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Pages-Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention & Management of Diabetes in Canada
Pages-Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention & Management of Diabetes in Canada
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Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (from Canadian Journal of Diabetes December 2003 Volume 27 Supplement 2)
Recommendations for:
• Screening and Prevention
• Organization and Delivery of Care
• Targets for Glycemic Control
• Monitoring Glycemic Control
• Physical Activity and Diabetes
• Nutrition Therapy
• Insulin Therapy in Type 1 Diabetes
• Pharmacologic Management of Type 2 Diabetes
• Hypoglycemia
• Management of Obesity in Diabetes
• Psychological Aspects of Diabetes
• Influenza and Pneumococcal Immunization
• Pancreas and Islet Transplantation
• Macrovascular Complications, Dyslipidemia and Hypertension
• Nephropathy
• Neuropathy
• Foot Care
• Retinopathy
• Erectile Dysfunction
• Type 1 Diabetes in Children and Adolescents
• Type 2 Diabetes in Children and Adolescents
• Pre-existing Diabetes and Pregnancy
• Gestational Diabetes Mellitus
• Diabetes in the Elderly
• Type 2 Diabetes in Aboriginal Peoples
• Perioperative Glycemic Control
• Peri-acute Coronary Syndrome Glycemic Control
Screening and Prevention (back to the top)
Recommendations
1) All individuals should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria [Grade D, Consensus].
2) Screening for diabetes using an FPG should be performed every 3 years in individuals >=40 years of age [Grade D, Consensus]. More frequent and/or earlier testing with either an FPG or 2hPG in a 75-g OGTT should be considered in people with additional risk factors for diabetes [Grade D, Consensus].
These risk factors include:
• First-degree relative with diabetes
• Member of high-risk population (e.g. people of Aboriginal, Hispanic, Asian, South Asian or African descent)
• History of IGT or IFG
• Presence of complications associated with diabetes
• Vascular disease
• History of GDM
• History of delivery of a macrosomic infant
• Hypertension
• Dyslipidemia
• Overweight
• Abdominal obesity
• Polycystic ovary syndrome
• Acanthosis nigricans
• Schizophrenia
• Other risk factors (see Appendix 1)
3) Testing with a 2hPG in a 75-g OGTT should be considered in individuals with an FPG of 5.7 to 6.9 mmol/L in order to identify individuals with IGT or diabetes [Grade D, Consensus].
4) In individuals with IGT, a structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be implemented to reduce the risk of type 2 diabetes [Grade A, Level 1A (25,26)].
5) In individuals with IGT, pharmacologic therapy with metformin (biguanide) [Grade A, Level 1A (26)] or acarbose (alpha-glucosidase inhibitor) [ Grade A, Level 1A (28)] should be considered to reduce the risk of type 2 diabetes.
Organization and Delivery of Care (back to the top)
Recommendations
1) Diabetes care should be organized around the person with diabetes using a multi- and interdisciplinary DHC team approach [Grade B, Level 2 (3,7)].
2) Diabetes care should be systematic and incorporate organizational interventions that have been shown to improve healthcare efficiencies, such as databases to provide patient and physician reminders and transfer of information, organized diabetes clinics, and tools, including clinical flow charts [Grade B, Level 2 (3,7,18)].
3) As an essential member of the DHC team, the family physician and/or specialist and the other members of the DHC team have the responsibility to:
• Ensure that systematic, structured and standardized diabetes care is available [Grade A, Level 1A (18)];
• Incorporate current standards of diabetes care into daily practice [Grade D, Consensus];
• Facilitate transfer of information among all members of the team to ensure continuity of care [Grade A, Level 1A (18,32)]; and
•Endeavour to identify and prevent diabetes in those identified to be at risk [Grade D, Consensus].
4) People with diabetes should be offered initial and ongoing needs-based diabetes education in a timely manner to enhance self-care practices and behaviours [Grade B, Level 2(33)].
5) The role of diabetes nurse educators [Grade B, Level 2 (3)] and other DHC team members [Grade D, Consensus] should be enhanced in cooperation with the physician to improve coordination of care and to effect timely diabetes management changes.
Targets for Glycemic Control (back to the top)
Recommendations
1) Glycemic targets must be individualized; however, therapy in most patients with type 1 or type 2 diabetes should be targeted to achieve and A1C <=7.0% in order to reduce the risk of microvascular [Grade A, Level 1A (1,3)] and macrovascular complications [Grade C, Level 3 (5)].
2) To achieve an A1C <=7.0%, patients with type 1 or type 2 diabetes should aim for FPG or preprandial PG targets of 4.0 to 7.0 mmol/L and 2-hour postprandial PG targets of 5.0 to 10.0 mmol/L [Grade B, Level 2 (1-3)].
3) If it can be safely achieved, lowering PG targets toward the normal range should be considered [Grade C, Level 3 (4,5,8,10)]:
• A1C <=6.0% [Grade D, Consensus];
• FPG/preprandial PG: 4.0 to 6.0 mmol/L [Grade D, Consensus]; and
• 2-hour postprandial PG: 5.0 to 8.0 mmol/L [Grade D, Consensus].
Monitoring Glycemic Control (back to the top)
Recommendations
1) A1C should be measured approximately every 3 months to ensure that glycemic goals are being met or maintained [Grade D, Consensus].
2) All people with diabetes, who are able, should be taught how to self-manage their diabetes, including SMBG [Grade A, Level 1A (4)].
