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CDE Diabetes

Practice Exam: Clinical Practice Guidelines Tools & Resources

Post author By Michael Boivin
Post date December 28, 2025

Tags CDE, Diabetes

Study Guide: Diabetes Canada Clinical Practice Tools

Post author By Michael Boivin
Post date December 28, 2025

1. Screening & Diagnosis: Postpartum GDM

Review the “Postpartum Screening” tool.

The “Why”: GDM increases the risk of T2D significantly. A fasting glucose alone can miss up to 40% of dysglycemia in postpartum women.
Screening Protocol:
- Method: 75g Oral Glucose Tolerance Test (OGTT).
- Timing: Between 6 weeks and 6 months postpartum.
- Ongoing Surveillance:
  - If negative: Rescreen every 3 years (or sooner if risk factors present) and before a future pregnancy.
  - If positive (Prediabetes/T2D): Refer to diabetes education/management.
Prevention: Lifestyle modification (diet/exercise) can reduce T2D risk by up to 60%.

2. Pharmacotherapy: T2D Management

Review the “Cardiorenal Protection” and “Stepwise Approach” tools.

A. Cardiorenal Protection (The “ABCDE” of Prevention)

Prioritize agents with proven benefit for ASCVD, HF, or CKD regardless of A1C target.

High CV Risk: Start GLP-1 RA and/or SGLT2i.
Heart Failure (HF): Start SGLT2i (Dapagliflozin, Empagliflozin, Canagliflozin).
CKD: Start SGLT2i, GLP-1 RA, and/or nsMRA (Finerenone).
Statin Therapy: Recommended if:
- Age $\ge$ 40.
- Age $\ge$ 30 with diabetes >15 years.
- Any microvascular complications or CV risk factors.

B. Renal Function & Medication Safety

Memorize the eGFR cut-offs for holding/stopping meds.

Metformin:
- eGFR < 15 or dialysis: Avoid/Stop.
- eGFR 15-29: Max dose 500 mg/day.
- eGFR 30–44: Max dose 1000 mg/day.
SGLT2 Inhibitors:
- Dapagliflozin: Do not initiate if eGFR < 25 (can continue until dialysis).
- Empagliflozin: Do not initiate if eGFR < 20 (can continue until dialysis).
- Canagliflozin: Do not initiate if eGFR < 30 (can continue until dialysis).
Sulfonylureas:
- Glyburide: Avoid if eGFR < 60 (Use Gliclazide instead).

3. Insulin Management

A. Initiation in Type 2 Diabetes

Basal Start:
- Start at 10 units at bedtime or 0.1–0.2 units/kg (for lean individuals <50kg).
- Titration: Increase by 1 unit every day until fasting BG is 4–7 mmol/L.
- Tresiba (Degludec): Increase by 2–4 units every 3–7 days.
Basal-Plus: If targets not met, add 1 injection of bolus insulin at the largest meal (start ~4 units or 10% of basal dose).
Basal-Bolus: Start TDD at 0.3–0.5 units/kg. Split 40-50% Basal / 50-60% Bolus.

B. Insulin Pharmacokinetics (Key for Exam scenarios)

Rapid-Acting (Aspart, Lispro, Glulisine): Onset 9–20 min, Peak 1–1.5 h, Duration 3–5 h.
Fiasp (Faster Aspart): Onset 4 min, Peak 0.5–1.5 h.
Basal:
- Glargine U-100 (Lantus): Duration up to 24h, no peak.
- Glargine U-300 (Toujeo): Duration >30h.
- Degludec (Tresiba): Duration 42h.
- Icodec (Awiqli): Once weekly, duration >7 days.

C. Automated Insulin Delivery (AID) Safety

If an AID pump fails, how do you transition to injections?

Basal Replacement: Total daily basal = Pump TDD $\div$ 2.
- Transition: Give rapid-acting insulin every hour until long-acting takes effect if pump off >1 hour.
Bolus: Use the pump’s Insulin-to-Carb Ratio (ICR).
Correction: Use the pump’s Insulin Sensitivity Factor (ISF).

4. Safety: Hypoglycemia & Sick Days

Review “Keeping People Safe” tools.

A. Sick Day Management: “SADMANS”

Hold the following medications during dehydrating illness (vomiting/diarrhea) to prevent kidney injury:

S – Sulfonylureas
A – ACE Inhibitors
D – Diuretics
M – Metformin
A – ARBs
N – NSAIDs
S – SGLT2 Inhibitors

B. Hypoglycemia Management

Level 1 (<3.9 mmol/L) & Level 2 (<3.0 mmol/L): Treat with 15g fast-acting carb. Retest in 15 min.
Level 3 (Severe/Unconscious): Glucagon (3mg intranasal or 1mg SC/IM).
Driving Guidelines (“5 to Drive”):
- Check BG before driving and every 4 hours.
- If BG < 4.0, stop and treat. Wait until BG $\ge$ 5.0 mmol/L to drive.
- Wait 45-60 mins for brain function to restore.

