Canadian Diabetes Association 2013 Clinical Practice Guidelines

Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Essentials
(Updated November 2016)
2016
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright 2016 Canadian Diabetes Association
Learning Objectives
By the end of this session, participants will be able to:
1. Understand the major changes within the 2013 CDA

clinical practice guidelines and, updates
2. Understand the rationale behind these changes
3. Apply the recommendations in clinical practice

Faculty for slide deck development
Jonathan Dawrant, BSc, MSc, MD, FRCPC

Zoe Lysy, MDCM, FRCPC
Geetha Mukerji, MD, FACP, FRCPC
Dina Reiss, MD, FACP, FRCPC
Steven Sovran, BSc, MD, MA, FRCPC
Alice Y.Y. Cheng, MD, FRCPC

Peter J. Lin, MD, CCFP
Catherine Yu, MD, FRCPC, MHSc

Victor
59 years old ACS 2001
Type 2 Diabetes Bypass 2001
PAD 2002
CKD 2002
MI 2003
Neuropathy 2003
Retinopathy 2004
MI 2004
Ischemic Toes Amputation 2004
TIA 2005
Stroke 2006
Victor Reorganize his history
59 years old He has EVERY complication of Diabetes
Type 2 Diabetes That is what we need to avoid
Macrovascular Microvascular
TIA 2005
Retinopathy 2004
Stroke 2006
ACS 2001 CKD 2002

Bypass 2001
MI 2003 Neuropathy 2003
MI 2004
PAD 2002
Ischemic Toes Amputation 2004
www.guidelines.diabetes.ca

What is new in making the
diagnosis of diabetes?

Diagnosis of Diabetes 2013
FPG 7.0 mmol/L

Fasting = 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 diabetes
or
2hPG in a 75-g OGTT 11.1 mmol/L
or
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 Prediabetes* 2013
Test Result Prediabetes Category

Fasting Plasma 6.1 - 6.9 Impaired fasting glucose
Glucose (IFG)
(mmol/L)
2-hr Plasma Glucose in 7.8 11.0 Impaired glucose tolerance
a 75-g Oral Glucose (IGT)
Tolerance Test (mmol/L)
Glycated
Hemoglobin 6.0 - 6.4 Prediabetes
(A1C) (%)
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

Individualizing A1C Targets 2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia

Self-Monitoring of
Blood Glucose (SMBG)
What should
we tell patients to do?

Regular SMBG is Required for:

Increased frequency of SMBG may be required:
Daily SMBG is not usually required if patient:

Medications for glycemia
How do we choose?

Pharmacotherapy in T2DM checklist 2013
CHOOSE initial therapy based on glycemia

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

AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
Symptomatic hyperglycemia with
A1C <8.5% A1C 8.5%
metabolic decompensation
L
I If not at glycemic
target (2-3 mos) Start metformin immediately Initiate
insulin +/-
F Consider initial combination with
another antihyperglycemic agent
metformin
Start / Increase
E metformin
S If not at glycemic targets
T Add another agent best suited to the individual by prioritizing patient characteristics:
Y PATIENT CHARACTERISTIC CHOICE OF AGENT

Antihyperglycemic agent with
PRIORITY:
L Clinical Cardiovascular Disease
demonstrated CV outcome benefit
(empagliflozin, liraglutide)
E Degree of hyperglycemia
Risk of hypoglycemia
Consider relative A1C lowering
Rare hypoglycemia
Overweight or obesity Weight loss or weight neutral
Cardiovascular disease or multiple risk factors Effect on cardiovascular outcome
Comorbidities (renal, CHF, hepatic) See therapeutic considerations, consider eGFR
Preferences & access to treatment See cost column; consider access

Copyright 2016 Canadian Diabetes Association See next page 11/2016
From prior page
L
I
F
E
S
T
Y
L
E
If not at glycemic target
Add another agent from a different class

Add/Intensify insulin regimen

2016 MakeDiabetes
Copyright 2016 Canadian timelyAssociation
adjustments to attain target A1C within 3-6 months
Add another class of agent best suited to the individual (agents listed in alphabetical order):
Class Relative Hypo- Weight Effect in Other therapeutic considerations Cost
A1C glycemi Cardiovascular
Lowering a Outcome Trial
-glucosidase Rare Neutral to Improved postprandial control, GI side-effects $$
inhibitor (acarbose)
DPP-4 Inhibitors
Rare Neutral to alo, saxa, sita: Caution with saxagliptin in heart failure $$$
Neutral
GLP-1R agonists to Rare lira: Superiority GI side-effects $$$$
in T2DM patients
with clinical CVD
lixi: Neutral
Insulin Yes Neutral (glar) No dose ceiling, flexible regimens $-$$$$
Insulin secretagogue: Less hypoglycemia in context of missed meals

