Type 2 Diabetes: How sweet it is!

Dr. Jeremy Gilbert

Division of EndocrinologyAssistant ProfessorUniversity of Toronto

Faculty/Presenter Disclosure

• Faculty: Dr. Jeremy Gilbert• Program: 51st Annual Scientific Assembly• Relationships with commercial interests:

– Honoraria:– AstraZeneca– Bristol Meyers Squibb– Eli Lilly– Merck– Novonordisk– Sanofi

Disclosure of Commercial Support

• This program has received financial support n/a from in the form of n/a• This program has received in-kind support from n/a in the form of n/a

• Potential for conflict(s) of interest:– Dr. Jeremy GIlbert has received no payment from any organization supporting

this program AND/OR organization whose product(s) are being discussed in this program.

Mitigating Potential Bias

• All recommendations will be based on the Canadian Diabetes Association Guidelines and relevant medical literature.

OBJECTIVES

• 1. Review highlights from the 2013 Canadian Diabetes Association Guidelines including diagnostic criteria and treatment goals

• 2. Discuss anti-hyperglyemic agent options after Metformin, focussing on newer medication options

• 3. Explore the complications of Diabetes and examine vascular protective strategies in individuals with Diabetes

www.guidelines.diabetes.ca

How common is Diabetes?

Diabetes in Canada: Prevalence by Province and Territory

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.

NL6.5%

ON 6.0%

QC 5.1%

PE5.6%

NB5.9%

NS 6.1%

MB 5.9%

SK 5.4%

AB 4.9%

BC 5.4%

NT 5.5%

YT 5.4%

NU 4.4%

† Age-standardized to the 1991 Canadian population.

Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09

NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest.

< 5.0

5.0 < 5.5

5.5 < 6.0

6.0 < 6.5

≥ 6.5

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.

Prevalence of diagnosed diabetes among individuals aged ≥ 1 year, by age group and sex, 2008/09

Diabetes in Canada: Prevalence of Diagnosed Diabetes by age and sex

Prevalence increased with age. The sharpest increase occurred after age 40 years. The highest prevalence was in the 75-79 year age group.

Pre

va

len

ce

(%

)

0

10

15

25

30

1-19

5

20

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥85 CanadaAge group (years)

Females

Males

Total

Overall Prevalence

6.4%

7.2%

6.8%

Patients with DM are more likely to be hospitalized for many conditions

Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).

Diminishedinsulin

Hyperglycemia

Liver

1. Insulin deficiency

2. Excess glucose output 3. Insulin resistance

Pancreas

Muscle and fat

Excess glucagon

Islet

Diminishedinsulin

α-cell produces excess glucagon

β-cell produces less insulin

The pathophysiology of T2DM includes three main defects

Type 2 Diabetes is a Progressive Disease

• 50% of ß-cell function is already lost at diagnosis • ß-cell function will continue to decline despite treatment• Majority of patients will eventually require insulin therapy

Impairedglucosetolerance

100

75

50

25

Years from Diagnosis

Bet

a C

ell F

un

ctio

n (

%)

-12 -10 -6 -2 0 2 6 10 14

Postprandial hyperglycemia

Type 2 diabetes phase I Type 2

diabetes phase II

Type 2 diabetes phase III

Lebovitz HE. Diabetes Review 1999; 7(3):139-53.UKPDS Group. Diabetes 1995; 44:1249.

Stages of Type 2 diabetes in relationship to ß-cell function

β-ce

ll fu

nctio

n (%

)

Years

100

75

50

25

00 1 2 3 4 5 6

β-cell function declines, while . . .

UK Prospective Diabetes Study Group. Diabetes. 1995;44:1249–1258.

