Effective Date: December 9, 2015
Recommendations and Topics
- Key Recommendations
- Classification and Risk Factors
- Screening and Diagnosis
This guideline describes the care objectives for the prevention, diagnosis and management of diabetes mellitus in adults aged ≥ 19 years. It focuses on the approaches and systems that are ideally in place to improve care for the majority of patients the majority of the time. Diabetes in pregnancy (gestational diabetes) is outside the scope of this guideline.
- Diabetes care is centred around the person living with diabetes and should include an individualized management plan developed by the patient and their primary care provider(s). [Level 3, amended 2015]
- The 5 R’s describe the key components to consider when organizing diabetes care in the office or clinic: recognize, register, resource, relay and recall. [Level 5, new 2015]
- Glycosylated hemoglobin (A1C; $12.69*) or glucose testing (e.g., fasting plasma glucose (FPG; $1.46) or 2-hour plasma glucose (2hPG; $12.94)) can be used for diagnosis and screening. Best choice of test will depend on clinical circumstances. [Level 2, new 2015]
- Individualized glycemic targets are based on patient’s age, duration of diabetes, risk of hypoglycemia, cardiovascular disease presence, and life expectancy. [Level 5, new 2015]
- Measure A1C every 3 months to assess glycemic goals are met. Consider testing every 6 months if targets are consistently met and treatment and lifestyle are stable. [Level 5, new 2015]
- There are a number of new antihyperglycemic agents available for treatment of type 2 diabetes that can be considered as part of an individualized care plan. [Level 3, new 2015]
- A systematic approach to vascular protection is recommended, including lifestyle management, glycemic control, blood pressure control, and pharmacological interventions. [Level 2, new 2015]
On average, over 29,000 people are diagnosed with diabetes every year in British Columbia. In 2012/2013, over 387,000 people have diabetes in the province.† Geographic variations exist in rates of diabetes and some regions have higher or lower rates of incidence and prevalence compared to the provincial totals. To find more data on diabetes in your local community, see the interactive BC Community Health Atlas or the BC Community Health Data, at website: www.phsa.ca.
Diabetes mellitus (diabetes in this guideline) is a complex chronic disease characterized by hyperglycemia due to defective insulin secretion, defective insulin action or both.1 Diabetes is classified into four categories: type 1, type 2, gestational, and other specific types due to other causes (e.g., MODY [maturity onset diabetes of the young] after genetic defects). See Table 1, or the Canadian Diabetes Association (CDA) Etiologic Classification of Diabetes Mellitus at website: guidelines.diabetes.ca, for more information.
Table 1. Diabetes categories
Type 1 Diabetes
Safe and effective therapies for the prevention of type 1 diabetes have not yet been identified.7
Type 2 Diabetes
The onset and course of type 2 diabetes can be ameliorated using lifestyle modification, including regular physical activity and/or pharmacologic intervention.8 Pharmacologic therapy with metformin or acarbose can be considered for patients with IGT.9-11
Note: general screening for type 1 diabetes is not recommended. Screening for type 2 diabetes should be performed every 3 years in individuals ≥ 40 years of age or those at high risk. Screen more frequently in people with additional risk factors for diabetes or at very high risk according to a validated risk assessment tool and test with either A1C ($12.69‡) and/or FPG ($1.46), or 2hPG ($12.94) in a 75g oral glucose tolerance test (OGTT). Best choice of test will depend on clinical circumstances.
- See Appendix A: Screening Algorithm for Type 2 Diabetes in Adults. https://guidelines.diabetes.ca/screening
- Canadian Diabetes Risk Assessment Questionnaire (CANRISK) is a statistically valid risk tool appropriate for use in the Canadian population, at website: www.healthycanadians.gc.ca.
- The CDA offers an interactive screening tool, at website: guidelines.diabetes.ca/screening
Diagnosis (type 1 & 2)
Diabetes can be diagnosed using any of the following criteria:
- FPG§ of ≥ 7.0 mmol/L.
- A1C¶ of ≥ 6.5%.12 See notes for contraindications.
- 2hPG of ≥ 11.1 mmol/L in a 75g OGTT.
- In a patient with classic symptoms of hyperglycemia (e.g., polyuria, polydipsia, and unexplained weight loss), a random plasma glucose (PG) ≥ 11.1 mmol/L.**
- In the absence of symptomatic hyperglycemia, if a single lab test is in diabetes range, a repeat confirmatory test (preferably the same test) must be done another day (in a timely fashion).