3) SMBG should be recommended as an essential part of daily diabetes management for all people using insulin or oral antihyperglycemic agents. People with type 1 diabetes should measure their BG at least 3 times per day. The frequency of SMBG in those with type 2 diabetes should be individualized depending on glycemic control and type of therapy. For most people with type 2 diabetes treated with insulin or oral antihyperglycemic agents, BG measurement at least once daily is recommended [Grade C, Level 3 (3)]. In many situations, more frequent testing may be required to provide the information needed to make behavioural or treatment adjustments required to achieve desired BG levels [Grade D, Consensus].
4) SMBG should include both preprandial and 2-hour postprantial testing [Grade D, Consensus].
5) Individuals who are conducting SMBG should receive initial instruction and periodic re-education regarding home glucose monitoring [Grade A, Level 1A (4)].
6) In order to ensure accuracy of BG meter readings, meter results should be compared with laboratory measurement of simultaneous venous FPG at least annually, and when indicators of glycemic control do not match meter readings [Grade D, Consensus].
7) During periods of acute illness, people with type 1 diabetes should be instructed to perform ketone testing when preprandial BG levels are >14.0 mmol/L and in the presence of symptoms of DKA [Grade D, Consensus]. If all of the conditions noted above are present in someone with type 2 diabetes, ketone testing should be considered [Grade D, Consensus].
Physical Activity and Diabetes (back to the top)
Recommendations
1) An exercise ECG stress test should be considered for previously sedentary individuals with diabetes at high risk for CVD who wish to undertake exercise more vigorous than brisk walking [Grade D, Consensus].
2) People with type 2 diabetes should accumulate at least 150 minutes of moderate-intensity aerobic exercise each week, spread over at least 3 nonconsecutive days of the week [Grade B, Level 2 (3)] or, if willing, should be encouraged to accumulate >=4 hours of exercise per week [Grade C, Level 3 (7)].
3) People with diabetes (including elderly people) should also be encouraged to perform resistance exercise 3 times per week [Grade B, Level 2 (11,17)].
Nutrition Therapy (back to the top)
Recommendations
1) Nutrition counselling by a registered dietitian is recommended for people with type 2 diabetes [Grade C, Level 3 (3)] and people with type 1 diabetes [Grade D, Consensus] to lower A1C levels. Counselling is equally effective when given in a small group or one-on-one setting [Grade B, Level 2 (5)].
2) To meet their nutritional needs, individuals with diabetes should be encouraged to follow Canada's Guidelines for Healthy Eating [Grade D, Consensus].
3) People with diabetes should choose low-glycemic-index foods in place of high-glycemic-index foods within the same category of foods more often to help optimize glycemic control [Grade B, Level 2 (23-26)].
4) Sucrose and sucrose-containing foods can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of energy, provided adequate control of BG and lipids is maintained [Grade B, Level 2 (27,28)].
5) All people with diabetes should consider restricting combined saturated fats and trans fatty acids to <10% of energy. Meal plans should favour monounsaturated fats, when possible, and include foods rich in polyunsaturated omega-3 fatty acids and plant oils [Grade D, Consensus].
6) For people with diabetes on intensive insulin treatment regimens, education on matching insulin to carbohydrate content (e.g. carbohydrate counting) is recommended [Grade D, Consensus].
7) The diabetes healthcare team should discuss alcohol use with people with diabetes [Grade D, Consensus]. People with type 1 diabetes should be informed of the risk of morning hypoglycemia resulting from alcohol consumed 2 to 3 hours after the previous evening's meal [Grade C, Level 3 (46)].
Insulin Therapy in Type 1 Diabetes (back to the top)
Recommendations
1) To achieve glycemic targets in people with type 1 diabetes, multiple daily insulin injections (3 or 4 per day) or the use of CSII as part of an intensive diabetes management regimen should be considered [Grade A, Level 1A (4)].
2) Insulin aspart or insulin lispro, in combination with adequate basal insulin, is preferred to regular insulin to achieve postprandial glycemic targets and improve A1C while minimizing the occurrence of hypoglycemia [Grade B, Level 2 (5-11)].
3) Insulin lispro or insulin aspart should be used when CSII is used in patients with type 1 diabetes [Grade B, Level 2 (13,14)]. Buffered regular insulin is equally effective in experienced insulin pump users [Grade B, Level 2 (14)]. (Buffered regular insulin is available only by special request through the manufacturer or Health Canada.)
4) Insulin glargine should be considered for use as the basal insulin in well-controlled patients who have problems controlling their FPG levels or to reduce overnight hypoglycemia [Grade B, Level 2 (12)].
5) Risk factors for severe hypoglycemia should be identified in people with type 1 diabetes so that appropriate strategies can be used to minimize hypoglycemia [Grade D, Consensus].
6) The following strategies should be implemented to reduce the risk of hypoglycemia and to increase physiologic counterregulatory responses to hypoglycemia in individuals with hypoglycemia unawareness:
• increased frequency of SMBG, including episodic assessment during sleeping hours;
• less stringent glycemic targets; and
• multiple insulin injections [Grade D, Level 4 (27,28)].
7) All individuals currently using insulin or starting intensive insulin therapy should be counselled about the risk and prevention of insulin-induced hypoglycemia [Grade D, Consensus].
8) In an attempt to reduce the development of hypoglycemia unawareness in people with type 1 diabetes, the frequency of mild hypoglycemic episodes should be minimized (<3 episodes per week), particularly in those at high risk [Grade D, Level 4 (22)].
