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2003 CDA Clinical Practice Guidelines

Diabetes Office Mgmt. 2003 CDA Clinical Practice Guidelines. J. Robin Conway M.D. Diabetes Clinic - Smiths Falls, ON. Toronto May 6 2004. www.diabetesclinic.ca. Worldwide rates of diabetes mellitus: predictions. 80 70 60 50 40 30 20 10 0. Prevalence (millions). Year 1995

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2003 CDA Clinical Practice Guidelines

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  1. Diabetes Office Mgmt 2003 CDA Clinical Practice Guidelines J. Robin Conway M.D. Diabetes Clinic - Smiths Falls, ON Toronto May 6 2004 www.diabetesclinic.ca www.diabetesclinic.ca

  2. Worldwide rates of diabetes mellitus: predictions 80 70 60 50 40 30 20 10 0 Prevalence (millions) Year 1995 2000 2025 North America Europe Southeast Asia World Health Organization.1997. Canadian Diabetes Association, 1998 website. www.diabetesclinic.ca

  3. 2 Million Canadians Have Diabetes Mellitus Frequency of diagnosed and undiagnosed diabetes and IGT, by age (U.S. data - Harris) Harris. Diabetes Care 1993;16:642-52. www.diabetesclinic.ca

  4. Cardiovascular Disease Risk is Increased 2 to 4 Times Framingham study: diabetes and CAD mortalityat 20-year follow-up Haffner Am J Cardiol 1999;84:11J-4J. www.diabetesclinic.ca

  5. What proportion of your office visits involve Diabetics? • <10% • 10-20% • 20-30% • 30-50% • >50% www.diabetesclinic.ca

  6. The burden of Diabetes • 87% of Type 2 Diabetes is managed in Primary Care • Diascan Study: 23.5% of patients in our office have diabetes • Quebec screening >2 Risk Factors 79% tested 7% Diabetes 13% IGT or IFG 74% No Treatment Advice Leiter et al. Diabetes Care 2000 Strychar I et al. Cdn J Diab 2003(abs) www.diabetesclinic.ca

  7. Glucose Monitoring • Do you do A1c to follow glycemic control 1= YES 2= NO www.diabetesclinic.ca

  8. Microvascular Complications • Do you order urine microalbumen test 1= YES 2= NO www.diabetesclinic.ca

  9. Microvascular Complications • Do you use a 10 gm filament for testing sensation in the feet? 1= YES 2= NO www.diabetesclinic.ca

  10. T2DM in Family Practice • 84% of patients had A1c in past year • Average A1c 7.9% (goal<7%) • 88% had BP check • 48% had lipid profiles • 28% tested for microalbuminuria • 15% had foot exams Harris S et al. Cdn Fam Phys 2003 www.diabetesclinic.ca

  11. Organization and Delivery of Care • Diabetes should be organized using a DHC (Diabetes Healthcare) team approach • People with diabetes should be offered initial and ongoing needs-based diabetes education • The role of diabetes nurse educators and other DHC team members should be enhanced in cooperation with the physician www.diabetesclinic.ca

  12. Structured care • ACLS • ATLS • Seattle Defibrillator Experience • GREACE Study www.diabetesclinic.ca

  13. Structured CareVSUsual Care • Patients received atorvastatin 10 mg/d (titrated up to 80 mg/d) to reach the NCEP LDL-C goal • Specialist care unit with a strict protocol to achieve NCEP LDL-C target • Treatment from a physician of pt’s choice • All patients had access to any necessary medications, including statins • Included lifestyle modifications (diet and exercise) as well as lipid-lowering medications Structured Care: Usual Care: Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228. www.diabetesclinic.ca

  14. Reduction in Relative Risk of Primary Endpoints % Reduction P=0.034 P=0.0021 P=0.0017 P=0.0001 P=0.0032 P=0.0011 P=0.021 Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228. www.diabetesclinic.ca

  15. Type 2 Diabetes • Increasing Prevalence • Primary Care Based • Forms a large part of a practice • Needs structured care approach • Team Approach • Multiple comorbidities • Limited Time & Funding www.diabetesclinic.ca

  16. How can we deal with this? • Refer all Diabetic Patients? • Community Education Programs? • Guidelines Based Structured Care? • Identify the Diabetics in the practice? • Diabetes Day in Office? • Get some Diabetes CME? • Team Approach in Office? • Office Tools? www.diabetesclinic.ca

  17. Diabetes Day in the Office • Book Diabetic Patients for one day • Get office support staff to follow formula • Office staff do Wt, BMI, BP, Glucose, lab • Have educational material, consider 1 room • Follow Guideline Algorithms • Use Tools & Flowsheet • Extra Staff? • Follow up Appt & Lab www.diabetesclinic.ca

  18. Educational Material • Canadian Diabetes Assoc: www.diabetes.ca • Pharma Companies; Lilly, Novo, Bayer • Web Site list www.diabetesclinic.ca • Hospital Diabetes Education Program • Community Diabetes Education Program www.diabetesclinic.ca

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  26. Screening and Prevention - Type 2 Diabetes • Screen all persons >40 years for type 2 diabetes, with a fasting blood glucose (FPG), every 3 years. • For people with risk factors, screen earlier and /or more frequently, with either FPG or Oral Glucose Tolerance test (OGTT). • If the FPG is 5.7 – 6.9mmol/L and suspicion of diabetes or IGT is high, recommend a 2hPG in a 75-g OGTT. www.diabetesclinic.ca