- In case of symptomatic hyperglycemia, a repeat test is not required. Diagnosis is confirmed.
- In individuals who are suspected of type 1 diabetes, confirmatory testing should not delay treatment.
- If the results of two different tests are both above diagnostic cutpoints, the diagnosis is confirmed.
1. Organization of Care
Diabetes care is centred around the person living with diabetes and it includes an individualized management plan developed by the patient, their family/caregivers and primary care provider(s). The 5 R’s describe the key components to consider for organizing diabetes care in the office or clinic.
Table 2. The 5 R’s of diabetes care
2. Individualized Targets
Blood Glucose: Glycemic Targets
- The focus of glycemic goals is on achieving target A1C levels and on minimizing symptomatic hyper- and hypoglycemia. Glycemic targets are individualized based on the patient’s age, duration of diabetes, risk of hypoglycemia, cardiovascular disease presence, and life expectancy. See Figure 1 for recommended targets, or to find a target for an individual patient, use the interactive CDA tool for A1C targets, at website: guidelines.diabetes.ca/BloodGlucoseLowering/A1Ctarget.
Figure 1. Recommendations for glycemic targets††
Blood Glucose: Hypoglycemia
- Hypoglycemia can be a serious complication of therapy. Use less stringent glycemic targets in patients at risk of hypoglycemia.
- Risk factors for hypoglycemia: Prior episode of severe hypoglycemia, long-term diabetes, current low A1C (< 6.0%), autonomic neuropathy, hypoglycemia unawareness, current treatment with insulin, and the elderly. Severe hypoglycemia is less common in persons with type 2 diabetes but the elderly and those on insulin, secretagogues are more vulnerable.
- Harm reduction for patients at high risk of hypoglycemia:
- Educate patients and families about prevention, detection and treatment of hypoglycemia.
- Revaluate glycemic control targets.
- Consider education for patients and family/caregivers in glucagon administration.
- In BC, a driver with a medical condition, like diabetes, that has the potential to affect their fitness to drive may be required to have a Driver’s Medical Examination Report completed by their primary care provider.13
- See the BC Driver Fitness Handbook for Medical Professionals for further information, at website: www.pssg.gov.bc.ca/osmv/medical-fitness/.
- To reduce the risk of hypoglycemia: increase the frequency of SMBG (including episodic assessment during sleeping hours), make glycemic targets less stringent, and consider multiple insulin injections.
- Treatment: See Appendix B: Treatment of Hypoglycemia in Diabetes.
Blood Glucose: Long-Term Control
- Studies suggest there is a long-term “legacy” benefit of glucose lowering early in the course of type 1 & 2 diabetes, in terms of reducing complications.14,15
- Measure A1C every 3 months to ensure that glycemic goals are being met or maintained.
- Consider testing A1C every 6 months if treatment and lifestyle remains stable and if targets have been consistently met.
- Focus on minimizing symptomatic hypo- and hyperglycemia, in addition to A1C levels.
Blood Glucose: Self-Monitoring of Blood Glucose (SMBG)
- Offer to develop a SMBG schedule with the patient and review records as needed. Frequency and timing of SMGB is individualized, based on type of diabetes, treatments (e.g., use of insulin), need for information, and individual’s capacity to use testing to modify behaviours or medications.
- SMBG is more important when using a drug that can cause hypoglycemia. People with low risk of hypoglycemia may need less frequent SMBG testing frequency and people at higher risk of hypoglycemia may need more frequent testing.
- For most adults with type 2 diabetes using oral antihyperglycemic agents (without insulin) or lifestyle management only to meet glycemic targets, the value of routine use of SMBG is limited.16 In these situations, SMBG may only be needed 1 or 2 times per week.
- SMBG frequency guidance tool is available at: guidelines.diabetes.ca/bloodglucoselowering/smbgtool.
- Annual accuracy verification of glucose meter is recommended (simultaneous fasting glucose meter/lab comparison within 20%).
- Blood glucose test strips are a Pharmacare benefit for those holding a valid Certificate of Training in SMBG from a BC diabetes education centre. See Appendix C: PharmaCare quantity limits for blood glucose test strips for information on coverage.
3. Non-Pharmacological Management
Healthy Living and Lifestyle Management
- Patients with diabetes will benefit from health behaviour education and healthy living interventions, including regular physical activity (at least 150 minutes per week of aerobic exercise and two sessions per week of resistance training, if not contraindicated), nutrition therapy, healthy diet, maintenance of a healthy body weight, and smoking cessation.
