Insert Self-management Goal Quick Reference Guide
r personalized goal)k of CKD and retinopathy)agogue, assess fordriving safetysk of falls% reduction fromth risk factors, ORpe 2, OR diabetes2018 Clinical Practice GuidelinesQuick ReferenceGuidestrated CV benefit (if haveot at target)vigorous aerobic activity/cises 2-3 times/weekn (eg Mediterranean diet,s if age 40 OR diabetesn yearly or more ifyearly, or more if abnormally; type 2 - q1-2 yrsgive advice, arrangeortindividualized goalaZeneca, Boehringernc. Diabetes Canada thanksight 2018 Diabetes Canada.416569-18alth and financial or otherrriers to achieving goalsguidelines.diabetes.cadiabetes.ca 1-800-BANTING (226-8464)
Screen every6 to 12monthsTestResultDysglycemia categoryFPG (mmol/L)No caloric intake for at least 8 hours6.1 – 6.9IFGA1C (%)** 7.06.0 – 6.4 6.5DiabetesPrediabetesDiabetesIf asymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1Cor FPG) as a confirmatory test. If both FPG and A1C are available and only one is in thediabetes range, repeat the test in the diabetes range as the confirmatory test. If bothA1C and FPG are available and are each in the diabetes range, diabetes is confirmed.If symptoms of overt hyperglycemia are present, diagnosis of diabetes can bedetermined with one test (A1C, FPG, 2hPG, random PG) in the diabetes range, seeChapter 3, CPG.*using a validated risk calculator (e.g. CANRISK)**Use a standardized, validated assay. Be aware of factors that affect A1C accuracy (see CPG Chapter 9, Table 1)MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETESor very high risk(50% chance of developing type 2diabetes within 10 years) 7.0Screen every3 yearsTargetsPresenceof riskfactorsAge 40 years or high risk*(33% chance of developingtype 2 diabetes within 10 years)A1C%No riskfactorsNo screenindicatedAdults with type 2 diabetes to reduce the risk of CKD and retinopathy if at lowrisk of hypoglycemia*Age 40 years orlow-moderate risk*Targets for glycemic controlHow to screenWho to screenAssess risk factors for type 2 diabetes ANNUALLY: Family history (first-degree relative with type 2 diabetes) High risk populations (non-white, low socioeconomic status) History of GDM/prediabetes Cardiovascular risk factors Presence of end organ damage associated with diabetes Other conditions and medications associated with diabetes(see CPG Chapter 4, Screening for Diabetes in Adults, Table 1) 6.5Screening and diagnosis of type 2diabetes in adults
reening and diagnosis of type 2abetes in adultsNo screenindicatedScreen every3 yearsAge 40 years orlow-moderate risk*Age 40 years or high risk*(33% chance of developingtype 2 diabetes within 10 years)Screen every6 to 12monthsDysglycemia categoryor very high risk(50% chance of developing type 2diabetes within 10 years)ResultIFGDiabetesPrediabetesDiabetes6.1 – 6.9 7.06.0 – 6.4 6.5sess risk factors for type 2 diabetes ANNUALLY:amily history (first-degree relative with type 2 diabetes)gh risk populations (non-white, low socioeconomic status)story of GDM/prediabetesardiovascular risk factorsesence of end organ damage associated with diabetesther conditions and medications associated with diabetesee CPG Chapter 4, Screening for Diabetes in Adults, Table 1)No riskfactorsPresenceof riskfactorsTestFPG (mmol/L)No caloric intake for at least 8 hoursA1C (%)**ymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1CPG) as a confirmatory test. If both FPG and A1C are available and only one is in theetes range, repeat the test in the diabetes range as the confirmatory test. If bothand FPG are available and are each in the diabetes range, diabetes is confirmed.mptoms of overt hyperglycemia are present, diagnosis of diabetes can bermined with one test (A1C, FPG, 2hPG, random PG) in the diabetes range, seepter 3, CPG.a validated risk calculator (e.g. CANRISK)a standardized, validated assay. Be aware of factors that affect A1C accuracy (see CPG Chapter 9, Table 1)Targets for glycemic controlA1C%Targets 6.5Adults with type 2 diabetes to reduce the risk of CKD and retinopathy if at lowrisk of hypoglycemia* 7.0MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES7.1Functionally dependent*: 7.1-8.0%Recurrent severe hypoglycemia and/or hypoglycemia unawareness: 7.1-8.5%Limited life expectancy: 7.1-8.5%Frail elderly and/or with dementia†: 7.1-8.5%8.5Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acuteand chronic complicationsEnd of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.