  27. Screening for Type 2 Diabetes, IFG and IGT Every 3 Years in individuals  40 years of age with no other risk factors Earlier and/or more frequently in individuals < 40 years of age with risk factors FPG < 5.7 mmol/L 5.7 - 6.9 mmol/L plus risk factor(s) for diabetes/IGT 6.1 - 6.9 mmol/L and not risk factors for diabetes/IGT  7.0 mmol/L 2hPG in 75-g OGTT Classify patients as normal, IFG (isolated), IGT (isolated), IFG & IGT or Diabetes Diabetes Normal Isolated IFG, Isolated IGT OR IFG & IGT IFG Strategies for prevention and rescreen at appropriate intervals Rescreen as clinically indicated Treatment www.diabetesclinic.ca

  28. Diagnostic Criteria • A confirmatory laboratory glucose test must be done on another day unless there is unequivocal hyperglycemia and acute metabolic decompensation • FPG = fasting plasma glucose, no caloric intake for at least 8 hours • OGTT = oral glucose tolerance test • 2hPG = 2-hour plasma glucose • Casual PG = any time of the day, without regard to the interval since the last meal • Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss www.diabetesclinic.ca

  29. Physical Activity and Diabetes • For people who have not previously exercised regularly and are at risk of CVD, an ECG stress test should be considered prior to starting an exercise program Testing is particularly important before, during and for many hours after exercise. www.diabetesclinic.ca

  30. Nutrition Therapy People with diabetes should: • Receive nutrition counseling by a registered dietitian • Receive individualizedmeal planning • Follow Canada’s Guidelines for Healthy Eating • People on intensive insulin should also be taught to adjust the insulin for the amount of carbohydrate consumed www.diabetesclinic.ca

  31. Recommended targets for glycemic control* FPG/preprandial PG (mmol/L) 2-hour postprandial PG (mmol/L) A1C** (%) Target for most patients 7.0 4.0-7.0 5.0-10.0 6.0 4.0-6.0 5.0-8.0 Normal range (considered for patients in whom it can be achieved safely) *Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors. †Glycemic targets for children 12 years of age and pregnant women differ from these targets. Please refer to “Other Relevant Guidelines” for further details. **An A1C of 7.0% corresponds to a laboratory value of 0.070. Where possible, Canadian laboratories should standardize their A1C values to DCCT levels (reference range: 0.040 to 0.060). However, as many laboratories continue to use a different reference range, the target A1C value should be adjusted based on the specific reference range used by the laboratory that performed the test. As a useful guide: an A1C target of 7.0% refers to a threshold that is approximately 15% above the upper limit of normal. A1C = glycosylated hemoglobin DCCT = Diabetes Control and Complications Trial FPG = fasting plasma glucose PG = plasma glucose www.diabetesclinic.ca

  32. If not at target If not at target If not at target If not at target Clinical assessment and initiation of nutrition and physical activity Marked hyperglycemia (A1C 9.0%) Mild to moderate hyperglycemia (A1C <9.0%) Basal and/or preprandial insulin Non-overweight (BMI 25 kg/m2) Overweight (BMI 25 kg/m2) 2 antihyperglycemic agents from different classes † • biguanide • insulin sensitizer* • insulin secretagogue • insulin • alpha-glucosidase • inhibitor L I F E S T Y L E Biguanide alone or in combination with 1 of: 1 or 2† antihyperglycemic agents from different classes • insulin sensitizer* • insulin secretagogue • insulin • alpha-glucosidase • inhibitor • biguanide • insulin sensitizer* • insulin secretagogue • insulin • alpha-glucosidase • inhibitor Add an oral antihyperglycemic agent from a different class of insulin* Add a drug from a different class or Use insulin alone or in combination with: Intensify insulin regimen or add • biguanide • insulin secretagogue • insulin sensitizer* • alpha-glucosidase inhibitor • biguanide • insulin • secretagogue** • insulin sensitizer* • alpha-glucosidase • inhibitor Timely adjustments to and/or additions of oral antihyperglycemic agents and/or insulin should be made to attain target A1C within 6 to 12 months www.diabetesclinic.ca

  33. Economics • Gen Ass A003 $54.10 • Int Ass A007 $28.50 • Counselling K013 $50.45 4x/yr • Insulin Rx K029 $50.45 6x/yr • Type 2 Flow K030 $30.00 3x/yr • Glucose G002 $ 1.97 • Urine G009 $ 4.20 • Venipuncture G489 $ 2.27 www.diabetesclinic.ca

  34. Economics • A003 G002, G009, G489 $ 62.54 • G030 G002 G009 G489 x3 $105.32 • K013 G00s G009 G489 x4 $235.76 • A007 x4 $114.00 • TOTAL $517.62 www.diabetesclinic.ca

  35. FLOWSHEETS www.diabetesclinic.ca

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  39. ABC of Diabetes • A1c <7 • Blood Pressure <130/80 • Chol/HDL <4, LDL <2.5, Trig <1.5 • ACR <2 men, <2.5 women • ACE • ASA www.diabetesclinic.ca

  40. INVOLVE THE PATIENT www.diabetesclinic.ca

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  43. In Conclusion • Prevalence of type 2 diabetes is increasing dramatically • Majority of patients are diagnosed and treated by the family physician • New paradigm: need to be much more aggressive early in the treatment of these patients utilizing dual therapies • Hypoglycemia can be managed through proper treatment choices and lifestyle management • Glucose is a continuous progressive risk factor for cardiovascular disease www.diabetesclinic.ca

  44. Questions? www.diabetesclinic.ca

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