9) To reduce the risk of asymptomatic nocturnal hypoglycemia, individuals should periodically monitor overnight BG levels at a time that corresponds with the peak action time of their overnight insulin and consume a bedtime snack with at least 15g of carbohydrate and 15g of protein if their bedtime BG level is <7.0 mmol/L [Grade B, Level 2 (54)].
Pharmacologic Management of Type 2 Diabetes (back to the top)
Recommendations
1) In people with type 2 diabetes, if glycemic targets are not achieved using lifestyle management within 2 to 3 months, antihyperglycemic agents should be initiated [Grade A, Level 1A (3)]. In the presence of marked hyperglycemia (A1C>=9.0%), antihyperglycemic agents should be initiated concomitant with lifestyle counselling [Grade D, Consensus].
2) If glycemic targets are not attained when a single antihyperglycemic agent is used initially, an antihyperglycemic agent or agents from other classes should be added. The lag period before adding other agent(s) should be kept to a minimum, taking into account the pharmacokinetics of the different agents. Timely adjustments to and/or additions of antihyperglycemic agents should be made in order to attain target A1C within 6 to 12 months [Grade D, Consensus].
3) The choice of antihyperglycemic agent(s) should take into account the individual and the following factors:
• Unless contraindicated, a biguanide (metformin) should be the primary drug used in overweight patients [Grade A, Level 1A (9)]; and
• Other classes of anithyperglycemic agents may be used either alone or in combination to attain glycemic targets, with consideration given to the information in Table 1 and Figure 1 [Grade D, Consensus for the order of antihyperglycemic agents listed in Figure 1].
4) In people with type 2 diabetes, if individual treatment goals have not been reached with a regimen of nutrition therapy, physical activity and sulfonylurea [Grade A, Level 1A (42)], sulfonylurea plus metformin [Grade A, Level 1A (34)] or other oral antihyperglycemic agents [Grade D, Consensus], insulin therapy should be initiated to improve glycemic control.
5) Combining insulin and the following oral antihyperglycemic agents (listed in alphabetical order) has been shown to be effective in people with type 2 diabetes:
• alpha-glucosidase inhibitors (acarbose) [Grade A, Level 1A (6,43)]
• biguanide (metformin) [Grade A, Level 1A (11,44,45)]
• insulin secretagogues (sulfonylureas) [Grade A, Level 1A (12)]
• insulin sensitizers (thiazolidinediones) [Grade A, Level 1A (46)]. (The combination of an insulin sensitizer plus insulin is currently not an approved indication in Canada.)
6) Insulin may be used as initial therapy in type 2 diabetes [Grade A, Level 1A (3)], especially in cases of marked hyperglycemia (A1C>=9.0%) [Grade D, Consensus].
7) To safely achieve optimal postprandial glycemic control, mealtime insulin lispro or insulin aspart is preferred over regular insulin [Grade B, Level 2 (47,48)].
8) When insulin given at night is added to oral antihyperglycemic agents, insulin glargine may be preferred over NPH to reduce overnight hypoglycemia [Grade B, Level 2 (14,49)] and weight gain [Grade B, Level 2 (14)].
9) All individuals with type 2 diabetes currently using or starting therapy with insulin or insulin secretagogues should be counselled about the recognition and prevention of drug-induced hypoglycemia [Grade D, Consensus].
Hypoglycemia (back to the top)
Recommendations
1) In hospitalized patients, efforts must be made to ensure that patients using insulin have ready access to an appropriate form of glucose at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus].
2) In adults, mild to moderate hypoglycemia should be treated by the oral ingestion of 15g of carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels [Grade B, Level 2 (4)]. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15g of carbohydrate if the BG level remains <4.0 mmol/L. In smaller children (<5 years of age or <20 kg), 10g of carbohydrate may be used initially [Grade D, Consensus].
3) Severe hypoglycemia in a conscious adult should be treated by the oral ingestion of 20g of carbohydrate, preferably as glucose tablets or equivalent. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15g of glucose if the BG level remains <4.0 mmol/L [Grade D, Consensus].
4) Severe hypoglycemia in an unconscious individual >=5 years of age, in the home situation, should be treated with 1mg of glucagon subcutaneously or intramuscularly. In children <5 years of age, a dose of 0.5mg of glucagon should be given. Caregivers or support persons should call for emergency services and the episode should be discussed with the diabetes healthcare team as soon as possible [Grade D, Consensus].
5) In the home situation, support persons should be taught how to administer glucagon by injection [Grade D, Consensus].
6) For severe hypoglycemia with unconsciousness in adults, when intravenous (IV) access is available, glucose 10 to 25g (20 to 50cc of D50W) should be given over 1 to 3 minutes. The pediatric dose of glucose for IV treatment is 0.5 to 1g/kg [Grade D, Consensus].
7) In hospitalized patients, a PRN order for glucagon should be considered for any patient at risk for severe hypoglycemia (i.e. requiring insulin and hospitalized for concurrent illness) when IV access is not readily available [Grade D, Consensus].
8) To prevent repeated hypoglycemia, once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day. If a meal is >1 hour away, a snack (including 15g of carbohydrate and a protein source) is recommended in the absence of complicating factors [Grade D, Consensus].
