Diabetes Canda has released a new clinical guideline in 2019 for family physicians managing diabetes. The guideline primarily focuses on discussing opportunities to reduce the risk of diabetes complications, discussing opportunities to ensure safety and prevent hypoglycemia, discussing progress on self-management goals and addressing barriers.
Key Recommendations of the guideline are :
- Patients without clinical cardiovascular disease (CVD) who fail to achieve glycemic targets with existing antihyperglycemic drug therapy and in whom reduced risk of hypoglycemia and weight gain are priorities should be considered for add-on treatment with incretin agents (dipeptidyl peptidase IV [DPP-4] inhibitors or glucagon-like peptide–1 [GLP-1] agonists) or selective sodium-glucose transporter–2 (SGLT-2) inhibitors, as alternatives to insulin secretagogues, insulin, and thiazolidinediones (TZDs).
- Patients without clinical cardiovascular disease (CVD) who fail to achieve glycemic targets with existing antihyperglycemic drug therapy should additionally receive an antihyperglycemic agent with demonstrated cardiovascular (CV) outcome benefit (such as empagliflozin or liraglutide) to decrease the likelihood of major CV events.
- In patients who fail to achieve glycemic targets with existing noninsulin antihyperglycemic drug therapy, consider adding a once-daily basal insulin regimen as an alternative to premixed insulin or bolus-only regimens, as a means of reducing weight gain and hypoglycemia.
- To decrease the likelihood of nocturnal and symptomatic hypoglycemia, long-acting insulin analogues should be considered as an alternative to neutral protamine Hagedorn (NPH) insulin.
Patients receiving insulin who fail to achieve glycemic targets should undergo dose adjustment or the administration of additional antihyperglycemic medication (noninsulin or bolus insulin), with the following kept in mind:
- To achieve better glycemic control with weight loss and a lower hypoglycemia risk than with single- or multiple-bolus insulin injections, consider administering a GLP-1 agonist as add-on treatment prior to initiating bolus insulin or intensifying insulin therapy
- Consider add-on therapy with an SGLT-2 inhibitor as a means of improving glycemic control with weight loss and reducing the likelihood of hypoglycemia, compared with the administration of additional insulin
- Consider add-on therapy with a DPP-4 inhibitor as a means of improving glycemic control without weight gain or greater likelihood of hypoglycemia, compared with the administration of additional insulin
All persons with diabetes should engage in a comprehensive, multifaceted approach to CV risk reduction, including the following:
- Hemoglobin A1c (HbA1c) target of ≤7.0% instigated early in the course of diabetes
- Systolic and diastolic blood pressure (BP) of <130 mm Hg and <80 mm Hg, respectively
- Additional vascular protective medications in most adults with diabetes
- Reaching and maintaining a healthy weight
- Engaging in healthy nutrition
- Regular physical activity
- Smoking cessation
Diabetes management typically requires adaptation over time by both the patient and the health professional with iterative goal setting. As biopsychosocial circumstances change, the treatment recommendations will also need to change. The guidelines makers hope that the new guideliness will come handy in this respect.