2024 CPG Quick Reference Guide 1

UPDATED FOR 2024
Clinical Practice Guidelines

Quick Reference Guide
416569-24
guidelines.diabetes.ca
diabetes.ca | 1-800-BANTING (226-8464)
Screening and diagnosis of type 2 diabetes in adults

Assess risk factors for type 2 diabetes ANNUALLY:
• Family history (first-degree relative with type 2 diabetes)
• High risk populations (non-white, low socioeconomic status)
• History of GDM/prediabetes
• Cardiovascular risk factors
• Presence of end organ damage associated with diabetes
• Other conditions and medications associated with diabetes
(see CPG Chapter 4, Screening for Diabetes in Adults, Table 1)
Age <40 years or low-moderate risk* No screen indicated

No risk factors
Who to screen
Age ≥40 years or high risk* (33% chance of

Screen every 3 years
developing type 2 diabetes within 10 years)
Presence of or very high risk (50% chance of developing Screen every

risk factors type 2 diabetes within 10 years) 6 to 12 months
Test Result Dysglycemia category

How to screen
6.1 – 6.9 IFG

FPG (mmol/L) No caloric intake for at least 8 hours
≥7.0 Diabetes
6.0 – 6.4 Prediabetes
A1C (%)**
≥6.5 Diabetes
If asymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1C or FPG) as a confirmatory test. If both FPG and A1C
are available and only one is in the diabetes range, repeat the test in the diabetes range as the confirmatory test. If both A1C and FPG are
available and are each in the diabetes range, diabetes is confirmed. If symptoms of overt hyperglycemia are present, diagnosis of diabetes
can be determined with one test (A1C, FPG, 2hPG, random PG) in the diabetes range, see Chapter 3, CPG.
*using a validated risk calculator (e.g. CANRISK)
**Use a standardized, validated assay. Be aware of factors that affect A1C accuracy (see CPG Chapter 9, Table 1)
A1C Targets for glycemic management

A1C% Targets
<6.0 Selected adults with type 2 diabetes with potential for remission to normoglycemia
If asymptomatic and A1C or FPG are in the diabetes range, repeat the same≥7.0 Diabetes
test (A1C or FPG) as a confirmatory test. If both FPG and A1C
How to
6.0 – 6.4
available and are each in the diabetes range, diabetes is confirmed. If symptoms Prediabetes
of overt hyperglycemia are present, diagnosis of diabetes
A1C (%)**
≥6.5 Diabetes
*using a validated risk calculator (e.g. CANRISK)

If asymptomatic and A1C or FPG are in the diabetes range, repeat the same test (A1C or FPG) as a confirmatory test. If both FPG and A1C
available and are each in the diabetes range, diabetes is confirmed. If symptoms of overt hyperglycemia are present, diagnosis of diabetes
A1C%
*using Targets
a validated risk calculator (e.g. CANRISK)
Adults with type 2 diabetes to reduce the risk of chronic kidney disease and retinopathy
≤6.5*
A1C% if Targets
at low risk of hypoglycemia†
≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES

7.1 7.1-8.0%: Functionally dependent†
Adults with type 2 diabetes to reduce the risk of chronic kidney disease and retinopathy
≤6.5* 7.1-8.5%:
if at low risk of hypoglycemia†
• Recurrent severe hypoglycemia and/or hypoglycemia unawareness
8.5
≤7.0 •MOST ADULTS
Limited WITH TYPE 1 OR TYPE 2 DIABETES
life expectancy
• Frail elderly and/or with dementia ‡
7.1 7.1-8.0%: Functionally dependent†
7.1-8.5%: Avoid higher A1C to minimize risk of symptomatic hyperglycemia and
• Recurrent severe hypoglycemia acuteand/or hypoglycemia
and chronic unawareness
complications
8.5 • Limited life expectancy
End of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.
* Target 6.0• to
Frail
<6.5elderly
for adultsand/or
with typewith dementia ‡
2 diabetes with potential for remission to prediabetes
† Based on class of antihyperglycemic medication(s) utilized and the person’s characteristics
Avoid
‡ See Diabetes in Older People higher A1C to minimize risk of symptomatic
chapter hyperglycemia and
acute and chronic complications
At diagnosis of
6.0 to <6.5 for adults withtype 2 diabetes
type 2 diabetes (Fig. to1)prediabetes
End of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.
* Target with potential for remission
2020
† Based on class of antihyperglycemic medication(s) utilized and the person’s characteristics
‡ See Diabetes in Older People chapter
• Assess glycemic control, cardiovascular and renal status*, recent dietary patterns and weight change†
• Select individualized A1C target (see Chapter 8, 2018 CPG)
• Provide and/or refer for diabetes education (see Chapter 7 2018 CPG)
At diagnosis of type 2 diabetes (Fig. 1)
• Start healthy behaviour interventions (see Chapters 10,11, 17 2018 CPG) 2020
• Assess glycemic control, cardiovascular and renal status*, recent dietary patterns and weight change†
Lifestyle
• Select individualized A1C target (seechanges
Chapter 8, 2018 CPG)Start metformin Symptomatic
Goal:
expected
• Provide and/or refer for diabetestoeducation
reduce blood (if A1C
(see Chapter is >CPG)
7 2018 1.5% above hyperglycemia and/or
Attain A1C target by
glucose levels
• Start healthy behaviour interventions (see Chapters target,
10,11, 17start metformin
2018 CPG) plus metabolic decompensation
3 months
No pharmacotherapy a second agent) Start Insulin†† ± metformin
Lifestyle changes Start metformin Symptomatic

