So here’s my attempt to summarize the latest 2018 Clinical Practice Guidelines from Diabetes Canada (as highlighted by Dr. R. Houlden) at Talk Diabetes 2018:
- Screening and Diagnosis
Start screening when ≥ 40 years every 3 years if no additional risk factor. Screen more frequently if there are additional risk factors. In this guideline, the role for screening with 75g oral glucose tolerance test has been de-emphasized (given it isn’t clinician’s favourite option for screening). Also the Arab population has been added as a high-risk group for Type 2 diabetes. In terms of diagnosis of diabetes (and prediabetes), the definition and classification have remained the same – still need at least two abnormal values for diagnosis. There is no criterion in terms of the time interval between the two abnormal values.
- Approach and Management
The new guidelines have developed a new mnemonic to describe the overall approach to Diabetes Care:
- A: Optimal Glycemic Control
A is for A1C target: In this guideline, there is more emphasis on achieving lower glycemic target of 6.5% especially for individual at low risk for hypoglycemia. A1C should be repeated q3 months to q6months and in special situations to repeat more frequently. In individuals not at A1C target, one may aim for fasting blood glucose target of 4-5.5 mmol/L and 2 hour Post prandial target of 5-8.0mmol/L
- B: Optimal Blood Pressure Control
B is for Blood Pressure Control. No real change in terms of how hypertension is managed other than the advocate for early use of single pill combination therapy.
- C: Cholesterol
In terms of management of dyslipidemia, one of the main changes is that there is a revised algorithm as to who should start statin therapy as well as the new lipid targets. The guideline also supports both fasting or non-fasting lipid profile.
For fasting lipid targets, we should aim for LDL-C consistently below 2.0mmol/L (formerly <2.0) or >50% reduction from baseline. [This is mainly driven from evidence from CARDS and HPS where subgroups that started with lower baseline LDL-C still benefited to the same relative degree as the whole population]. If patient is not at target after starting a statin, agents such as ezetimibe should be considered. However to reduce major adverse cardiac events or for those with concomitant familiar hypercholesterolemia, both ezetimibe or evolocumab (PCSK9 inhibitor) should be considered.
In terms of non-fasting lipid profile, alternate targets include apo B <0.8 g/L or non-HDL-C <2.6 mmol/L
- Other Drugs for Cardiovascular Protection Strategies
Other than evaluating the patient for statin, ACEi/ARB and ASA, patients should also be evaluated to start an antihyperglycemic agent with established cardiovascular benefits.
These include: empagliflozin, liraglutide, canagliflozin. Note that the guidelines can only discuss agents that have a notice of compliance as of Dec 2017, therefore semaglutide was not included but it has also been demonstrated to offer cardiovascular benefits.
The general pharmacological approach to managing Type 2 diabetes has not changed significantly from the last update in 2016. However, it has de-emphasized agents that may cause weight gain or hypoglycemia (e.g. sulfonylurea / insulins). Agents that may promote weight loss with less risk for hypoglycemia are recommended but the key is to individualize therapy as needed. If using one of the newer insulin with longer duration of action (degludec), it is important to titrate by 2 units every 3-4 days.
- Screening for complications
There has been no major change in how complications should be screened except for the emerging role of SGLT2 inhibitors in reducing progression of nephropathy in CKD and the need to repeat resting ECG every 3-5 years in special population.
- Physical activity
In terms of physical activity, the guidelines emphasize the importance of minimizing sedentary time activities, setting exercise goals and prescriptions. There is also a discussion on the emerging role of step count monitoring with a pedometer or accelerometer as well as strategies to reduce the risk of hypoglycemia during and after exercise.
- Nutritional Management
In terms of nutritional management, several diets have been identified to help manage Type 2 diabetes: Mediterranean diet, Vegetarian diet, Porfolio diet and DASH diet.
There are many other highlights from the guidelines that are beyond the scope of this post. So I encourage you to check out their official website here.
Thank you for reading my post. Have you reviewed the latest Diabetes Guidelines? Do you have any thoughts or comments?