Years0 1 2 3 4 5 6

9

10

8

7

6

5

HbA

1c

. . . hyperglycemiaincreases

Progressive impairment in β-cell functionDiet/conv Rx (n=376)Metformin (n=159)SU/intensive (n=511)

SU = sulfonylurea

Question• How often should should a FPG be done in

most individuals > 40 years of age:A) every yearB) every 2 yearsC) every 3 yearsD) every 4 yearsE) every 5 years

FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hours

or

A1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the

accuracy of the A1C and not for suspected type 1 diabetesor

2hPG in a 75-g OGTT ≥11.1 mmol/Lor

Random PG ≥11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal

2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

Diagnosis of Diabetes2013

Diagnosis of Prediabetes*Test Result Prediabetes Category

Fasting Plasma Glucose(mmol/L)

6.1 - 6.9

Impaired fasting glucose (IFG)

2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)

7.8 – 11.0 Impaired glucose tolerance (IGT)

GlycatedHemoglobin(A1C) (%)

6.0 - 6.4 Prediabetes

* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

2013

Screening Checklist

ASSESS all adults clinically every year for risk of type 2 diabetes (T2DM)

SCREEN every 3 years if ≥ 40 years or high risk on risk calculator

SCREEN earlier and more frequently if very high risk on risk calculator or additional risk factors present

USE fasting plasma glucose (FPG) and/or A1C as initial screening tests

A1C (%) mmol/L

12% ________________ 16.5

11% __________________14.9

10% _________________ 13.4

8% __________________10.1

7% ___________________ 8.6

6% ___________________

Glycated Hemoglobin (A1C) /Glucose

7.0

9% __________________11.8

Kollman (2008) Diabetes Care. 31:381-385

What is new in making the diagnosis of diabetes?

Individualizing A1C Targets

which must be balanced against the risk of hypoglycemia

Consider 7.1-8.5% if:

2013

Why ≤ 7%?Macro and Microvascular Benefits?

DCCTn=1441 T1DM

Intensive(≥ 3

injections/day or CSII)

vs Conventional (1-2 injections

per day)

Reduction in Retinopathy

The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-986.

Primary Prevention Secondary Intervention

76% RRR(95% CI 62-85%)

54% RRR(95% CI 39-

66%)

RRR = relative risk reduction CI = confidence interval

Solid line = risk of developing microalbuminuriaDashed line = risk of developing macroalbuminuria

DCCT: Reduction in Albuminuria

The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-986.

34% RRR (p<0.04)

43% RRR(p=0.001)

56% RRR(p=0.01)

Primary Prevention Secondary Intervention

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

RRR = relative risk reductionCI = confidence interval

Reduction in Neuropathy

The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-986.

UKPDS: N = 3867 T2DM

06

8

9

0 3 6 9 12 15

A1C

(%

)

Conventional7.9%

Intensive7.0%

7

UKPDS Study Group. Lancet 1998:352:837-53.

After median 8.5 years post-trial follow-upAggregate Endpoint 1997 2007Any diabetes related endpoint RRR: 12% 9%

P: 0.029 0.040

Microvascular disease RRR: 25% 24% P: 0.0099 0.001

Myocardial infarction RRR: 16% 15% P: 0.052 0.014

All-cause mortality RRR: 6% 13% P: 0.44 0.007

Legacy Effect of Earlier Glucose Control

Holman R, et al. N Engl J Med 2008;359.

Lifestyle Modification&

Medications for hyperglycemia How do we choose?

Macronutrient Distribution (% Total Energy)

Carbohydrates Protein Fat

% of total energy

45-60% 15-20%(or 1-1.5g / kg BW)

20-35%

Calories per gram

4 4 9

Grams for 2000 calorie/day diet

225-300 75-100 44-78

BW = body weight

Physical Activity Checklist

DO a minimum of 150 minutes of moderate-to vigorous-

intensity aerobic exercise per week

INCLUDE resistance exercise ≥ 2 times a week

SET physical activity goals and INVOLVE a multi-

disciplinary team

ASSESS patient’s health before prescribing an exercise

regimen

2013

Modest weight loss CAN make a difference

• Goal is to prevent weight gain, promote weight loss and prevent weight re-gain

• Weight loss of only 5-10% improves:– Insulin sensitivity – Glycemic control – Blood pressure– Lipid levels