Management of Obesity in Diabetes (back to the top)
Recommendations
1) An interdisciplinary program of lifestyle modification, including regular physical activity or exercise and calorie reduction, should be implemented to promote long-term weight loss, weight maintenance and prevention of weight gain [Grade D, Consensus].
2) A weight-loss goal of 5 to 10% of initial body weight over a 6-month period should be recommended to improve overall metabolic and glycemic control in obese people with type 2 diabetes [Grade C, Level 3 (14)]. The recommended energy deficit should be approximately 500kcal/day, which can lead to an expected weight loss of 1 to 2kg/month (2 to 4lb/month) [Grade D, Consensus].
3) In obese people with type 2 diabetes, medical therapy with the antiobesity agent orlistat (gastrointestinal lipase inhibitor) [Grade A, Level 1A (24)] or sibutramine (norepinephrine and serotonin reuptake inhibitor) [Grade B, Level 2 (31)] may be considered as an adjunct to lifestyle modification to expedite achievement of weight-loss goals and weight maintenance.
4) For individuals with class III obesity (BMI >=40.0 kg/m) or class II obesity (BMI=35.0 to 39.9kg/m) with comorbidities who are unable to achieve weight-loss goals following an adequate trial of lifestyle intervention, bariatric surgery may be considered to reduce metabolic comorbidities [Grade C, Level 3 (37)].
Psychological Aspects of Diabetes (back to the top)
Recommendations
1) Individuals with diabetes should be regularly screened for psychosocial problems, depression and anxiety disorders [Grade D, Consensus] by direct questioning or with a standardized questionnaire [Grade B, Level 2 (15)]. Those diagnosed with depression should be offered treatment with cognitive-behaviour therapy [Grade B, Level 2 (36)] and/or antidepressant medication [Grade B, Level 2 (35)].
2) Individuals with diabetes should be regularly screened for psychological problems by open-ended questioning about stress, social support, beliefs about their disease and behaviour that could impair glycemic control [Grade D, Consensus]. Interventions including ongoing psychological support and reinforcement, coping skills training and family behaviour therapy should be offered as appropriate [Grade B, Level 2 (25,29,31)].
3) Interventions that increase patients' participation in healthcare decision making should be offered to adults with diabetes [Grade B, Level 2 (27)].
Influenza and Pneumococcal Immunization (back to the top)
Recommendation
1) Adults with diabetes should receive an annual influenza vaccine to reduce the risk of complications associated with these epidemics [Grade D, Consensus]. Adults with diabetes should also be considered for immunization against pneumococcus [Grade D, Consensus].
2) Children with diabetes should receive influenza and pneumococcal immunization according to national guidelines [Grade D, Consensus].
Pancreas and Islet Transplantation (back to the top)
Recommendation
1) In centres with personnel appropriately skilled in the technical aspects of the surgery, pancreas transplantation is a preferred option for patients whose type 1 diabetes has been difficult to control and who are undergoing kidney transplantation for diabetic nephropathy [Grade D, Consensus]. Whole organ pancreas transplant for nonuremic patients remains a high-risk procedure, and should be considered only for the patient with persistent major problems with diabetes control resulting in significant lifestyle disruption despite efforts at intensive insulin therapy [Grade D, Consensus].
2) In centres with personnel appropriately skilled in the technical aspects of islet isolation and clinical use of immunosuppression, islet transplantation is an option for patients whose type 1 diabetes has been particularly difficult to control and that is associated with significant lifestyle disruption despite optimal medical therapy [Grade D, Consensus].
Macrovascular Complications, Dyslipidemia and Hypertension (back to the top)
Recommendation
1) The first priority in the prevention of diabetes complications should be reduction of cardiovascular (CV) risk by vascular protection through a comprehensive multifaceted approach (in alphabetical order): ACE inhibitor and antiplatelet therapy (e.g. acetylsalicylic acid [ASA]) as recommended, optimize BP and glycemic control, lifestyle modifications, optimize lipid control and smoking cessation [Grade D, Consensus].
2) People with type 1 or type 2 diabetes should be encouraged to adopt a healthy lifestyle to lower their risk of CVD. This entails adopting healthy eating habits, achieving and maintaining a healthy weight, engaging in regular physical activity, and stopping smoking [Grade D, Consensus].
3) A fasting lipid profile (TC, HDL-C, TG and calculated LDL-C) should be conducted at the time of diagnosis of diabetes and then every 1 to 3 years as clinically indicated. Apo B can also be measured to accurately estimate atherogenic particle number. More frequent testing should be done if treatment for dyslipidemia is initiated [Grade D, Consensus].
4) Most people with type 1 and type 2 diabetes should be considered at high risk for vascular disease [Grade A, Level 1 (20,27,28)]. However, some people with type 1 or type 2 diabetes may be considered at moderate risk, such as younger patients with shorter duration of disease and without complications of diabetes and without other risk factors [Grade A, Level 1 (4,20,29)].
5) Patients with diabetes should be treated to achieve the following target lipid goals: for patients at high risk of a vascular event: LDL-C <2.5 mmol/L and TC:HDL-C<4.0; and for patients at moderate risk of a vascular event: LDL-C <3.5 mmol/L and TC:HDL-C <5.0 [Grade D, Consensus]. Although current evidence does not support specific targets for apo B or TG, the optimal TG level is <1.5 mmol/L, and the optimal levels for apo B are <0.9 g/L for high-risk patients and <1.05g/L for moderate-risk patients [Grade D, Consensus].
