Introduction Chapter 1 Alice YY. Cheng Canadian Diabetes Association 2013 Clinical Practice Guidelines

Introduction

Chapter 1

Alice YY. Cheng

Canadian Diabetes Association 2013 Clinical Practice Guidelines

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Faculty for Slide Deck Development

• Jonathan Dawrant, BSc, MSc, MD, FRCPC• Zoe Lysy, MDCM, FRCPC• Geetha Mukerji, MD, FACP, FRCPC• Dina Reiss, MD, FACP, FRCPC• Steven Sovran, BSc, MD, MA, FRCPC

• Alice Y.Y. Cheng, MD, FRCPC• Peter J. Lin, MD, CCFP• Catherine Yu, MD, FRCPC, MHSc


Outline

• Epidemiology of diabetes in Canada

• Care gap still exists

• Overview

• Committee structure

• Major changes in 2013


Prevalence of Diabetes among Individuals aged 20-79 years, Europe, North America, Oceania, 2010


Diabetes in Canada: Prevalence by Province and Territory

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.

NL6.5%

ON 6.0%

QC 5.1%

PE5.6%

NB5.9%

NS 6.1%

MB 5.9%

SK 5.4%

AB 4.9%

BC 5.4%

NT 5.5%

YT 5.4%

NU 4.4%

† Age-standardized to the 1991 Canadian population.

Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09

NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest.

< 5.0

5.0 < 5.5

5.5 < 6.0

6.0 < 6.5

≥ 6.5

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.

Prevalence increased with age. The sharpest increase occurred after age 40 years. The highest prevalence was in the 75-79 year age group.

Pre

va

len

ce

(%

)

0

10

15

25

30

1-19

5

20

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥85 CanadaAge group (years)

Females

Males

Total

Overall Prevalence

6.4%

7.2%

6.8%

Diabetes in Canada: Prevalence of Diagnosed Diabetes by Age and Sex

Prevalence of diagnosed diabetes among individuals aged ≥ 1 year, by age group and sex, 2008/09


Diabetes in Canada: Prevalence of Diagnosed Diabetes 1998/99 to 2008/09Age-standardized prevalence and number of cases of diagnosed diabetes among

individuals aged ≥ 1 year, 1998/99 to 2008/09

3.3%

5.6%



Diabetes in Canada: Incidence of Diagnosed Diabetes 1998/99 to 2008/09

Age-standardized incidence and number of cases of diagnosed diabetes among individuals aged ≥ 1 year, 1998/99 to 2008/09


5.6 per 1000

individuals

5.6 per 1000

individuals


Guideline Targets Achieved

A1c (≤7%) (n=5103) LDL (≤2.0 mmol/L) (n=5069) SBP/DBP (<130/80 mm HG) (n=5099)

All 3 Endpoints (A1c, LDL,

BP) (n=5104)

0%

20%

40%

60%

50%

57%

36%

13%

% o

f p

atie

nts

Leiter LA et al. Can J Diabetes 2013; in press


Dr. Meng-Hee Tan

16 pages


Dr. Sara Meltzer and Dr. Lawrence Leiter

31 pages


Dr. Stewart Harris

150 pages


Dr. Vincent Woo

201 pages


Dr. Alice Cheng

212 pages


CPG Objective

• Provide guidance on the most appropriate

management for people with diabetes mellitus

• Enhance diabetes prevention efforts with the goal of

reducing the burden of diabetes related complications

• Inform clinical decisions made by healthcare

professionals


Overview

• 38 chapters

• 120 professional volunteers– Family medicine, Endocrine, Internal medicine, Pediatrics,

Cardiology, Neurology, Infectious Disease, Ophthalmology,

Nephrology, Urology, Psychology, Obstetrics, Optometry

– Nurses, Dietitians, Nurse Practitioners, Pharmacists,

Psychologists, Exercise Physiologists

2013


Committee structure

Expert committee

Steering committee

Executive committee

Executive Editor Independent LibrarianCDA Support Team

External R

eviewers

(National and International)

Independent Methods R

eview

DISSEMINATION AND IMPLEMENTATION COMMITTEE


Executive Committee

• Alice Y.Y. Cheng, Chair

• Gillian Booth, Methodology Chair

• Maureen Clement

• William Harper

• Aileen Knip

• Vincent Woo

2013


Steering Committee

Sub-Group Chairs

– Ron Goldenberg - Diagnosis & Classification

– Robyn Houlden - Management (1)

– Amir Hanna - Management (2)

– Bruce Perkins - Microvascular

– David Fitchett - Macrovascular

– Danièle Pacaud - Pediatrics

– David Thompson - Pregnancy

2013


Steering Committee

Advisors

– Onil Battarcharya

– Lori Berard

– Stewart Harris

– Lawrence Leiter

– Stuart Ross

– Jean-François Yale

– Catherine Yu

2013


Community Representatives

• Mr. Ram Krishna

• Ms. Diana Provenzano

2013


Expert CommitteeRejeanne GougeonSteven GroverGord GubitzBetty HarveyRob Hegele Cheri HernandezJonathan HowlettCéline HuotNadira HuseinS. Ali ImranHelen JonesTina KaderErin KeelyGlen KennyAngela KohSharon KozakRam KrishnaPhilippe L'AllierEric LaroseDavid Lau Richard LewanczukPeter LinMeera LuthraLori MacCallum