Meglitinide Yes but usually requires TID to QID dosing $$
Gliclazide and glimepiride associated with less
Sulfonylurea Yes hypoglycemia than glyburide $
SGLT2 inhibitors to Rare empa: Genital infections, UTI, hypotension, dose- $$$
Superiority in related changes in LDL-C, caution with renal
T2DM patients dysfunction and loop diuretics, dapagliflozin not
with clinical CVD to be used if bladder cancer, rare diabetic
ketoacidosis (may occur with no hyperglycemia)
Thiazolidinediones Rare Neutral CHF, edema, fractures, rare bladder cancer $$

(pioglitazone), cardiovascular controversy
(rosiglitazone), 6-12 weeks required for
maximal effect
Weight loss agent None GI side effects $$$
(orlistat)

Copyright alo=alogliptin;
2016 Canadian glar=glargine; saxa=saxagliptin; sita=sitagliptin; lira=liraglutide; lixi=lixisenatide; empa=empagliflozin
Diabetes Association 11/2016
Antihyperglycemic agents and Renal Function
CKD Stage: 5 4 3 2 1
eGFR (mL/min/1.73 m2): <15 1529 3059 6089 90
Alpha-
glucosidase Acarbose Not recommended 25
Inhibitor
Biguanide Metformin 30 60
Alogliptin Not recommended
6.25 mg 30 12.5 mg 50
DPP-4 Linagliptin 15
inhibitors
Saxagliptin 15 2.5 mg 50
Sitagliptin 25 mg 30 50 mg 50
Albiglutide 50
GLP-1R Dulaglutide 50
agonists
Exenatide (BID/QW) 30 50
Liraglutide 30 50
Insulin
Gliclazide/Glimepiride 15 30
Secreta-
gogues Glyburide 30 50
Repaglinide
Canagliflozin 25 45 100 mg 60*
SGLT2
inhibitors Dapagliflozin 60
Empagliflozin 45 60*
Thiazolidinediones 30
Contraindicated Not recommended Caution and/or reduce dose Safe
* =guidelines.diabetes.ca | 1-800-BANTING
do not initiate if eGFR <60 ml/min (226-8464) | diabetes.ca
Copyright 2016 Canadian Diabetes Association 11/2016
Adapted from: Product Monographs as of March 2016 No dose adjustment but close monitoring of renal function
Harper W et al. Can J Diabetes 2015;39:440.
What are the
options for Insulin?

2016
Types of Insulin
Insulin Type (trade name) Onset Peak Duration
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):

Insulin aspart (NovoRapid) 10 - 15 min 1 - 1.5 h 3-5h
Insulin glulisine (Apidra) 10 - 15 min 1 - 1.5 h 3-5h
Insulin lispro (Humalog) 10 - 15 min 1-2h 3.5 - 4.75 h
Insulin lispro U200 (Humalog 200 units/mL) 10 - 15 min 1-2h 3.5 - 4.75 h
Short-acting insulins (clear):

Insulin regular (Humulin-R) 30 min 2-3h 6.5 h
Insulin regular (NovolingeToronto)
Basal Insulins
Intermediate-acting insulins (cloudy):

Insulin NPH (Humulin-N) 1-3h 5-8h Up to 18 h
Insulin NPH (Novolinge NPH)
Long-acting basal insulin analogues (clear)

90 min Up to 24 h (detemir 16-24 h)
Insulin detemir (Levemir)
90 min Not Up to 24 h (glargine 24 h)
Insulin glargine (Lantus) applicable
Up to 6 h Up to 30 h
Insulin glargine U300 (Toujeo)
90 min Up to 24 h (glargine 24 h)
guidelines.diabetes.ca
Insulin glargine (Basaglar TM)
| 1-800-BANTING (226-8464) | diabetes.ca
Types of Insulin (continued)
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
(Novolinge 30/70) A single vial or cartridge contains a
40% insulin regular/ 60% insulin NPH fixed ratio of insulin
(Novolinge 40/60) (% of rapid-acting or short-acting
50% insulin regular/ 50% insulin NPH insulin to % of intermediate-acting
(Novolinge 50/50) 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)
Serum Insulin Level
Time
Human Basal Human Bolus
Analogue Basal Analogue Bolus

Serum Insulin Level
Time
Human Premixed
Analogue Premixed

What about Hypoglycemia?