- For more information, see BCGuidelines.ca – Lifestyle & Self-Management Supplement.
- Bariatric surgery is an emerging intervention for patients with diabetes type 2 in association with marked obesity (body mass index ≥ 35.0 kg/m2).17-19 Some procedures are covered by the Medical Services Plan.
- For more information on obesity management, see BCGuidelines.ca – Overweight and Obese Adults: Diagnosis and Management.
4. Individualized Pharmacologic Management
- Type 1 diabetes: Multiple (3-4) daily insulin injections or the use of Continuous Subcutaneous Insulin Infusion (insulin pump) should be considered as part of an intensive diabetes management program.
- Type 2 diabetes: please refer to Appendix D: Management of Hyperglycemia in Type 2 Diabetes, including details on when to initiate oral antihyperglycemic medications or insulin without a 2-3 month trial of lifestyle modifications alone.
- For more information:
- Appendix E: Antihyperglycemic Agents and Adjunctive Agents for Use in Type 2 Diabetes.
- Appendix F: Insulin and Therapeutic Considerations.
- Canadian Agency for Drugs and Technologies in Health reviews of second and third-line pharmacotherapy, at website: www.cadth.ca.20,21
5. Preventing complications and comorbidities
Global Cardiovascular Management
- People with diabetes are at significantly increased risk of cardiovascular disease. The BCGuidelines.ca – Cardiovascular Disease: Primary Prevention recommends using a risk assessment tool, medical history, physical examination, and full fasting lipid profile.22
- See Controversies in Care about use of risk calculators in the type 2 diabetes population.
- A risk assessment calculator is not recommended for people with type 1 diabetes.
- The time interval (e.g., 1 – 5 years) for a reassessment for cardiovascular disease is based on the initial risk stratification, if the patient’s risk factors change and clinical indication.
- A systematic approach to vascular protection is recommended, including lifestyle management, glycemic control, blood pressure control, and pharmacological interventions. ‘Consider the ABCDEs’ is a useful mnemonic device for vascular protection strategies and is described in table 3 below.
Table 3. Consider the ABCDEs
- Blood pressure control is a priority for patients with diabetes. Record at diagnosis and regularly thereafter.31
- The BCGuidelines.ca - Hypertension: Diagnosis and Management recommends a desirable blood pressure reading of ≤140/90 for patients with diabetes.32 See controversies in care section below.
- If lifestyle modification is not sufficient, pharmacological treatment may be required:
- Diabetes with moderately or severely increased albuminuria, chronic kidney disease, cardiovascular disease or cardiovascular disease risk factors:
- First-line – ACE-I or ARB (if ACE-I intolerant).
- Second-line – Dihydropyridine calcium channel blocker (DHP-CCB; e.g., amlodipine, felodipine, and nifedipine).
- Diabetes (no chronic kidney disease or cardiovascular disease risk factors):
- First-line – ACE-I or ARB or Thiazide/Thiazide-like diuretic or DHP-CCB.
- Second-line – Combination of first line drugs (note: in combination with ACE-I, a DHP-CCB is preferable to a thiazide/thiazide-like diuretic.
- Diabetes with moderately or severely increased albuminuria, chronic kidney disease, cardiovascular disease or cardiovascular disease risk factors:
- Primary prevention: Lifestyle interventions are usual first-line strategies in vascular protection. Statin therapy is a second-line intervention, considered in an individualized discussion with the patient and after evaluation of risk and benefits.
- Recent meta-analyses and other guidelines have indicated that statin therapy in people with diabetes who are at moderate or high risk of cardiovascular disease events, may be considered.1,2,33-38
- The CDA recommends statin therapy to reduce cardiovascular disease risk in adults with type 1 or type 2 diabetes with any of the following features:
- Clinical macrovascular disease;
- Age ≥ 40 years;
- Age < 40 years and 1 of the following: diabetes duration > 15 years and age > 30 years; microvascular complications; or other circumstances that warrant therapy based on particular risk factors according to 2012 Canadian Cardiovascular Society (CCS) guidelines.