5. Special Populations: Ramadan Fasting

Review “Ramadan Fasting Position Statement”.

A. Risk Stratification

Very High Risk (MUST NOT FAST): T1D with A1C >9%, hypoglycemia unawareness, recent DKA/severe hypo, pregnancy (on insulin).
High Risk (SHOULD NOT FAST): T2D with poor control, pregnancy (diet controlled), intense labor.

B. Medication Adjustments During Fasting

Metformin/SGLT2i/GLP-1: No dose change usually needed (SGLT2i take at Iftar). Note: Hold SGLT2i if elderly/diuretic use.
Sulfonylureas: Switch to Gliclazide/Repaglinide (lower hypo risk).
- Gliclazide: Take at Iftar (sunset); reduce dose if needed.
Insulin:
- Basal: Reduce dose by 15–30%.
- Premix: Take normal morning dose at Iftar; reduce Suhur (predawn) dose by 25–50%.

6. Complications Screening: Foot Care

Review “Inlow’s 60-second Diabetic Foot Screen”.

A. The 60-Second Screen

Look: Skin (ulcer, callus), Nails (thick, ingrown), Deformity (Charcot, bunions).
Feel: Temperature (hot=infection/Charcot, cool=ischemia).
Ask: “Do your feet ever feel numb, tingle, or burn?”.

B. Risk Categories & Management

Risk Category	Definition	Screen Frequency
Very Low (0)	No LOPS (Loss of Protective Sensation), No PAD	Yearly
Low (1)	LOPS or PAD	6–12 Months
Moderate (2)	LOPS + PAD or Deformity	3–6 Months
High (3)	History of ulcer/amputation	1–3 Months
Urgent	Active ulcer, infection, Charcot	Immediate

7. Psychosocial & Immunizations

Review “Diabetes Distress Scale” and “Immunizations”.

A. Diabetes Distress Scale (DDS)

Interpretation: A mean item score $\ge$ 2.0 indicates moderate distress worthy of clinical attention.
Domains: Emotional Burden, Physician Distress, Regimen Distress, Interpersonal Distress.
Action: If score $\ge$ 3.0, administer full scale and discuss specific sources.

B. Recommended Immunizations

Adults with diabetes should receive:

Annual: Influenza, COVID-19.
One-time/Series:
- Pneumococcal: Pneu-C-20 or Pneu-C-21 (one dose).
- Hepatitis B: If not vaccinated in childhood.
- Shingles (Herpes Zoster): Recombinant Zoster Vaccine (RZV) (2 doses) for age $\ge$ 50.
- RSV: Adults $\ge$ 50 (individualized).

References:

Many tools can be downloaded at: For Health-Care Providers Tools & Resources

Tags CDE, Diabetes

CDE Diabetes

Flashcards: Clinical Tools & Resources (Appendices)

Post author By Michael Boivin
Post date December 28, 2025

The Appendices of the Clinical Practice Guidelines are the practical “engine room” of diabetes care, containing the specific tools needed to translate theory into action. These flashcards are designed to help pharmacists and healthcare professionals quickly recall critical lists—from the “SADMANS” sick-day protocol to insulin pharmacokinetics—ensuring you have these references at your fingertips when patient safety is on the line.

Key Topics Covered:

Sick Day Management: Memorizing the “SADMANS” mnemonic to identify medications (Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors) that must be held during acute illness to prevent kidney injury.
Insulin Pharmacokinetics: Recalling the specific onset, peak, and duration profiles for rapid-acting, short-acting, intermediate, and long-acting insulins to optimize timing and avoid hypoglycemia.
Neuropathy Screening: Reviewing the correct application of the 10g Semmes-Weinstein monofilament and 128 Hz tuning fork to detect loss of protective sensation.
Etiologic Classification: Distinguishing between different types of diabetes, including those induced by drugs (e.g., atypical antipsychotics, glucocorticoids) or genetic defects (e.g., MODY).
Titration Protocols: Mastering the standard initiation and titration rules for basal insulin (e.g., starting at 10 units and increasing by 1 unit daily until fasting targets are met).

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Clinical Tools & Resources (Appendices)

Post author By Michael Boivin
Post date December 28, 2025

The Appendices of the 2018 Guidelines are not merely supplementary material; they are the “engine room” of clinical practice. They provide the practical tools, algorithms, and reference charts necessary to translate evidence into daily patient care—from safe insulin titration and sick day management to comprehensive foot exams and driving safety assessments.

