1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 CANADIAN...
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1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999 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
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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)
Slide 2
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 3
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 1998 Clinical Practice Guidelines
for the Management of Diabetes in Canada January 1999 CANADIAN
DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABTE Introduction
and Methodology
Slide 4
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 1998 Clinical Practice Guidelines
Whats really changed? What does it mean in terms of practice
changes? Whats really changed? What does it mean in terms of
practice changes?
Slide 5
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 6
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Clinical Guidelines are...
systematically developed statements which assist clinicians and
patients in making decisions - KGMM Alberti
Slide 7
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 8
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 9
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 10
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 11
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 12
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 13
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 14
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Evidence-Based Evaluation
Slide 15
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 16
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Evidence-Based = evidence - linked
guidelines whose development requires the explicit linkage of the
evidence with the recommendation Process
Slide 17
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 18
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 19
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 20
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Organization of Diabetes Care
Slide 21
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Organization of Diabetes Care
Chair: Sora Ludwig, MD Members: Andr Blanger, MD Peggy Dunbar, PTD,
CDE James McSherry, MD Beryl Schultz, RN, CDE Chair: Sora Ludwig,
MD Members: Andr Blanger, MD Peggy Dunbar, PTD, CDE James McSherry,
MD Beryl Schultz, RN, CDE
Slide 22
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 23
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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...
Slide 24
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 25
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 26
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 27
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 28
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE -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
Slide 29
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 30
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Definition, Classification,
Diagnosis and Screening
Slide 31
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 32
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 33
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 34
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 35
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 36
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 37
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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.
Slide 38
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 39
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 40
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 41
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 42
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Management of Diabetes
Slide 43
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Chair: Jean-Franois Yale, MD
Members: Heather Dean, MD Lynn Edwards, PDT Franois 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-Franois Yale, MD
Members: Heather Dean, MD Lynn Edwards, PDT Franois 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
Slide 44
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 45
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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)
Slide 46
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 47
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 48
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 49
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 50
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 51
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 52
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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 )
Slide 53
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 54
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 55
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 56
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Follow-up visits Routine clinical
care -routine visit at 24 months with directed history for diabetes
(table 7) -blood pressure, foot examination at each visit
-evaluation of progress toward reduction of risks of long-term
complications -adjustment of treatment plans Routine clinical care
-routine visit at 24 months with directed history for diabetes
(table 7) -blood pressure, foot examination at each visit
-evaluation of progress toward reduction of risks of long-term
complications -adjustment of treatment plans Management
Slide 57
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Follow-up visits Glycemic control
-glycated hemoglobin every 24 months -laboratory-meter glucose
correlation at least annually -FPG level (preferred for
correlation), as needed Glycemic control -glycated hemoglobin every
24 months -laboratory-meter glucose correlation at least annually
-FPG level (preferred for correlation), as needed Management
Slide 58
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 59
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 60
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Level Ideal (normal nondiabetic)
Glycated Hb (% of upper limit) e.g., HbA 1c assay Fasting or
premeal glucose level (mmol/L) Glucose level 12 h after meal
(mmol/L) < 100 (0.040.06) 3.86.1 4.47 < 100 (0.040.06) 3.86.1
4.47 < 115 ( 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
Slide 61
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 62
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 63
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 64
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE All people with diabetes should
receive individual advice on nutrition from a registered dietitian.
[Grade D] Management Nutritional approaches
Slide 65
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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.
Slide 66
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
:
Slide 67
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 68
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE [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
Slide 69
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 70
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 71
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 72
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE [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
Slide 73
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 74
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 75
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 76
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 77
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 78
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 79
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 80
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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.
Slide 81
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 82
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 83
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 84
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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.
Slide 85
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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.
Slide 86
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 87
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 88
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 89
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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:
Slide 90
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 91
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 92
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 93
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 94
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 95
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 96
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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:
Slide 97
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 98
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 99
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 100
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 101
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 102
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 103
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Complications of Diabetes
Slide 104
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Co-chairs: Bernard Zinman, MD
David Lau, MD, PhD Members: Timothy Benstead, MDC Iain Begg, MB
Jean-Marie Eko, 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 Eko, MD Andrew Steele, MDC
Catharine Whiteside, MD, PhD Complications of Diabetes
Slide 105
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 106
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 107
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 108
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE Definition of microalbuminuria
Complications Normal Normoalbuminuria Microalbuminuria
Macroalbuminuria Normal Normoalbuminuria Microalbuminuria
Macroalbuminuria Standard urinalysis (protein) Urinary AER* (mg/24
h) Urinary AER* (g/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
Slide 109
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 110
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 111
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 1998 Clinical Practice Guidelines
for the Management of Diabetes in Canada January 1999 CANADIAN
DIABETES ASSOCIATION ASSOCIATION CANADIENNE DU DIABTE 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
Slide 112
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 113
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 114
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 115
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 116
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 117
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 118
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
Slide 119
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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]
Slide 120
1998 Clinical Practice Guidelines for the Management of
Diabetes in Canada January 1999 CANADIAN DIABETES ASSOCIATION
ASSOCIATION CANADIENNE DU DIABTE 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