* based on class of antihyperglycemic medication(s) utilized and the person’s characteristics† see Diabetes in Older People chapter, p. S283Blood glucose-lowering therapies (type 2 diabetes)At diagnosis of type 2 diabetesStart healthy behaviour interventions (nutritional therapy, weight management, physical activity) /- metforminA1C 1.5% above targetIf not at glycemic targetwithin 3 months,Start/Increase metforminA1C 1.5% above targetStart metformin immediatelyConsider a second concurrentantihyperglycemic agentIf not at glycemic targetSymptomatic hyperglycemiaand/ormetabolic decompensation*Initiateinsulin† /- metforminIf not at glycemic targetClinical CVD?YESStart antihyperglycemic agentwith demonstratedCV benefit empagliflozin(Grade A, Level 1A)liraglutide(Grade A, Level 1A)canagliflozin† †NOAdd additional antihyperglycemic agent best suited tothe individual based on the following:Clinical ConsiderationsChoice of AgentAvoidance of hypoglycemiaand/or weight gain with adequateglycemic efficacyDPP-4 inhibitor, GLP-1receptor agonist or SGLT2 inhibitor
Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acuteand chronic complicationsEnd of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.* based on class of antihyperglycemic medication(s) utilized and the person’s characteristics† see Diabetes in Older People chapter, p. S283Blood glucose-lowering therapies (type 2 diabetes)At diagnosis of type 2 diabetesStart healthy behaviour interventions (nutritional therapy, weight management, physical activity) /- metforminA1C 1.5% above targetSymptomatic hyperglycemiaand/ormetabolic decompensation*A1C 1.5% above targetStart metformin immediatelyConsider a second concurrentantihyperglycemic agentIf not at glycemic targetwithin 3 months,Start/Increase metforminInitiateinsulin† /- metforminIf not at glycemic targetIf not at glycemic targetClinical CVD?YESNOAdd additional antihyperglycemic agent best suited tothe individual based on the following:Start antihyperglycemic agentwith demonstratedCV benefit empagliflozin(Grade A, Level 1A)liraglutide(Grade A, Level 1A)canagliflozin† †(Grade C, Level 2)Clinical ConsiderationsChoice of AgentAvoidance of hypoglycemiaand/or weight gain with adequateglycemic efficacyDPP-4 inhibitor, GLP-1receptor agonist or SGLT2 inhibitorOther considerations:Reduced eGFR and/or albuminuriaClinical CVD or CV risk factorsDegree of hyperglycemiaOther comorbidities (CHF, hepaticdisease‡)Planning pregnancy‡Cost/coveragePatient preferenceIf not at glycemic targetSee Table belowAdd additional antihyperglycemic agent best suited to the individual by prioritizingpatient characteristics (agents listed in alphabetical order by CV outcome data)HEALTHY BEHAVIOUR INTERVENTIONSClass**Effect onCVDoutcomesHypoglycemiaWeight Relative A1Cloweringwhen addedto metforminOther therapeuticconsiderationsCost GLP-1 receptor lira:RareagonistsSuperiorityin peoplewith type2 diabeteswith clinicalCVDexenatideLAR & lixi:Neutral to GI side-effectsGallstone diseaseContraindicated with personal/familyhistory of medullary thyroid cancer orMEN 2Requires subcutaneous injectionSGLT2inhibitorscana &Rareempa:Superiorityin peoplewith type2 diabeteswith clinicalCVD to Genital infections, UTI, hypotension,dose-related changes in LDL-C. Cautionwith renal dysfunction, loop diuretics, inthe elderly. Dapagliflozin not to be used ifbladder cancer. Rare diabetic