This practice exam tests your proficiency in utilizing these essential tools to ensure patient safety, accurate classification, and effective self-management support.

Key Concepts Covered in This Exam:

Sick Day Management: Mastering the “SADMANS” protocol—knowing which medications (like sulfonylureas, ACE inhibitors, diuretics, metformin, and SGLT2 inhibitors) to pause during acute illness to prevent kidney injury and adverse effects.
Insulin Pharmacokinetics: Memorizing the onset, peak, and duration of various insulin types (e.g., rapid-acting analogues vs. NPH vs. long-acting basal insulins) to optimize timing and prevent hypoglycemia.
Titration Protocols: Applying the specific algorithms for starting and adjusting basal insulin, such as the rule to increase basal insulin by 1 unit daily until the fasting glucose target is reached.
Neuropathy Screening: Understanding the correct technique for using the 10g Semmes-Weinstein monofilament and the 128 Hz tuning fork to detect loss of protective sensation and assess ulcer risk.
Etiologic Classification: Differentiating between Type 1, Type 2, and “Other specific types” of diabetes, including those induced by drugs (e.g., glucocorticoids, atypical antipsychotics) or genetic defects (e.g., MODY).

Please go to Practice Exam: Clinical Tools & Resources (Appendices) to view this quiz

Tags CDE, Diabetes

CDE Diabetes

CDE Exam Study Guide: Clinical Practice Guidelines Appendices (2018)

Post author By Michael Boivin
Post date December 28, 2025

1. Diabetes Charter (Appendix 1)

Key Takeaway: The Charter defines the rights and responsibilities of people living with diabetes, healthcare providers, governments, and organizations. The central theme is dignity, respect, and equity.

The Vision: A country where people with diabetes live to their full potential.
Guiding Principles:
- Treat people with dignity and respect.
- Advocate for equitable access to care.
- Enhance quality of life for patients and caregivers.

A. Rights of Canadians with Diabetes

Respect & Dignity: To be free from stigma and discrimination.
Access: Affordable/timely access to meds, devices, supplies, and healthy food regardless of income or location.
Care Team: Timely diagnosis and education from an interprofessional team (nurse, dietitian, pharmacist, etc.).
Decision Making: To be an active partner in decisions regarding their own care.
Accommodation:
- Schools/Daycares: Full participation with reasonable accommodation and assistance.
- Workplaces: Supportive environments that do not discriminate and provide reasonable accommodation.

B. Responsibilities of Canadians with Diabetes

Self-Management: Manage diet, exercise, and medication to the best of their ability and personal circumstances.
Transparency: Be honest and open with health providers to allow for suitable care plans.
Education: Actively seek information and support.

C. Responsibilities of Health-Care Providers

Partnership: Treat people with diabetes as full partners in their care.
Evidence-Based Care: Apply up-to-date clinical practice guidelines (CPG).
Early Diagnosis: Diagnose diabetes as early as possible.
System Navigation: Help patients navigate the healthcare system.

D. Institutional Responsibilities

Schools/Daycares: Must ensure staff have accurate information, provide a safe environment for self-management, and protect children from discrimination.
Workplaces: Must eliminate discrimination and provide accommodation.
Governments: Guarantee fair access to care regardless of income/location and address disparities in vulnerable populations.

2. Etiology & Classification (Appendix 2)

Key Takeaway: While Type 1 and Type 2 are most common, you must recognize “Other Specific Types” often triggered by medications or genetics.

Drug-Induced Diabetes: Be able to identify drugs that induce hyperglycemia:
- Glucocorticoids (e.g., prednisone)
- Atypical Antipsychotics (e.g., clozapine, olanzapine)
- Statins (HMG CoA reductase inhibitors)
- Thiazides (diuretics)
- Calcineurin inhibitors (transplant drugs)
Genetic Syndromes: Commonly associated with diabetes include Down syndrome, Turner syndrome, and Klinefelter syndrome.

3. Physical Activity Prescription (Appendix 4)

Key Takeaway: “Smarter Step Count” prescription.

Goal: Increase baseline step count by 3,000 steps per day within 1 year.
Increments:
- If baseline <5,000 steps: Add 500 steps at first visit.
- If baseline 5,000-7,499: Add 750 steps at first visit.
- If baseline $\ge$ 7,500: Add 1,000 steps at first visit.

5. Self-Monitoring of Blood Glucose (SMBG) (Appendix 5)

Key Takeaway: Frequency of testing depends on the treatment regimen and glycemic stability.

