GPAC: Guidelines and Protocols Advisory Committee

Diabetes Care

Effective Date: September, 2005

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF | Body Mass Index

Recommendations and Topics

Scope

1. Patient Self-Management

2. Meeting Care Objectives

3. Care Objectives

4. Prevention

5. Diagnosis of Diabetes, Impaired Fasting Glucose and Impaired Glucose Tolerance

6. Treatment

7. Additional Practice Points

Rationale

References

Abbreviations and Terms

Algorithm 1. Diagnosis of Diabetes, IFG and IGT

Algorithm 2. Management of Hyperglycemia in Type 2 Diabetes

Body Mass Index

Scope

This guideline describes the care objectives for the prevention, diagnosis and management of diabetes in non-pregnant adults. It is intended primarily for family practitioners, and focuses on approaches and systems that should be in place to improve care for the majority of patients the majority of the time.

RECOMMENDATION 1: Patient self-management

The management of diabetes hinges on the commitment of the person with diabetes to self-management, balancing appropriate lifestyle choices, self-monitoring of blood glucose levels, and pharmacologic or insulin therapy. To support patient self-management, the physician should:

• Encourage the patient to accept responsibility for the care of their diabetes
• Reinforce the importance of lifestyle modifications including healthy eating, active living/exercise, weight management, social support and smoking cessation
• Encourage the use of diaries or logbooks
• Help the patient identify a support team
• Refer the patient to the local Diabetes Education Centre
• Define, with the patient, the best possible goals such as blood glucose concentration, A1C, blood pressure, lipids, lifestyle modifications and appropriate follow-up
• Provide the patient with appropriate, individualized education (culturally sensitive information, skills and support)

Note: Resources to support patient self-management are listed in the attached Resources for Patients with Diabetes and will be available at www.health.gov.bc.ca/cdm/index.html. Other resources are available at www.diabetes.ca.

RECOMMENDATION 2: Meeting care objectives

Evidence indicates that organizational interventions such as registration, recall, and regular review can improve the care of diabetes. Physicians are encouraged to:

• Routinely prescribe regular exercise and moderate weight loss for over-weight adults, as evidence shows many cases of adult onset diabetes can be prevented
• Identify all patients with diabetes in their practice - test all patients over age 40 every three years with a fasting blood sugar
• Maintain patient registries for patients with diabetes and cooperate with regional and provincial registries whenever possible
• Use a flow sheet* for each patient with diabetes
• Use recall systems to ensure that patients with diabetes are seen at appropriate intervals
• Review patient records to ensure care objectives are met
• Consider pre-arranging for tests that need to be repeated on a regular basis, e.g. A1C q 3 months.

* A flow sheet is a one to two page form that gathers all important data regarding a patient’s diabetes. Attached to a patient’s chart, the flow sheet serves as a reminder and a record of whether care objectives have been met. See attached flow sheet.

Physicians interested in knowing how their practices compare to others may wish to use performance measures. For further information, see www.health.gov.bc.ca/cdm/index.html.

RECOMMENDATION 3: Care Objectives

Depending on the type of diabetes and therapy required, these care objectives may be more or less difficult to achieve without adverse effects. Also, there will be circumstances where the patient’s condition (dementia, terminal illnesses) means that end of life care will take priority over the diabetes care objectives. Therefore, treatment goals must be tailored to the individual.

Care Objectives

(printable PDF)

Practice Points

When setting goals with the patient, consider the following:

• Minimization of symptomatic hyperglycemia or hypoglycemia may override target A1C levels.
• More frequent lipid measurement is required for patients receiving treatment for dyslipidemia.
• Reduction of hypertension has been shown to reduce the risk of complications and mortality rates. (See Hypertension - Detection, Diagnosis and Management).
• Several clinical trials have been published in recent years that identify patients who are most likely to benefit from statin therapy. Adverse events are more common in elderly patients (70+).
• Co-existing depression and other psychiatric conditions are common in patients with diabetes. Treatment of these conditions may improve diabetes outcomes.

RECOMMENDATION 4: Prevention

A large proportion of type 2 diabetes can be prevented using lifestyle modification and/or pharmacologic intervention. All individuals should be encouraged to pursue a program of lifestyle modification that includes regular physical activity (at least 150 minutes of moderate intensity aerobic exercise each week spread over 3 non-consecutive days and resistance exercise 3 times a week) and moderate weight loss (5-10% of initial body weight). Lifestyle modification is particularly important for persons considered at high-risk for diabetes. Pharmacologic therapy with metformin or acarbose should also be considered for those at high risk.

RECOMMENDATION 5: Diagnosis of Diabetes, Impaired Fasting Glucose and Impaired Glucose Tolerance

Classic symptoms of polyuria, polydipsia, and unexplained weight loss with a casual PG > 11.1 mmol/L are diagnostic. Casual means any time of day, without regard to the interval since the last meal.