Goal:
If A1C NOT at target expected
start to reduce blood
Metformin (if Adjust
A1C is or Advance
> 1.5% above hyperglycemia and/or
Attainat A1C target by
3 months Therapy
glucose levels target, start metformin plus metabolic decompensation
3 months
No pharmacotherapy a second agent) Start Insulin†† ± metformin
Reassess A1C in 3-6 months (see Chapter 9 2018 CPG)

If A1C NOT at target Adjust or Advance
start Metformin
at 3 months Therapy
Go to Fig. 2 Go to Fig. 3
* In individuals with atherosclerotic cardiovascular disease, history of heart failure (with reduced ejection fraction) or chronic kidney
Reassess
disease, agents with cardiorenal benefits may beA1C in 3-6 months
considered (see Chapter
(see Pharmacologic 9 2018
Glycemic CPG)
Management of Type 2 Diabetes in Adults 2020
Update – The Users Guide)
† Unintentional weight loss should prompt consideration of other diagnoses (e.g. type 1 diabetes or pancreatic disease)
†† Reassess need for ongoing insulin therapy once type of diabetes is established
Go to Fig. 2 and response to healthy behaviour interventions
Go to Fig. 3 is
assessed
* In individuals with atherosclerotic cardiovascular disease, history of heart failure (with reduced ejection fraction) or chronic kidney
Reviewing, adjusting or advancing therapy

disease, agents with cardiorenal benefits may be considered (see Pharmacologic Glycemic Management of Type 2 Diabetes in Adults 2020
in type 2 diabetes (Fig. 2) 2020
†† Reassess need for ongoing insulin therapy once type of diabetes is established and response to healthy behaviour interventions is
assessed
Regular Review
• Assess glycemic control, cardiovascular and renal status
Reviewing, adjusting or advancing therapy
• Continue to screen for complications
if A1C NOT at Target
in type 2 diabetes (Fig. 2)
(eyes, feet, kidney, heart)
and/or 2020
• Review efficacy, side effects, safety and ability to take
Change in Clinical Status
current medications
Regular Review
• Reinforce and support healthy behaviour interventions
if A1C NOT at Target
(eyes, feet, kidney, heart)
Adjust or Advance Therapy1 and/or
• Review efficacy, side effects, safety and ability to take
Change in Clinical Status
current medications
ASCVD, CKD or HF, OR Age >60 with 2 CV risk factors2 A1C above target and glucose lowering required
* In individuals
disease, with
agents withatherosclerotic cardiovascular
cardiorenal benefits disease, history
may be considered of heart failure Glycemic
(see Pharmacologic (with reduced ejection fraction)
Management of Type 2or chronic in
Diabetes kidney
Adults 2020
disease,
Update –agents withGuide)
The Users cardiorenal benefits may be considered (see Pharmacologic Glycemic Management of Type 2 Diabetes in Adults 2020
†
††Unintentional
Reassess need weight loss should
for ongoing prompt
insulin consideration
therapy once type ofofdiabetes
other diagnoses (e.g. type
is established 1 diabetestoorhealthy
and response pancreatic disease)
behaviour interventions is
†† Reassess
assessed need for ongoing insulin therapy once type of diabetes is established and response to healthy behaviour interventions is
assessed
Reviewing,
Reviewing, adjusting
adjusting or
or advancing
advancing therapy
therapy
in type 2 diabetes (Fig. 2) 2020
2020
in type 2 diabetes (Fig. 2)
Regular Review
Regular Review
• Continue to screen for complications if A1C NOT at Target
(eyes, feet, kidney, heart) if A1C NOT at Target
(eyes, feet, kidney, heart) and/or
• Review efficacy, side effects, safety and ability to take and/or
• Review efficacy, side effects, safety and ability to take Change in Clinical Status
current medications Change in Clinical Status
current medications
Adjust or Advance Therapy1

Adjust or Advance Therapy1
ASCVD, CKD or HF, OR Age >60 with 2 CV risk factors22 A1C above target and glucose lowering required
ASCVD, CKD or HF, OR Age >60 with 2 CV risk factors A1C above target and glucose lowering required
ADD or SUBSTITUTE AHA ADD or SUBSTITUTE AHA3 according to clinical priorities4

ADD or SUBSTITUTE AHA ADD or SUBSTITUTE AHA3 according to clinical priorities4
with demonstrated cardiorenal benefits Start insulin for symptomatic
with demonstrated cardiorenal benefits Start insulin for symptomatic
hyperglycemia and/or metabolic decompensation
hyperglycemia and/or metabolic decompensation
Go to Fig. 2.1 Go to Fig. 2.2 or Fig. 3

