This week, the Canadian Diabetes Association released their 2018 Canadian Diabetes Guidelines.
CONGRATS to those of you who didn’t notice because you were too busy writing your exam this week! But even though the exam is over, there are some things you’ll need to know for your clinical practice starting soon.
And for those of you yet to write your exam, you’ll want to know this guideline well.
In case you haven't yet read the 342-page guideline, don't worry - not only have we reviewed the new guideline for you, but we've also done a side-by-side comparison with the 2013 guideline to help you focus on what's new, what's different, and what's changed (sneak preview – not much.)
Though the newer guidelines are generally more complicated and longer than the 2013 guidelines (which were “only” 227 pages), here’s overall the bottom line:
BOTTOM LINE: There are no earth-shattering changes in this guideline.
In fact, even the chapter and appendix titles are virtually identical, with a few additions (see below). The individual chapter recommendations are almost all identical as well.
QUICK TIP: AT THE VERY LEAST… know the details in the 2018 quick reference guide
Below, we’ve provided some more details than you’ll find in the quick reference. Read on for our summary of some of the most notable changes in the 2018 Canadian Diabetes Guidelines:
HOW TO SCREEN
WHO TO SCREEN
MORE REAL-LIFE TIPS (which are great for exam questions)
MORE FOCUS ON TARGETS
MORE FREQUENT A1Cs
HOW TO SCREEN: Less complicated - Dump the 75g OGTT
You may not believe this, but back when I was a medical student, not only did we make our patients fast, but we also made them drink a hypersweet glucose drink if they were just under the cutoff for prediabetes. Can you imagine?!
The 2018 guidelines have now de-emphasized the use of the 75g OGTT. It’s removed from the screening algorithm and quick reference guide, and the word is changed from you “should” use it to “consider” it if the patient is just under the prediabetes cutoff (A1C 5.5-5.9% or Fasting glucose 5.6-6.0 mmol/L).
Those of you who have ever tried the super sugary sweet substance used for this screen will understand why this was dropped – it definitely met the criteria for unusual, if not cruel, punishment.
WHO TO SCREEN: More aggressive, more complicated
The 2018 guidelines have the addition of an “annual risk assessment” for highest-risk patients i.e. the burdensome CANRISK calculator.
Though the “who to screen” section of the new guidelines is more complicated, we’ve distilled it down into a more simplified 2-question tool:
1) Is my patient ≥ 40 years?
NO? then do a CANRISK.
YES? Go to question 2.
2) Do they have any additional risk factors for diabetes?
NO (or if CANRISK ≥ 33%): screen EVERY 3 years
YES (or if CANRISK ≥ 50%): screen EVERY 6-12 months
Recommendations in the medication chapter have increased from 6 to 17. Some of these are covered in “4. Real life tips” below. Some other highlights:
NEW ULTRA-LONG ACTING INSULIN:
NPH, Glargine, and Degludec: long, longer, ultra-long acting. Though decludec is mentioned briefly in the 2013 guidelines, there is now much more evidence to clarify its role:
“may be considered over insulin glargine U-100 to reduce overall and nocturnal hypoglycemia and severe hypoglycemia in patients at high CV risk”.
NEW DRUG EVIDENCE:
We finally have evidence showing vascular benefit for some antidiabetic agents.
Vascular benefit means less CV events, heart failure hospitalization, and progression of nephropathy (except for Liraglutide which only has evidence for less CV events).
· Empagliflozin (strongest evidence)
· Canagliflozin (twofold increased risk of amputations, and increased risk of fractures)
· Liraglutide (increased risk of pancreatitis)
These have been added to the Vascular Protection algorithm and the Medication algorithm - to be given to ALL pts with CVD… IF the patient is not at glycemic target.
Not new, but some medication clarifications:
· A 2013 guideline Key Message said that “metformin should be the initial agent of choice.” The 2018 guidelines uphold this but emphasize that INSULIN with or without metformin is the initial agent of choice if the patient’s has metabolic decompensation and/or symptomatic hyperglycemia. This was in the 2013 guidelines but it has been made much more explicit.
· More explicit recommendation to avoid thiazolidines in patients with heart failure
NEW WEIGHT MANAGEMENT MEDS
A recommendation has been added to consider liraglutide or orlistat to help control body weight now that both are approved in Canada for weight loss.