- Treatment with a statin is expected to result in a significant reduction in elevated baseline lipids levels. Treating to a specific target is not recommended by the BCGuidelines.ca - Cardiovascular Disease: Primary Prevention guideline, although the CCS and CDA recommend treating high risk and intermediate risk patients to a specific low density lipoprotein cholesterol (LDL-C) target of ≤ 2.0 mmol/L.1,22,30 The National Institute for Health and Clinical Excellence (NICE) and American College of Cardiology and American Heart Association (ACC/AHA) guidelines do not recommend target LDL-C levels, but they recommend specific target statin doses.35, 39
- If statin therapy is decided upon, select statin based on tolerability, potential for drug interactions, and cost.40 For information on dosages, see BCGuidelines.ca - Cardiovascular Disease: Primary Prevention.
- Early recognition and treatment of retinopathy can prevent vision loss.1,2
- Ensure patient receives dilated pupil retinal examination at diagnosis, then every 1-2 years or as indicated (for patient with type 1 diabetes the first follow-up pupil retinal exam can start at 5 years post-diagnosis, then every 1-2 years). Annual referral to optometrist/ophthalmologist recommended.
- Retinopathy can worsen during pregnancy. Women with existing diabetes considering pregnancy or in early pregnancy should be assessed by an ophthalmologist.
Nephropathy and Chronic Kidney Disease
- Optimize blood pressure and glucose control to prevent or slow progression of nephropathy.
- Screen for macroscopic proteinuria & non-renal disease with urine dipstick.
- Measure albumin/creatinine ratio (ACR), creatinine/estimated glomerular filtration rate (eGFR), and urinalysis annually: If tests are normal, screen and monitor annually.41 If tests are abnormal, repeat within 3 months in a well hydrated state to confirm, unless there is deteriorating renal function which requires urgent investigation, management and referral.
- See BCGuidelines.ca - Chronic Kidney Disease – Identification, Evaluation and Management of Adult Patients for further information.
- The best way to prevent diabetic neuropathy is to achieve long-term glycemic control.1
- Screening can be performed via 10-g monofilament or 128-Hz tuning fork during foot exam.
- Check at least annually for symptoms or findings such as peripheral anesthesic neuropathy or pain, or autonomic neuropathy (e.g., erectile dysfunction, gastrointestinal disturbance, orthostatic hypotension).
- Examine feet annually, and more frequently for those at high risk (e.g., neuropathy, macrovascular complications, smokers, patient with foot or leg abnormalities).
- Management of foot ulceration requires interdisciplinary care approach to address infection, wound care, glycemic control, lower-extremity vascular status, and off-loading of high pressure areas.
- Encourage regular self-examination of feet. A foot care patient’s checklist is available, at website: guidelines.diabetes.ca/Browse/Appendices/Appendix9
Psychosocial Aspects of Diabetes
- Psychosocial factors affect many aspects of diabetes management and glycemic control.
- Screen for depression, anxiety and eating disorders. Treatment of these conditions may improve outcomes.7
- Cognitive behaviour therapy (CBT) based techniques such as stress management strategies and coping skills can be implemented to improve outcomes.42
- Annual influenza vaccination is recommended.
- In adults with diabetes, pneumococcal vaccination is recommended. Note: re-vaccination is not routinely recommended. Once-only revaccination 5 years after the initial dose is suggested for specific medical conditions (e.g. chronic kidney disease, chronic liver disease, sickle cell disease, immunosuppression due to disease). For further information, see the BC Centre for Disease Control Immunization Manual, at website: www.bccdc.ca.43
- Patients who experience illness and are unable to maintain adequate fluid intake, or have acute decline in renal function (e.g., gastrointestinal upset or dehydration) should increase the frequency of SMBG and they may need to adjust doses of insulin, oral antihyperglycemic agents and/or other medications.1 See the Sick Day medication list, at website: guidelines.diabetes.ca/Browse/Appendices/Appendix7.
- Encourage individuals with type 1 diabetes to perform ketone testing during acute illness accompanied by elevated blood glucose. Blood ketone testing may be preferred over urine ketone testing.
6. Special Populations
In frail elderly people with diabetes:
- Pay attention to potential for polypharmacy. Review medication list periodically, particularly if patient presents with depression, falls, cognitive impairment, perceptual difficulties, or urinary incontinence.
- Use sulfonylureas (especially glyburide) with caution as the risk of hypoglycemia increases with age. Generally, initial doses can be half of those for younger people and increased more slowly.
- Monitor postural blood pressure.
- Consider less strict glycemic targets (7.1 - 8.5% A1C) if the individual has limited life expectancy, high functional dependency, extensive disease or multiple co-morbidities etc.
