery

Neuropathy PREVENT with optimal blood glucose control 2013 PREVENT with optimal blood glucose control SCREEN annually by testing for loss of protective sensation using a 10 gram monofilament or tuning fork TREAT pain symptoms with anticonvulsants or antidepressants, and improved glycemic control Use Geetha’s check marks

40-50% of People with Diabetes will have Detectable Neuropathy within 10 years Sensorimotor poly- or mono-neuropathy Motor neuropathy Autonomic neuropathy Increased risk for: Foot ulceration and amputation Neuropathic pain Hypoglycemia unawareness Significant morbidity

Special Populations: Elderly Women of child-bearing age

Diabetes in the Elderly 2013 ASSESS for level of functional dependency (frailty) INDIVIDUALIZE glycemic targets based on frailty and co-morbid conditions (A1C ≤ 8.5% for frail elderly, limited life expectancy) but if otherwise healthy, use the same targets as younger people AVOID hypoglycemia in cognitive impairment, frail elderly SELECT anti-hyperglycemic therapy carefully caution with sulfonylureas or thiazolidinediones Long-acting insulin analogues instead of NPH or human 30/70 insulin – lower risk of hypoglycemia Premixed insulins instead of mixing insulins separately GIVE regular diets instead of “diabetic diets” in nursing homes

(depending on level of frailty) 2013 Among frail elderly Parameter Target A1C ≤ 8.5% FPG or preprandial glucose 5.0-12.0 mmol/L (depending on level of frailty) AVOID HYPOGLYCEMIA FPG= fasting plasma glucose

If choosing to use insulin … 2013 If choosing to use insulin … Clock drawing test can be used to predict who is likely to have problems with insulin therapy “Write numbers on the blank clock face and draw hands on the clock to show 10 minutes past 11 o’clock” http://www.diabetes.ca/publications/cjd/2005/06/ Trimble LA et al. Can J Diabetes 2005;29(2):102-104.

Women of child-bearing age - Recommendations 2013 Women of child-bearing age - Recommendations All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of optimal glycemic control prior to pregnancy, impact of BMI on pregnancy outcomes, need for folic acid and the need to stop potentially embyropathic drugs prior to pregnancy [Grade D, Level 4]. Women with type 2 diabetes and irregular menses/PCOS who are started on metformin or a thiazolidinedione should be advised that fertility may improve and be warned about possible pregnancy [Grade D, consensus].

Preconception checklist – for women with pre-existing diabetes 2013 Preconception checklist – for women with pre-existing diabetes Attain a preconception A1C of ≤ 7.0% (if safe) Assess for and manage any diabetic complications such as retinopathy, nephropathy Switch to insulin if on oral agents; may continue on metformin if T2DM Folic Acid 5 mg/day: 3 months pre-conception to 12 weeks post-conception Discontinue potentially embryopathic meds: Ace-inhibitors/ARB (prior to or upon detection of pregnancy) Statin therapy (prior to pregnancy) Script:

Other Topics Mental Health and Diabetes Pregnant women - GDM Children with Type 1 Diabetes Children with Type 2 Diabetes In-hospital therapy Diabetic Foot Immunizations www.guidelines.diabetes.ca