Canadian Diabetes Association 2013 Clinical Practice Guidelines Screening for Type 1 and Type 2 Diabetes

Chapter 4 Jean-Marie Ekoé, Zubin Punthakee, Thomas Ransom, Ally PH Prebtani, Ron Goldenberg

Screening Checklist
 ASSESS all adults clinically every year for risk of type 2 diabetes (T2DM)  SCREEN every 3 years if ≥ 40 years or high risk on risk calculator  SCREEN earlier and more frequently if very high risk on risk calculator or additional risk factors present  USE fasting plasma glucose (FPG) and/or A1C as initial screening tests

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4% NU 4.4% BC 5.0 < 6.9% SK 5.9% ON 6.4% QC 5. guidelines. Ottawa.Diabetes in Canada: Prevalence by Province and Territory Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year.ca Copyright © 2013 Canadian Diabetes Association Public Health Agency of Canada.0 6.5 NT 5. .5 5.4% MB 5.1% PE 5. while NU. Diabetes in Canada: Facts and figures from a public health perspective .diabetes.ca | 1-800-BANTING (226-8464) | diabetes. NS and ON had the highest prevalence.9% NS 6. NL.0% NL 6.1% † Age-standardized to the 1991 Canadian population.0 5.5% AB 4.5% YT 5. AB and QC had the lowest.0 < 5.5 < 6.6% NB 5.5 ≥ 6. 2008/09 < 5.

1% IFG. 0% IGT. 78% Leiter LA et al. 2% 5. Diabetes Care 2001. guidelines. 3% New DM.24:1038-43.ca | 1-800-BANTING (226-8464) | diabetes.7% undiagnosed glucose abnormalities Normal.ca Copyright © 2013 Canadian Diabetes Association .DIASCAN: Canadian Screening for T2DM in those age > 40 Years in Primary Care Known DM. 16% Probable DM.diabetes.

guidelines.ADDITION-Cambridge: No Mortality Benefit of Screening for T2DM in United Kingdom Simmons RK et al. Lancet 2012.ca | 1-800-BANTING (226-8464) | diabetes.380:1741-48.ca Copyright © 2013 Canadian Diabetes Association .diabetes.

380:1741-48.ADDITION-Cambridge: Prevalence of Diabetes • Prevalence of diabetes only 3.ca | 1-800-BANTING (226-8464) | diabetes.3% in this study Prevalence of diabetes in Canada 6. 2011. Lancet 2012. Simmons RK et al.8% • Can the results of ADDITION-Cambridge be applied to Canada? Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective.diabetes.0-3. Ottawa. guidelines.ca Copyright © 2013 Canadian Diabetes Association .

g.Assessing Risk: Risk Factors for T2DM Personal factors: • • First-degree relative with T2DM Member of high-risk population (e. Asian. Hispanic or South Asian) History of prediabetes History of gestational diabetes (GDM) History of delivery of macrosomic infant • • • guidelines. Aboriginal.ca | 1-800-BANTING (226-8464) | diabetes.diabetes. African.ca Copyright © 2013 Canadian Diabetes Association .

ca | 1-800-BANTING (226-8464) | diabetes.diabetes. 1.ca Copyright © 2013 Canadian Diabetes Association . neuropathy.7 mmol/L Hypertension. cerebrovascular.0 mmol/L males. abdominal obesity • Vascular risk factors – – – guidelines. peripheral arterial) Low HDL-cholesterol (< 1.3 mmol/L females) Triglycerides ≥ 1. nephropathy) Macrovascular (coronary.Assessing Risk: Risk Factors for T2DM Presence of associated problems: • End organ damage complications associated with diabetes – – Microvascular (retinopathy. overweight.

obstructive sleep apnea. psychiatric disorders (bipolar.ca | 1-800-BANTING (226-8464) | diabetes. depression. HIV infection Presence of secondary causes: • Use of drugs associated with diabetes Glucocorticoids – Atypical antipsychotics – Highly active antiretroviral therapy (HAART) – Others (see Appendix 1 in CPG document) – • Other secondary causes (see Appendix 1 in CPG document) guidelines.diabetes. acanthosis nigricans.ca Copyright © 2013 Canadian Diabetes Association .Assessing Risk: Risk Factors for T2DM Presence of associated problems (continued): • Associated diseases – Polycystic ovarian syndrome. schizophrenia).

BMI. sex.If you choose to use a diabetes risk calculator … • • • Public Health Agency of Canada CANRISK calculator http://www. history of dysglycemia (GDM.ca Copyright © 2013 Canadian Diabetes Association . ethnicity.ca | 1-800-BANTING (226-8464) | diabetes.74 years old Components – – – – Age. level of education • Calculates low. eating veg and fruits Hypertension.phac-aspc.ca/cd-mc/diabetes-diabete/canrisk For people 40 . acute illness etc.diabetes. waist circumference Physical activity level. moderate or high risk groups guidelines.) macrosomia Family history.gc.

ca Copyright © 2013 Canadian Diabetes Association .ca | 1-800-BANTING (226-8464) | diabetes.guidelines.diabetes.

ca | 1-800-BANTING (226-8464) | diabetes.FINRISK calculator • • Similar to CANRISK Does not include: – – – Macrosomia Ethnicity Level of education • Risk categories differ: Low-moderate – High – Very high http://canadiantaskforce.ca/guidelines/2012-diabetes / – • guidelines.ca Copyright © 2013 Canadian Diabetes Association .diabetes.

ca Copyright © 2013 Canadian Diabetes Association .ca | 1-800-BANTING (226-8464) | diabetes.diabetes.Screening for Type 2 Diabetes in Adults 2013 Algorithm presented on next slides guidelines.