Go to Fig. 2.1 Go to Fig. 2.2 or Fig. 3
1 Changes in clinical status may necessitate adjustment of glycemic targets and/or deprescribing
1
2 Changes in clinical
Tobacco use; status may
dyslipidemia (usenecessitate adjustment
of lipid modifying of glycemic
therapy targets and/or
or a documented deprescribing
untreated LDL ≥3.4 mmol/L, or HDL-C <1.0 mmol/L for men
2 Tobacco
and <1.3 use;
mmol/Ldyslipidemia
for women, (use
orof lipid modifying
triglycerides ≥2.3 therapy
mmol/L);orora hypertension
documented untreated LDLpressure
(use of blood ≥3.4 mmol/L,
drug oror HDL-C <1.0SBP
untreated mmol/L
≥140for
mmmen
Hg or
and
DBP <1.3 mmol/L for women, or triglycerides ≥2.3 mmol/L); or hypertension (use of blood pressure drug or untreated SBP ≥140 mm Hg or
≥95 mmHg)
DBP
3 All ≥95 mmHg)
AHA’s have Grade A evidence for effectiveness to reduce blood glucose levels
3 Consider
4 All AHA’s have
degreeGrade A evidence forcosts
of hyperglycemia, effectiveness to reduce
and coverage, renalblood glucose
function, levels
comorbidity, side effect profile, and potential for pregnancy
4 Consider degree of hyperglycemia, costs and coverage, renal function, comorbidity, side effect profile, and potential for pregnancy
For
For people
people with
with ASCVD,
ASCVD, CKD
CKD or
or HF,
HF,
OR 2020
OR >60 yrs and 2 CV risk factors (Fig.
>60 yrs and 2 CV risk factors (Fig. 2.1)
2.1) 2020
ADD or SUBSTITUTE AHA with demonstrated cardiorenal benefits
ADD or SUBSTITUTE AHA with demonstrated cardiorenal benefits
Established Cardiovascular or Renal Disease Risk Factors

Established Cardiovascular or Renal Disease Risk Factors
>60 yrs with
ASCVD CKD HF >60 yrs with
ASCVD CKD HF 2 CV risk factors††
2 CV risk factors
GLP1-RA††
GLP1-RA †† SGLT2i*
or GLP1-RA††
Observed
MACE
or or SGLT2i*
GLP1-RA†† GLP1-RA††
RisksObserved
MACE
Trials
SGLT2i* or GLP1-RA††
OutcomesTrials
SGLT2i*
SGLT2i*
SGLT2i*
ininOutcomes
HHF SGLT2i* SGLT2i* (and lower CV SGLT2i*

HHF SGLT2i* SGLT2i* (and lower CV SGLT2i*
LowerRisks
mortality)
mortality)
Lower
Progression of
Progression of SGLT2i* SGLT2i* SGLT2i*
Nephropathy SGLT2i* SGLT2i* SGLT2i*
Nephropathy
Highest level of evidence Grade A Grade B Grade C or D

Highest level of evidence Grade A Grade B Grade C or D
† Tobacco use; dyslipidemia (use of lipid modifying therapy or a documented untreated LDL ≥3.4 mmol/L, or HDL-C <1.0 mmol/L for men
† Tobacco
and <1.3 use;
mmol/L dyslipidemia (use
for women, orof lipid modifying
triglycerides ≥2.3 therapy
mmol/L);orora hypertension
documented untreated LDLpressure
(use of blood ≥3.4 mmol/L,
drug or
or HDL-C <1.0SBP
untreated mmol/L
≥140for
mmmen
Hg or
and
DBP <1.3 mmol/L for
≥90 mmHg); women,
central or triglycerides ≥2.3 mmol/L); or hypertension (use of blood pressure drug or untreated SBP ≥140 mm Hg or
obesity
DBP ≥90 mmHg); central obesity
†† Stop DPP4i when starting a GLP1-RA
††Initiate
* Stop DPP4i
only ifwhen
eGFRstarting a GLP1-RA 2
>30 ml/min/1.73m
* Initiate only if eGFR >30 ml/min/1.73m2
Where 2020
Where additional
additional glucose
glucose lowering
lowering is
is required
required (Fig.
(Fig. 2.2)
2.2) 2020
ADD or SUBSTITUTE AHA†† according to clinical priorities†††
start insulin for symptomatic hyperglycemia and/or metabolic decompensation (Fig. 3)
†† All AHA’s have PROVEN cardiorenal benefit CV safety, but NO proven RISK of HF
Grade A evidence in high-risk populations** cardiorenal benefit**
for effectiveness to
for effectiveness to Weight Loss
reduce blood glucose GLP1-RA Weight Loss GLP1-RA
reduce blood glucose GLP1-RA GLP1-RA
levels dulaglutide, liraglutide, exenatide ER, lixisenatide
semaglutide
semaglutide ertugliflozin*** (SGLT2i)
SGLT2i ertugliflozin*** (SGLT2i)
† Tobacco use; dyslipidemia (use of lipid modifying therapy or a documented untreated LDL ≥3.4 mmol/L, or HDL-C <1.0 mmol/L for men
and <1.3 mmol/L for women, or triglycerides ≥2.3 mmol/L); or hypertension (use of blood pressure drug or untreated SBP ≥140 mm Hg or
DBP ≥90 mmHg); central obesity
†† Stop DPP4i when starting a GLP1-RA
* Initiate only if eGFR >30 ml/min/1.73m2
Where additional glucose lowering is required (Fig. 2.2) 2020

for effectiveness to
Weight Loss
reduce blood glucose GLP1-RA GLP1-RA
semaglutide
SGLT2i ertugliflozin*** (SGLT2i)
††† Consider degree canagliflozin, dapagliflozin,
of hyperglycemia, empagliflozin
costs and coverage,
renal function, DPP4i
comorbidity, side sitagliptin, linagliptin, alogliptin saxagliptin (DPP4i)
Acarbose
effect profile,
and potential for
pregnancy Sulfonylureas
Meglitinides
Insulin Thiazolidinediones
Hypoglycemia Weight gain
** In CV outcome trials performed in people with ASCVD, CKD, HF or at high CV risk