ketoacidosis (may occur with no hyperglycemia). Increased risk of fractures and amputationswith canagliflozinReduced progression of nephropathyand CHF hospitalizations with empagliflozin and canagliflozin in persons withclinical CVDDPP-4InhibitorsNeutral(alo, saxa,sita)Neutral Insulinglar:YesNeutraldegludec:noninferiorto glar to RareThiazolidinedi- NeutralonesRare Alpha-glucosidase inhibitors(acarbose)RareNeutral Insulinsecretatogue:MeglitinideYes SulfonylureaYes Weight lossagent (orlistat)None Caution with saxagliptin in heart failureRare joint pain No dose ceiling, flexible regimensRequires subcutaneous injection CHF, edema, fractures, rare bladdercancer (pioglitazone), cardiovascularcontroversy (rosiglitazone), 6-12 weeksrequired for maximal effect GI side-effects commonRequires 3 times daily dosing More rapid BG-lowering responseReduced postprandial glycemia withmeglitinides but usually requires 3 to 4times daily dosingGliclazide and glimepiride associated with less hypoglycemia than glyburidePoor durabilityGI side effectsRequires 3 times daily dosing alo, alogliptin; cana, canagliflozin; empa, empagliflozin; glar, glargine; lira, liraglutide;exe LAR, exenatide long-acting release; lixi, lixisenatide; saxa, saxagliptin; sita, sitagliptin.If not at glycemic targetsAdd another antihyperglycemic agent from a different class and/or add/intensify insulin regimenMake timely adjustments to attain target A1C within 3-6 months* May include dehydration, DKA, HHS** Listed by CV outcome data† Insulin may be required at any point for symptomatic hyperglycemia/metabolic decompensation or if unable to achieveglycemic targets with other antihyperglycemic agents† † Avoid in people with prior lower extremity amputation‡ See product monographsWhich caare indicAND ifat glycDoes the pacardiovascu- Cardiac isc- Peripheral- CerebrovasNONODoes the pamicrovascul- Retinopath- Kidney dise- NeuropathIs the patien- age 55 wiCV risk fact- age 40?- age 30 an- warrantedbased on tCardiovasc1 Dose adjustmebeing met.2 ACE-inhibitor ordemonstrated vaonce daily [HOPE3 ASA should notpeople with diabeASA-intolerant.4 Canagliflozin: av
* May include dehydration, DKA, HHS** Listed by CV outcome data† Insulin may be required at any point for symptomatic hyperglycemia/metabolic decompensation or if unable to achieveglycemic targets with other antihyperglycemic agents† † Avoid in people with prior lower extremity amputation‡ See product monographsAdd another antihyperglycemic agent from a different class and/or add/intensify insulin regimenMake timely adjustments to attain target A1C within 3-6 monthsWhich cardiovascular protection medicationsare indicated for my patient?Does the patient havecardiovascular disease?- Cardiac ischemia (silent or overt)- Peripheral arterial disease- Cerebrovascular/carotid diseaseAND if the patient is NOTat glycemic targetYESADDNODoes the patient havemicrovascular disease?- Retinopathy- Kidney disease (ACR 2.0)- NeuropathyLiraglutide, Empagliflozinor Canagliflozin4(only for patients withtype 2 diabetes)YESStatin1 ACEi/ARB2NOIs the patient:- age 55 with additionalCV risk factors?Statin1 ACEi/ARB2 ASA3YES- age 40?- age 30 and diabetes 15 years?- warranted for statin therapyYESbased on the CanadianCardiovascular Society Lipid Guidelines?Statin11 Dose adjustments or additional lipid therapy warranted if lipid target (LDL-C 2.0 mmol/L) notbeing met.2 ACE-inhibitor or ARB (angiotensin receptor blocker) should be given at doses that havedemonstrated vascular protection (eg. perindopril 8 mg once daily [EUROPA trial], ramipril 10 mgonce daily [HOPE trial], telmisartan 80 mg once daily [ONTARGET trial]).3 ASA should not routinely be used for the primary prevention of cardiovascular disease inpeople with diabetes. ASA may be used for secondary prevention. Consider clopidogrel ifASA-intolerant.4 Canagliflozin: avoid in people with prior lower extremity amputation.
