1998 Clinical Practice Guidelines for the Management of Diabetes in Canada

1. 1998 Clinical PracticeGuidelines for the Management of Diabetes in Canada Canadian Diabetes Association Steering and Expert Committees CMAJ;Oct.20,1998;159(8 Suppl)

2. Steering Committee co-chairs: • Sara Meltzer, MD • Lawrence Leiter, MD • Steering Committee members: • Keith Dawson, MD, PhD • Jana Havrankova, MD • Beverley Madrick, RD, CDE • Meng-Hee Tan, MD • Stewart Harris, MD, MPH • Donna Lillie, RN, BA • Beryl Schultz, RN, CDE

3. CANADIANDIABETES ASSOCIATION ASSOCIATIONCANADIENNEDU DIABÈTE Introduction and Methodology 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada January 1999

4. 1998 Clinical Practice Guidelines • • What’s really changed? • • What does it mean in terms of practice changes?

5. 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

6. Clinical Guidelines are... “ systematically developed statements which assist clinicians and patients in making decisions ” - KGMM Alberti

7. 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

8. Role of guidelines • Promote optimal treatment and good medical practice (i.e.: quality control) • Facilitate development of education programs for those less familiar • Provide justification for improvements to the health care system - policy development - financial re-imbursement issues

9. Process 1. Formation of team 2. Outline plan 3. Review literature 4. Production 5. External review 6. Amendments 7. Implementation

10. 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

11. 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

12. Process 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

13. Process 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

14. Evidence-Based Evaluation

15. Evidence-Based Evaluation • Chair: • Hertzel Gerstein, MD, MSc • Members: • Dereck Hunt, MD • Anne Holbrook, MD, MSc

16. Process “Evidence-Based” • = evidence - linked guidelines whose development requires the explicit linkage of the evidence with the recommendation

17. Process Evidence-Based Guidelines Methodology • • Identify clinically important questions • • Search and review the literature • • Assign a level of evidence for key citations

18. Process Evidence-Based Guidelines Methodology • • Develop recommendations based on key citations • • Assign a grade to the recommendation • • Independent review of the recommendations and supporting citations

19. Process 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

20. Organization of Diabetes Care

21. Organization of Diabetes Care • Chair: • Sora Ludwig, MD • Members: • André Bélanger, MD • Peggy Dunbar, PTD, CDE • James McSherry, MD • Beryl Schultz, RN, CDE

22. Organisation of Diabetes Care Central Themes • • 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

23. Organization of Diabetes Care Role of Primary Care Physician • 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...

24. Organization of Diabetes Care 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

25. Organization of Diabetes Care Education • • Diabetes self - management is complex • • Initial and ongoing education of the individual with diabetes is an integral part of diabetes management

26. Organization of Diabetes Care 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

27. Organization of Diabetes Care Rights and Responsibilities Health Care System-2 - 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

28. Organization of Diabetes Care Rights and Responsibilities Health Care System-3 - 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

29. Organization of Diabetes Carea Rights and ResponsibilitiesIndividuals with Diabetes 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)

30. Definition, Classification, Diagnosis and Screening

31. Definition, Classification, Diagnosis and Screening • Chair: • Denis Daneman, MD • Members: • Jeff Mahon, MD • Stuart Ross, MD • Edward Ryan, MD • Claude Catellier, MD

32. 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”

33. 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

34. Classification and Diagnosis Recommendations • 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

35. 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

36. 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]

37. Classification and Diagnosis Diagnosis of diabetes mellitus • • 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 Or 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.

38. Classification and Diagnosis Glucose levels for diagnosis in non-pregnant adults Plasma glucose 2 hours after75-g glucose load;mmol/L Fasting plasma glucose;mmol/L Category Impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) Diabetes mellitus (DM) 6.1 – 6.9 < 7.0 > 7.0 N/A 7.8 – 11.0 > 11.1 N/A = not applicable.

39. Classification and Diagnosis Screening for type 2 diabetes Approximately 3% to 5% of the general adult population has unrecognized type 2 diabetes. 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]

40. Classification and Diagnosis Screening for type 2 diabetes More frequent or earlier testing if : Annual screening if : • History of GDM or delivery of neonate > 4kg • History IGT or IFG • Coronary artery disease • Hypertension • Presence of complications associated with diabetes • Member of high risk population (Aboriginal, Hispanic, Asian, African descent) • Diabetes in a first-degree relative • Obesity • Low HDL chol.(< 0.9) or high triglycerides (> 2.8) [Grade D] [Grade D]

41. Classification and Diagnosis Prevention • • 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]

42. Management of Diabetes

43. Management of Diabetes • Chair: • Jean-François Yale, MD • Members: • Heather Dean, MD • Lynn Edwards, PDT • François 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

44. Management 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)

45. Management History to be taken during initial visit • Past history • Endocrine disorders • Infections • Cardiovascular disease • Surgery (e.g.: pancreatic) • Obstetric (if relevant)

46. Management 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 * Hirsutism, obesity and fertility are statistically associated with increased risk for diabetes

47. Management 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

48. Management 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

49. Management History to be obtained at initial and follow-up visits 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

50. Management History to be obtained at initial and follow-up visits 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