Screening for Type 2 Diabetes in Adults (continued) *If both FPG and A1C are available. but discordant. guidelines. use the test that appears furthest to the right side of the algorithm.ca | 1-800-BANTING (226-8464) | diabetes.diabetes.ca Copyright © 2013 Canadian Diabetes Association .

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association .

ca Copyright © 2013 Canadian Diabetes Association .guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.

(in a timely fashion) If resultsfor of two confirmation. laboratory if test a single is in laboratory the diabetes test range. It is same preferable test bethat repeated the (in same a timely testfashion) be repeated for confirmation. confirmed. the diagnosis of diabetes is confirmed. 2hPG test in (FPG.‡ In ‡ Diabetes: the absence In of the symptomatic absence of hyperglycemia. both are above the diagnosis the diagnostic of diabetes is cutpoints. a repeat laboratory confirmatory test (FPG. laboratory A1C. different tests If results are available of two different and both tests are above are the available diagnostic and cutpoints. guidelines. a 75-g A1C. is in the a repeat diabetes confirmatory range.ca Copyright © 2013 Canadian Diabetes Association . done It ison preferable another that daythe .ca | 1-800-BANTING (226-8464) | diabetes. OGTT) 2hPG must in a be 75-g done OGTT) on another must be day.diabetes. symptomatic if a single hyperglycemia.

diabetes.guidelines.ca Copyright © 2013 Canadian Diabetes Association .ca | 1-800-BANTING (226-8464) | diabetes.

ca Copyright © 2013 Canadian Diabetes Association .diabetes.ca | 1-800-BANTING (226-8464) | diabetes.guidelines.

4% .diabetes.ca Copyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.ca | 1-800-BANTING (226-8464) | diabetes.guidelines.

diabetes.ca Copyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.ca | 1-800-BANTING (226-8464) | diabetes.guidelines.0 to 6.4% .

Do we need to screen for Type 1 diabetes (T1DM)? NO There is insufficient evidence for interventions to prevent or delay T1DM.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association . guidelines.diabetes.

diabetes. All individuals should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria [Grade D.ca Copyright © 2013 Canadian Diabetes Association . guidelines.ca | 1-800-BANTING (226-8464) | diabetes. Consensus].Recommendation 1 1.

Recommendation 2 2. More frequent and/or earlier testing with either a FPG and/or A1c or a 2h PG in a 75 g OGTT should be considered in those at very high risk using a risk calculator or in people with additional risk factors for diabetes [Grade D. Consensus]. Screening for diabetes using a FPG and/or A1C should be performed every 3 years in individuals ≥ 40 years of age or at high risk using a risk calculator [Grade D. guidelines.diabetes.ca Copyright © 2013 Canadian Diabetes Association .ca | 1-800-BANTING (226-8464) | diabetes. Consensus].

Hispanic.g. Asian.ca Copyright © 2013 Canadian Diabetes Association . Risk factors include: – – First-degree relative with T2DM Member of high-risk population (e. Aboriginal. or South Asian) History of prediabetes History of gestational diabetes (GDM) History of delivery of macrosomic infant – – – guidelines.diabetes.Recommendation 2 (continued) 2. African.ca | 1-800-BANTING (226-8464) | diabetes.

diabetes.3 mmol/L females) Triglycerides ≥ 1.7 mmol/L Hypertension. cerebrovascular. overweight.0 mmol/L males.ca | 1-800-BANTING (226-8464) | diabetes.Recommendation 2 (continued) Presence of associated problems – End organ damage complications associated with diabetes – – Microvascular (retinopathy. abdominal obesity guidelines. 1.ca Copyright © 2013 Canadian Diabetes Association . peripheral arterial) – – – – Vascular risk factors Low HDL-cholesterol (< 1. nephropathy) Macrovascular (coronary. neuropathy.

depression.Recommendation 2 (continued) Presence of associated problems (continued) – Associated diseases – Polycystic ovarian syndrome.ca | 1-800-BANTING (226-8464) | diabetes. acanthosis nigricans. psychiatric disorders (bipolar.ca Copyright © 2013 Canadian Diabetes Association . schizophrenia).diabetes. HIV infection – – – – – Use of drugs associated with diabetes Glucocorticoids Atypical antipsychotics Highly active antiretroviral therapy (HAART) Others (See Appendix 1 in the full document) – Other secondary causes (See Appendix 1 in the full document) guidelines. obstructive sleep apnea.

Testing with a 2hPG in a 75-g OGTT may be undertaken in individuals with a FPG of 5. Consensus] 5.diabetes.ca Copyright © 2013 Canadian Diabetes Association .4% in order to identify individuals with IGT or diabetes [Grade D. Testing with a 2hrPG in a 75-g OGTT should be undertaken in individuals with FPG of 6. Consensus] guidelines.1 to 6.9% and >1 risk factor(s) 2013 in order to identify individuals with IGT or diabetes [Grade D.5 to 5.0 mmol/L and/or A1C 5.0 to 6.Recommendation 3 and 4 3.9 2013 mmol/L and/or A1C 6.ca | 1-800-BANTING (226-8464) | diabetes.6 to 6.

ca | 1-800-BANTING (226-8464) | diabetes.ca – for patients guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.CDA Clinical Practice Guidelines http://guidelines.ca Copyright © 2013 Canadian Diabetes Association .diabetes.

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