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| Targets for Glycemic Control Glycemic targets must be individualized; however, therapy in most patients with type 1 or type 2 diabetes should be targeted to achieve an A1C ≤ 7.0% in order to reduce the risk of microvascular [Grade A, Level 1A] and macrovascular complications [Grade C, Level 3]. 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)].
Monitoring Glycemic Control All people with diabetes, who are able, should be taught how to self-manage their diabetes, including SMBG [Grade A, Level 1A]. 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 measurements are recommended at least once daily [Grade C, Level 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]. SMBG should include both preprandial and 2-hour postprandial BG testing [Grade D, Consensus]. 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 & Diabetes 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]. 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] or, if willing, should be encouraged to accumulate ô4 hours of exercise per week [Grade C, Level 3]. People with diabetes (including elderly people) should also be encouraged to perform resistance exercise 3 times per week [Grade B, Level 2]. Nutrition Therapy 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]. People with diabetes (including elderly people) should also be encouraged to perform resistance exercise 3 times per week [Grade B, Level 2]. Insulin Regimens For Type 1 Diabetes 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]. 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]. Insulin lispro or insulin aspart should be used when continuous subcutaneous insulin infusion is used in patients with type 1 diabetes [Grade B, Level 2]. Buffered regular insulin is equally effective in experienced insulin pump users [Grade B, Level 2]. (Buffered regular insulin is available only by special request through manufacturer or Health Canada.) 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]. Hypoglycemia 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]. 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:
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]. 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]. 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 15 g of carbohydrate and 15 g of protein if their bedtime BG level is <7.0 mmol/L [Grade B, Level 2]. Pharmacologic Management of Type 2 Diabetes 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]. In the presence of marked hyperglycemia (A1C ≥9.0%), antihyperglycemic agents should be initiated concomitant with lifestyle counselling [Grade D, Consensus]. The choice of antihyperglycemic agent(s) should take into account the individual and the following factors:
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], sulfonylurea plus metformin [Grade A, Level 1A] or other oral antihyperglycemic agents [Grade D, Consensus], insulin therapy should be initiated to improve glycemic control. Combining insulin and the following oral antihyperglycemic agents (listed in alphabetical order) has been shown to be effective in people with type 2 diabetes:
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]. To safely achieve optimal postprandial glycemic control, mealtime insulin lispro or insulin aspart is preferred over regular insulin [Grade B, Level 2]. 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] and weight gain [Grade B, Level 2]. 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 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]. In adults, mild to moderate hypoglycemia should be treated by the oral ingestion of 15 g of carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels [Grade B, Level 2]. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15 g of carbohydrate if the BG level remains <4.0 mmol/L. In smaller children (<5 years of age or <20 kg), 10 g of carbohydrate may be used initially [Grade D, Consensus]. Severe hypoglycemia in a conscious adult should be treated by the oral ingestion of 20 g of carbohydrate, preferably as glucose tablets or equivalent. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15 g of glucose if the BG level remains <4.0 mmol/L [Grade D, Consensus]. Severe hypoglycemia in an unconscious individual >5 years of age, in the home situation, should be treated with 1 mg of glucagon subcutaneously or intramuscularly. In children ?5 years of age, a dose of 0.5 mg 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]. In the home situation, support persons should be taught how to administer glucagon by injection [Grade D, Consensus]. For severe hypoglycemia with unconsciousness in adults, when intravenous (IV) access is available, glucose 10 to 25 g (20 to 50 cc of D50W) should be given over 1 to 3 minutes. The pediatric dose of glucose for IV treatment is 0.5 to 1 g/kg [Grade D, Consensus]. 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]. Management of Obesity in Diabetes: 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]. In obese people with type 2 diabetes, medical therapy with the antiobesity agent orlistat (gastrointestinal lipase inhibitor) [Grade A, Level 1A] or sibutramine (norepinephrine and serotonin reuptake inhibitor) [Grade B, Level 2] may be considered as an adjunct to lifestyle modification to expedite achievement of weight-loss goals and weight maintenance. For individuals with class III obesity (BMI ô40 kg/m2) or class II obesity (BMI=35 to 39.9 kg/m2) 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]. 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]. Those diagnosed with depression should be offered treatment with cognitive-behaviour therapy [Grade B, Level 2] and/or antidepressant medication [Grade B, Level 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 C, Level 3]. Interventions that increase patients’ participation in healthcare decision making should be offered to adults with diabetes [Grade B, Level 2]. 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]. Complications Vascular Protection 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]. Most people with type 1 and type 2 diabetes should be considered at high risk for vascular disease [Grade A, Level 1]. 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]. Patients with diabetes should be treated to achieve the following target lipid goals: for patients at high risk of a vascular event: LDL-C <2.0 mmol/L and TC:HDL-C <4.0 [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 <1.05 g/L for moderate-risk patients [Grade D, Consensus]. The following should be considered when choosing treatments for patients with dyslipidemia: Hypertension Lifestyle interventions to reduce BP, including achieving and maintaining a healthy weight, and limiting sodium and alcohol intake, should be considered [Grade D, Consensus]. BP should be measured at every diabetes visit. Patients with systolic BP ›130 mm Hg or diastolic BP ›80 mm Hg should have their BP remeasured on a separate visit [Grade D, Consensus]. Persons with diabetes should be treated to target a systolic BP <130 mm Hg [Grade C, Level 3] and a diastolic BP ≤80 mm Hg [Grade A, Level 1A]. Systolic BP >130 mm Hg and diastolic BP >80 mm Hg are the thresholds recommended to initiate treatment [Grade D, Consensus]. For people with diabetes, no diabetic nephropathy, and BP levels >130 mm Hg and/or >80 mm Hg despite lifestyle modification, any 1 of the following drugs are recommended as the initial choice of therapy, in the following order [Grade D, Consensus for the order].
Alpha-adrenergic blockers are not recommended as first-line agents for the treatment of hypertension in persons with diabetes [Grade A, Level 1A]. Unless contraindicated, low-dose ASA therapy (80 to 325 mg/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]. Nephropathy 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]. 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].
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]. Neuropathy 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]. Tricyclic antidepressants and/or anticonvulsants should be considered for relief of painful peripheral neuropathy [Grade A, Level 1A]. 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 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]. Foot examination should include assessment of structural abnormalities, neuropathy, vascular disease, ulcerations and evidence of infection [Grade D, Level 4]. 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]. 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]. 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 Screening 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]. Screening for retinopathy should be performed by experienced professionals either in person or through their interpretation of photographs [Grade A, Level 1]. Prevention Of Onset And Progression 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]. |
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