diabetes management pearls feb 2017

Tiffany Keenan, MD Miramichi

Diabetes update from Topguns ConferenceCanadian Diabetes Association 2013 Clinical Practice Guidelines, update 2016

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

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

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

3.3%

5.6%

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

2016-12.9%


Zone Incidence (new cases)per 1000 population**

Prevalence (all cases since 1995-2015) per 1000 pop**

Zone 16 101 11%

Zone 26 99

Zone 37 94

Zone 46 96

Zone 56 136 15.2%

Zone 69 120

Zone 78 125 14.9%

NB6 103

Prepared by: Claire Jardine, Technical Analyst with the Chronic Disease Prevention and Management unit, Department of Health, February 2017

NB Statistics


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


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

Highlights of Major Changes (continued) 2013


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

Highlights of Major Changes (continued) 2013


2013

Screening for Type 2 Diabetes in Adults

HbA1c $1.83ac gluc $0.51

*fasting labs 13% hypoglycemia

Reducing the Risk of Developing Diabetes

Chapter 5

Thomas Ransom, Ronald Goldenberg, Amanda Mikalachki, Ally PH Prebtani, Zubin Punthakee

Canadian Diabetes Association 2013 Clinical Practice Guidelines


Onset

15 Years!


Key Points

1. At this time, there are no safe and effective strategies to prevent T1DM

2. Intensive lifestyle modification with weight loss can reduce the risk of progression from pre-diabetes to T2DM by almost 60%

3. Progression from pre-diabetes to T2DM can be reduced by Metformin or Acarbose by approximately 30%

2013


Diabetes Prevention Program (DPP)

Diabetes Prevention Program (DPP) Research Group. N Engl J Med 2002;346:393-403.

Years

• Benefit of diet and exercise or Metformin on diabetes prevention in at-risk patients

• N = 3234 with IFG and IGT, without diabetes

00

10

20

30

40

1.0 2.0 3.0 4.0

Placebo

Metformin

Lifestyle

Cumulativeincidence of diabetes(%)

↓31%

↓58%

P*< 0.001

< 0.001

*vs placeboIFG = impaired fasting glucose, IGT = impaired glucose tolerance


Pharmacology to Reduce Progression to T2DM

• Metformin has been shown to reduce the incidence of T2DM by approximately 30% in the Diabetes Prevention Program (DPP)

• Acarbose has been shown to reduce the risk of progression to diabetes by approximately 30% in the Study to Prevent Non-Insulin Dependent Diabetes (STOP-NIDDM) study

• Intensify management early, first 5 years of Key Importance


Recommendation 1 and 2

1. A structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be implemented to reduce risk of T2DM in individuals with IGT [Grade A, Level 1A] or IFG [Grade

B, Level 2] or A1C 6.0-6.4% [Grade D, consensus].

2. In individuals with IGT, pharmacologic therapy with Metformin [Grade A, Level 1A] or Acarbose [Grade A, level 1A] may be used to reduce the risk of T2DM.

2013

Canadian Diabetes Association 2013 Clinical Practice Guidelines

Targets for Glycemic Control

Chapter 8

S. Ali Imran, Rémi Rabasa-Lhoret, Stuart Ross


Individualizing A1C Targets

which must be balanced against the risk of hypoglycemia

Consider 7.1-8.5% if:

2013


Adherence• 65% of patients have a1c<7 at 5 years (Dr

Costain get <6.5% within 3-6 months)

• Patient compliance with meds:• cost• side effects• set a goal and work with the patient

60% adherence to medication21% stopped at one year+predictors: older age, first Rx by GP, >5 Rx


Medication Adherence

• Every 10 increase adherence, lowers A1c by 0.1%• once daily med 70-94% versus bid 60-70%• avoid tid, no metformin at lunchtime• Question: In the last 30 days how many times have

you forgotten to take your medication?• Simplify treatment!• pill boxes, fixed dose meds, blister packs, app on

phone, tie to a routine activity (ex. brushing teeth), tabtime vibrating pill reminder, app for phone

• Minicog testing - all patients over 65, tell them it is a standard test for diabetics


Onset

15 Years!


Reduction in Retinopathy

The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-986.