*** VERTIS (CV outcome trial for ertugliflozin) presented at ADA June 2020 showed non-inferiority for MACE. Manuscript not published at
time of writing.
Starting or advancing
insulin in type 2 diabetes (Fig. 3) 2020
Decision to initiate Insulin (from Fig. 1 or Fig. 2)
Fasting Glucose and/or A1C NOT at target on current AHA or symptomatic hyperglycemia and/or metabolic decompensation
Regular Review Start Basal Insulin and titrate to achieve fasting glucose target
Continue Metformin unless contraindicated. Review / adjust other AHAs1
Assess glycemic
control,
ADD ADD SGLT2i ADD DPP4i
cardiovascular and
GLP1-RA2,3 (for glycemia (unless taking If GLP1-
renal status
(stop DPP4i) if eGFR >454) GLP1-RA) RA, SGLT2i,
Continue to screen
for complications DPP4i are Advance Therapy if
(eyes, feet, kidneys, contraindicated A1C not at Target
heart) add SGLT2i (for glycemia add GLP1-RA 2,3 or not options within 3-6 months
Review efficacy, if eGFR >454) (stop DPP4i) despite adequate
side effects, safety titration of insulin1
and ability to take and supports
add bolus insulin step-wise, beginning with one meal injection for lifestyle and
current medications
per day (consider stopping SUs5) pharmacotherapy
Reinforce and
support healthy
behaviour Advance to multiple injections with bolus injection at each meal
interventions (stop SUs5, review or adjust other AHAs)
1 titration of basal insulin to achieve FPG target without hypoglycemia
2 and titrate dose of GLP1-RA as tolerated Highest level of evidence Grade A Grade B Grade C or D
3 or fixed ratio combination
4 for cardiorenal benefit, SGLT2i may be initiated at eGFR >30 ml/min/1.73m2 (and continued at lower eGFR depending on the SGT2i)
5 sulfonylureas or meglitinides
Which cardiovascular non-antihyperglycemic

medications are indicated for my patient?
Does the patient have cardiovascular disease? Statin1
- Cardiac ischemia (silent or overt) YES
+
- Peripheral arterial disease ACEi/ARB2
- Cerebrovascular/carotid disease +
NO
ASA3
Does the patient have microvascular disease? YES

- Retinopathy
- Kidney disease (ACR ≥2.0) Statin1
4 for cardiorenal benefit, SGLT2i may be initiated at eGFR >30 ml/min/1.73m22 (and continued at lower eGFR depending on the SGT2i)
4 for cardiorenal benefit, SGLT2i may be initiated at eGFR >30 ml/min/1.73m (and continued at lower eGFR depending on the SGT2i)
Which
Which cardiovascular
cardiovascular non-antihyperglycemic
non-antihyperglycemic
medications
medications are indicated for
are indicated for my
my patient?
patient?
Does
Does the
the patient
patient have
have cardiovascular
cardiovascular disease?
disease? Statin 1
YES Statin1
-- Cardiac
Cardiac ischemia (silent or
ischemia (silent or overt)
overt) YES +
+
-- Peripheral ACEi/ARB
Peripheral arterial
arterial disease
2
disease ACEi/ARB2
-- Cerebrovascular/carotid +
Cerebrovascular/carotid disease
disease + 3
ASA
NO
NO
ASA3
Does
Does thethe patient
patient have
have microvascular
microvascular disease?
disease? YES
-- Retinopathy YES
Retinopathy
-- Kidney
Kidney disease
disease (ACR
(ACR ≥2.0)
≥2.0) Statin 1
Statin1
-- Neuropathy
Neuropathy +
+
NO ACEi/ARB
ACEi/ARB2
2
NO
Is
Is the
the patient:
patient: YES
YES
-- age
age ≥55
≥55 with
with additional
additional CV
CV risk
risk factors?
4
factors?4
-- age
age ≥40?
≥40?
-- age
age ≥30
≥30 and
and diabetes
diabetes >15
>15 years?
years? Statin 1
-- warranted YES Statin1

