SOHIL RANGWALAMDCM, CCFP

PRIMROSE FAMILY MEDICINE CENTRE

Diabetes in a nutshell

Objectives

Review screening and diagnostic criteria for DM2

Review management of DM2

Review the use of Diabetic Flow sheets

Review of CDA interactive website

Who do you screen for diabetes?

A) EveryoneB) Men and women over 50C) Men and women over 40D) It doesn’t really matterE) Someone who scores moderate risk on the

FINRISK or CANRISK calculator

How frequently do you screen?

A) yearlyB) every 2 yearsC) Every 3 yearsD) After the holiday seasonE) Every 5 years

When do you screen earlier than 40 for DM2?

A) If they have metabolic syndromeB) If they are very high risk using the

FINRISK/CANRISK calculatorC)Family History of DMD) history of GDME) all of the above

When do you screen more frequently than every 3 years?

A) If they request itB) If they have additional risk factors for DM2C) If they are high risk on FINRISK or

CANRISKD) If they are very high risk on FINRISK or

CANRISKE) B and D

How do you screen for DM2?

A) Ask the patientB) using HBA1cC) using Fasting Blood sugarD) using HsCRPE) B or C

How do you diagnose DM2?

A )HbA1c > 7%B) FBS > 7C) HbA1c> 6.5%D) RBS > 11.1 with symptomsE) Always need second confirmatory testF) B, C, D, E

When do you do a 2 hour OgTT?

A) All of the belowB) if HbA1c is between 6.0-6.4%C) if HbA1c is between 5.6- 5.9% and have

a risk factorD) if FBS is between 5.6-6.0 and have a risk

factorE) if FBS is between 6.1-6.9

Screening and Diagnosis review

Type 2 DM risk factors

CANRISK calculator

http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/diabetes-diabete/canrisk/index-eng.php

Management

1. Lowering Blood sugar

2. Lowering Vascular risk

What are the complications?

What is the target HbA1c?

A) less than 6.5%B) less than 7 %C) it depends on the dayD) less than 6%E) if I’m on metformin who cares!

When should Hba1c less than 6.5%

A) to help reduce complications from retinopathy

B) to help reduce complications from neuropathy

C) to help reduce complications from nephropathy

D) A + CE) A+ B

How much physical activity is recommended in diabetes?

A) as toleratedB) 150 minutes of aerobic exerciseC) Resistance exercise 2-3 times a weekD) Daily weights at the gymE) B and C

Physical Activity ChecklistDO a minimum of 150 minutes of moderate-to

vigorous-intensity aerobic exercise per week

INCLUDE resistance exercise ≥ 2 times a week

SET physical activity goals and INVOLVE a

multi-disciplinary team

ASSESS patient’s health before prescribing an

exercise regimen

www.guidelines.diabetes.ca

2013

What dietary advice should be given in diabetes?

A) Patients should see a registered dieticianB)Dietary advice should emphasize low

glycemic index foodsC) Canada Food guide should be followedD) All of the above

By how much can dietary changes lower HbA1c?

A) 1%B) 3%C) it’ s a rumorD) 2%E) 1-2%

Nutrition Checklist

REFER for nutrition counseling by a registered dietitian

FOLLOW Eating Well with Canada’s Food Guide

INDIVIDUALIZE dietary advice based on preferences and treatment goals

CHOOSE low glycemic index carbohydrate food sources

www.guidelines.diabetes.ca

2013

Choose low glycemic index carbohydrates

www.guidelines.diabetes.ca

At diagnosis of Diabetes, I should:

A) Always start MetforminB) Consider MetforminC) Always recommend lifestyle changesD) A +CE) B + C

If the A1C is > 8.5 %, I should:

A) Refer to endocrinologyB) Start Metformin ImmediatelyC) Consider combination therapyD) Start Glicazide ImmediatelyE) B and C

If HbA1c is < 8.5% but not at target, I should:

A) Make no changesB) Start/Increase MetforminC) Start InsulinD) Run(away)

After diagnosis, how long should it take me to reach target HbA1c?

A) one yearB) 9 monthsC) 3-6 monthsD) one monthE) 2 years

Which of the following has the greatest effect in lowering HbA1c?

A) diet and exerciseB) insulinC) DPP4 inhibitorsD) GlicazideE) Metformin

What is the most common side effect of metformin?

A) HeadachesB) HypoglycemiaC) VomitingD) Kidney FailureE) Diarrhea

What is Sitagliptin?

A) DPP-4 inhibitorB) SulfonylureaC) GLP-1 receptor agonistD) Meglitinide

Which sulfonylurea causes less hypoglycemia?

