www.diabetesclinic.ca 2003 cda clinical practice guidelines j. robin conway m.d. diabetes clinic -...
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www.diabetesclinic.ca
2003 CDA Clinical Practice Guidelines
J. Robin Conway M.D.Diabetes Clinic - Smiths Falls, ON
Diabetes Office Mgmt
www.diabetesclinic.ca
TorontoMay 6 2004
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80
70
60
50
40
30
20
10
0
Prevalence (millions)
North America
Europe SoutheastAsia
Year199520002025
World Health Organization. 1997.Canadian Diabetes Association, 1998 website.
Worldwide rates of diabetes mellitus: predictions
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Frequency of diagnosed and undiagnosed diabetes and IGT, by age (U.S. data - Harris)
2 Million Canadians Have Diabetes Mellitus
0
5
10
15
20
25
30
35
40
20-34 35-44 45-54 55-64 65-74
% ofpopulation
IGTUndiagnosed diabetesDiagnosed diabetes
Harris. Diabetes Care 1993;16:642-52.
www.diabetesclinic.caHaffner Am J Cardiol 1999;84:11J-4J.
Framingham study: diabetes and CAD mortalityat 20-year follow-up
Cardiovascular Disease Risk is Increased 2 to 4 Times
17.4
8.5
17.0
3.602468
101214161820
Annual CAD Deaths per 1,000
Persons
Men Women
Diabetics Nondiabetics
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What proportion of your office visits involve Diabetics?
1. <10%
2. 10-20%
3. 20-30%
4. 30-50%
5. >50%
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The burden of Diabetes• 87% of Type 2 Diabetes is managed
in Primary Care
• Diascan Study: 23.5% of patients in our office have diabetes
• Quebec screening >2 Risk Factors 79% tested 7% Diabetes 13% IGT or IFG
74% No Treatment AdviceStrychar I et al. Cdn J Diab 2003(abs)
Leiter et al. Diabetes Care 2000
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Glucose Monitoring
• Do you do A1c to follow glycemic control
1= YES
2= NO
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Microvascular Complications
• Do you order urine microalbumen test
1= YES
2= NO
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Microvascular Complications
• Do you use a 10 gm filament for testing sensation in the feet?
1= YES
2= NO
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T2DM in Family Practice
• 84% of patients had A1c in past year
• Average A1c 7.9% (goal<7%)
• 88% had BP check
• 48% had lipid profiles
• 28% tested for microalbuminuria
• 15% had foot examsHarris S et al. Cdn Fam Phys 2003
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Organization and Delivery of Care
• Diabetes should be organized using a DHC (Diabetes Healthcare) team approach
• People with diabetes should be offered initial and
ongoing needs-based diabetes education• The role of diabetes nurse educators and other
DHC team members should be enhanced in cooperation with the physician
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Structured care
• ACLS
• ATLS
• Seattle Defibrillator Experience
• GREACE Study
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Structured Care VS Usual Care
Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228.
• Patients received atorvastatin 10 mg/d (titrated up to 80 mg/d) to reach the NCEP LDL-C goal
• Specialist care unit with a strict protocol to achieve NCEP LDL-C target
• Treatment from a physician of pt’s choice• All patients had access to any necessary medications,
including statins• Included lifestyle modifications (diet and exercise) as well
as lipid-lowering medications
Str
uctu
red
Car
e:U
sual
Car
e:
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Reduction in Relative Risk of Primary Endpoints
-43
-59-52 -51 -50
-47-47
-60
-50
-40
-30
-20
-10
0Total Mortality
CoronaryMortality Nonfatal MI
UnstableAngina PTCA/CABG CHF Stroke
Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228.
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Type 2 Diabetes
• Increasing Prevalence
• Primary Care Based
• Forms a large part of a practice
• Needs structured care approach
• Team Approach
• Multiple comorbidities
• Limited Time & Funding
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How can we deal with this?
• Refer all Diabetic Patients?• Community Education Programs?• Guidelines Based Structured Care?• Identify the Diabetics in the practice?• Diabetes Day in Office?• Get some Diabetes CME?• Team Approach in Office?• Office Tools?
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Diabetes Day in the Office
• Book Diabetic Patients for one day• Get office support staff to follow formula• Office staff do Wt, BMI, BP, Glucose, lab• Have educational material, consider 1 room• Follow Guideline Algorithms• Use Tools & Flowsheet• Extra Staff?• Follow up Appt & Lab
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Educational Material
• Canadian Diabetes Assoc: www.diabetes.ca
• Pharma Companies; Lilly, Novo, Bayer
• Web Site list www.diabetesclinic.ca
• Hospital Diabetes Education Program
• Community Diabetes Education Program
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Screening and Prevention - Type 2 Diabetes
• Screen all persons >40 years for type 2 diabetes, with a fasting blood glucose (FPG), every 3 years.
• For people with risk factors, screen earlier and /or more frequently, with either FPG or Oral Glucose Tolerance test (OGTT).
• If the FPG is 5.7 – 6.9mmol/L and suspicion of diabetes or IGT is high, recommend a 2hPG in a 75-g OGTT.