6) The following should be considered when choosing treatments for patients with dyslipidemia:
• In cases where LDL-C is above target, a statin should be prescribed [Grade A, Level 1A (15)].
• In high-risk patients with TG levels of 1.5 to 4.5mmol/L, HDL-C <1.0mmol/L, and LDL-C at target, either a statin [Grade A, Level 1A (15)] or fibrate [Grade B, Level 2 (22,23)] can be prescribed. In patients with marked hypertriglyceridemia (TG level >4.5mmol/L), a fibrate should be prescribed [Grade D, Consensus].
• When monotherapy fails to achieve lipid targets, the addition of a second drug from another class should be considered [Grade D, Consensus].
7) Lifestyle interventions to reduce BP, including achieving and maintaining a healthy weight, and limiting sodium and alcohol intake, should be considered [Grade D, Consensus].
8) BP should be measured at every diabetes visit. Patients with systolic BP >130mm Hg or diastolic BP >80mm Hg should have their BP remeasured on a separate visit [Grade D, Consensus].
9) Persons with diabetes should be treated to target a systolic BP <130mm Hg [Grade C, Level 3 (27,28,32)] and a diastolic BP <=80mm Hg [Grade A, Level 1A (30)]. Systolic BP >130mm Hg and diastolic BP >80mm Hg are the thresholds recommended to initiate treatment [Grade D, Consensus].
10) For people with diabetes, no diabetic nephropathy, and BP levels >130mm Hg and/or >80mm Hg despite lifestyle modification, any 1 of the following drugs is recommended as the initial choice of therapy, in the following order [Grade D, Consensus for the order].
• ACE inhibitor [Grade A, Level 1A (33)];
• ARB [Grade A, Level 1A for co-existent left ventricular hypertrophy (LVH) (34); Grade B, Level 2 if LVH is not present (34)];
• cardioselective beta blocker [Grade B, Level 2 (35)];
• thiazide-like diuretic [Grade A, Level 1A (36)]; or
• long-acting CCB [Grade B, Level 2 (38)].
11) If BP targets cannot be reached despite the use of 1 of the above drug choices as monotherapy, use of 1 or more of these or other antihypertensive drugs in combination should be considered [Grade D, Consensus].
12) Alpha-adrenergic blockers are not recommended as first-line agents for the treatment of hypertension in persons with diabetes [Grade A, Level 1A (37)].
13) Unless contraindicated, low-dose ASA therapy (80 to 325mg/day) is recommended in all patients with diabetes with evidence of CVD, as well as for those individuals with atherosclerotic risk factors that increase their likelihood of CV events [Grade A, Level 1A (30,42,44,45)].
Nephropathy (back to the top)
Recommendations
1) The best possible glycemic control and, if necessary, intensive diabetes management should be instituted in people with type 1 or type 2 diabetes for the prevention, onset and delay in progression of early nephropathy [Grade A, Level 1A (35,50,51)].
2) Screening for diabetic nephropathy should be conducted using a random urine ACR [Grade D, Consensus]. Postpubertal individuals with type 1 diabetes of >=5 years' duration should be screened annually. Individuals with type 2 diabetes should be screened at diagnosis of diabetes and yearly thereafter [Grade D, Consensus].
3) Serum creatinine levels should be measured and creatinine clearance estimated annually in those patients with diabetes without albuminuria and at least every 6 months in those with albuminuria [Grade D, Consensus].
4) Individuals with albuminuria should receive treatment to protect renal function, even in the absence of hypertension:
• In people with type 1 diabetes and albuminuria, an ACE inhibitor should be given to reduce urinary albumin and prevent progression of nephropathy [Grade A, Level 1A (39)]. An ARB should be considered in patients unable to tolerate an ACE inhibitor [Grade D, Consensus].
• In people with type 2 diabetes, albuminuria and creatinine clearance >60mL/minute, an ACE inhibitor [Grade A, Level 1A (40)] or an ARB [Grade A, Level 1A (41)] should be given to reduce urinary albumin and prevent progression of nephropathy [Grade A, Level 1A (40,41)].
• In people with type 2 diabetes, albuminuria and creatinine clearance <=60mL/minute, an ARB should be given to prevent progression of nephropathy [Grade A, Level 1A (42,43)].
5) Patients placed on an ACE inhibitor or an ARB should have their serum creatinine and potassium levels checked within 2 weeks of initiation of therapy and periodically thereafter [Grade D, Consensus].
6) The use of nondihydropyridine CCBs (diltiazem, verapamil) may be considered to reduce urinary albumin excretion in proteinuric hypertensive patients [Grade B, Level 2 (38)].
7) A referral to a nephrologist or internist with an expertise in diabetic nephropathy should be considered if the ACR is >75mg/mmol, there is persistent hyperkalemia, there is a >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or ARB, or the creatinine clearance is <60mL/minute [Grade D, Consensus].
Neuropathy (back to the top)
Recommendations
1) Screening for peripheral neuropathy should be carried out annually to identify those at high risk of developing foot ulcers. Screening should begin at diagnosis in people with type 2 diabetes and after 5 years' duration of type 1 diabetes in postpubertal individuals [Grade D, Consensus].
2) Detection of peripheral neuropathy should be conducted by assessing loss of sensitivity to the 10-g monofilament at the great toe or loss of sensitivity to vibration at the great toe [Grade A, Level 1 (7)].