MORE REAL LIFE TIPS
The complete guideline recommendations are worth a skim – here we’re mostly covering what’s new, but there are lots of great tips carried over from 2013.
The 2018 quick reference guide has added helpful tips, including on:
· Driving and diabetes (Sample SOO: "When can I start driving again after a low sugar episode?") See our upcoming blog post on Driving and Diabetes which includes The Review Course 2-4-6 Rule for Driving and Diabetes
· Vomiting, diarrhea, and diabetes (Sample SAMP: List 7 classes of medications to hold when a patient is at risk of dehydration due to vomiting or diarrhea.)
· Diabetes and preconception counseling is now more robust, and metformin can now be continued in all pregnant patients, not just pregnant patients with PCOS (Sample SOO: "can I get pregnant even though I am being treated for diabetes?")
Answers to the sample questions above are found in the 2018 quick reference guide
The guideline also includes new tips on exercise. Remember, don’t skip the lifestyle advice when studying – nutrition therapy alone can improve A1C by 1-2%.
· NEW FOR 2018 TIP: Don’t sit for prolonged periods
· NEW FOR 2018 TIP: Consider using a pedometer
· NEW FOR 2018 TIP: Dietary fibre recommendations increased to 30-50g/day
Other NEW FOR 2018 tips:
· Ask about hypoglycemia at EVERY clinic visit. This has been upgraded from the guideline text in 2013 to a formal recommendation in 2018. As well the hypoglycemia chapter focuses more on STRATEGIES FOR PREVENTING HYPOGLYCEMIA instead of just TREATMENT of hypoglycemia. See our upcoming blog post on this topic.
· Diabetic ketoacidosis can happen with a NORMAL blood glucose in two scenarios: Pregnancy and use of SGLT2 inhibitors. As well, negative urine ketones do not rule out diabetic ketoacidosis.
· Don’t forget mental health. The 2018 chapter on mental health includes added psychsocial interventions (stress management, coping skills training, family therapy etc.) and mental health and body image screening recommendations (especially in children and adolescents).
· Make sure all routine vaccines are up to date (including herpes zoster and hepatitis B), not just the vaccines strongly recommended in diabetes (influenza, pneumococcal)
EXAM & CLINIC TIP: Not new, but great to mention on a SOO or pull up in clinic: The 2018 Guidelines came with several online interactive tools that can automatically generate guideline-based recommendations for your patient. For example by typing in your patient’s numbers, you can:
· figure out the best a1c target
· find out the medication options
MORE FOCUS ON TARGETS
· <= 7 for A1C for most patients
· 130/80 for Blood Pressure
· 8 to 10 for critically ill patients on continuous IV infusion (blood glucose in mmol/L, changed from 6 to 10 in the 2013 guidelines)
· <=2 for LDL. Nonfasting is OK unless triglycerides > 4.5 mmol/L.
MORE FREQUENT A1Cs
A consensus (grade D) recommendation is made to check A1C:
· every 3 months for most patients
· every 6 months for more stable patients
· NEW IN 2018: More frequently IF significant changes are made OR in pregnancy
Notable chapter changes:
· New chapter added: Diabetes and Driving. See our upcoming blog post on this topic.
· "Influenza and Pneumococcal immunization" chapter has added "Hepatitis B and Herpes Zoster"
· "Erectile dysfunction" (underdiagnosed in men with diabetes - up to FIFTY percent suffer from this!) is now "Sexual dysfunction and Hypogonadism in Men with Diabetes"
· The recommendations are almost the same – the only change is that 2018 guidelines recommend that investigation for hypogonadism should occur in patients who do not respond to a PDE5 inhibitor, rather than all men with erectile dysfunction and diabetes.
Notable new appendix:
· Appendix 4: Smarter Step Count Prescription
· Appendix 6: Types of insulin
· Removed - Appendix 5: Approximate Cost Reference List for Antihyperglycemic Agents. Though we are expected to know approximate costs, these seem to be increasingly difficult to find.
CLINICAL TIP: Find approximate drug costs using http://pharmacycompass.com
Again – not much has changed. The biggest addition is the new chapter on Diabetes & Driving – our blog post on these recommendations is coming soon!