John MacFadyenGail MacNeillAndrea MainG.B. John Mancini Phil McFarlane Angela McGibbonGraydon MeneillyAmanda MikalachkiDavid MillerBeth MitchellRichard NahasMariam NaqshbandiConstadina PanagiotopoulosBreay W.PatyRonald PlotnikoffPaul PoirierAlly PrebtaniDiana ProvenzanoZubin PunthakeeRémi Rabasa-LhoretDoreen RabiTom RansomSonja Reichert

Ravi RetnakaranCindy RichardsonMichael RiddellDavid RobinsonRob Roscoe Edmond RyanElizabeth SellersPeter SeniorMathew SermerArya SharmaMichael SharmaDiana SherifaliJohn SievenpiperRonald SigalFrank Stockl James StoneJean-Claude TardifDaniel TessierCory TothEllen TothMicheal VallisChristina VinokuroffSean WhartonDiane WherrettDana WhithamSandi Williams

Andrew AdvaniFiliberto AltomareKathryn ArcudiMarni ArmstrongHoward BergerIan BlumerKeith BoweringShelley BoydVera BrilGerald BrockSarah CapesAndre CarpentierDale ClaytonPam ColbyJohn DornanRobert DufourPaula DworatzekRoland DyckJean-Marie EkoéJohn EmbilDenice FeigRobert Gagnon Jeremy GilbertRichard Gilbert Jeannette Goguen

2013


Changes to Structure in 2013

• Harmonization: – Canadian Hypertension Education Panel (CHEP)

– Society of Obstetrics and Gynecology of Canada (SOGC)

– Canadian Cardiovascular Society (CCS)

– C-CHANGE

• Inclusions:– Drug cost table included

– “Practical Tips” box

2013


Changes to Structure in 2013 (continued) 2013

• Expanded Dissemination & Implementation

• Diabetes in high-risk ethnic populations chapter moved into Screening and Reduction of risk chapters

• Stroke in Diabetes is a new chapter


Highlights of Major Changes

Diagnosis • A1C for the diagnosis of diabetes (A1C ≥6.5%)

• A1C for the diagnosis of prediabetes (A1C 6.0-6.4%)

Organization of Care • New “Diabetes Patient Care Flow Sheet”

Glycemic Targets • Individualization of glycemic targets

• Vast majority of people with diabetes target an A1C ≤7.0%

• Better definition of scenarios to consider a target A1C ≤6.5%

or less stringent target of A1C 7.1-8.5%

2013


Highlights of Major Changes (continued)

Self-monitoring Blood Glucose (SMBG)

• Recommendations for frequency of SMBG for those with

type 2 diabetes, not receiving insulin therapy

Nutrition Therapy

• Continued emphasis on balanced, individualized nutritional

therapy with the inclusion of alternative dietary patterns as

options

2013


Pharmacologic Management of type 2 diabetes– Achieve target A1C within 3-6 months of diagnosis

– New algorithm for the pharmacologic management of

T2DM with emphasis on individualization of agent choice

– Metformin may be used at the time of diagnosis

– A1C ≥8.5% at the time of diagnosis should receive

immediate pharmacologic therapy and consideration for

use of ≥ 2 antihyperglycemic therapies and/or insulin

– Inclusion of Cost Table for antihyperglycemic therapies

Highlights of Major Changes (continued) 2013


In-hospital Management– Glycemic targets premeal blood glucose (BG) 5-8 mmol/L

and random BG <10 mmol/L for the majority of non-

critically ill patients

– BG 8-10 mmol/L for critically ill

– BG 5-10 mmol/L in the perioperative period



Vascular Protection • Statins if:

– Macrovascular or microvascular disease

– Age ≥ 40 years

– DM > 15 years and age > 30 years, or

– As per CCS 2012 lipid guidelines

• ACE-inhibitor or ARB if:

– Macrovascular or microvascular disease

– Age ≥ 55 years

• ASA not routinely recommended for primary prevention



Chronic Kidney Disease• Microalbuminuria = albumin-creatinine ratio (ACR) ≥2.0

mg/mmol for both men and women

• Sick Day Management document for acute illness

Diabetes in Pregnancy • New criteria for screening and diagnosis of gestational

diabetes

Diabetes in the Elderly• Frail elderly glycemic target of A1C ≤8.5%, fasting and pre-

prandial BG of 5-12 mmol/L



“Neither evidence nor clinical judgment alone is sufficient.

Evidence without judgment can be applied by a technician.

Judgment without evidence can be applied by a friend.

But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best clinical care.”

(Hertzel Gerstein, 2012)


CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

Documents

Introduction Chapter 1 Alice YY. Cheng Canadian Diabetes Association 2013 Clinical Practice Guidelines