Keeping patients safe when they areat risk of hypoglycemiaKeeping patienof dehydrationFor patients using insulin or insulin secretagogues, e.g. glyburide,gliclazide, repaglinide:Re-hydrate appropriatediet Jell-O ; avoid caffeinRecognize ASK at each visit ASSESS impact, including fear/intentional avoidance of lows SCREEN for hypoglycemia unawarenessAct/Treat EDUCATE on appropriate treatment and the need to havefast-acting sugar treatment available at all timesPrevent CONSIDER medications with lower risk of hypoglycemia DISCUSS POSSIBLE CAUSES and how to avoid future hypoglycemiaReduce Driving Risk EDUCATE patients to drive safely with diabetesPrepare Keep fast-acting sugar within reach and othersnacks nearbyBe Aware of blood glucose (BG) before driving and every 4 hoursduring long drives. If BG is below 4 mmol/L, treatStop driving and treat if any symptoms appearAfter treating a low, wait until BG is above 5 mmol/L to startdriving again. Note: Brain function may not be fully restored until40 minutes after hypoglycemia is resolvedIf a patient is unaware of symptoms of hypoglycemia, he/she mustcheck their BG before driving and every 2 hours while driving, orwear a real-time continuous glucose monitorHold SADMANS meds.SADMANSsulfonylureas, otheACE-inhibitorsdiuretics, direct renmetforminangiotensin receptnon-steroidal antiSGLT2 inhibitorsSpecial considetype 1 or typePregnancy should be placonception: A1C 7% or less, but strpersonalized target) Stop:- Non-insulin antihype- Statins- ACEi/ARB prior to pruntil detection of pre Start:- Folic acid 1 mg per d- Insulin if target A1C i- Other antihypertensif hypertension cont Screen for complicat- Eye appointment, se Aim for healthy BMI Ensure appropriate va Refer to diabetes clinic
ey aree.g. glyburide,dance of lowsneed to haveesoglycemiafuture hypoglycemiasand otherng and every 4 hourseatrmmol/L to startfully restored untilycemia, he/she musturs while driving, orKeeping patients safe when they are at riskof dehydration (vomiting/diarrhea)3 Quick questyour patientsRe-hydrate appropriately (water, broth, diet soft drinks, sugar-free Kool-Aid ,diet Jell-O ; avoid caffeinated beverages).For patients who arequestions to identifyHold SADMANS meds. Restart once able to eat/drink normally.SADMANSsulfonylureas, other secretagoguesACE-inhibitorsdiuretics, direct renin inhibitorsmetforminangiotensin receptor blockersnon-steroidal anti-inflammatory drugsSGLT2 inhibitorsSpecial considerations for women withtype 1 or type 2 diabetesPregnancy should be planned, with the following steps taken prior toconception: A1C 7% or less, but strive for 6.5% (ensure contraception until atpersonalized target) Stop:- Non-insulin antihyperglycemic agents (except metformin and/or glyburide)- Statins- ACEi/ARB prior to pregnancy, but if overt nephropathy exists, continueuntil detection of pregnancy Start:- Folic acid 1 mg per day x 3 months prior to conception- Insulin if target A1C is not achieved on metformin and/or glyburide (type 2)- Other antihypertensive agents safe for pregnancy (Labetalol, nifedepine XL)if hypertension control needed Screen for complications:- Eye appointment, serum creatinine, urine ACR, blood pressure Aim for healthy BMI Ensure appropriate vaccinations have occurred Refer to diabetes clinic1. How important- low, medium, o(Goal examples: inimprove A1C, loweIf importance (mothappen for importA high level of impoto change.2. How confident aoutcome here -If their confidenceincrease their confiknowledge, skills oA high level of confichange.3. Can we set a spetime we meet? WEncourage S.M.A.RSpecific Meas
are at riska)sugar-free Kool-Aid ,normally.n withaken prior totion until atrmin and/or glyburide)hy exists, continueonnd/or glyburide (type 2)abetalol, nifedepine XL)d pressure3 Quick questions to helpyour patients meet their goalsFor patients who are not making expected progress, try asking thesequestions to identify a path forward:1. How important is it for you to insert self-management goal - low, medium, or high?(Goal examples: increase levels of physical activity, reduce weight,improve A1C, lower BP)If importance (motivation) is rated low, ask what would need tohappen for importance to go up?A high level of importance will indicate that the person is readyto change.2. How confident are you in your ability to insert targetoutcome here - low, medium, or high?If their confidence is rated low, explore what needs to happen toincrease their confidence. Usually this has to do with improvingknowledge, skills or resources and support.A high level of confidence indicates that the person is ready tochange.3. Can we set a specific goal for you to try before the nextIndividualizedPotential Selfmanagement GoalsEat healthierBe more activeLose weightTake medicationregularlyAvoid hypoglycemiaCheck blood glucosCheck feetManage stresstime we meet? What steps will you take to achieve it?Encourage S.M.A.R.T. Goals:Specific Measurable Achievable Realistic TimelyReduce or stopsmoking