- Consider a cognitive assessment before initiating insulin. See the BCGuidelines.ca - Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care for assessment tests.44
- Contraception and pre-pregnancy planning in all patients with diabetes is encouraged.
- Identify patients with previous gestational diabetes. These patients can develop type 2 diabetes and special attention prior to next pregnancy and in later life, is necessary.
- See the CDA guide on women of child-bearing age, at website: guidelines.diabetes.ca/SpecialPopulations/WomenPregnancyRefGuide
7. Controversies in Care
Some controversy exists around the use of risk calculator tools with the type 2 diabetes population. Risk calculators generally predict an individual’s proximate (5-10 year) risk for a cardiovascular event. The CDA guideline does not promote use of a cardiovascular disease risk calculator to assess risk and notes that lifetime risk is generally very high in all people with diabetes, even if as a younger individual, they can have a low proximate risk. Very high lifetime risk may justify early interventions. Alternatively, the CCS and the BCGuidelines.ca - Cardiovascular Disease: Primary Prevention recommends using a risk calculator tool to assess cardiovascular disease risk.22,45 Two tools that can be used for the type 2 diabetes population are:
- Cardiovascular Risk/Benefit Calculator, at website: chd.bestsciencemedicine.com/calc2.html
- United Kingdom Prospective Diabetes (UKPDS) risk engine, at website: www.dtu.ox.ac.uk/riskengine
Some recent validation studies have shown conflicting results about effectiveness of cardiovascular risk calculator tools (including UKPDS) and more evidence is needed.46,47 It is also important to note that cardiovascular disease risk scores were developed mainly with caucasian populations and there may be variability in predictive ability with different populations.48
Controversies in Care: Blood Pressure
This guideline aligns with the BCGuidelines.ca: Hypertension: Diagnosis and Management guideline in recommending a desirable blood pressure reading of 140/90 for the diabetes population. This does not match the CDA or Canadian Hypertension Education Program (CHEP)’s targets of 130/80 but is consistent with 2014 Eight Joint National Committee (JNC 8) and 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines and is similar to NICE (140/80 in type 2 and 135/85 type 1) and ADA (140/80) guidelines.1,31,49-53 A recent Cochrane review and other systematic review and meta analyses have indicated there is no evidence to support blood pressure targets lower than standard targets in people with hypertension and diabetes, although there may be a small reduction in risk for stroke.54,55 Due to the lack of convincing evidence to support more intensive blood pressure control, this guideline recommends the same desirable blood pressure reading in adults with diabetes and hypertension as the general population.
Controversies in Care: Sulfonylureas
There is some conflicting evidence about the cardiovascular safety of sulfonylureas. Some studies suggest that sulfonylureas may be associated with poorer outcomes after a myocardial infarction.56 Cohort studies have found higher risks of death and cardiovascular outcomes, though it is unclear if these results demonstrate the protective effect of the metformin comparator rather than harm from the sulfonylurea, and observational studies cannot establish causality. In addition, older agents, higher historical doses and tighter glucose targets were used which may have contributed to seen differences, and cohort populations were highly heterogeneous. This potential harm does not appear to be as well associated with gliclazide. Cardiovascular safety of sulfonylureas is supported by a meta-analysis and the ADVANCE trial.57, 58 In addition, the UKPDS trial reported long term mortality and cardiovascular benefit in patients given a sulfonylurea.59 At present, there is a lack of evidence clearly demonstrating cardiovascular harm, and clinicians should interpret this data cautiously.
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250 – Diabetes mellitus
- Appendix A: Screening Algorithm for Type 2 Diabetes in Adults (PDF, 98KB)
- Appendix B:Treatment of Hypoglycemia in Diabetes (PDF, 94KB)
- Appendix C: PharmaCare quantity limits for blood glucose test strips (PDF, 100KB)
- Appendix D: Management of Hyperglycemia in Type 2 Diabetes (PDF, 98KB)
- Appendix E: Antihyperglycemic Agents and Adjunctive Agents for Use in Type 2 Diabetes (PDF, 118KB)
- Appendix F: Insulin and Therapeutic Considerations (PDF, 104KB)
The following documents accompanies this guideline:
This guideline is based on scientific evidence current as of the Effective Date.
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.
The principles of the Guidelines and Protocols Advisory Committee are to:
Guidelines and Protocols Advisory Committee
Web site: www.BCGuidelines.ca
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.