Primary Prevention Secondary Intervention

76% RRR(95% CI 62-85%)

54% RRR(95% CI 39-66%)

RRR = relative risk reduction CI = confidence interval


DCCT/EDIC Study Research Group. N Engl J Med 2005;353:2643–2653.

DCCT/EDIC: Early intensive therapy reduced the risk of nonfatal MI, stroke or death from CVD

57% risk reduction(P=0.02; 95% CI: 12–

79%)

MI,

stro

ke o

r CV

deat

h

Conventionaltreatment

Intensivetreatment

0 1 2 3 4 5 6 7 8 9 10 11 1213 14 15 16 17 18 19 20 21Years since entry

0.12

0.10

0.08

0.06

0.04

0.02

0.00

Canadian Diabetes Association Clinical Practice Guidelines

Pharmacologic Management of Type 2 Diabetes Chapter 13(Updated November 2016)

2016

Start metformin immediately

Consider initial combination with another antihyperglycemic agent

Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin

A1C <8.5% Symptomatic hyperglycemia with metabolic decompensationA1C ≥8.5%

Initiate insulin +/-

metformin

If not at glycemic target (2-3 mos)

Start / Increase metformin

If not at glycemic targets

LIFESTYLE

Add another agent best suited to the individual by prioritizing patient characteristics:

Degree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityCardiovascular disease or multiple risk factorsComorbidities (renal, CHF, hepatic)Preferences & access to treatment

See next page…

AT DIAGNOSIS OF TYPE 2 DIABETES

Consider relative A1C loweringRare hypoglycemiaWeight loss or weight neutralEffect on cardiovascular outcomeSee therapeutic considerations, consider eGFRSee cost column; consider access

PATIENT CHARACTERISTIC CHOICE OF AGENTPRIORITY: Clinical Cardiovascular Disease

Antihyperglycemic agent withdemonstrated CV outcome benefit(empagliflozin, liraglutide)

11/2016

Beta cell apoptosis


Insulin

• lean elderly: insulin deficient, not resistant• injection: leave in skin 10-12 seconds to ensure

absorption• Humulin N, Novolin NPH - cloudy, mix 20 times, very

cheap• Apidra, Humalog, Novorapid: give 10-15 minutes

before meals to keep dose down• hypoglycemia: 15 g carbohydrate only, recheck 15

min– 3/4 cup juice, 6 lifesavers, 1 Tbsp honey, 3 packs sugar

Add another class of agent best suited to the individual (agents listed in alphabetical order):Class Relative

A1C Lowering

Hypo-glycemia

Weight Effect in Cardiovascular Outcome Trial

Other therapeutic considerations Cost

α-glucosidase inhibitor (acarbose)

↓ Rare Neutral to ↓ Improved postprandial control, GI side-effectsIt’s worth a try

$$

DPP-4 Inhibitors↓↓ Rare Neutral to ↓ alo, saxa, sita:

NeutralCaution with saxagliptin in heart failure $$$

GLP-1R agonists ↓↓to ↓↓↓ Rare ↓↓ lira: Superiorityin T2DM patientswith clinical CVD

lixi: Neutral

GI side-effects $$$$

Insulin ↓↓↓ Yes ↑↑ Neutral (glar) No dose ceiling, flexible regimens $-$$$$Insulin secretagogue: Meglitinide Sulfonylurea

↓↓

↓↓

Yes

Yes

↑

↑

Less hypoglycemia in context of missed meals but usually requires TID to QID dosingGliclazide and glimepiride associated with less hypoglycemia than glyburideCost of test strips, not worth the savings

$$

$

SGLT2 inhibitors(Invokana, Jardiance)

↓↓to ↓↓↓ Rare ↓↓ empa:Superiority inT2DM patients

with clinical CVD

Genital infections, UTI, hypotension, dose-related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)Yeast, prostate, BPH, dehydration, GFR>60

$$$

Thiazolidinediones(actos, avandia)

↓↓ Rare ↑↑ Neutral CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect

$$

Weight loss agent (orlistat)

↓ None ↓ GI side effects $$$

alo=alogliptin; glar=glargine; saxa=saxagliptin; sita=sitagliptin; lira=liraglutide; lixi=lixisenatide; empa=empagliflozin11/2016

Empagliflozin/Jardiance 45

eGFR (mL/min/1.73 m2): <15 15–29 30–59 60–89 ≥ 90CKD Stage: 5 4 3 2 1

Acarbose Not recommended25

Dapagliflozin/Forxiga 60

Thiazolidinediones 30Contraindicated

SafeCaution and/or reduce dose

Canagliflozin/Invokana 25 60*100 mg45

Adapted from: Product Monographs as of March 2016 Harper W et al. Can J Diabetes 2015;39:440.