It can be done!460 Pounds 256 Pounds

Pharmacotherapy in T2DM checklist

CHOOSE initial therapy based on degree of

hyperglycemia

START with Metformin +/- others

INDIVIDUALIZE your therapy choice based on

characteristics of the patient and the agent

REACH TARGET within 3-6 months of diagnosis

2013

Start metformin immediately

Consider initial combination with another antihyperglycemic agent

Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin

A1C <8.5%Symptomatic hyperglycemia with

metabolic decompensationA1C 8.5%

Initiate insulin +/-metformin

If not at glycemic target (2-3 mos)

Start / Increase metformin

If not at glycemic targets

LIFESTYLE

Add an agent best suited to the individual:

Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOther

See next page…

AT DIAGNOSIS OF TYPE 2 DIABETES

Agent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOther

2013

2013

Foodintake

Stomach

GI tract

Intestine

α-cells

Pancreas

Insulin release

Net effect: Blood glucose

Beta-cells

Glucagon secretion

GLP-1

GLP-1 Actions

Adapted from: Barnett A. Int J Clin Pract 2006;60:1454-70; Drucker DJ, et al. Lancet 2006;368:1696-705; Idris I, et al. Diabetes Obes Metab 2007;9:153-65.

DPP-4

Brain: reduced appetite

Stomach: reduced emptying

Toft-Nielsen MB, et al. J Clin Endocrinol Metab. 2001;86:3717–3723.

Baseline

Impaired GLP-1 secretion in T2DM

0 60 120 180 240

20

15

10

5

0

Normal subjectsIGTT2DM patients

Time (min)

GLP

-1 (p

mol

/l)

* * * * **

*

*p<0.05

GLP-1 AUC T2DM vs. NGT is decreased by 53%, p<0.001

Currently Available Incretins in Canada

• GLP-1 Analogues– Liraglutide = Victoza– Exenetide = Byetta

• More effective than DPP-IV Inhibitors

• Potential weight loss• Temporary Nausea• Injections• Expensive• Long term safety data

• DPP-IV Inhbitors– Sitaglipitin = Januvia– Saxagliptin = Onglyza– Linagliptin = Trajenta

• Less effective than GLP-1 Analogues

• Weight neutral• Well tolerated• Oral• Often covered by ODB• Long term safety data

Adapted from: Product Monographs as of March 1, 2013; CDA Guidelines 2008; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.

Antihyperglycemic agents and Renal Function

Not recommended / contraindicated SafeCaution and/or dose reduction

Repaglinide

Metformin 30 60

Saxagliptin

Linagliptin

Glyburide 30 50

Thiazolidinediones 30

GFR (mL/min): < 15 15-29 30-59 60-89 ≥ 90

CKD Stage: 5 4 3 2 1

Gliclazide/Glimepiride 15 30

Liraglutide 50

Exenatide 30 50

Acarbose 25

Sitagliptin 50

5015 2.5 mg

15

30 50 mg25 mg

What are the options for Insulin?

Insulin Type (trade name) Onset Peak Duration

Bolus (prandial) Insulins

Rapid-acting insulin analogues (clear):• Insulin aspart (NovoRapid®)• Insulin glulisine (Apidra™)• Insulin lispro (Humalog®)

10 - 15 min10 - 15 min10 - 15 min

1 - 1.5 h1 - 1.5 h1 - 2 h

3 - 5 h3 - 5 h

3.5 - 4.75 h

Short-acting insulins (clear):• Insulin regular (Humulin®-R)• Insulin regular (Novolin®geToronto)

30 min 2 - 3 h 6.5 h

Basal Insulins

Intermediate-acting insulins (cloudy):• Insulin NPH (Humulin®-N)• Insulin NPH (Novolin®ge NPH)