warranted for statin therapy based
for statin therapy based on
on the
the Canadian
Canadian YES
Cardiovascular Society Lipid Guidelines?
Cardiovascular Society Lipid Guidelines?
1 Dose adjustments or additional lipid therapy warranted if lipid target (LDL-C <2.0 mmol/L) not being met.
1 Dose adjustments or additional lipid therapy warranted if lipid target (LDL-C <2.0 mmol/L) not being met.
2 ACE-inhibitor or ARB (angiotensin receptor blocker) should be given at doses that have demonstrated vascular protection (eg. perindopril
2 ACE-inhibitor or ARB (angiotensin receptor blocker) should be given at doses that have demonstrated vascular protection (eg. perindopril
8 mg once daily [EUROPA trial], ramipril 10 mg once daily [HOPE trial], telmisartan 80 mg once daily [ONTARGET trial]).
8 mg once daily [EUROPA trial], ramipril 10 mg once daily [HOPE trial], telmisartan 80 mg once daily [ONTARGET trial]).
3 ASA should not routinely be used for the primary prevention of cardiovascular disease in people with diabetes. ASA may be used for
3 ASA should not routinely be used for the primary prevention of cardiovascular disease in people with diabetes. ASA may be used for
secondary prevention. Consider clopidogrel if ASA-intolerant.
secondary prevention. Consider clopidogrel if ASA-intolerant.
4 TC > 5.2 mmol/L, HDL-C < 0.9 mmol/L, hypertension, albuminuria, smoking.
4 TC > 5.2 mmol/L, HDL-C < 0.9 mmol/L, hypertension, albuminuria, smoking.
For
For antihyperglycemic
antihyperglycemic medications
medications with
with CVD
CVD and/or
and/or cardiorenal
cardiorenal benefits
benefits see
see Fig.
Fig. 2.1
2.1
Special
Special considerations
considerations regarding
regarding pregnancy
pregnancy
Keeping
Keeping patients
patients safe
safe for women with type 1 or type 2 diabetes
for women with type 1 or type 2 diabetes
when they are
when they are atat
For
For women
women planning
planning pregnancy,
pregnancy, the
the following
following steps
steps taken
taken prior
prior to
risk
risk of
of dehydration
dehydration conception:
to
conception:
(vomiting/diarrhea)
(vomiting/diarrhea) •• A1C A1C 7% 7% or
or less,
less, but
but strive
strive for
for ≤6.5%
≤6.5% (ensure
(ensure contraception
contraception until
until at
at
Re-hydrate
Re-hydrate appropriately
appropriately (water, personalized
(water, personalized target) target)
broth,
broth, diet soft drinks,
diet soft drinks, sugar-free
sugar-free •• Stop:Stop:
Kool-Aid™,
Kool-Aid™, diet
diet Jell-O™;
Jell-O™; avoid -- Non-insulin
avoid Non-insulin antihyperglycemic
antihyperglycemic agents
agents (except
(except metformin
metformin
caffeinated beverages).
caffeinated beverages). and/or glyburide)
and/or glyburide)
Hold -- Statins
Hold SADMANS meds. Restart
SADMANS meds. Restart Statins
once -- ACEi/ARB
ACEi/ARB priorprior to
to pregnancy,
pregnancy, but
but if
if overt
overt nephropathy
nephropathy exists,
once able to eat/drink normally.
able to eat/drink normally. exists,
continue until detection of pregnancy
continue until detection of pregnancy
S
S sulfonylureas,
sulfonylureas, other
other •• Start:
Start:
secretagogues -- Folic
secretagogues Folic acid
acid 1 1 mg
mg per
per day
day xx33 months
months prior
prior to
to conception
conception
A ACE-inhibitors
ACE-inhibitors -- Insulin
A Insulin if target A1C is not achieved on metformin and/or
if target A1C is not achieved on metformin and/or
D
D diuretics,
diuretics, direct
direct renin glyburide
renin glyburide (type
(type 2)
2)
inhibitors -- Other
inhibitors Other antihypertensive
antihypertensive agents agents safe
safe for
for pregnancy
pregnancy (Labetalol,
(Labetalol,
M metformin
metformin nifedepine
M nifedepine XL) XL) if
if hypertension
hypertension control
control needed
needed
A angiotensin receptor
receptor blockers
blockers •• Screen
A angiotensin Screen for for complications:
complications:
N non-steroidal anti- -- Eye
N non-steroidal anti- Eye appointment, serum
appointment, serum creatinine,
creatinine, urine
urine ACR,
ACR, blood
blood pressure
pressure
inflammatory drugs
inflammatory drugs •• Aim for healthy BMI
Aim for healthy BMI
S SGLT2 inhibitors
S SGLT2 inhibitors •• Ensure appropriate vaccinations
Ensure appropriate vaccinations have
have occurred
occurred
•• Refer to diabetes
Refer to diabetes clinic clinic
Keeping
Keeping people
people with
with diabetes
diabetes safe
safe when
when they
they are
are at
at risk
risk of
of hypoglycemia:
hypoglycemia:
For
For people
people using
using glyburide,
glyburide, gliclazide,
gliclazide, repaglinide
repaglinide or
or insulin
insulin
Signs of
Signs of
hypoglycemia Classification of hypoglycemia Treatment*
hypoglycemia Classification of hypoglycemia Treatment*
Adrenergic Level 1 Level 1 or 2 hypoglycemia:
(autonomic) • Glucose level below normal (often • Ingest 15 g of carbohydrate, preferably as glucose or
• Trembling between 3.0 and 3.9 mmol/L) sucrose (i.e. tablets or solution). Glucose levels should be
• Palpitations • Associated with autonomic symptoms retested after 15 minutes and re-treated with another 15 g
• Sweating • Without neuroglycopenic symptoms or of carbohydrate if the glucose level remains <3.9 mmol/L
• Anxiety changes to mental status Examples of 15 g of carbohydrate:
• Hunger • 4 x 4 g glucose tablets
• Nausea Level 2 • 15 mL (3 teaspoons) or 3 packets of table
• Tingling • Glucose level below normal sugar dissolved in water
• Tingling sugar dissolved in water
A angiotensin receptor blockers - Eye appointment,
• Screen serum creatinine, urine ACR, blood pressure
for complications:
N inflammatory drugs
non-steroidal anti- • Aim healthy BMIserum creatinine, urine ACR, blood pressure
forappointment,
- Eye
S SGLT2 inhibitors
inflammatory drugs Ensure
• Aim healthy BMIvaccinations have occurred
for appropriate
S SGLT2 inhibitors Refer toappropriate
• Ensure diabetes clinic
vaccinations have occurred
• Refer to diabetes clinic
Keeping people with diabetes safe when they are at risk of hypoglycemia:
Keeping
For people
people using withgliclazide,
glyburide, diabetes safe when
repaglinide or insulinthey are at risk of hypoglycemia:
For people
Signs of using glyburide, gliclazide, repaglinide or insulin
hypoglycemia
Signs of Classification of hypoglycemia Treatment*
hypoglycemia
Adrenergic Classification
Level 1 of hypoglycemia Treatment*
Level 1 or 2 hypoglycemia:
(often <3.0 mmol/L) • 5 cubes of sugar
Neuroglycopenic • Associated with neuroglycopenic • 150 mL juice or regular soft drink
(often <3.0 mmol/L) • 5 cubes of sugar
• Difficulty symptoms • 6 LifeSavers™
Neuroglycopenic • Associated with neuroglycopenic • 150 mL juice or regular soft drink
concentrating • Without significant impact on mental • 15 mL (1 tablespoon) honey
• Difficulty symptoms • 6 LifeSavers™
• Confusion status
concentrating • Without significant impact on mental • 15 mL (1 tablespoon) honey
• Weakness • With or without autonomic symptoms
• Confusion status
• Drowsiness
• Weakness • With or without autonomic symptoms
• Vision Level 3 Level 3 hypoglycemia:
• Drowsiness
changes • Glucose level below normal • Conscious: Treat with oral ingestion of 20 g of carbo-
• Vision Level 3 Level 3 hypoglycemia:
• Slurred speech (regardless of glucose reading) hydrate, preferably as glucose tablets or equivalent (if
changes • Glucose level below normal • Conscious: Treat with oral ingestion of 20 g of carbo-
• Headache • Associated with neuroglycopenic capable of swallowing) or 3 mg of glucagon intranasal or
• Slurred speech (regardless of glucose reading) hydrate, preferably as glucose tablets or equivalent (if
• Dizziness symptoms resulting in significantly glucagon 1 mg SC/IM. Retreat with additional doses after
• Headache • Associated with neuroglycopenic capable of swallowing) or 3 mg of glucagon intranasal or
• Dizziness altered mental/physical status 15 minutes if glucose level remains <3.9 mmol/L
symptoms resulting in significantly glucagon 1 mg SC/IM. Retreat with additional doses after
• Requires assistance to treat • Unconscious: Treat with glucagon (as above) or 10-25 g (20-
altered mental/physical status 15 minutes if glucose level remains <3.9 mmol/L
• Requires assistance to treat 50 mL of D50W) of glucose IV. Retreat with additional doses
• Unconscious: Treat with glucagon (as above) or 10-25 g (20-
after 15 minutes if glucose level remains <3.9 mmol/L
50 mL of D50W) of glucose IV. Retreat with additional doses
after 15 minutes if glucose level remains <3.9 mmol/L
* After treatment of hypoglycemia, consume usual meal or snack that is due at that time of the day. If a meal is >1 hour away, consume a
snack (including 15 g carbohydrate and a protein source)
* After treatment of hypoglycemia, consume usual meal or snack that is due at that time of the day. If a meal is >1 hour away, consume a
snack (including 15 g carbohydrate and a protein source)
EDUCATE people at risk of hypoglycemia to drive safely with diabetes