* = do not initiate if eGFR <60 ml/min Not recommended

Metformin 30 60

15Linagliptin/Trajenta

Sitagliptin/Januvia 5030 50 mg25 mgSaxagliptin/Onglyza 5015 2.5 mg

Alogliptin Not recommended 506.25 mg 12.5 mg30

Exenatide (BID/QW)/Byetta 30 50Liraglutide/Victoza 50

Albiglutide 50

30

Repaglinide/Gluconorm

Gliclazide/Glimepiride 15 30Glyburide 30 50

Insulin Secreta-gogues

SGLT2 inhibitors

GLP-1R agonists

Alpha-glucosidase Inhibitor

Biguanide

DPP-4 inhibitors

Dulaglutide/Trulicity 50

Antihyperglycemic agents and Renal Function

11/2016

60*45

No dose adjustment but close monitoring of renal function


Drug Coverage

• NBPDP– bookmark pdf– it’s searchable

– CRITERIA is key• prepare standard forms to ensure meet criteria for patient• needle phobia, increase pp glycemia• cognitive ability, shift worker, risk of falls• list patient experience with other meds

Canadian Diabetes Association Clinical Practice Guidelines

Nutrition Therapy

Chapter 11

Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein, John L. Sievenpiper, Sandi Williams


Recommendation 10

10. Alternative dietary patterns may be used in people with T2DM to improve glycemic control, (including):• Mediterranean-style dietary pattern [Grade B, Level 2]• Vegan or vegetarian dietary pattern [Grade B, Level 2]• Incorporation of dietary pulses (e.g., beans, peas, check peas,

lentils) [Grade B, Level 2]

10. Dietary Approaches to stop Hypertension (DASH) dietary pattern [Grade B, Level 2]

11. Low Carb - High Fat (ie. Atkins, Banting, Ideal Protein) Future?

2013


Recommendations 11 and 12

11. An intensive lifestyle intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control, and cardiovascular risk factors [Grade A, Level 1A]

12. People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2]; or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4]

***Dr Macsween, no carb counting 15 units large meal, 10 units small meal***


The Growing Epidemic

• 80-90% of patients with T2DM overweight or obese*

• Some antihyperglycemic therapies contribute to weight gain

• Higher BMI increases mortality

BUT, weight loss of only 5-10% can improve metabolic parameters!

Overweight or Obese

*Wing RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B editor(s). Evidence-Based Diabetes Care. Ontario, Canada: B.C. Decker, Inc, 2000:252–76.

Diabetes Prevention & Weight Change

Diabetes Prevention Program (DPP)Diabetes Incidence (per 100 Person-Years) by Change in Weight After Baseline

Adapted from Hamman, et al, Diabetes Care 2006

- 83%- 58%

Sharma AM, Obes Rev 2010

Sharma & Padwal, Obes Rev 2009


How will this change my practice?


Physician Adherence to Guidelines

Zone

Glycemic categories

No test Excellent≤7%

Good>7-≤8%

Moderate>8-≤9%

Poor>9%

Zone 1 16.5% 43.8% 21.3% 10.1% 8.3%

Zone 2 23.2% 35.7% 19.6% 11.4% 10.1%

Zone 3 18.4% 33.5% 21.9% 12.9% 13.3%

Zone 4 17.3% 45.4% 20.3% 9.6% 7.4%

Zone 5 25.1% 41.3% 17.3% 8.4% 7.9%

Zone 6 14.7% 47.0% 21.4% 8.7% 8.2%

Zone 7 19.7% 36.4% 21.4% 11.9% 10.5%

New Brunswick 19.0% 39.6% 20.8% 10.8% 9.8%

Prepared by: Claire Jardine, Technical Analyst with the Chronic Disease Prevention and Management unit, Department of Health, February 2017

You

Your doctor

Your nurse

Your dietitian

Your pharmacist YOU

Optometrist or ophthalmologist Local diabetes education centre

Foot care specialistMental Health Professional

Other people you know who have diabetes

Physical activity specialist

Dentist

Heart specialist

Kidney specialist

Family and friends

Your diabetes care team may include a …….