1 - 3 h 5 - 8 h Up to 18 h

Long-acting basal insulin analogues (clear)• Insulin detemir (Levemir®)• Insulin glargine (Lantus®)

90 min Not applicable

Up to 24 h(glargine 24 h,

detemir 16 - 24 h)

Types of Insulin

Insulin Type (trade name) Time action profile

Premixed Insulins

Premixed regular insulin – NPH (cloudy):• 30% insulin regular/ 70% insulin NPH (Humulin® 30/70)• 30% insulin regular/ 70% insulin NPH (Novolin®ge 30/70) • 40% insulin regular/ 60% insulin NPH (Novolin®ge 40/60)• 50% insulin regular/ 50% insulin NPH (Novolin®ge 50/50)

A single vial or cartridge contains a fixed ratio of insulin

(% of rapid-acting or short-acting insulin to % of intermediate-acting

insulin)

Premixed insulin analogues (cloudy):• 30% Insulin aspart/70% insulin aspart protamine crystals (NovoMix® 30)• 25% insulin lispro / 75% insulin lispro protamine (Humalog® Mix25®)• 50% insulin lispro / 50% insulin lispro protamine (Humalog® Mix50®)

Types of Insulin (continued)

Ser

um

Insu

lin L

evel

Time

Analogue Bolus: Apidra, Humalog, NovoRapid

Human Basal: Humulin-N, Novolin ge NPH

Analogue Basal: Lantus, Levemir

Human Bolus: Humulin-R, Novolin ge Toronto

Time

Ser

um

Insu

lin L

evel

Human Premixed: Humulin 30/70, Novolin ge 30/70

Analogue Premixed: Humalog Mix25, NovoMix 30

What about Hypoglycemia?

3 phases of hypo treatment

1. Acute

2. Intermediate

3. Future

¾ cup OJ 3 gluc tab 3 packs sugar

6 LifeSavers 1 tbsp honey

Acute

Intermediate

15 min recheck

Future

Why did it happen?

How do I prevent it?

Causes of hypo

Too little food

Too much activity

Too much insulin

Steps to Address Hypoglycemia1. Recognize autonomic or neuroglycopenic symptoms

2. Confirm if possible (blood glucose <4.0 mmol/L)

3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms

4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed

5. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein

Hypoglycemia and Driving

• If BG <5.0 mmol/L prior to driving:– Take 15 g carbohydrate

– Re-check in 15 minutes

– When BG >5 mmol/L for at least 45 minutes safe to drive

• Need to re-check BG every 4 hours of continuous driving and carry simple carbohydrate snacks

Iain S. Begg et al . Canadian Journal of Diabetes. 2003;27(2):128-140.

Safe blood glucose (BG) prior to drivingBG ≥ 5.0 mmol/L

Diabetes ComplicationsMacrovascular MicrovascularCerebral vascular disease

2-4 fold increase in CV mortality & stroke

Coronary artery disease8/10 will die from a CV event

Foot problems

RetinopathyLeading cause of blindness inworking-age adults

NephropathyLeading cause of ESRD

Peripheral NeuropathyLeading cause of non-traumatic LEA

Peripheral vascular disease

Erectile Dysfunction

C J Diabetes (2008); 32(suppl1): S1-S201

• ≥40 yrs old or

• Macrovascular disease or• Microvascular disease or• DM >15 yrs duration and age >30 years

or• Warrants therapy based on the 2012

Canadian Cardiovascular Society lipid guidelines

Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling &

reliable contraception. Stop statins prior to conception.

2013Who Should Receive Statins?

Who Should Receive ACEi or ARB Therapy?

