Alice Y.Y. Cheng

Use of Glycated Hemoglobin (A1C) in the Diagnosis of Type 2 Diabetes Mellitus in Adults

The Canadian Diabetes Association (CDA) reviewed the use of glycated hemoglobin (A1C) in the diagnosis of diabetes mellitus. An International Expert Committee, the American Diabetes Association, a joint statement from the American Association of Clinical Endocrinologists/American College of Endocrinology, and a World Health Organization Consultation each recommend an A1C of 6.5% or higher as a criterion for the diagnosis of diabetes (1-4). The relationship between A1C and retinopathy is similar to that of fasting plasma glucose (FPG) or 2-hour plasma glucose (2hPG) with a threshold at around 6.5% (5-8). Although the diagnosis of diabetes is based on an A1C threshold for developing microvascular disease, A1C is also a continuous cardiovascular risk factor and a better predictor of macrovasRonald M. Goldenberg MD FRCPC FACE, Alice Y.Y. Cheng MD FRCPC, Zubin Punthakee MD FRCPC, Maureen Clement MD CCFP

The Canadian Diabetes Association 2013 Clinical Practice Guidelines—Raising the Bar and Setting Higher Standards!

The “Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada” (1) were published in April as a supplement in the Canadian Journal of Diabetes. The clinical practice guidelines (CPGs) were the fruit of 3 years of arduous work by a dedicated team of 120 Canadian diabetes experts spanning 19 different disciplines. The first set of the Canadian Diabetes Association (CDA) CPGs was published in 1992 by a relatively small group of 24 experts, and was 16 pages in length (2). The professional members of the CDA published the first comprehensive, evidence-based CPGs in North America on the management of diabetes in 1998 (3). The guidelines contained a total of 93 recommendations, which covered all aspects of ambulatory diabetes care, ranging from organization, responsibilities, diagnosis, glycemic and metabolic management, to screening, prevention and treatment of longterm complications. These were updated by a larger committee of expert volunteers every 5 years, in 2003 (4) and in 2008 (5). The CPGs became more comprehensive and expanded from 29 pages in 1998 to 152 pages in 2003 and to 201 pages in 2008 to take into consideration the new advances in diagnosis, treatment and prevention of diabetes and its attendant complications. The 2013 CPGs were slightly longer (212 pages) but its contents embrace even a broader scope with greater details, and reflect the explosion of new knowledge that contribute to deeper insights into our understanding, prevention and management of diabetes and its attendant complications. Over the years, the CDA CPGs have grown significantly in its recognition and stature at an international level. The Society of Endocrinology, Metabolism and Diabetes of South Africa incorporated and adapted many of the 2008 CPGs recommendations when they developed their own guidelines for the management of diabetes (6). More recently, a systematic review conducted by the Johns Hopkins University Evidence-Based Practice Center evaluated 11 international guidelines on oral medications for type 2 diabetes mellitus. The CDA CPGs scored 100% for consistency with the evidence, 100% for editorial independence and 97.6% for rigour of developmentdmissing the 100% mark due the length of the update process (7). The only other evidencebased guidelines that ranked similarly were from the United Kingdom National Institute for Health and Clinical Evidence (8). The skeptical reader might ask the question of why do we need CPGs and regular updates. There are 3 reasons why CPGs are relevant and important. First, diabetes is a serious and one of the most common and yet complex noncommunicable diseases in the world, and its prevalence and burden continue to soar at an alarming rate. In Canada, diabetes rates have doubled over the past decade, with 2.4 million adults (6.8%) living with diabetes in 2009 and the number will reach 3.7 million by 2019 (9). More

SGLT2 Inhibitor–associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis

PURPOSEnSodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA.nnnMETHODSnReports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel.nnnFINDINGSnDKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended.nnnIMPLICATIONSnPreventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.

Policies, Guidelines and Consensus Statements: Pharmacologic Management of Type 2 Diabetes-2015 Interim Update.