In the absence of classic symptoms or metabolic decompensation, a fasting plasma glucose is recommended as the initial diagnostic test for diabetes. In the absence of classical symptoms a FPG >7.0 mmol/L is considered diagnostic, but a confirmatory test must be done on another day. Fasting means no caloric intake for at least 8 hours.

Testing for diabetes using a fasting plasma glucose should be performed every 3 years for individuals over 40 years of age. More frequent or earlier testing should be considered in people with additional risk factors for diabetes. See Algorithm 1.

Neither the A1C nor the 2-hour post-75g OGTT are recommended as the initial test for diagnosis of diabetes. However, the 2-hour post 75g OGTT should be considered in individuals with a fasting plasma glucose between 5.7 and 6.9 mmol/L and risk factors.

Note: The term prediabetes refers to impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Individuals with prediabetes are at risk of developing diabetes and its complications. They should be monitored regularly and benefit from CVD risk factor modification.

RECOMMENDATION 6: Treatment

1. Vascular Protection

• Lifestyle modification
• Engaging in regular physical activity
• Healthy eating habits
• Achieving and maintaining a healthy weight
• Stopping smoking
• Anti-platelet therapy - low dose ASA
• ACE inhibitors are indicated for any of:
• Age 55 or over
• Hypertension
• Confirmed albuminuria
• Optimize BP to less than or equal to 130/80. If lifestyle modification is not sufficient, choose from the following first-line agents: a thiazide diuretic, ACEI/ARB, or cardioselective B-blockers. See Hypertension - Detection, Diagnosis and Management.
• Optimize glycemic control - see below
• Calculate 10 year coronary heart disease (CHD) risk using UKPDS risk calculator or table and treat dyslipidemia per Table 1.

Table 1. Initial Treatment of Dyslipidemia

(printable PDF)

2. Glycemic Control - see Algorithm 2

The first step in management of hyperglycemia should be a complete clinical assessment and initiation of nutrition therapy and physical activity.

Patients with type 1 diabetes should see an experienced diabetes care team at diagnosis and at least annually.

To achieve glycemic targets in people with type 1 diabetes, multiple daily injections (3 or 4 per day) or the use of continuous subcutaneous insulin infusions (CSII) should be considered as part of an intensive diabetes management program. See Table 2.

Table 2. Types of Insulin

(printable PDF)

Pharmacare coverage - valid at date of printing:

Table 3. Antihyperglycemic Agents for Use in Type 2 Diabetes

(printable PDF)

Hypoglycemia - prevention

Risk factors for severe hypoglycemia should be identified in people with type 1 diabetes so that appropriate strategies can be used to minimize hypoglycemia. All individuals on insulin should be counselled about the risk and prevention of insulin-induced hypoglycemia

Severe hypoglycemia is less common in persons with type 2 diabetes, but the elderly and those on insulin or secretagogues are more vulnerable.

Strategies to reduce the risk of hypoglycemia include:

• Increased frequency of SMBG, including episodic assessment during sleeping hours
• Less stringent glycemic targets
• Multiple insulin injections.

Table 4. Treatment of Hypoglycemia

(printable PDF)

RECOMMENDATION 7: Additional Practice Points

• Otherwise healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people. In people with multiple comorbidities, high level of functional dependency or limited life expectancy, the goals should be more conservative.
• Aerobic exercise and/or resistance training may benefit elderly people with type 2 diabetes and should be recommended if not contraindicated.
• Consider an ECG stress test for previously sedentary people with risk factors for CVD who wish to undertake exercise more vigorous than brisk walking.
• Early recognition and treatment of retinopathy can prevent blindness.
• Tricyclic antidepressants and/or anticonvulsants should be considered for relief of painful peripheral neuropathy.
• Patients with anaesthetic neuropathy are at very high risk of foot problems.
• Discuss alcohol use with the healthcare team.
• Those on intensive insulin treatment regimen should receive education on matching insulin to carbohydrate content (carb counting).
• Ask about erectile dysfunction

In elderly people with type 2 diabetes:

• Polypharmacy-review the medication list of an older adult with DM who presents with depression, falls, cognitive impairment or urinary incontinence
• Alpha-glucosidase inhibitors are modestly effective
• Thiazolidinedione insulin sensitizers are effective, but should be used with caution in those at risk for fluid retention.
• Sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age. In general initial doses should be half of those for younger people and increased more slowly.
• In elderly people, the use of premixed insulins and prefilled insulin pens should be considered to reduce dosage errors and potentially improve glycemic control.
• People with clinically significant autonomic dysfunction should be appropriately assessed and referred to a specialist experienced in managing the affected body system.

Commonly overlooked comorbid conditions include: cataracts, entrapment neuropathy (carpal tunnel), tendon problems and dental problems.