The Five ‘Rs’

Recognize:Consider diabetes risk factors for all of your patients and screen

appropriately for diabetes.

Register:Develop a registry or a method of tracking all your patients

with diabetes.

Resource:Support self-management through the use of interprofessional

teams which could include the primary care provider, diabetes

educator nurse, pharmacist, dietitian, and other specialists.

Relay:Facilitate information sharing between the person with diabetes and

team members for coordinated care and timely management change.

Recall:Develop a system to remind your patients and caregivers of timely

review and reassessment of targets and risk of complications.

Screen with Hba1c, no fasting required

Update records based on patient profile

Refer patient to diabetic clinic or community resources

Ask adherence at each visitCommunicate with patient tx goals & diabetes care team

Annual recalls at time of birthdayStickers on medicare card as reminder

Team care & Organization of Care


Physician Resources• http

://www2.gnb.ca/content/gnb/en/departments/health/patientinformation/PrimaryHealthCare/A-Comprehensive-Diabetes-Strategy-for-New-Brunswickers-2011-2015/OfficeToolsFormsForPrimaryCareProviders.html

• www.diabetes.ca

• Diabetes Clinic: Nurse Sara Trevor, Case Managers Rosline Dugas & Jacqueline Savoie• Send paper chart to physician after each visit. Visit GP offices regularly. Record information in paper chart.• Foot clinic. 1-2 days per month. • Staff: Infectious disease physician, Tracy Fournier, Cheryl Buggie• Dr Caissie Consultations. • Clinic held every second wednesday at OPC. Flow sheets are completed.• Peripheral Clinics:• Burnt Church every second month. Nurse Sara Trevors• Blackville monthly, third thursday of the month. Nurse Sara Trevors• Rogersville - monthly• Neguac - Rosaline Dugas 3 times per month with Dietitian

• Pre-Diabetes Group Class. Held monthly at Sobey's in Douglastown. RN and Dietitian present. Average is 6 patients per session

• Followup: Yearly recall list.

• New Diabetes Group Class. Every second Friday at Sobeys, 2 1/2 hours. Average is 4-12 patients.• Followup: book an individual 45 minute appointment if the patients are not controlled and then q3months.

http://www2.gnb.ca/content/gnb/en/departments/health/patientinformation/PrimaryHealthCare/A-Comprehensive-Diabetes-Strategy-for-New-Brunswickers-2011-2015/OfficeToolsFormsForPrimaryCareProviders.html



http://www.diabetes.ca/


Patient ResourcesIndividual:Newcastle Superstore Dietitian - Karine Roy, [email protected] 5-6-545-8950 visits weekly. Free personalized consultation 60 minutes with optional food tour.Eel Ground - Nurse Wendy Chaddick assesses patient, referral to Lucy MacRae DietitianSobey's Dietitian- Dietitian Kayla Daigle, Personal consultations and Quarterly Free Healthy Lifestyle Program [email protected] 506-778-0163Gisela Roux - Sculpt - Peak Performance (506) 624-4229 sculpthealthandwellness.com/

Group:

Weight Watchers -

Blackville Monday at 7 PM, contact Arlene Waugh 6:20-7:30 843-6142

Goodie Shop, Wednesday @ 9:45 am and 6:30 PM

Sobey's Dietitian- Dietitian Kayla Daigle, Personal consultations and Quarterly Free Healthy Lifestyle Program [email protected] 506-778-0163

Gisela Roux - Dietitian, Miramichi

TOPS (Take off Pounds Sensibly) Knights of Columbus Miramichi Monday 6:00,

Caring Friends Activity Center, Wed @ 4:30

Boom Road Pentecost Church Monday @ 6:00

Renous Fire Hall Tuesday @6:15

Contact Patsy Anne Holt 622-1785, [email protected]

Online:

diet.mayoclinic.org Daily emails, recipes and meal planning

Apps:

My Fitness Pal

mailto:[email protected]

mailto:[email protected]

http://sculpthealthandwellness.com/

diabetes management pearls feb 2017

Health & Medicine