Steps to Address Hypoglycemia
1. 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
Macrovascular Disease
Vascular Protection:
Who and When?

Vascular Protection Checklist 2013
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 heart (regardless of baseline BP or LDL)
A ACEi or ARB S Statin A ASA if indicated
E Exercise / Eating healthily regular physical
activity, achieve and maintain healthy body weight
S Smoking cessation

Who Should Receive Statins? 2013
(regardless of baseline LDL-C)
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.

What if baseline LDL-C 2.0 mmol/L?
Within CARDS and HPS, the subgroups that started

with lower baseline LDL-C still benefited to the same
degree as the whole population
If the patient qualifies for statin therapy based on the

algorithm, use the statin regardless of the baseline
LDL-C and then target an LDL reduction of 50%
HPS Lancet 2002;360:7-22

Colhoun HM, et al. Lancet 2004;364:685.

2013
Who Should Receive ACEi or ARB Therapy?
(regardless of baseline blood pressure)
55 years of age or
Macrovascular disease or
Microvascular disease
At doses that have shown vascular protection
[perindopril 8 mg daily (EUROPA), ramipril 10 mg daily
(HOPE), telmisartan 80 mg daily (ONTARGET)]
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
EUROPA Investigators, Lancet 2003;362(9386):782-788.
HOPE study investigators. Lancet. 2000;355:253-59.
Copyright 2016 Canadian Diabetes Association ONTARGET study investigators. NEJM. 2008:358:1547-59
Recommendation 2013
ASA should not be routinely used for the primary

prevention of cardiovascular disease in people with
diabetes [Grade B, Level 2]
ASA may be used in the presence of additional

cardiovascular risk factors [Grade D, Consensus]

Summary of Pharmacotherapy for Hypertension
in Patients with Diabetes
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
With ACE Inhibitor Combination of 2 first line
Nephropathy, or ARB drugs may be considered
CVD or CV as initial therapy if the
risk factors blood pressure is >20
Diabetes mmHg systolic or >10
1. ACE Inhibitor mmHg diastolic above
Without or ARB or target
the above
2. Thiazide diuretic
> 2-drug
or DHP-CCB combinations
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 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a
loop diuretic
Copyright should
2016 Canadian be substituted
Diabetes Association for a thiazide
diuretic if control of volume is desired
Vascular Protection Checklist 2013
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 heart (regardless of baseline BP or LDL)
A ACEi or ARB S Statin A ASA if indicated
E Exercise / Eating healthily regular physical
activity, achieve and maintain healthy body weight
S Smoking cessation

What if we did all the right
things?
How much could we protect

our patients?

STENO-2: Intensive Group Achieved Targets
Gaede et al. NEJM. 2003: 348;383-393

Intensive Group had Improved CV Outcomes
60
P = 0.007
50
53 % RRR
Any CV 40
Conventional therapy
event Intensive therapy
30
NNT = 5 20
10
0
12 24 36 48 60 72 84 96
Months of Follow-up
RRR= relative risk reduction
Gaede et al. NEJM. 2003: 348;383-393

STENO 2 Microvascular Disease
Gaede et al. NEJM. 2003: 348;383-393

What about Microvascular Disease?
Nephropathy
Retinopathy
Neuropathy

2013
Chronic Kidney Disease (CKD) Checklist
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

Counsel all
Patients
About
Sick Day
Medication
List
2015

Retinopathy Checklist 2013
SCREEN 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

Delaying Retinopathy
1. Glycemic control: target A1C 7%

2. Blood pressure control: target BP <130/80
3. Lipid-lowering therapy: fibrates have been
shown to decrease progression and may be
considered 2013

Neuropathy Checklist 2013
PREVENT with blood glucose control
SCREEN with monofilament or tuning fork
TREAT pain symptoms with anticonvulsants

or antidepressants

Recommendation 4 2013
4. The following agents may be used alone or in

combination for relief of painful peripheral
neuropathy:
Anticonvulsants (pregabalin [Grade A, Level 1],
gabapentin, valproate) [Grade B, Level 2]
Antidepressants (amitriptyline, duloxetine,
venlafaxine) [Grade B, Level 2]
Opioid analgesics (tapentadol ER, oxycodone
ER, tramadol) [Grade B, Level 2]
Topical nitrate spray [Grade B, Level 2]
This drug is not currently approved by Health Canada for the management of neuropathic pain associated with
diabetic peripheral neuropathy.
Foot Care:
What are the
DOs and DONTs
of foot care?

