New 2018 Diabetes Canada Guidelines - Weight Management

As an author of the Weight Management chapter of the new 2018 Diabetes Canada Clinical Practice Guidelines, I'm thrilled to share with you some key points and exciting changes!

So what is new since the last guidelines in 2013?

1.  People first language.  We have made an important change in the entire 2018 Diabetes Canada guidelines in the way we talk about obesity.  Obesity is a diagnosis, and not a way to describe a person.  Thus, instead of the terminology 'overweight or obese people', the correct terminology is 'people with overweight or obesity'.  This is a critical step in breaking down the stigma against obesity!


2.  New information on medications for weight management in type 2 diabetes.  Liraglutide (Saxenda) is a new medication available for weight management in Canada since the last guidelines.

(note: Naltrexone/Bupropion (Contrave) is now approved in Canada as well, but this approval occurred after the literature reviews for the Guidelines were completed, so is not included in this iteration)

Medications for weight management have not been adequately studied in people with type 1 diabetes.


3.  Updates on bariatric surgery:

• Gastric banding is not as effective as other bariatric procedures for type 2 diabetes control or remission.  
• Predictors of who is more likely to enjoy type 2 diabetes remission after bariatric surgery include a shorter duration of diabetes, younger age, not needing insulin preoperatively, and higher preoperative serum C-peptide (a marker of insulin production). 
• An update on the effect of bariatric surgery on complications of diabetes is discussed as well.
• The BMI criteria for bariatric surgery remain unchanged.  Evidence of risk and outcomes of bariatric surgery for people with a BMI of 30-35 is limited and cannot be recommended at this time. 
• Bariatric surgery has not been adequately studied in people with type 1 diabetes. 

KEY MESSAGES: 

1. Sustained weight loss of 5% or more can improve diabetes control and cardiovascular risk factors.

2.  In people with diabetes and obesity, weight loss and improvement in diabetes control can be achieved with healthy behaviour interventions.  Weight management medications can improve diabetes and metabolic control.

3.  Bariatric surgery may be considered appropriate for people with diabetes and obesity.

4.  When selecting the most appropriate diabetes medications, the effect on body weight should be considered.



KEY MESSAGES FOR PEOPLE WITH DIABETES: 

1. When you have diabetes, having overweight or obesity increases your risk for complications.

2.  Healthy behaviour modifications, including regular physical activity and eating well can help with your blood sugar control, and reduce your risk for other health problems associated with diabetes.

3.  Your diabetes health care team can help you with weight management.  For some people with diabetes, weight management medications and bariatric surgery may be helpful.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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New 2018 Diabetes Canada Guidelines - Cardiovascular Protection

We know that reducing the risk of heart attacks and strokes in people with diabetes includes much more than just having good blood sugar control.

So what's new in the Cardiovascular Protection chapter of the Diabetes Canada Guidelines since the last Guidelines in 2013?  Well, as for every chapter, there are now...


KEY MESSAGES FOR PEOPLE WITH DIABETES: 

Ask your doctor about the ABCDEs to reduce your risk of heart attack and stroke:

A = A1C - blood sugar control (the target is usually 7% or less)

B = BP - blood pressure control (less than 130/80)

C = Cholesterol - LDL cholesterol less than 2.0 mmol/L.  Your health care profider may advise you to start cholesterol lowering medication.

D - Drugs to protect your heart - these include blood pressure pills (ACE inhibitors or ARBs), cholesterol lowering medication ('statins'),  and in people with existing cardiovascular disease, certain blood glucose lowering medications, which can protect your heart even if your BP and/or LDL cholesterol are already at target

E = Exercise/Eating - Regular physical activity, healthy eating, and achievement and maintenance of a healthy body weight.

S = Stop smoking and manage stress.


The recommendations for ACE/ARB have loosened a little bit.  While it was recommended in 2013 that anyone over the age of 55 with diabetes should be on an ACE or ARB provided no contraindications, this recommendation has now been modified, as no studies have clearly demonstrated CV benefit for people with diabetes over 55 without any additional cardiovascular risk factors.  However, ACE/ARB is still recommended for:

• anyone with clinical cardiovascular disease
• anyone with microvascular complications
• age 55 or older with an additional cardiovascular risk factor or organ damage (protein in the urine, retinopathy, left ventricular hypertrophy)

So, since most people with diabetes age 55 or older have at least one additional cardiovascular risk factor, the vast majority of people over age 55 will still be recommended to take an ACE or ARB.

As far as cholesterol medication goes, guidelines for treatment with statins are unchanged.  If LDL cholesterol goals (LDL of less than 2 mmol/L, or greater than 50% reduction from baseline) are not achieved, consideration for the addition of ezetimibe is recommended. In people with diabetes who also have cardiovascular disease, a PCSK9 inhibitor may be used.