A) GlyburideB) Glicazide

Initial Choice of Therapy Depends on Glycemia

www.guidelines.diabetes.ca

Initial A1C ≥8.5%

Start metformin

AND

Consider combo therapy to achieve ≥1.5% A1C reduction

Initial A1C <8.5%

Start metformin

OR

Reassess in 2-3 months then decide on starting metformin

2013

When starting insulin, should I use basal or bolus?

A) Basal insulinB) Bolus Insulin

Generally, how many units of basal insulin should be started?

A) 5 unitsB) 15 unitsC) 10 unitsD) pick out of a hatE) 20 units

When bolus insulin is added to basal, should oral secretagogues be stopped?

A) YesB) No

Insulin pen

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

What is the definition of hypoglycemia?

A) Blood sugar < 6B) Blood sugar < 4C) Autonomic symptomsD) Response to carbohydrate loadE) B, C, D

How do we treat mild-moderate hypoglycemia?

A) Equivalent of 15 g carbohydrate loadB) Equivalent of 30 g carbohydrate loadC) InsulinD) Equivalent of 10 g carbohydrate load

1. Development of neurogenic or neuroglycopenic symptoms

2. Low blood glucose (<4 mmol/L if on insulin or secretagogue)

3. Response to carbohydrate load

Neurogenic (autonomic)

Neuroglycopenic

Trembling Difficulty Concentrating

Palpitations Confusion

Sweating Weakness

Anxiety Drowsiness

Hunger Vision Changes

Nausea Difficulty Speaking

Dizziness

Definition of Hypoglycemia

Steps to Address Hypoglycemia

1. Recognize autonomic or neuroglycopenic symptoms

2. Confirm if possible (blood glucose <4.0 mmol/L)

3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms

4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed

5. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein

15 g of glucose in the form of glucose tablets

15 mL (3 teaspoons) or 3 packets of sugar dissolved in water

175 mL (3/4 cup) of juice or regular soft drink

6 Lifesavers (1=2.5 g of carbohydrate)

15 mL (1 tablespoon) of honey

Examples of 15 g Simple Carbohydrate

Vascular protection

Which of the following people with DM 2 should receive a statin?

A) 28 year old male recently diagnosed with diabetes

B)EveryoneC) 38 year old male with recent diagnosis of

diabetes and ACR of 7 mmol/LD) 45 year old female with diabetesE) C and D

Which of the following people with DM2 should receive an ACE/ARB?

A) 48 year old male with Dm2B) 52 year old female with DM2 and hx of

retinopathyC) 68 year old maleD) EveryoneE) B and C

Which of the following patients with Diabetes should receive ASA?

A) EveryoneB) All patients over 50 with diabetesC) all patient over 40 with diabetesD) all patients with diabetes who have had a

vascular eventE) Nobody

Vascular Protection Checklist2013

Who Should Receive Statins? (regardless of baseline LDL-C)

≥40 yrs old or Macrovascular disease orMicrovascular disease orDM >15 yrs duration and age >30 years orWarrants therapy based on the 2012 Canadian

Cardiovascular Society lipid guidelines

www.guidelines.diabetes.ca

Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception.

2013

Who Should Receive ACEi or ARB Therapy?(regardless of baseline blood pressure)

≥55 years of age or Macrovascular disease or Microvascular disease

At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily

(HOPE), telmisartan 80 mg daily (ONTARGET)]

Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception

counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy

2013

EUROPA Investigators, Lancet 2003;362(9386):782-788.HOPE study investigators. Lancet. 2000;355:253-59.

ONTARGET study investigators. NEJM. 2008:358:1547-59

Insufficient evidence to support use of ASA for primary prevention

Risk of bleeding CVD protection

www.guidelines.diabetes.ca

2013

ASA Not Routinely Recommended for 1 ⁰Prevention for CVD Among Patients with DM

How often should my patients with DM2 receive the pneumococcal vaccination?

A) Once over the age 50B) Every 5 yearsC) Over the age of 18D)One time revaccination if > 65 and> 5

years between administrationE) C+ D

Immunization Checklist

GIVE annual influenza immunization

OFFER pneumococcal immunization if >18 years of age

RE-VACCINATE for pneumococcal for those >65 years of age; ensure ≥5 years between administrations

2013

What to do when?

A1c check- every 3 months ( less than 7%)ACR check- Yearly( target less than 2.0)Retinopathy check- YearlyLDL check- yearly( LDL less than 2.0)BP check- every visit( less than 130/80)Neuropathy check- Yearly

Conclusions

Diabetes is very prevalent and having a grasp on diagnosis and management is key!

CDA guidelines are interactive and a great tool for health care providers and patients!

References

http://guidelines.diabetes.ca/fullguidelines