Rationale

Diabetes is a serious health problem with significant impacts on individuals, families, communities and health services. It is one of the most common chronic diseases, affecting approximately five per cent of Canadians¹ Because many cases are undiagnosed, the true prevalence of diabetes is substantially underestimated. Moreover, diabetes prevalence is expected to increase dramatically due to an ageing population and increased rates of obesity. In B.C., approximately 200,000 people have been diagnosed with diabetes; this number is expected to grow to 325,000 by 2010. Diabetes poses a significant financial burden for both patients and society; this burden will increase with the rise in prevalence.

Although diabetes is associated with many serious complications, these are largely preventable through proper diabetes management. Diabetes is a significant cause of death in Canada and the most common cause of end-stage renal disease, new cases of blindness in the working age population and non-traumatic lower limb amputations.² It is also a major risk factor for cardiovascular disease, the leading cause of death in Canada.¹ Diabetes often disables people in their most productive years, and people with diabetes die younger than those not affected by it.

Evidence clearly indicates that efforts to control hyperglycemia, hypertension and dyslipidemia can prevent or postpone the development of complications in persons with diabetes.^3,4 The Canadian Diabetes Association’s 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada 1 are based on such evidence and have been widely disseminated. However, levels of care for persons with diabetes remain suboptimal and practitioners often are challenged to organize care in accordance with published guidelines.⁵ In recent years, a wide range of interventions targeting professional behavior or the structure of care have been designed to improve care delivered to persons with diabetes.^6-9 A recent Cochrane review showed that multifaceted interventions to improve the performance of practitioners and organizational interventions to improve recall and review can enhance the care of diabetes.¹⁰ Several clinical trials have been published in recent years that identify patients who are most likely to benefit from statin therapy. Adverse events are more common in elderly patients (70+).^11-16 A multifactorial intervention in patients with type 2 diabetes and microalbuminuria has shown a significant reduction in cardiovascular disease, nephropathy, retinopathy and autonomic neuropathy.¹⁷

This guideline outlines strategies which may help the primary care practitioner meet the complex needs of persons with diabetes

References

Grateful recognition is given to the Canadian Diabetes Association for permission to use tables and wording from their 2003 Diabetes Care guideline.

1. Canadian Diabetes Association Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2003; 27 (suppl 2): S1-S152. (Available on-line at www.diabetes.ca/cpg2003/)
2. Diabetes in British Columbia Synthesis Report, Ministry of Health Working Group on Diabetes, August 2000. www.healthservices.gov.bc.ca/prevent/pdf/Diabetes-Synthesis.pdf
3. Diabetes Control and Complication Trial Research Group (DCCT). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-986.
4. United Kingdom Prospective Diabetes Study Group (UKPDS). Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes. Lancet 1998;352:837-853.
5. Larme AC, Pugh JA. Evidence-based guidelines meet the real world. The case of diabetes care. Diabetes Care 2001;24(10):1728-33.
6. Diabetes Care Program of Nova Scotia. (1997) Surveying and Preventing the Complications of Diabetes in Nova Scotia. Nova Scotia Department of Health.
7. Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen PA. Randomized controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 2001;323(7319):970-5.
8. Task Force on Community Preventive Services. Strategies for reducing morbidity and mortality from diabetes through health-care system interventions and diabetes self-management education in community settings. MMWR 2001;50(RR16): 1-15.
9. Miller D. Use of a chronic care model to direct the care of persons with diabetes in the Capital Health Region of BC. Annals of the Royal College of Physicians and Surgeons of Canada 2002;35:495-9.
10. Renders CM, Valk GD, Griffin SJ, Wagner EH, van Eijk J, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient and community settings. A systematic review. Diabetes Care 2001;(10):1821-1833.
11. MRC/BHF investigators. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised controlled trial. Lancet 361:2003:2005-16
12. ALLHAT investigators. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomised to pravastatin vs usual care. The antihypertensive and lipid lowering treatment to prevent heart attack trial (ALLHAT-LLT). JAMA 2002 288;2998-3007.
13. Sever PS et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have an average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003;361:1149-58.
14. Calhoun HM, Betteridge TD, Durrington PN et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-696.
15. Walsh JME and Pignone M.. Drug treatment of hyperlipidemia in women. JAMA 2004; 291:2243-52.
16. Shepherd J et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. 2002:360:1623-30.
17. Gaede P, Vedel, P, Larsen N et al. Multifactorial Intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348:383-93.
18. Meier C Kraenzlin ME and Bodmer M et al. Use of thiazolidinediones and fracture risk. Arch Intern Med 2008;168(8):820-825.
19. Nissen SE and K Wolski. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun 14;356(24):2457-71.

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, tested in the BC Diabetes Collaborative, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Funding for this guideline was provided in full or part by the Primary Health Care Transition Fund.

Revised Date: June 4, 2008

This guideline is based on scientific evidence current as of the effective date.

List of Abbreviations and Terms

Algorithm 1. Diagnosis of diabetes, IFG and IGT

Download Algorithm 1 in PDF format

Algorithm 2. Management of hyperglycemia in type 2 diabetes

Download Algorithm 2 in PDF format

Body Mass Index

Download Body Mass Index in PDF format

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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