3) People with type 1 diabetes should be treated with intensive glycemic control management to delay the onset and slow the progression of peripheral neuropathy [Grade A, Level 1A (2,9)]. Intensified glycemic control management should be considered for people with type 2 diabetes to prevent the onset and progression of neuropathy [Grade B, Level 2 (12)].
4) Tricyclic antidepressants and/or anticonvulsants should be considered for relief of painful peripheral neuropathy [Grade A, Level 1A (13,19)].
5) Carpal tunnel syndrome should be diagnosed on clinical grounds [Grade A, Level 1 (6)] and managed accordingly with supplementary electrophysiological testing as needed in patients with diabetes [Grade D, Consensus].
6) People with clinically significant autonomic dysfunction should be appropriately assessed and referred to a specialist experienced in managing the affected body system [Grade D, Consensus].
Foot Care (back to the top)
Recommendations
1) Foot examinations in adults by both patients and healthcare providers should be an integral component of diabetes management to decrease the risk of foot lesions and amputations [Grade B, Level 2 (15,19)]. Foot examination should include assessment of structural abnormalities, neuropathy, vascular disease, ulcerations and evidence of infection [Grade D, Level 4 (9,19)]. Foot examinations should be performed at least annually in all people with diabetes, commencing at puberty and at more frequent intervals in those at high risk [Grade D, Consensus].
2) People at high risk of foot ulceration and amputation require foot care education, proper footwear, counselling to avoid foot trauma, smoking cessation and early referrals if problems occur [Grade B, Level 2 (19)].
3) A person with diabetes who develops a foot ulcer requires therapy by healthcare professionals who have experience in diabetes foot care. Any infection must be treated aggressively [Grade D, Consensus].
Retinopathy (back to the top)
Recommendations
1) In people with type 1 diabetes, screening and evaluation for retinopathy by an experienced professional should be performed annually 5 years after the onset of diabetes in individuals >=15 years of age [Grade A, Level 1 (8,10)].
2) In people with type 2 diabetes, screening and evaluation for retinopathy by an experienced professional should be performed at the time of diagnosis [Grade A, Level 1 (9,11)]. The interval for follow-up assessments should be tailored to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is 1 to 2 years [Grade A, Level 1 (9,11)].
3) Screening for retinopathy should be performed by experienced professionals either in person or through their interpretation of photographs [Grade A, Level 1 (23)].
4) To prevent the onset and delay the progression of diabetic retinopathy, people with diabetes should be treated to achieve optimal control of blood glucose [Grade A, Level 1A (38,41)], BP [Grade A, Level 1A (49)] and lipids [Grade D, Level 4 (31)].
5) Patients with proliferative or severe nonproliferative retinopathy, vitreous hemorrhage or macular edema should be assessed by an ophthalmologist or retina specialist [Grade D, Consensus] and should be considered for laser therapy and/or vitrectomy [Grade A, Level 1A (51,53,55,56)].
6) Visually disabled people should be referred for low-vision evaluation and rehabilitation [Grade D, Consensus].
Erectile Dysfunction (back to the top)
Recommendations
1) All adult men with diabetes should be periodically screened for ED with a sexual function history. Screening for ED in men with type 2 diabetes should begin at diagnosis of diabetes [Grade D, Consensus].
2) A PDE5 inhibitor should be offered as first-line therapy to men with diabetes with ED wishing treatment if there are no contraindications to its use [Grade A, Level 1A (15-18)].
3) Referral to a specialist in ED should be considered for men who do not respond to PDE5 inhibitors or for whom the use of PDE5 inhibitors is contraindicated [Grade D, Consensus].
Type 1 Diabetes in Children and Adolescents (back to the top)
Recommendations
1) All children and adolescents with diabetes should have access to an experienced DHC team and specialized care starting at the time of diagnosis [Grade D, Level 4 (7)].
2) For children and adolescents with new-onset type 1 diabetes who are medically stable, initial education and management in an outpatient setting should be considered, providing appropriate personnel and daily telephone consultation service are available in the community [Grade C, Level 3 (3)].
3) Adolescents should employ the same therapeutic strategies and aim for the same glycemic targets as adults [Grade A, Level 1A (8)]. Children 5 to 12 years of age should aim for a glycosylated hemoglobin (A1C) target of <=8.0%, with glycemic and A1C targets graduated according to the child's age [Grade D, Consensus]. In children <5 years of age, an A1C of <=9.0% is acceptable, and extreme caution should be exercised to avoid hypoglycemia because of the risk of cognitive impairment that may occur in this age group [Grade D, Level 4 (11,15,17)].
4) Consideration should be given to increasing the frequency of injections or changing the type of intermediate-acting insulin and fast-acting insulin, or changing to CSII (insulin pump) therapy when the 2 or 3 daily insulin injection regimen fails to optimize metabolic control and/or for quality of life reasons [Grade D, Consensus].
5) Formal smoking prevention and cessation counselling should be part of diabetes management for adolescents with diabetes [Grade D, Consensus].
6) Adolescent females with type 1 diabetes should receive counselling on contraception and sexual health in order to avoid unplanned pregnancy [Grade D, Consensus].
7) Adolescent females and young women with type 1 diabetes should be regularly screened for eating disorders using nonjudgemental questions about weight and shape concerns, dieting, binge eating and insulin omission for weight loss [Grade B, Level 2 (28)].