EDUCATEKeep
PREPARE fast-acting
people sugar
at risk of within reach
hypoglycemia and other
to drive safelysnacks nearby
with diabetes
Risk
BE AWAREKeep
PREPARE of blood glucose
fast-acting (BG)within
sugar beforereach
driving and
and every
other 4 hours
snacks during long drives. If BG is below
nearby
Reduce
4 mmol/L, treat
Risk
BE AWARE of blood glucose (BG) before driving and every 4 hours during long drives. If BG is below
Driving
STOP driving and treat if any symptoms appear

Reduce
4 mmol/L, treat
AFTERdriving treatWAIT
Driving
STOP treating
anda low, if anyuntil BG is above
symptoms 5 mmol/L to start driving. Note: Brain function may not be fully
appear
restored for some
AFTER treating time
a low, afteruntil
WAIT bloodBGglucose level
is above returnstotostart
5 mmol/L normal
driving. Note: Brain function may not be fully
If a person
restored forhas impaired
some awareness
time after of hypoglycemia,
blood glucose he/she
level returns must check their BG before driving and every
to normal
2
If hours while
a person hasdriving,
impairedor monitor glucoses
awareness with a real-time
of hypoglycemia, continuous
he/she glucose
must check sensor
their BG before driving and every
2 hours while driving, or monitor glucoses with a real-time continuous glucose sensor
Psychoeducational training
• Structured diabetestraining
Psychoeducational education programs focused on recognizing and reducing frequency of hypoglycemia
•Choice of pharmacotherapy
Structured diabetes education programs focused on recognizing and reducing frequency of hypoglycemia
Strategies
•Choice
Avoid, of
reduce dose of, or discontinue pharmacotherapies associated with increased risk of hypoglycemia if
pharmacotherapy
appropriate
Strategies
• Avoid, reduce dose of, or discontinue pharmacotherapies associated with increased risk of hypoglycemia if
Hypoglycemia
• appropriate
Consider long-acting analogues (insulin glargine-100, glargine-300, detemir, or degludec) over NPH insulin
Hypoglycemia
second-generation
• Consider long-acting basal
analogues insulin
(insulin analogues (insulin
glargine-100, glargine-300
glargine-300, and
detemir, ordegludec)
degludec)over
overinsulin
NPH insulin
• glargine-100 and detemir to reduce
Consider second-generation the risk
basal insulin of hypoglycemia,
analogues including nocturnal
(insulin glargine-300 hypoglycemia
and degludec) in type 1 and
over insulin
Prevention
type 2 diabetes
glargine-100 and detemir to reduce the risk of hypoglycemia, including nocturnal hypoglycemia in type 1 and
Prevention
Glucose monitoring
type 2 diabetes
• Use of continuous
Glucose monitoringglucose monitoring (CGM) and increased frequency of capillary blood glucose (CBG)
• monitoring to identify
Use of continuous episodes
glucose of hypoglycemia
monitoring (CGM) and increased frequency of capillary blood glucose (CBG)
Surgical (for to
monitoring type 1 diabetes)
identify episodes of hypoglycemia
• Islet cell(for
Surgical transplant
type 1 diabetes)
•• Pancreas transplant
Islet cell transplant
• Pancreas transplant
Individualized goal setting