Individualized goal settingPotential Selfmanagement GoalsExamplesEat healthierSee a dietitian to help develop a healthyeating plan.Be more activeIncrease physical activity with the goal ofgetting to 150 minutes aerobic activity/weekand resistance exercise 2-3 times/week.Choose physical activity that meetspreferences/needs.Lose weightUse strategies (e.g., reduce calories orportions) to lose 5-10% of initial weight.Take medicationregularlyTaking medication will help to improvesymptoms and take control of your life.Consider using a pillbox or setting a timer.Avoid hypoglycemiaRecognize the signs of hypoglycemia and takeaction to prevent it.Check blood glucoseEstablish a routine and act accordingly.Check feetDo a daily self-check and follow-up with ahealth-care provider if anything is abnormal.before the nextto achieve it?Manage stressScreen for distress (depressive and anxioussymptoms) by interview or a standardizedquestionnaire (e.g. PHQ-9www.phqscreeners.com).Realistic TimelyReduce or stopsmokingss, try asking thesef-management goal ity, reduce weight,t would need toperson is ready insert targeteds to happen too with improvingson is ready toIdentify barriers to quitting and develop aplan to address each of these.ABCDES of diaA A1C targetsB BP targetsCCholesterol taD Drugs for CVD risk reductionEExercise goalshealthy eatingSScreening forcomplicationsSSmoking cessaSSelf-managemstress, other baEducational grant funding forIngelheim Canada /Eli Lilly Cathese organizations for their
evelop a healthywith the goal oferobic activity/week2-3 times/week.that meetsce calories orof initial weight.elp to improvetrol of your life.or setting a timer.ABCDES of diabetes careGUIDELINE TARGET (or personalized goal)A A1C targetsA1C 7.0% (or 6.5% to risk of CKD and retinopathy)If on insulin or insulin secretagogue, assess forhypoglycemia and ensure driving safetyB BP targetsBP 130/80 mmHgIf on treatment, assess for risk of fallsCD Drugs for CVD risk reductionE150 minutes of moderate to vigorous aerobic activity/week and resistance exercises 2-3 times/weekFollow healthy dietary pattern (eg Mediterranean diet,low glycemic index)SScreening forcomplicationsSSmoking cessationIf smoker: Ask permission to give advice, arrangetherapy and provide supportSSelf-management, setting” panel)stress, other barriers Assess for stress, mental health and financial or otherQuickGuideSet personalized goals (see “individualized goalconcerns that might be barriers to achieving goalsEducational grant funding for this resource was provided in part by AstraZeneca, BoehringerIngelheim Canada /Eli Lilly Canada Alliance, and Novo Nordisk Canada Inc. Diabetes Canada thanksthese organizations for their commitment to diabetes in Canada. Copyright 2018 Diabetes Canada.416569-18ng and develop athese.Exercise goals andhealthy eatingCardiac: ECG every 3-5 years if age 40 OR diabetescomplicationsFoot: Monofilament/Vibration yearly or more ifabnormalKidney: Test eGFR and ACR yearly, or more if abnormalRetinopathy: type 1 - annually; type 2 - q1-2 yrsfollow-up with anything is abnormal.essive and anxiousor a standardized9).baseline)ACEi/ARB (if CVD, age 55 with risk factors, ORdiabetes complications)Statin (if CVD, age 40 for type 2, OR diabetescomplications)ASA (if CVD)SGLT2i/GLP1ra with demonstrated CV benefit (if havetype 2 with CVD and A1C not at target)ypoglycemia and takeact accordingly.Cholesterol targets LDL-C 2.0 mmol/L (or 50 % reduction from2018 Clindia
Quick Reference Guide guidelines.diabetes.ca diabetes.ca 1-800-BANTING (226-8464) Individualized goal setting Potential Self-management Goals Examples Eat healthier See a dietitian to help develop a healthy eating plan. Be more active Increase physical activity with
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