8) In children with duration of type 1 diabetes of >=5 years, screening for microalbuminuria should commence at onset of puberty and be performed yearly thereafter. Postpubertal adolescents should be screened yearly after 5 years' duration of type 1 diabetes. Prepubertal children need not be screened [Grade D, Consensus].
9) Screening for microalbuminuria in adolescents with type 1 diabetes should be conducted using a first morning urine test for determination of the ACR [Grade B, Level 2 (45)]. If compliance prohibits a first morning urine test, a random urine ACR should be obtained. Abnormal results require confirmation [Grade B, Level 2 (47)] with a first morning ACR, or a timed overnight or 24-hour split urine collection [Grade D, Consensus] for determination of the albumin excretion rate. At least 1 month should elapse between the abnormal screening test and the confirmatory test [Grade D, Consensus].
10) Prior to initiating treatment, persistence and/or progression of microalbuminuria must be demonstrated by repeat sampling conducted every 3 to 4 months over a 12-month period [Grade D, Consensus].
11) Only those children and adolescents with type 1 diabetes and other risk factors, such as severe obesity (body mass index >95th percentile), and/or a family history of hyperlipidemia or premature coronary artery disease, or those with poor metabolic control should be screened for dyslipidemia [Grade D, Level 4 (60,61)].
12) To ensure ongoing and adequate metabolic control, pediatric and adult diabetes care services should collaborate to prepare adolescents and young adults for the transition to adult diabetes care [Grade D, Consensus].
Type 2 Diabetes in Children and Adolescents (back to the top)
Recommendation
1) Obese children >=10 years of age should be considered for screening for type 2 diabetes every 2 years using an FPG test if they meet 2 of the following criteria:
• member of a high-risk ethnic group;
• family history of type 2 diabetes, especially if the child was exposed to diabetes in utero;
• acanthosis nigricans;
• PCOS;
• hypertension; or
• dyslipidemia.
An OGTT may also be considered as a screening test [Grade D, Consensus].
2) Adolescents with type 2 diabetes should receive intensive counselling regarding lifestyle modification. If glycemic targets are not achieved using lifestyle modification alone, metformin [Grade B, Level 2 (36)] or insulin should be considered [Grade D, Consensus].
Pre-existing Diabetes and Pregnancy (back to the top)
Recommendations
1) Women with pre-existing diabetes should plan their pregnancy, preferably in consultation with an interdisciplinary pregnancy team, to optimize maternal and neonatal outcomes [Grade C, Level 3 (3,5,8)].
2) Women with type 1 diabetes who are planning a pregnancy should strive to attain a preconception glycosylated hemoglobin (A1C) <=7.0% to decrease the risk of spontaneous abortion, congenital malformations [Grade C, Level 3 (5,10)], pre-eclampsia [Grade C, Level 3 (35)], and the progression of retinopathy [Grade A, Level 1A (11)].
3) Women with type 2 diabetes who are planning pregnancy should be encouraged to attain a preconception A1C <=7.0% to reduce the risk of congenital anomalies [Grade D, Consensus].
4) Women with type 2 diabetes who are planning pregnancy should discontinue oral antihyperglycemic agents prior to conception and attain glycemic targets using insulin, if needed [Grade D, Consensus].
5) Prior to conception, women with pre-existing diabetes should receive nutrition counselling from a registered dietitian who is part of the DHC team [Grade C, Level 3 (3)] with reassessment as needed during pregnancy and postpartum [Grade D, Consensus]. Recommendations for weight gain during pregnancy should be based on pregravid body mass index [Grade D, Consensus].
6) If planning pregnancy, women using ACE inhibitors or ARBs should change to other antihypertensives that are safe in pregnancy for BP control [Grade D, Consensus].
7) Women with type 1 and type 2 diabetes who are planning a pregnancy should have ophthalmologic assessments prior to conception, during the first trimester, as needed during pregnancy and within the first year postpartum [Grade A, Level 1 for type 1 diabetes (11,25); Grade D, Consensus for type 2 diabetes].
8) Prior to conception, women with diabetes should be screened for nephropathy [Grade A, Level 1 (29)]. If microalbuminuria or overt nephropathy is found, glycemic and BP control should be optimized to minimize maternal and fetal complications and progression of nephropathy [Grade D, Consensus].
9) During pregnancy, women with type 1 or type 2 diabetes should aim to achieve glycemic targets while avoiding significant hypoglycemia [Grade D, Consensus].
10) To attain glycemic targets during pregnancy, women with type 1 diabetes should receive intensive insulin therapy using multiple daily injections or CSII [Grade A, Level 1A (1,59,61)]. Insulin regimens for women with type 2 diabetes should be individualized and adjusted to achieve glycemic targets, with consideration given to intensive insulin regimens, as needed [Grade A, Level 1A (59)].
11) Pregnant women with type 1 or type 2 diabetes should use both preprandial and postprandial SMBG, often >=4 times per day, in order to make insulin adjustments to attain glycemic targets [Grade C, Level 3 (2)].
12) Ketosis should be avoided during pregnancy [Grade C, Level 3 (52)].
Gestational Diabetes Mellitus (back to the top)
Recommendations
1) All pregnant women should be screened for GDM between 24 and 28 weeks' gestation [Grade D, Consensus]. Plasma glucose (PG) should be measured 1 hour after a 50-g glucose load [Grade B, Level 1 (29)]. Women with multiple risk factors should be screened during the first trimester and, if negative, should be reassessed during subsequent trimesters [Grade D, Consensus].