Examples
Potential
Self-management
Potential Goals Examples
Self-management
Eat healthier Goals See a dietitian to help develop a healthy eating plan.
Eat healthier See a dietitian to help develop a healthy eating plan.
Be more active Increase physical activity with the goal of getting to 150 minutes aerobic
Be more active activity/week and activity
Increase physical resistance
withexercise
the goal2-3
of times/week. Choose
getting to 150 physical
minutes activity
aerobic
that meets preferences/needs.
activity/week and resistance exercise 2-3 times/week. Choose physical activity
• Islet cell(for
Surgical type 1 diabetes)
transplant
Pancreas
• Islet transplant
cell transplant
• Pancreas transplant

Potential Examples
Potential
Self-management Goals Examples
Self-management Goals
Be more active Increase physical activity with the goal of getting to 150 minutes aerobic
Be more active Increase physical
activity/week and activity withexercise
resistance the goal2-3
of times/week.
getting to 150 minutes
Choose aerobic
physical activity
activity/week and resistance exercise 2-3 times/week. Choose physical activity
Lose weight Use strategies (e.g., reduce calories or portions) to lose 5-10% of initial weight.
Lose weight Use strategies (e.g., reduce calories or portions) to lose 5-10% of initial weight.
Take medication Taking medication will help to improve symptoms and take control of your
Take medication
regularly Taking medication
life. Consider usingwill help to
a pillbox orimprove
setting asymptoms
timer. and take control of your
regularly life. Consider using a pillbox or setting a timer.
Avoid hypoglycemia Recognize the signs of hypoglycemia and take action to prevent it.
Avoid hypoglycemia Recognize the signs of hypoglycemia and take action to prevent it.
Check blood glucose Establish a routine and act accordingly.
Check blood glucose Establish a routine and act accordingly.
Check feet Do a daily self-check and follow-up with a health-care provider if anything is
Check feet Do a daily self-check and follow-up with a health-care provider if anything is
abnormal.
abnormal.
Manage stress Screen for distress (depressive and anxious symptoms) by interview or a
Manage stress Screen for distress
standardized (depressive
questionnaire and
(e.g. anxious
PHQ-9 symptoms) by interview or a
www.phqscreeners.com).
standardized questionnaire (e.g. PHQ-9 www.phqscreeners.com).
Reduce or stop smoking Identify barriers to quitting and develop a plan to address each of these.
Reduce or stop smoking Identify barriers to quitting and develop a plan to address each of these.
3 Quick questions to
3 Quick
help questions
your patientsto
meet their goals
help your patients meet their goals
For patients who are not making expected progress, try asking
For patients
these whoto
questions are not making
identify a pathexpected
forward: progress, try asking
these questions to identify a path forward:
1. How important is it for you to <insert self-management goal> - low, medium, or high?
1. How
• (Goalimportant
examples:isincrease
it for you to <insert
levels self-management
of physical activity, reducegoal> - low,
weight, medium,
improve A1C,or high?
lower BP)
(Goal
• If examples:
importance increase levels
(motivation) of physical
is rated low, ask activity,
what wouldreduce weight,
need improve
to happen for A1C, lower BP)
importance to go up?
•AIf importance
high level of(motivation)
importance is rated
will low, that
indicate ask what would is
the person need to to
ready happen for importance to go up?
change.
• A high level of importance will indicate that the person is ready to change.
2. How confident are you in your ability to <insert target outcome here> - low, medium, or high?
2. How confident
• If their are is
confidence you in your
rated ability to
low, explore <insert
what needstarget outcome
to happen here> - low,
to increase theirmedium, or high?
confidence.
• If their confidence
Usually this has to is
dorated
with low, explore
improving what needs
knowledge, to happen
skills to increase
or resources their confidence.
and support.
•AUsually this of
high level hasconfidence
to do withindicates
improving knowledge,
that the personskills or resources
is ready and support.
to change.
• A high level of confidence indicates that the person is ready to change.
3. Can we set a specific goal for you to try before the next time we meet?
3. What
Can we set awill
steps specific goalto
you take for you to it?
achieve try before the next time we meet?
What steps will you take to
• Encourage S.M.A.R.T. Goals: achieve it?
• Encourage S.M.A.R.T. Goals:
S pecific M easurable A chievable R ealistic T imely

