r personalized goal)

k of CKD and retinopathy)

agogue, assess for
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2018 Clinical Practice Guidelines
sk of falls
% reduction from
Quick Reference
Guide
th risk factors, OR

pe 2, OR diabetes

strated CV benefit (if have

ot at target)
vigorous aerobic activity/
cises 2-3 times/week
n (eg Mediterranean diet,

s if age >40 OR diabetes

n yearly or more if

yearly, or more if abnormal

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individualized goal

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416569-18

rriers to achieving goals

aZeneca, Boehringer- guidelines.diabetes.ca
nc. Diabetes Canada thanks
ight © 2018 Diabetes Canada. diabetes.ca | 1-800-BANTING (226-8464)
Screening and diagnosis of type 2

Adults with type 2 diabetes to reduce the risk of CKD and retinopathy if at low
diabetes in adults
Assess 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

MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES

(see CPG Chapter 4, Screening for Diabetes in Adults, Table 1)

Age <40 years or No screen

low-moderate risk* indicated
Who to screen

No risk
factors Age ≥40 years or high risk*
Screen every
(33% chance of developing
3 years
type 2 diabetes within 10 years)
Presence or very high risk Screen every
(50% chance of developing type 2 6 to 12

Targets for glycemic control

of risk
factors diabetes within 10 years) months

Test Result Dysglycemia category

How to screen

FPG (mmol/L) 6.1 – 6.9 IFG

No caloric intake for at least 8 hours

risk of hypoglycemia*
≥7.0 Diabetes
6.0 – 6.4 Prediabetes
A1C (%)**
≥6.5 Diabetes

If asymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1C
Targets

or FPG) as a confirmatory test. If both FPG and A1C are available and only one is in the
diabetes range, repeat the test in the diabetes range as the confirmatory test. If both
A1C 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 be
determined with one test (A1C, FPG, 2hPG, random PG) in the diabetes range, see
A1C%

≤7.0
≤6.5

Chapter 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)
 abetes in adults
mptoms of overt hyperglycemia are present, diagnosis of diabetes can be

PG) as a confirmatory test. If both FPG and A1C are available and only one is in the
pter 3, CPG.

amily history (first-degree relative with type 2 diabetes)

reening and diagnosis of type 2

ymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1C

sess risk factors for type 2 diabetes ANNUALLY:

ardiovascular risk factors
etes range, repeat the test in the diabetes range as the confirmatory test. If both

ee CPG Chapter 4, Screening for Diabetes in Adults, Table 1)

ther conditions and medications associated with diabetes
rmined with one test (A1C, FPG, 2hPG, random PG) in the diabetes range, see

and FPG are available and are—each in the diabetes range, diabetes—is confirmed.

story of GDM/prediabetes
gh risk populations (non-white, low socioeconomic status)
esence of end organ damage associated with diabetes
a standardized, validated assay. Be aware of factors that affect A1C accuracy (see CPG Chapter 9, Table 1)

A1C (%)**

No caloric intake for at least 8 hours

FPG (mmol/L)
a validated risk calculator (e.g. CANRISK)

Presence

No risk
factors

factors
of risk
Test

diabetes within 10 years)

(50% chance of developing type 2
or very high risk
type 2 diabetes within 10 years)
(33% chance of developing
Age ≥40 years or high risk*
low-moderate risk*
Age <40 years or
≥6.5
6.0 – 6.4
≥7.0
6.1 – 6.9
Result
Dysglycemia category
Prediabetes
Diabetes

Diabetes
IFG

Screen every

Screen every

No screen
indicated
months

3 years
6 to 12

Targets for glycemic control

A1C% Targets
Adults with type 2 diabetes to reduce the risk of CKD and retinopathy if at low
≤6.5 risk of hypoglycemia*

≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES

7.1 Functionally dependent*: 7.1-8.0%

Recurrent severe hypoglycemia and/or hypoglycemia unawareness: 7.1-8.5%
Limited life expectancy: 7.1-8.5%
8.5 Frail elderly and/or with dementia†: 7.1-8.5%

Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute

and chronic complications
End 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. S283

Blood glucose-lowering therapies (type 2 diabetes)

At diagnosis of type 2 diabetes
Start healthy behaviour interventions (nutritional therapy, weight management, physical activity) +/- metformin

Symptomatic hyperglycemia
A1C <1.5% above target A1C ≥1.5% above target and/or
metabolic decompensation*

If not at glycemic target Start metformin immediately

Initiate
within 3 months, Consider a second concurrent
insulin† +/- metformin
Start/Increase metformin antihyperglycemic agent

If not at glycemic target If not at glycemic target

Clinical CVD?