2) If the 1hPG in the 50-g glucose screening test is 7.8 to 10.2mmol/L, a 75-g OGTT should be conducted, and fasting plasma glucose (FPG), 1hPG and 2-hour plasma glucose (2hPG) levels obtained [Grade D, Consensus]. In view of the controversies about diagnostic tests in this area, other accepted methods may be used [Grade D, Consensus].
3) Women with GDM should strive to attain the following glycemic targets, as these are associated with the best pregnancy outcomes:
• Preprandial PG <5.3mmol/L [Grade D, Consensus];
• 1-hour postprandial PG <7.8mmol/L [Grade A, Level 1 (30)]; and
• 2-hour postprandial PG <6.7mmol/L [Grade D, Consensus].
4) If women with GDM do not achieve glycemic targets within 2 weeks with nutrition therapy alone, insulin therapy should be initiated [Grade D, Consensus]. When insulin therapy is initiated, up to 4 injections/day should be considered [Grade A, Level 1A (19)].
5) Women with GDM should conduct frequent FBG and postprandial home BG monitoring [Grade C, Level 3 (32,35)].
6) As women who have had GDM have an elevated risk of subsequent type 2 diabetes, they should be re-evaluated within 6 months of delivery with a 2hPG in a 75-g OGTT (preferred test) or an FPG test, and be counselled on a healthy lifestyle [Grade D, Consensus].
Diabetes in the Elderly (back to the top)
Recommendations
1) Lifestyle interventions, including nutrition therapy and exercise, should be considered as therapeutic interventions to prevent type 2 diabetes in elderly patients at risk [Grade A, Level 1A(2)].
2) Otherwise healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people with diabetes [Grade D, Consensus]. In people with multiple comorbidities, high level of functional dependency or limited life expectancy, the goals should be more conservative [Grade D, Consensus].
3) As interdisciplinary interventions have been shown to improve glycemic control in elderly people with diabetes, these patients should be referred to a DHC team [Grade C, Level 3 (3,4)].
4) Either aerobic exercise or resistance training may benefit elderly people with type 2 diabetes and should be recommended for those individuals in whom it is not contraindicated [Grade B, Level 2 (17,20-22)].
5) Alpha-glucosidase inhibitors are modestly effective in the elderly with type 2 diabetes [Grade A, Level 1A (30)].
6) Insulin sensitizers (thiazolidinediones) are effective in elderly patients with type 2 diabetes, but should be used with caution in elderly patients at risk for fluid retention [Grade D, Consensus].
7) In elderly people with type 2 diabetes, sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age [Grade D, Level 4 (53)]. In general, initial doses of sulfonylureas in the elderly should be half those used for younger people, and doses should be increased more slowly [Grade D, Consensus]. Gliclazide [Grade B, Level 2 (34)] and glimepiride [Grade C, Level 3 (35)] are the preferred sulfonylureas, as they are associated with a reduced frequency of hypoglycemic events compared with glyburide.
8) In elderly people, the use of premixed insulins and prefilled insulin pens as an alternative to mixing insulins should be encouraged to reduce dosages errors and potentially improve glycemic control [Grade B, Level 2 (37-39)].
9) Isolated systolic hypertension or combined systolic and diastolic hypertension in elderly patients with diabetes should be treated to reduce CV morbidity and mortality [Grade A, Level 1A (42,44)].
Type 2 Diabetes in Aboriginal Peoples (back to the top)
Recommendations
1) Treatment of diabetes in Aboriginal peoples should follow clinical practice guidelines [Grade D, Consensus].
2) There must be recognition of, respect for and sensitivity regarding the unique language, culture and geographic issues as they relate to diabetes care and education in Aboriginal communities across Canada [Grade D, Consensus].
3) Culturally appropriate primary prevention programs should be initiated by Aboriginal communities to increase awareness of diabetes, increase physical activity, improve eating habits and achieve healthy body weights, and to promote environments that are supportive of a healthy lifestyle [Grade D, Consensus].
4) Community-based diabetes screening programs should be established in Aboriginal communities. Urban people of Aboriginal origin should be screened for diabetes in primary care settings [Grade D, Consensus].
Perioperative Glycemic Control (back to the top)
Recommendations
1) A continuous IV insulin infusion should be used to achieve glycemic levels of 4.5 to 6.0mmol/L in postoperative patients who require intensive care and mechanical ventilation and demonstrate hyperglycemia (random PG >6.1mmol/L) [Grade A, Level 1A (6)].
2) A continuous IV insulin infusion should be used to maintain intraoperative glycemic levels between 5.0 and 11.0mmol/L for patients with diabetes undergoing cardiac surgery [Grade C, Level 3 (8)].
3) Perioperative glycemic levels should be maintained between 5.0 and 11.0 mmol/L for most other surgical situations [Grade D, Consensus].
Peri-acute Coronary Syndrome Glycemic Control (back to the top)
Recommendation
1) All patients with acute MI, regardless of whether or not they have a prior diagnosis of diabetes, should have their BG level measured on admission [Grade D, Consensus], and those with BG >12.0 mmol/L should receive insulin-glucose infusion therapy to maintain BG between 7.0 and 10.0 mmol/L for at least 24 hours, followed by multidose SC insulin for at least 3 months [Grade A, Level 1A (10,11)]. An appropriate protocol should be developed and staff trained to ensure the safe and effective implementation of this therapy and to minimize the likelihood of hypoglycemia [Grade D, Consensus].