Risk Factors
Age 40 years Vascular disease Abdominal obesity
1st degree relative with diabetes Previous GDM Overweight
High risk population Delivery of macrosomic infant Polycystic ovary disease
Previous IGT or IFG Hypertension Acanthosis nigricans
Complications present Dyslipidemia Schizophrenia
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Every 3 Years in individuals 40 years of age with no other risk factors
Earlier and/or more frequently in individuals < 40 years of age with risk factors
FPG
< 5.7 mmol/L 5.7 - 6.9 mmol/L plus risk factor(s) for diabetes/IGT
6.1 - 6.9 mmol/L and not risk factors for diabetes/IGT
7.0 mmol/L
2hPG in 75-g OGTT
Classify patients as normal, IFG (isolated), IGT (isolated), IFG &
IGT or Diabetes
Isolated IFG, Isolated IGT OR IFG & IGT IFG DiabetesNormal
Rescreen as clinically indicated
Strategies for prevention and rescreen at appropriate intervals Treatment
Screening for Type 2 Diabetes, IFG and IGT
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Diagnostic CriteriaDiagnosis of diabetes
FPG 7.0 mmol/L
or
Casual PG 11.1 mmol/L + symptoms of diabetes
or
2hPG in a 75g OGTT 11.1 mmol/L
•FPG = fasting plasma glucose, no caloric intake for at least 8 hours•OGTT = oral glucose tolerance test•2hPG = 2-hour plasma glucose•Casual PG = any time of the day, without regard to the interval since the last meal•Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss
• A confirmatory laboratory glucose test must be done on another day unless there is unequivocal hyperglycemia and acute metabolic decompensation
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Physical Activity and Diabetes
• For people who have not previously exercised regularly and are at risk of CVD, an ECG stress test should be considered prior to starting an exercise program
Type Recommendation Example
Aerobic – especially type 2
150 minutes of moderate-intensity exercise each week
spread out over at least 3 non-consecutive days
gradually increase to 4 hours or more a week
sessions should be at least 10 minutes at a time
Brisk walking Biking Raking leaves Continuous swimming Dancing Water aerobics
Resistance – all persons with diabetes, including elderly
3 times a week start with 1 set of 10-15 repetitions progress to 2 sets of 10-15 then 3 sets of 8
Weight lifting Exercise with weight machines
Testing is particularly important before, during and for many hours after exercise.
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Nutrition TherapyPeople with diabetes should:
• Receive nutrition counseling by a registered dietitian
• Receive individualized meal planning
• Follow Canada’s Guidelines for Healthy Eating
• People on intensive insulin should also be taught to adjust the insulin for the amount of carbohydrate consumed
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Recommended targets for glycemic control*
A1C**(%)
FPG/preprandial PG(mmol/L)
2-hour postprandial PG(mmol/L)
Target for most patients 7.0 4.0-7.0 5.0-10.0
Normal range (considered for patients in whom it can beachieved safely)
6.0 4.0-6.0 5.0-8.0
*Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors.†Glycemic targets for children 12 years of age and pregnant women differ from these targets. Please refer to “Other Relevant Guidelines” for further details.**An A1C of 7.0% corresponds to a laboratory value of 0.070. Where possible, Canadian laboratories should standardize theirA1C values to DCCT levels (reference range: 0.040 to 0.060). However, as many laboratories continue to use a differentreference range, the target A1C value should be adjusted based on the specific reference range used by the laboratory thatperformed the test. As a useful guide: an A1C target of 7.0% refers to a threshold that is approximately 15% above the upper limit of normal.
A1C = glycosylated hemoglobinDCCT = Diabetes Control and Complications TrialFPG = fasting plasma glucosePG = plasma glucose
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Clinical assessment and initiation of nutrition and physical activity
Mild to moderate hyperglycemia (A1C <9.0%)
Overweight(BMI 25 kg/m2)
Non-overweight(BMI 25 kg/m2)
Biguanide alone or incombination with 1 of:
• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor
1 or 2† antihyperglycemicagents from differentclasses
• biguanide• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor
Add a drug from a different class orUse insulin alone or in combination with:
• biguanide• insulin secretagogue• insulin sensitizer*• alpha-glucosidase inhibitor
Marked hyperglycemia (A1C 9.0%)
2 antihyperglycemic agentsfrom different classes †
• biguanide• insulin sensitizer*• insulin secretagogue• insulin• alpha-glucosidase inhibitor
Basal and/orpreprandial insulin
Add an oral
antihyperglycemic agentfrom a differentclass of insulin*
Intensify insulinregimen or add
• biguanide• insulin secretagogue**• insulin sensitizer*• alpha-glucosidase inhibitor
If not at targetIf not at targetIf not at targetIf not at target
L
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F
E
S
T
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L
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Timely adjustments to and/or additions of oral antihyperglycemic agentsand/or insulin should be made to attain target A1C within 6 to 12 months
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Economics
• Gen Ass A003 $54.10• Int Ass A007 $28.50• Counselling K013 $50.45 4x/yr• Insulin Rx K029 $50.45 6x/yr• Type 2 FlowK030 $30.00 3x/yr• Glucose G002 $ 1.97• Urine G009 $ 4.20• Venipuncture G489 $ 2.27
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Economics
• A003 G002, G009, G489 $ 62.54
• G030 G002 G009 G489 x3 $105.32
• K013 G00s G009 G489 x4 $235.76
• A007 x4 $114.00
• TOTAL $517.62
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FLOWSHEETS
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ABC of Diabetes
• A1c <7
• Blood Pressure <130/80
• Chol/HDL <4, LDL <2.5, Trig <1.5• ACR <2 men, <2.5 women• ACE• ASA
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INVOLVE THE PATIENT
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In Conclusion• Prevalence of type 2 diabetes is increasing
dramatically• Majority of patients are diagnosed and treated by
the family physician• New paradigm: need to be much more aggressive
early in the treatment of these patients utilizing dual therapies
• Hypoglycemia can be managed through proper treatment choices and lifestyle management
• Glucose is a continuous progressive risk factor for cardiovascular disease
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Questions?