Educate patients on proper foot care The DOs
DO
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual
markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. Wipe off excess.
Change your socks every day

Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
See a foot care specialist if you need advice or treatment
Educate patients on proper foot care The DONTs
DO NOT
Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket may cause burns unknowingly
Soak your feet
Take very hot baths

Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles may cause blisters if not right for your feet
Sit for long periods of time
Smoke
Special populations

Diabetes in the Elderly Checklist 2013
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
guidelines.diabetes.ca in nursing
| 1-800-BANTING homes
(226-8464) | diabetes.ca
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
CAUTION in the elderly
Initial doses = HALF of usual dose
Avoid glyburide
Use gliclazide, gliclazide MR, glimepiride,
nateglinide or repaglinide instead
CAUTION with renal dysfunction
CAUTION in the elderly

Increased risk of fractures
Increased risk of heart failure

2016
2013
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 CDA diagnostic criteria for GDM 2013
PREFERRED APPROACH (2 steps)

1. 50 gram glucose challenge test
2. 75 gram oral glucose tolerance test
Using thresholds of OR 2.0
ALTERNATIVE APPROACH (1 step)

1. 75 gram oral glucose tolerance test
Using thresholds of OR 1.75

2013 GDM diagnosis: Two approaches 2013

How can we keep track of all
the parameters for our
patients with Diabetes?

Tools to help us
keep track of our
patients

Tools to help us
keep track of our
patients

Back Page:
Cheat Sheet of
Targets and Goals

Back Page:
Cheat Sheet of
Targets and Goals

Neither evidence nor clinical judgment alone
is sufficient.
Evidence without judgment can be applied by
a technician.
Judgment without evidence can be applied
by a friend.
But the integration of evidence and judgment
is what the healthcare provider does in
order to dispense the best clinical care.
(Hertzel Gerstein, 2012)

CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
www.diabetes.ca for patients


Canadian Diabetes Association 2013 Clinical Practice Guidelines

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Canadian Diabetes Association 2013 Clinical Practice Guidelines

Hochgeladen von

Copyright:

Verfügbare Formate

Canadian Diabetes Association

2013 Clinical Practice Guidelines

By the end of this session, participants will be able to:

1. Understand the major changes within the 2013 CDA

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Jonathan Dawrant, BSc, MSc, MD, FRCPC

Alice Y.Y. Cheng, MD, FRCPC

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

ACS 2001 CKD 2002

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

FPG 7.0 mmol/L

Test Result Prediabetes Category

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Consider 7.1-8.5% if:

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Daily SMBG is not usually required if patient:

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

CHOOSE initial therapy based on glycemia

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

S If not at glycemic targets

Y PATIENT CHARACTERISTIC CHOICE OF AGENT

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Add another agent from a different class

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Insulin secretagogue: Less hypoglycemia in context of missed meals

Thiazolidinediones Rare Neutral CHF, edema, fractures, rare bladder cancer $$

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Bolus (prandial) Insulins

Rapid-acting insulin analogues (clear):

Short-acting insulins (clear):

Intermediate-acting insulins (cloudy):

Long-acting basal insulin analogues (clear)

Premixed insulin analogues (cloudy):

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

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

3. Treat with fast sugar (simple carbohydrate) (15 g) to

4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and

5. Eat usual snack or meal due at that time of day or a

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

A A1C optimal glycemic control (usually 7%)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Among women with childbearing potential, statins should only

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Within CARDS and HPS, the subgroups that started

If the patient qualifies for statin therapy based on the

HPS Lancet 2002;360:7-22

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Among women with childbearing potential, ACEi or ARB should

ASA should not be routinely used for the primary

ASA may be used in the presence of additional

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

A A1C optimal glycemic control (usually 7%)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

How much could we protect

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Gaede et al. NEJM. 2003: 348;383-393