YES NO

Start antihyperglycemic agent Add additional antihyperglycemic agent best suited to

with demonstrated the individual based on the following:
CV benefit empagliflozin Clinical Considerations Choice of Agent
(Grade A, Level 1A)
liraglutide Avoidance of hypoglycemia DPP-4 inhibitor, GLP-1
(Grade A, Level 1A) and/or weight gain with adequate receptor agonist or SGLT2 inhibitor
canagliflozin† † glycemic efficacy
 Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute
and chronic complications
End 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. S283

Blood glucose-lowering therapies (type 2 diabetes)

At diagnosis of type 2 diabetes
Start healthy behaviour interventions (nutritional therapy, weight management, physical activity) +/- metformin

Symptomatic hyperglycemia
A1C <1.5% above target A1C ≥1.5% above target and/or
metabolic decompensation*

If not at glycemic target Start metformin immediately

Initiate
within 3 months, Consider a second concurrent
insulin† +/- metformin
Start/Increase metformin antihyperglycemic agent

If not at glycemic target If not at glycemic target

Clinical CVD?

YES NO

Start antihyperglycemic agent Add additional antihyperglycemic agent best suited to

with demonstrated the individual based on the following:
CV benefit empagliflozin Clinical Considerations Choice of Agent
(Grade A, Level 1A)
liraglutide Avoidance of hypoglycemia DPP-4 inhibitor, GLP-1
(Grade A, Level 1A) and/or weight gain with adequate receptor agonist or SGLT2 inhibitor
canagliflozin† † glycemic efficacy
(Grade C, Level 2) Other considerations:
Reduced eGFR and/or albuminuria
Clinical CVD or CV risk factors
If not at glycemic target Degree of hyperglycemia See Table below
Other comorbidities (CHF, hepatic
disease‡)
Planning pregnancy‡
Cost/coverage
Patient preference

Add additional antihyperglycemic agent best suited to the individual by prioritizing

patient characteristics (agents listed in alphabetical order by CV outcome data)
Class** Effect on Hypo- Weight Relative A1C Other therapeutic Cost
CVD glyce- lowering considerations
outcomes mia when added
to metformin
HEALTHY BEHAVIOUR INTERVENTIONS

GLP-1 receptor lira: Rare ”” ”” GI side-effects $$$$

agonists Superiority to Gallstone disease
”””
in people Contraindicated with personal/family
with type history of medullary thyroid cancer or
2 diabetes MEN 2
with clinical Requires subcutaneous injection
CVD
exenatide
LAR & lixi:
Neutral
SGLT2 cana & Rare ”” ”” Genital infections, UTI, hypotension, $$$
inhibitors empa: to dose-related changes in LDL-C. Caution
”””
Superiority with renal dysfunction, loop diuretics, in
in people the elderly. Dapagliflozin not to be used if
with type bladder cancer. Rare diabetic ketoacido-
2 diabetes sis (may occur with no hyperglycemia). In-
with clinical creased risk of fractures and amputations
CVD with canagliflozin
Reduced progression of nephropathy
and CHF hospitalizations with empagli-
flozin and canagliflozin in persons with
clinical CVD
DPP-4 Neutral Rare Neutral ”” Caution with saxagliptin in heart failure $$$
Inhibitors (alo, saxa, Rare joint pain
sita)
Insulin glar: Yes ““ ”” No dose ceiling, flexible regimens $-
Neutral to Requires subcutaneous injection $$$$
””””
degludec:
noninferior
to glar
Thiazolidinedi- Neutral Rare ““ ”” CHF, edema, fractures, rare bladder $$
ones cancer (pioglitazone), cardiovascular
controversy (rosiglitazone), 6-12 weeks
required for maximal effect
Alpha-glucosi- Rare Neutral ” GI side-effects common $$
dase inhibitors Requires 3 times daily dosing
(acarbose)
Insulin
secretatogue:
“ ”” $$
Meglitinide Yes More rapid BG-lowering response
Reduced postprandial glycemia with
meglitinides but usually requires 3 to 4
“ ”” times daily dosing
Sulfonylurea Yes Gliclazide and glimepiride associated with $
less hypoglycemia than glyburide
Poor durability
Weight loss None ” ” GI side effects $$$
agent (orlistat) Requires 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 targets