• ≥55 years of age or • Macrovascular disease or • Microvascular disease

At doses that have shown vascular protection (ramipril 10 mg daily, perindopril 8 mg daily, telmisartan 80 mg daily)

Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception

counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy

2013

Summary of Pharmacotherapy for Hypertension in Patients with Diabetes

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

With Nephropathy, CVD or CV risk factors

ACE Inhibitor or ARB

Diabetes

Withoutthe above

1. ACE Inhibitor or ARB or

2. Thiazide diureticor DHP-CCB

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria

More than 3 drugs may be needed to reach target values

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Combination of 2 first line drugs may be considered

as initial therapy if the blood pressure is >20

mmHg systolic or >10 mmHg diastolic above

target

> 2-drug combinations

Vascular Protection Checklist A • A1C – optimal glycemic control (usually ≤7%)

B • BP – optimal blood pressure control (<130/80)

C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat

D • Drugs to protect the heartA – ACEi or ARB │ S – Statin │ A – ASA if indicated

E • Exercise – regular physical activity, healthy diet,

achieve and maintain healthy body weight

S • Smoking cessation

2013

SCREEN regularly with random urine albumin creatinine ratio (ACR) and serum creatinine for estimated glomerular filtration rate (eGFR)

DIAGNOSE with repeat confirmed ACR ≥2.0 mg/mmol and/or eGFR <60 mL/min

DELAY onset and/or progression with glycemic and blood pressure control and ACE-inhibitor or Angiotensin Receptor Blocker (ARB)

PREVENT complications with “sick day management” counselling and referral when appropriate

2013

Chronic Kidney Disease (CKD) Checklist

CKD in Diabetes

ACR ≥2.0 mg/mmol

and / or

eGFR <60 mL/min

2013

Stages of Diabetic Nephropathy

Note: change in definition of microalbuminuria ACR ≥2.0 mg/mmol2013

Beware of Transient Albuminuria

Reducing Progression of Diabetic Nephropathy

• Optimal glycemic control

• Optimal blood pressure control

• ACE-inhibitor (ACEi) or Angiotensin Receptor Blocker (ARB)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Counsel all Patients About

Sick Day Medication

List

2013

Retinopathy is rare in prepubertal children

Screen annually in T1DM, 5 years after onset in

individuals ≥15 years of age

Retinopathy Screening Reduces Risk of Blindness (T1DM)

Retinopathy may be present in 21-39% of patients with T2DM at diagnosis

Screen every 1-2 years in T2DM beginning at diagnosis

Screening Reduces Risk of Blindness (T2DM)

Retinopathy ChecklistSCREEN regularly

DELAY onset and progression with glycemic and blood pressure control ± fibrate

TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery

2013

FIELD: Retinopathy Requiring Laser

FIELD Study Investigators. Lancet 2005 ; 366 (9500): 1849-61

Cum

ulat

ive

risk

(%)

Years from randomization

HR = 0.7095% CI = 0.58–0.85p = 0.0003

10

8

6

4

2

0

0 1 2 3 4 5

Placebo

6

Fenofibrate

• Longer duration of diabetes• Elevated A1C• Hypertension• Dyslipidemia• Low hemoglobin level• Pregnancy (with T1DM)• Proteinuria• Severe retinopathy itself

Risk Factors for Progression

Neuropathy

In people with type 2 diabetes, screening for peripheral neuropathy should begin at diagnosis of diabetes and occur annually thereafter. In people with type 1 diabetes, annual screening should commence after 5 years’ postpubertal duration of diabetes [Grade D, Consensus].

40-50% of People with DM will have Detectable Neuropathy within 10 years

• Sensorimotor poly- or mono-neuropathy• Increased risk for:

– Foot ulceration and amputation– Neuropathic pain– Significant morbidity– Usage of health care resources

• Elevated blood glucose• Elevated triglycerides• High BMI• Smoking• Hypertension

Risk Factors

Refer to neurology if non-diabetic neuropathy is suspected

Screening

Neuropathy

• Screen– 5 years after dx for Type 1 diabetes– At dx for Type 2 diabetes

• Method– Vibration sense on big toe– Monofilament testing

• Treatment– Optimize glycemic control– Antidepressant, anticonvulsants, opioids, topical agents

can be considered

Foot care• By individual AND health care professional• Screening at least annually and more often if high

risk• Evaluate for structural abnormalities, neuropathy,

PVD, ulcerations, infection• If high risk, provide foot care education,

professionally fitted footwear, early referral to professional trained in foot care

