Type 2 Diabetes Dialogue 2020November 19, 2020

Joanne LewisDirector, Healthcare Provider Education and EngagementDiabetes Canada

1. Diabetes Canada Clinical Practice Guidelines 2020 Update: Pharmacotherapy for Type 2 Diabetes

2. Diabetes Canada relevant Policy Position Statements 2020: Policy Positions

3. Diabetes Canada’s pivot to support people affected by diabetes with information and education: Diabetes and COVID-19

Pharmacotherapy for Type 2 Diabetes:Unchanged: Pharmacotherapy ChecklistCHOOSE therapy after assessing glycemia,

cardiovascular and renal status, diet and weight change

ESTABLISH TARGET for A1C

REACH TARGET within 3-6 months

INDIVIDUALIZE therapy based on characteristics and preferences of the person with diabetes

START with metformin +/- others

Pharmacotherapy for Type 2 Diabetes:Unchanged: Initial choice of therapy

A1C <1.5% over target Initiate healthy behavior interventions and start metformin if not at target in 3 months

A1C ≥ 1.5% over target Start metformin with healthy behavior interventions AND Consider second concurrent agent

Pharmacotherapy for Type 2 Diabetes:Unchanged: Initial choice of therapy

Symptomatic Hyperglycemia

and/or Metabolic

Decompensation

• Polyuria• Polydipsia• Weight loss• Volume depletion

Start INSULIN +/- metformin

Regular Review• Assess glycemic control, cardiovascular and

renal status• Screen for complications (eyes, feet, kidneys)• Review efficacy, side effects, safety and ability

to take current medications• Reinforce & support healthy behaviour

interventions

if A1C NOT at Targetand/or

Change in Clinical Status

Adjust or Advance Therapy1

A1C above target and glucose lowering requiredASCVD, CKD or HF, OR Age >60 with 2 CV risk factors2

ADD or SUBSTITUTEAHA with demonstrated cardiorenal benefits (see Fig 2b)

ADD or SUBSTITUTE AHA3

according to clinical priorities4start insulin for symptomatic hyperglycemia and/or metabolic decompensation (fig 3)

1. Changes in clinical status may necessitate adjustment of glycemic targets and/or deprescribing2. Tobacco use; dyslipidemia (use of lipid modifying therapy or a documented untreated LDL ≥3.4 mmol/L, or HDL-C <1.0

mmol/L for men and <1.3 mmol/L for women, or triglycerides ≥2.3 mmol/L); or hypertension (use of blood pressure drug or untreated SBP ≥140 mm Hg or DBP ≥95 mmHg)

3. All AHA’s have Grade A evidence for effectiveness to reduce blood glucose levels4. Consider degree of hyperglycemia, costs and coverage, renal function, comorbidity, side effect profile, and potential

for pregnancy

NEW

NEW

NEW

Pharmacotherapy for Type 2 Diabetes:Reviewing, Adjusting or Advancing Therapy 2020

** In CV outcome trials performed in people with ASCVD, CKD, HF or at high CV risk*** VERTIS (CV outcome trial for ertugliflozin) presented at ADA June 2020 showed non-inferiority for MACE. Manuscript not published at time of writing.

†† All AHA’s have Grade A evidence for effectiveness to reduce blood glucose levels

††† Consider degree of hyperglycemia, costs and coverage, renal function, comorbidity, side effect profile, and potential for pregnancy

AGENT CHARACTERISTICS

PATI

ENT

PRIO

RITI

ES/P

REFE

REN

CES

2020Pharmacotherapy for Type 2 Diabetes:Where additional glucose lowering is required

Hypoglycemia Weight gain

• Regular review of clinical status and support of healthy behaviours

• Glycemic targets should be individualized• In high risk populations, GLP1-RA or SGLT2i are recommended

for cardio-renal protection, even if A1c at target• ASCVD, CHF, CKD • >60 years with multiple risk factors

• Choice of AHAs should be based on clinical status and patient preferences

• Where weight loss is a priority, GLP1-RA and SGLT2i are preferred• if reducing risk of hypoglycemia is a priority, agents other than

secretagogues and insulin are preferred

Pharmacotherapy for Type 2 Diabetes:Key Messages 2020

Pharmacotherapy for Type 2 Diabetes:The User’s Guide

Policy Positions: Published to date 2020

• Low Carb Diets position statement

• Food Security position statement

• Built Environment position statement

• Language Matters consensus statement

https://www.diabetes.ca

Diabetes and COVID:Education for patientsVirtual diabetes classes for people with type 2 diabetes: A registered nurse and a registered dietitian address diabetes, what to eat, active living and how to better manage blood sugar levels.

Educational webinars delivered in multiple languages: Cantonese, Italian, Urdu, Portuguese, Farsi, Punjabi and for the Metis Community

Diabetes education phone line: Personalized medical advice by Certified Diabetes experts

Diabetes and COVID:Information for patients

Maintaining a website: Provides current, key information about diabetes and COVID-19 as research becomes available

Ask the Experts videos: Broadcast regular videos for patients in response to questions and concerns about diabetes and COVID-19

Guidance to locate resources and supports: Provide direction to government programs and how to access support for medications and supplies

Diabetes and COVID:Education for Healthcare Providers

Webinars for HCPs: Educating healthcare providers on diabetes and COVID-19

Thank you from Diabetes Canada!Joanne Lewis joanne.lewis@diabetes.ca

CPGs, Education and Support at:www.diabetes.caDiabetes Canada – Youtube (videos)1-800-BANTING