Add another antihyperglycemic agent from a different class and/or add/intensify insulin regimen
Make 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 achieve
glycemic targets with other antihyperglycemic agents
† † Avoid in people with prior lower extremity amputation
‡ See product monographs
4 Canagliflozin: av
ASA-intolerant.
people with diabe
3 ASA should not
once daily [HOPE
demonstrated va
2 ACE-inhibitor or
being met.
1 Dose adjustme

- warranted
- age ≥30 an
- age ≥40?

- age ≥55 wi
Is the patien

- Neuropath
- Kidney dise
- Retinopath
microvascul
Does the pa

- Cerebrovas
- Peripheral
- Cardiac isc
cardiovascu
Does the pa
are indic
Which ca
Cardiovasc
based on t

CV risk fact

NO

NO

at glyc
AND if
 Which cardiovascular protection medications
are indicated for my patient?
Does the patient have YES Statin1
cardiovascular disease? +
Add another antihyperglycemic agent from a different class and/or add/intensify insulin regimen

† Insulin may be required at any point for symptomatic hyperglycemia/metabolic decompensation or if unable to achieve

- Cardiac ischemia (silent or overt) ACEi/ARB2

- Peripheral arterial disease +
- Cerebrovascular/carotid disease ASA3
Liraglutide, Empagliflozin
Make timely adjustments to attain target A1C within 3-6 months

AND if the patient is NOT ADD

at glycemic target or Canagliflozin4
(only for patients with
NO type 2 diabetes)
Does the patient have
YES
microvascular disease?
- Retinopathy
- Kidney disease (ACR ≥2.0) Statin1
- Neuropathy +
NO ACEi/ARB2
Is the patient:
- age ≥55 with additional
† † Avoid in people with prior lower extremity amputation

YES
glycemic targets with other antihyperglycemic agents

CV risk factors?
- age ≥40?
- age ≥30 and diabetes >15 years?
- warranted for statin therapy
* May include dehydration, DKA, HHS

YES Statin1
based on the Canadian
Cardiovascular Society Lipid Guidelines?
‡ See product monographs
** Listed by CV outcome data