• Advise to stop smoking• If foot ulcer is present, need multidisciplinary team

Question• What percentage of people with diabetes and

established coronary artery disease have NO chest pain/symptoms of angina?1) 10-30%2) 20-50%3) 40-70%4) 50-80%

Screening for Coronary Artery Disease (CAD) Checklist

SCREEN with baseline resting ECG in select patients

STRESS TESTING for patients with symptoms or other associated diseases

REFER patients with inducible ischaemia to a cardiac specialist

2013

Age >40 years

Duration of DM >15 years +

Age >30 years

End organ damage– Microvascular– Macrovascular

Cardiac risk factors

Baseline resting

ECG

Repeat every 2 years

Who Should be Screened with ECG?

Exercise ECG stress testing

If cannot exercise or resting ECG abnormality present:– Pharmacologic stress

echo– Pharmacologic stress

nuclear imaging

Typical or atypical cardiac symptoms

Associated diseases:– PAD– Carotid bruits– TIA– Stroke

Resting ECG abnormalities (e.g. Q waves)

Who Should have Stress Testing and/or Functional Imaging to Screen for CAD?

Special populations …

Diabetes in the Elderly Checklist ASSESS for level of functional dependency (frailty)

INDIVIDUALIZE glycemic targets based on the above (A1C ≤ 8.5% for frail elderly) but if otherwise healthy, use the same targets as younger people

AVOID hypoglycemia in cognitive impairment

SELECT antihyperglycemic therapy carefully caution with sulfonylureas or thiazolidinediones Basal analogues instead of NPH or human 30/70 insulin Premixed insulins instead of mixing insulins separately

GIVE regular diets instead of “diabetic diets” or nutritional formulas in nursing homes

2013

Add an agent best suited to the individual (agents listed in alphabetical order):

Class RelativeA1C

Lowering

Hypo-glycemia

Weight Other therapeutic considerations Cost

-glucosidase inhibitor (acarbose)

Rare Neutral to

Improved postprandial control, GI side-effects

$$

Incretin agents: DPP-4 Inhibitors GLP-1 receptor agonists

to

RareRare

neutral GI side-effects

$$$$$$$

Insulin Yes No dose ceiling, flexible regimens $-$$$$

Insulin secretagogue: Meglitinide Sulfonylurea

Yes*Yes

*Less hypoglycemia in context of missed meals but usually requires TID to QID dosingGliclazide and glimepiride associated with less hypoglycemia than glyburide

$$$

Thiazolidinediones Rare CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect

$$

Weight loss agent (orlistat)

None GI side effects $$$

• CAUTION in the elderly• Initial doses = HALF of usual dose• Avoid glyburide• Use gliclazide, gliclazide MR, glimepiride,

nateglinide or repaglinide instead

• CAUTION in the elderly • Increased risk of fractures• Increased risk of heart failure

• May use detemir or glargine instead of NPH or human 30/70 for less hypos

• Premixed insulins and prefilled insulin pens instead of mixing insulin to reduce dosing errors

Need a PRECONCEPTION checklist for women with pre-existing diabetes

1. Attain a preconception A1C of ≤ 7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 mo pre-conception to 12 weeks post-conception

5. Discontinue potential embryopathic meds: Ace-inhibitors/ARB (prior to or upon detection of

pregnancy) Statin therapy

2013

OBJECTIVES/SUMMARY

• 1. Review highlights from the 2013 Canadian Diabetes Association Guidelines including diagnostic criteria and treatment goals

• 2. Discuss anti-hyperglyemic agent options after Metformin, focussing on newer medication options

• 3. Explore the complications of Diabetes and examine vascular protective strategies in individuals with Diabetes

THANK YOU!