The initial draft of this commentary was prepared by William Harper MD, FRCPC, Maureen Clement MD, CCFP, Ronald Goldenberg MD, FRCPC, FACE, Amir Hanna MB, BCh, FRCPC, FACP, Andrea Main BScPhm, CDE, Ravi Retnakaran MD, MSc, FRCPC, Diana Sherifali RN, PhD, CDE, Vincent Woo MD, FRCPC, Jean-François Yale MD, CSPQ, FRCPC, and Alice Y.Y. Cheng MD, FRCPC on behalf of the Steering Committee for the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE): 2014 update

In Canada, the multiple chronic conditions and cardiovascular risk factors of our aging population continue to challenge health care providers and burden health systems. Cardiovascular disease is a major contributor to chronic illness, with four in five Canadians having at least one risk factor for

Metabolic syndrome under fire: Weighing in on the truth

In the past two decades, the metabolic syndrome has raised much clinical and research interest and remains a controversial topic. The constellation of commonly coexisting cardiovascular risk factors, now known as the metabolic syndrome, has had many definitions which has added to the confusion surrounding the syndrome. Recently, the controversy has been escalated by a joint statement from the American Diabetes Association and the European Association for the Study of Diabetes calling into question the existence and clinical utility of the metabolic syndrome as a discrete clinical entity. Despite the controversy, there is agreement that the risk factors of abdominal obesity, hypertension, elevated glucose and dyslipidemia commonly coexist in the same patient, and are important to identify when assessing an individual patients risk. Therefore, whether the syndrome is a distinct clinical entity is not important. By definition, a syndrome is a group of signs or symptoms that commonly group together. It remains a useful clinical tool to raise awareness among health care professionals to look for nontraditional cardiovascular risk factors, such as glucose intolerance or elevated waist circumference, in patients with other components of the syndrome, without negating the importance of identifying and treating the other traditional risk factors not identified in the syndrome. It also reminds clinicians of the importance of lifestyle interventions to treat all of the components of the syndrome. Therefore, the metabolic syndrome continues to serve a useful clinical purpose to raise awareness among health care professionals and aid in identifying high-risk individuals.

Glucose lowering and cardiovascular disease: what do we know and what should we do?

For the reduction of microvascular complications in type 2 diabetes, glycemic control has been shown to be an important and effective intervention. However, considering the findings from several recent, large, randomized controlled trials, the utility of very tight glycemic control in all those with type 2 diabetes, for the reduction of cardiovascular disease remains controversial. The decision to aim for very tight glycemic control must be individualized and the potential benefit of reduced risk of nephropathy must be weighed against the increased risk for hypoglycemia. The results of the 10-year posttrial monitoring of the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated macrovascular benefits of glycemic control in newly diagnosed type 2 diabetes but lengthy follow-up was required to demonstrate the effect. This raises the possibility that benefits of glucose lowering to reduce cardiovascular risk is more evident in those with a shorter duration of diabetes and requires many years to manifest. For the time being, there remains good evidence for targeting A1c [ 7% for microvascular protection but attempts to lower A1c beyond this must be considered on an individual basis. Eur J Cardiovasc Prev Rehabil 17 (Suppl 1):S25-S31 ©2010 The European Society of Cardiology

Insights Into the Current Management of Older Adults With Type 2 Diabetes in the Ontario Primary Care Setting

OBJECTIVEnThe Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care.nnnMETHODSnData were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics.nnnRESULTSnMore than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80u2009mm Hg, and 73% had low-density lipoprotein levels of 2.0u2009mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents.nnnCONCLUSIONSnOlder persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a sicker population is not known. Personalized strategies are necessary to avoid undertreatment of healthy older patients and overtreatment of the frail elderly.

Cardiovascular risk and glycemic control

The use of a multifactorial approach to the treatment of diabetes mellitus is associated with dramatic reductions in both macrovascular and microvascular complications of diabetes. [1][1],[2][2] Nevertheless, intensive glycemic control, with a target hemoglobin A1c level of less than 6%–6.5%, has

Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2018 update

KEY POINTSnThe Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) is a nationally endorsed guideline process, targeting primary care health care practitioners. The C-CHANGE guideline is a composite of nine of Canada’s cardiovascular-focused clinical practice guidelines ([