ABCDES of diabetes care 2022
ABCDES of diabetes care
GUIDELINE TARGET (or personalized goal) 2022
A1C targets GUIDELINE
A1C ≤7.0% (or TARGET
≤6.5%(or
to personalized goal)retinopathy)
risk of CKD and
A1C targets If on≤7.0%
A1C insulin(oror≤6.5%
insulintosecretagogue,
 risk of CKD assess for hypoglycemia and ensure driving safety
and retinopathy)
A A1C
If on6.0 - <6.5%
insulin for selected
or insulin adults with
secretagogue, typefor
assess 2 diabetes with potential
hypoglycemia remission
and ensure drivingtosafety
prediabetes
A A1C 6.0
<6.0- <6.5%
for selected adults adults
for selected with type
with2type
diabetes with potential
2 diabetes remission
with potential to normoglycemia
remission to prediabetes
BP targets A1C <6.0 formmHg
BP <130/80 selected adults with type 2 diabetes with potential remission to normoglycemia
B BP targets If on
BP treatment,
<130/80 mmHg assess for risk of falls
B
C Cholesterol targets If
LDL-C <2.0 mmol/L
on treatment, (or >50
assess % reduction
for risk of falls from baseline)
C Cholesterol
Drugs for CVtargets
and/ LDL-C <2.0 mmol/L (or >50 % reduction from baseline)
(non-AHA)
or Cardiorenal
Drugs for CV and/ • ACEi/ARB (if CVD, age ≥55 with risk factors, OR diabetes complications)
(non-AHA)
protection
or Cardiorenal Statin (if CVD,
• ACEi/ARB ageage
(if CVD, ≥40≥55for type
with 2, OR
risk diabetes
factors, ORcomplications)
diabetes complications)
• ASA (if CVD)
ABCDES of diabetes care 2022

GUIDELINE TARGET (or personalized goal)
A1C targets A1C ≤7.0% (or ≤6.5% to  risk of CKD and retinopathy)
If on insulin or insulin secretagogue, assess for hypoglycemia and ensure driving safety
A A1C 6.0 - <6.5% for selected adults with type 2 diabetes with potential remission to prediabetes
A1C <6.0 for selected adults with type 2 diabetes with potential remission to normoglycemia
BP targets BP <130/80 mmHg
B If on treatment, assess for risk of falls
C Cholesterol targets LDL-C <2.0 mmol/L (or >50 % reduction from baseline)
Drugs for CV and/ (non-AHA)
or Cardiorenal • ACEi/ARB (if CVD, age ≥55 with risk factors, OR diabetes complications)
protection • Statin (if CVD, age ≥40 for type 2, OR diabetes complications)
D • ASA (if CVD)
(Antihyperglycemic Agents)
• SGLT2i/GLP1-RA with demonstrated cardiorenal benefits in high risk type 2 with ASCVD, CKD
or HF, OR Age >60 with 2 CV risk factors
Exercise goals and • 150 minutes of moderate to vigorous aerobic activity/ week and resistance exercises
E healthy eating 2-3 times/week
• Follow healthy dietary pattern (eg Mediterranean diet, low glycemic index)
Screening for • Cardiac: ECG every 3-5 years if age >40 OR diabetes complications
complications • Foot: Monofilament/Vibration yearly or more if abnormal
S • Kidney: Test eGFR and ACR yearly, or more if abnormal
• Retinopathy: type 1 - annually; type 2 - q1-2 yrs
S Smoking cessation If smoker: Ask permission to give advice, arrange therapy and provide support
Self-management, • Set personalized goals (see “individualized goal setting” panel)
S stress, other • Assess for stress, mental health and financial or other concerns that might be barriers to
barriers achieving goals

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UPDATED FOR 2024

Clinical Practice Guidelines

Screening and diagnosis of type 2 diabetes in adults

Age <40 years or low-moderate risk* No screen indicated

Age ≥40 years or high risk* (33% chance of

Presence of or very high risk (50% chance of developing Screen every

Test Result Dysglycemia category

6.1 – 6.9 IFG

A1C Targets for glycemic management

A1C Targets for glycemic management

≤7.0 MOST ADULTS WITH TYPE 1 OR TYPE 2 DIABETES

Lifestyle changes Start metformin Symptomatic

Reassess A1C in 3-6 months (see Chapter 9 2018 CPG)

Reviewing, adjusting or advancing therapy

Adjust or Advance Therapy1

ADD or SUBSTITUTE AHA ADD or SUBSTITUTE AHA3 according to clinical priorities4

Go to Fig. 2.1 Go to Fig. 2.2 or Fig. 3

Established Cardiovascular or Renal Disease Risk Factors

HHF SGLT2i* SGLT2i* (and lower CV SGLT2i*

Highest level of evidence Grade A Grade B Grade C or D

Where additional glucose lowering is required (Fig. 2.2) 2020

ADD or SUBSTITUTE AHA†† according to clinical priorities†††

** In CV outcome trials performed in people with ASCVD, CKD, HF or at high CV risk

Which cardiovascular non-antihyperglycemic

Does the patient have microvascular disease? YES

-- warranted YES Statin1

EDUCATE people at risk of hypoglycemia to drive safely with diabetes

STOP driving and treat if any symptoms appear

Individualized goal setting

Individualized goal setting

S pecific M easurable A chievable R ealistic T imely

ABCDES of diabetes care 2022

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