1 Dose adjustments or additional lipid therapy warranted if lipid target (LDL-C <2.0 mmol/L) not
being met.
2 ACE-inhibitor or ARB (angiotensin receptor blocker) should be given at doses that have
demonstrated vascular protection (eg. perindopril 8 mg once daily [EUROPA trial], ramipril 10 mg
once daily [HOPE trial], telmisartan 80 mg once daily [ONTARGET trial]).
3 ASA should not routinely be used for the primary prevention of cardiovascular disease in
people with diabetes. ASA may be used for secondary prevention. Consider clopidogrel if
ASA-intolerant.
4 Canagliflozin: avoid in people with prior lower extremity amputation.
Keeping patients safe when they are Keeping patien
at risk of hypoglycemia of dehydration
For patients using insulin or insulin secretagogues, e.g. glyburide, Re-hydrate appropriate
gliclazide, repaglinide: diet Jell-O™; avoid caffein
Hold SADMANS meds.
Recognize S sulfonylureas, othe
• ASK at each visit A ACE-inhibitors
• ASSESS impact, including fear/intentional avoidance of lows D diuretics, direct ren
• SCREEN for hypoglycemia unawareness M metformin
A angiotensin recept
Act/Treat N non-steroidal anti-
• EDUCATE on appropriate treatment and the need to have S SGLT2 inhibitors
fast-acting sugar treatment available at all times
Special conside
Prevent type 1 or type
• CONSIDER medications with lower risk of hypoglycemia Pregnancy should be pla
• DISCUSS POSSIBLE CAUSES and how to avoid future hypoglycemia conception:
• A1C 7% or less, but str
Reduce Driving Risk personalized target)
• Stop:
• EDUCATE patients to drive safely with diabetes
- Non-insulin antihype
Prepare Keep fast-acting sugar within reach and other - Statins
snacks nearby - ACEi/ARB prior to pr
Be Aware of blood glucose (BG) before driving and every 4 hours until detection of pre
during long drives. If BG is below 4 mmol/L, treat • Start:
Stop driving and treat if any symptoms appear - Folic acid 1 mg per d
- Insulin if target A1C i
After treating a low, wait until BG is above 5 mmol/L to start
- Other antihypertens
driving again. Note: Brain function may not be fully restored until if hypertension cont
40 minutes after hypoglycemia is resolved • Screen for complicat
- Eye appointment, se
If a patient is unaware of symptoms of hypoglycemia, he/she must • Aim for healthy BMI
check their BG before driving and every 2 hours while driving, or • Ensure appropriate va
wear a real-time continuous glucose monitor • Refer to diabetes clinic
ey are Keeping patients safe when they are at risk 3 Quick quest
of dehydration (vomiting/diarrhea) your patients
e.g. glyburide, Re-hydrate appropriately (water, broth, diet soft drinks, sugar-free Kool-Aid™, For patients who are
diet Jell-O™; avoid caffeinated beverages). questions to identify
Hold SADMANS meds. Restart once able to eat/drink normally.
S sulfonylureas, other secretagogues
1. How important
A ACE-inhibitors
dance of lows D diuretics, direct renin inhibitors - low, medium, o
M metformin (Goal examples: in
A angiotensin receptor blockers improve A1C, lowe
N non-steroidal anti-inflammatory drugs If importance (mot
need to have S SGLT2 inhibitors happen for import
es
Special considerations for women with A high level of impo
type 1 or type 2 diabetes to change.
oglycemia Pregnancy should be planned, with the following steps taken prior to
future hypoglycemia conception: 2. How confident a
• A1C 7% or less, but strive for ≤6.5% (ensure contraception until at
outcome here> -
personalized target)
• Stop: If their confidence
s increase their confi
- Non-insulin antihyperglycemic agents (except metformin and/or glyburide)
and other - Statins knowledge, skills o
- ACEi/ARB prior to pregnancy, but if overt nephropathy exists, continue A high level of confi
ng and every 4 hours until detection of pregnancy
change.
eat • Start:
r - 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) 3. Can we set a spe
mmol/L to start
- Other antihypertensive agents safe for pregnancy (Labetalol, nifedepine XL)
fully restored until if hypertension control needed time we meet? W
• Screen for complications: Encourage S.M.A.R
- Eye appointment, serum creatinine, urine ACR, blood pressure
ycemia, he/she must • Aim for healthy BMI Specific Meas
urs while driving, or • Ensure appropriate vaccinations have occurred
• Refer to diabetes clinic
are at risk 3 Quick questions to help Individualized
a) your patients meet their goals Potential Self-
sugar-free Kool-Aid™, For patients who are not making expected progress, try asking these management Goals
questions to identify a path forward: Eat healthier
normally.