And, as blogged last week, for people with type 2 diabetes and established cardiovascular disease, consideration should be given for using a glucose lowering medication that has been shown to reduce the risk of cardiovascular events. 

Aspirin continues to be recommended for patients with established cardiovascular disease, at a dose now of 81-162mg daily (in line with the Canadian antiplatelet therapy guidelines). 

One of the Key Messages is also that there is emerging evidence that heart failure, even in the absence of a previous heart attack, is an important (and often unrecognized) complication of diabetes.  Health care professionals should be on the lookout for heart failure in their patients with diabetes.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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2018 Diabetes Canada Guidelines - Medications for Type 2 Diabetes

It can seem daunting to consider that in the treatment of type 2 diabetes, there are now 9 classes of medications available that lower blood sugars (and several different medications within each of these classes).  Which medications to choose, and in which order, are driven by data surrounding efficacy, safety, and ability to prevent cardiovascular events (one of the major diabetes complications we are aiming to prevent).  Over the last few years, we have seen several diabetes medications emerge that reduce the risk of cardiovascular events, and with this information, we are seeing more of an algorithm emerge that guides clinicians on which order to consider these different medications.

The 2018 Diabetes Canada Clinical Practice Guidelines Pharmacotherapy chapter now provides an algorithm that not only takes into account cardiovascular risk protection, but also prioritizes the diabetes medications that do not cause two unwanted side effects that are cause by some types of diabetes medications: weight gain, and low blood sugars (hypoglycemia).

This chapter is excellent, comprehensive, and the list of key messages is long - I encourage patients to read the Key Messages for People With Diabetes, and clinicians to read the entire chapter, but here are some of the highlights:

1.  In people with type 2 diabetes with A1C less than 1.5% above the individual patient's target, glucose lowering medication should be added if targets are not reached with healthy lifestyle interventions within 3 months.

2.  In people with type 2 diabetes with A1C 1.5% or more above the patient's target, medication should be initiated concomitantly with healthy behavior interventions, and consideration could be given to initiating combination therapy with 2 medications.

(note that the old guidelines used an A1C of 8.5% as the cutoffs above. The new wording reflects that the A1C target, though usually 7% or less,  can be different from one person to the next - more on this here.)


3. Insulin should be started immediately if there is syptomatic hyperglycemia or metabolic decompensation.  In the absence of metabolic decompensation, metformin is still the first choice of medication in people with new type 2 diabetes.

4.  Target diabetes control should be achieved within 3-6 months.


5.  In people with cardiovascular disease in whom A1C targets are not achieved, a medication with cardiovascular benefit should be added to existing therapy: empagliflozin, liraglutide; or canagliflozin (with a lower grade and level of evidence for canagliflozin).

6.   In people without cardiovascular disease who are not at glycemic targets, DPP4 inhibitors, GLP1 receptor agonists, and/or SGLT2 inhibitors should be considered as add on medication over sulfonylureas, meglitinides, insulin and thiazolidinedones, if lower risk of hypoglycemia and/or weight gain are priorities. (Grade A, Level 1A evidence)

7.  In people who are on insulin who are not at blood sugar targets, adding a GLP1 receptor agonist, DPP4 inhibitor, or SGLT2 inhibitor may be considered before adding or intensifying mealtime insulin therapy, with less weight gain and comparable or lower hypoglycaemia risk.


8.  Newer basal insulins (degludec and U-300 glargine) may be considered over U-100 glargine to reduce overall and overnight hypoglycaemia.


This chapter now includes an excellent table (see table 1 here) that lists the effect of diabetes medications on A1C, weight, cardiovascular outcomes, and other therapeutic considerations as well.




Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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2018 Diabetes Canada Guidelines Are Out!

The Diabetes Canada (formerly Canadian Diabetes Association) Guidelines are issued in full every 5 years.   As a coauthor of the Weight Management Chapter, I can tell you that these Guidelines have truly been a labor of love for all of us - more than two years with several rounds of evidence review, drafting, re-drafting as new data comes out.... and this is what makes our guidelines one of the most respected diabetes documents in the world!

The 2018 Guidelines are exciting, with a number of substantial changes from the 2013 edition in terms of approach, rigour of methodology, and recommendations.

Each chapter in the Guidelines is structured with a framework including:

Key Messages

Key Messages For People With Diabetes (this is new and awesome, and reflects that the Guidelines are intended not only for the use of health care providers, but also for people with diabetes)

Recommendations


Over the next weeks, I will be posting blogs highlighting some of the key points and changes to the guidelines, and I'll always include a link to the chapter itself if you'd like to read it in full.

Enjoy!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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