https://www.australiawidefirstaid.com.au/what-is-diabetes / Update on Diabetes Praveena Sivapalan MD, FRCPC Canadian Society of Internal Medicine Division of General Internal Medicine, Oct 11, 2018 University of Saskatchewan
Conflict Disclosures I have the following conflicts to declare: Speaker honoraria from Servier Canada Inc. •
Objectives 1. Describe highlights of changes in the 2018 Diabetes Canada clinical practice guidelines. 2. Write an appropriate exercise prescription for a patient living with diabetes. 3. Discuss the role of newer antihyperglycemic therapies in hospital. 4. Describe the role of medical and surgical therapies in managing obesity in diabetes and utilize practical clinical tips when managing a patient with diabetes who undergoes bariatric surgery. 5. Compare medical and surgical approaches to achieving type 2 diabetes remission.
Objectives 1. Describe highlights of changes in the 2018 Diabetes Canada clinical practice guidelines. 2. Write an appropriate exercise prescription for a patient living with diabetes. 3. Discuss the role of newer antihyperglycemic therapies in hospital. 4. Describe the role of medical and surgical therapies in managing obesity in diabetes and utilize practical clinical tips when managing a patient with diabetes who undergoes bariatric surgery. 5. Compare medical and surgical approaches to achieving type 2 diabetes remission.
What’s New?
What’s New? Greater focus on 3 key areas • Reducing complications 1. Patient safety 2. New section on driving and diabetes Self-management 3. Increased diversity on Expert Committee: • Greater representation from allied health/interprofessional stakeholders • Involvement of informed people with diabetes • Involvement of indigenous authors, health-care providers and • Can J Diabetes. 2018;42:S1-S32 organizations 5
Can J Diabetes. 2018;42:S1-S32 5.
Updated Targets for Glycemic Control ADVANCE Randomized 11 000+ patients over 55 with T2DM • (mean duration 8 years), microvascular or macrovascular disease and 1 CV risk factor Intensive versus standard control • Significant decrease in incidence of microvascular • disease at 8 years with intensive (A1C 6.5%) vs standard control (7.3%) • Incidence of nephropathy 4.1% in intensive versus 5.2% in standard groups N Engl J Med. 2008;358(24):2560-7 2..
Updated Targets for Glycemic Control ACCORD Randomized 10 000+ patients (mean age 62) with T2DM • (mean duration 10 years) and CVD or multiple risk factors Intensive versus standard control (< 6 vs 7-7.9%) • Stopped early due to increased CV death at 3.5 years (257 vs • 203) No difference in CV outcomes overall • Observational follow-up at median of 8.8 years shows neutral • long-term effect on mortality and CV outcomes Etiology unclear – ?increased incidence of severe • hypoglycemia (10.5 vs 3.5%) versus difference in medications N Engl J Med. 2011;364:818-828 .
Updated Targets for Glycemic Control Consider if: Shorter duration of diabetes • Can use agents that are less likely to cause hypoglycemia • At low risk of hypoglycemia • Avoid if: Older/frail individuals • Longer duration of diabetes • Advanced coronary artery disease (CAD) • Known history of severe hypoglycemia •
Can J Diabetes. 2018;42:S1-S32 5
Can J Diabetes. 2018;42:S1-S32 5
EMPA-REG OUTCOME 7 020 patients with T2DM (most > 5 years) and clinical CVD • Randomized to empagliflozin vs placebo • CV events 10.5% versus 12.1% at median 3.1 years N Engl J Med. 2015; 373:2117-2 8
LEADER ~9 300 patients with T2DM (median duration 12.8 years), majority over • 50 with at least 1 CV condition Randomized to liraglutide or placebo • CV events 13% versus 14.9% at median 3.8 years N Engl J Med. 2016;375(4):311- 22.
CANVAS 10 000+ patients with T2DM (mean duration 13.5 years), age • 30+ AND symptomatic CVD or 50+ AND 2 CV RFs Randomized to canagliflozin versus placebo • CV events 26.5 vs 31.5 per 1000 pt years at median 2.9 • years Increased rate of genital infections (68.8 vs 17.5 per 1000 pt • years) – Similar to other trials Increased fracture rate (15.4 vs 11.9 per 1000 pt years) Increased risk of lower extremity amputation (6.3 vs 3.4 per 1000 pt years) N Engl J Med. 2017;377:644-657 .