1. How important is it for you to <insert self-management goal> Be more active

- 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 to
happen for importance to go up?
Lose weight
n with A high level of importance will indicate that the person is ready
to change.
Take medication
aken prior to
regularly
2. How confident are you in your ability to <insert target
tion until at
outcome here> - low, medium, or high?
If their confidence is rated low, explore what needs to happen to Avoid hypoglycemia
rmin and/or glyburide) increase their confidence. Usually this has to do with improving
knowledge, skills or resources and support. Check blood glucos
hy exists, continue A high level of confidence indicates that the person is ready to
change. Check feet
on
nd/or glyburide (type 2) 3. Can we set a specific goal for you to try before the next Manage stress
abetalol, nifedepine XL)
time we meet? What steps will you take to achieve it?
Encourage S.M.A.R.T. Goals:
d pressure
Specific Measurable Achievable Realistic Timely Reduce or stop
smoking
 Individualized goal setting ABCDES of dia
Potential Self- Examples
ss, try asking these management Goals
Eat healthier See a dietitian to help develop a healthy A A1CŒtargets
eating plan.
f-management goal> B BPŒtargets
Be more active Increase physical activity with the goal of
getting to 150 minutes aerobic activity/week C CholesterolŒta
ity, reduce weight, and resistance exercise 2-3 times/week.
Choose physical activity that meets
t would need to preferences/needs.
D Drugs for CVDŒ
Lose weight Use strategies (e.g., reduce calories or risk reduction
person is ready
portions) to lose 5-10% of initial weight.
Take medication Taking medication will help to improve
regularly symptoms and take control of your life.
<insert target E ExerciseŒgoals
Consider using a pillbox or setting a timer.
healthyŒeating
eds to happen to Avoid hypoglycemia Recognize the signs of hypoglycemia and take
o with improving action to prevent it.
Check blood glucose Establish a routine and act accordingly. S ScreeningŒfor
son is ready to complications
Check feet Do a daily self-check and follow-up with a
health-care provider if anything is abnormal.
Manage stress Screen for distress (depressive and anxious S Smokingƒcessa
before the next
to achieve it? symptoms) by interview or a standardized
questionnaire (e.g. PHQ-9 S Self-managem
www.phqscreeners.com). stress, other ba
Realistic Timely Reduce or stop Identify barriers to quitting and develop a Educational grant funding for
smoking plan to address each of these. Ingelheim Canada /Eli Lilly Ca
these organizations for their
 ABCDES of diabetes care
GUIDELINE TARGET (or personalized goal)
A1C ≤7.0% (or ≤6.5% to ” risk of CKD and retinopathy)
A A1CŒtargets If on insulin or insulin secretagogue, assess for
evelop a healthy hypoglycemia and ensure driving safety

B BPŒtargets
BP <130/80 mmHg 2018 Clin
with the goal of If on treatment, assess for risk of falls
erobic activity/week
2-3 times/week.
that meets
C CholesterolŒtargets LDL-C <2.0 mmol/L (or >50 % reduction from
baseline) Quick
Guide
ACEi/ARB (if CVD, age ≥55 with risk factors, OR
diabetes complications)
Statin (if CVD, age ≥40 for type 2, OR diabetes
D Drugs for CVDΠcomplications)
ce calories or risk reduction ASA (if CVD)
of initial weight. SGLT2i/GLP1ra with demonstrated CV benefit (if have
type 2 with CVD and A1C not at target)
elp to improve
trol of your life. 150 minutes of moderate to vigorous aerobic activity/
week and resistance exercises 2-3 times/week
or setting a timer. E ExerciseŒgoals and Follow healthy dietary pattern (eg Mediterranean diet,
healthyŒeating low glycemic index)
ypoglycemia and take
Cardiac: ECG every 3-5 years if age >40 OR diabetes
complications
act accordingly. S ScreeningŒfor Foot: Monofilament/Vibration yearly or more if
complications abnormal
follow-up with a Kidney: Test eGFR and ACR yearly, or more if abnormal
Retinopathy: type 1 - annually; type 2 - q1-2 yrs
nything is abnormal.
If smoker: Ask permission to give advice, arrange
essive and anxious S Smokingƒcessation therapy and provide support
or a standardized Set personalized goals (see “individualized goal
9 S Self-management, setting” panel)
stress, other barriers Assess for stress, mental health and financial or other
416569-18

).
concerns that might be barriers to achieving goals
ng and develop a Educational grant funding for this resource was provided in part by AstraZeneca, Boehringer-
these. Ingelheim Canada /Eli Lilly Canada Alliance, and Novo Nordisk Canada Inc. Diabetes Canada thanks
these organizations for their commitment to diabetes in Canada. Copyright © 2018 Diabetes Canada. dia