What’s New?
Diabetes and Driving • “All drivers with diabetes should undergo a medical examination at least every 2 years to assess fitness to drive. Commercial drivers should undergo an assessment at the time of application for a commercial license and as per provincial requirements thereafter. • People with diabetes should play an active role in assessing their fitness to drive.” Can J Diabetes. 2018;42:S1-S32 5.
Driving and Diabetes Can J Diabetes. 2018;42:S1-S32 5.
Objectives 1. Describe highlights of changes in the 2018 Diabetes Canada clinical practice guidelines. 2. Write an appropriate exercise prescription for a patient living with diabetes. 3. Discuss the role of newer antihyperglycemic therapies in hospital. 4. Describe the role of medical and surgical therapies in managing obesity in diabetes and utilize practical clinical tips when managing a patient with diabetes who undergoes bariatric surgery. 5. Compare medical and surgical approaches to achieving type 2 diabetes remission.
Physical Activity and Diabetes Aerobic exercise: Improves A1C in T2DM, especially duration > 150 mins/week • Meta-analysis: A1C reduction 0.89% in >150 min group vs • 0.36% in < 150 min Higher intensity exercise results in lower A1C than lower • intensity Meta-analysis (small): Weighted mean difference in A1C - • 0.22% Improves CV and overall mortality, lipids, BP, weight, CV fitness, • peripheral neuropathy in T1 and T2DM JAMA. 2011;305:1790-9. Acta Diabetol 2016;53:769–81. Consider aquatic exercise if barriers, such as osteoarthritis •
Physical Activity and Diabetes Interval Training: Leads to improvement in CV fitness compared to • continuous, moderate-intensity exercise Lower A1C in some studies • Meta-analysis: A1C 0.31%, weight 1.3kg, FBG • 0.92mmol/L Lower risk of hypoglycemia during activity in T1 diabetics • Obes Rev 2015;16:942–61. PLoS ONE 2015;10:e0136489.
Physical Activity and Diabetes Resistance exercise Lowers A1C and decreases insulin resistance in type 2 • diabetes RCT 2002 – Progressive resistance training over 16 • weeks resulted in 1.1% reduction in A1C in older adults Improvements in muscle mass, strength and BMD • Lower risk of hypoglycemia in T1 diabetics • Diabetes Care 2002;25:2335–41. Can J Diabetes. 2018;42:S1-S325
Physical Activity and Diabetes Pedometers More steps per day associated with lower CV events, all- • cause mortality and A1C in T2DM NAVIGATOR trial - cohort study of 9300+ patients • Increasing steps by 2000/day associated with 8% • reduction in mortality at 6 years SMARTER trial – 275 patients randomized to • pedometer-based prescription versus standard care A1C 0.38% lower and step count 1200/day higher in • intervention group Lancet 2014;383:1059-66. Diabetes Obes Metab 2017;19:695-704.
Physical Activity and Diabetes Minimizing sedentary time Sedentary behaviours associated with increased • mortality, A1C, central obesity, BMI and other metabolic risk factors Breaking up sitting associated with better glycemic • control, insulin sensitivity and postprandial glucose Duvivier et al. – small randomized study: • Breaking up sitting with frequent light exercise 24 • hour glucose > structured exercise Can J Diabetes. 2018;42:S1-S32 5 Diabetologica. 2016;60:490-8.
Recommendations People with diabetes should ideally accumulate a 1. minimum of 150 minutes of moderate- to vigorous-intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise, to improve glycemic control [Grade B, Level 2, for adults with type 2 diabetes and children with type 1 diabetes]; and to reduce risk of CVD and overall mortality [Grade C, Level 3, for adults with type 1 diabetes and type 2 diabetes]. Can J Diabetes. 2018;42:S1-S32 5.
Recommendation People with diabetes (including elderly people) 2. should perform resistance exercise at least twice a week and preferably 3 times per week [Grade B, Level 2] in addition to aerobic exercise [Grade B, Level 2]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, Level 3] In addition to achieving physical activity goals, people 3. with diabetes should minimize the amount of time spent in sedentary activities and periodically break up long periods of sitting [Grade C, Level 3] Can J Diabetes. 2018;42:S1-S32 5.
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