Basal-Bolus (MDI) or Pump: Test $\ge$ 4 times daily (before meals and bedtime).
Oral Agents / Lifestyle only: If meeting targets, frequent testing is not usually required.
Newly Diagnosed (<6 mos): Test $\ge$ 1 time/day at different times to learn how lifestyle affects BG.
Safety Occupations: As required by employer/driving guidelines.

6. Insulin Pharmacokinetics (Appendix 6)

Key Takeaway: You must know the Onset, Peak, and Duration to troubleshoot hypoglycemia or hyperglycemia patterns.

Insulin Type	Examples	Onset	Peak	Duration
Rapid- Acting	Aspart, Lispro, Glulisine	10–15 min	1–2 h	3–5 h
Short- Acting	Regular (Toronto)	30 min	2–3 h	6.5 h
Intermediate	NPH (Cloudy)	1–3 h	5–8 h	Up to 18 h
Long- Acting	Glargine U-100, Detemir	90 min	None	Up to 24 h
Ultra-Long	Degludec, Glargine U-300	90 min	None	>30 h

7. Sick Day Management: "SADMANS" (Appendix 8)

Key Takeaway: When a patient is ill, dehydrated, or has acute renal decline, certain medications must be PAUSED to prevent acute kidney injury (AKI) or adverse effects.

Instructions: Stop the following meds if unable to maintain hydration; restart when well.

S – Sulfonylureas (risk of hypoglycemia)
A – ACE Inhibitors (risk of renal decline)
D – Diuretics / Direct Renin Inhibitors (risk of volume depletion)
M – Metformin (risk of lactic acidosis/reduced clearance)
A – Angiotensin Receptor Blockers (ARBs) (risk of renal decline)
N – Non-steroidal Anti-inflammatory Drugs (NSAIDs) (risk of renal decline)
S – SGLT2 Inhibitors (risk of DKA/volume depletion)

Exam Tip: Remember that insulin should not inherently be stopped during sick days; often doses need adjustment (usually increasing) due to stress hyperglycemia, but the “SADMANS” list refers specifically to non-insulin meds that pose safety risks during dehydration.

8. Insulin Initiation & Titration in T2D (Appendix 9)

Key Takeaway: The standard approach for starting insulin in Type 2 Diabetes involves safety first (avoiding hypo) and gradual titration.

Starting Basal Insulin:
- Start: 10 units at bedtime.
- Titrate: Increase by 1 unit per day until fasting glucose target (4.0–7.0 mmol/L) is reached.
- Exception: Degludec is titrated every 3–4 days (2 units) or once weekly (4 units) due to longer half-life.
Safety Rule: Do not increase dose if the patient has >2 hypo episodes (<4.0 mmol/L) in a week or any nocturnal hypoglycemia.
Adding Bolus (Basal Plus): Start 2–4 units at one meal (usually largest). Titrate by 1 unit daily to target 2hr post-meal $\le$ 8.0 mmol/L .

9. Driving Guidelines (Appendix 10)

Key Takeaway: Assessment for fitness to drive focuses on hypoglycemia awareness and severity.

Commercial Drivers: Disqualified if they have any episodes of severe hypoglycemia during waking hours in the past 12 months .
Private Drivers: Assessment focuses on severe hypoglycemia in the past 6 months .
Monitoring Rule: Drivers on insulin/secretagogues must monitor at least every 4 hours while driving.
Supplies: Must have monitoring equipment and rapid carbs within reach in the vehicle.

10. Foot Care & Neuropathy Screening (Appendices 11, 12, 13)

Key Takeaway: Screening must be done annually using a 10g Monofilament or 128 Hz Tuning fork to assess risk of ulceration.

A. 10g Semmes-Weinstein Monofilament Test

Technique: Apply perpendicular to skin until it buckles for ~1 second.
Sites: Dorsum of great toe (screening) or plantar sites (comprehensive).
Scoring (Screening):
- Test 8 stimuli (4 per foot).
- Score < 3/8 correct = Likely Neuropathy.
- Protective sensation is absent if 2 out of 3 applications at a single site are incorrect.

B. 128 Hz Tuning Fork (On-Off Method)

Apply to the bony prominence of the great toe.
Patient must identify when vibration is felt and when it stops.

C. Foot Care Checklist

DO: Check feet daily, use mirror, trim nails straight across, buy shoes in late afternoon (feet swell).
DO NOT: Soak feet, use hot water bottles, walk barefoot, use over-the-counter corn/wart removers.

References:

Appendix 1: Diabetes Canada Diabetes Charter. Canadian Journal of Diabetes. 2018;42:S307. doi:10.1016/j.jcjd.2017.11.001

Appendix 2: Etiologic Classification of Diabetes Mellitus. Canadian Journal of Diabetes. 2018;42:S308. doi:10.1016/j.jcjd.2017.10.041

Appendix 3: Examples of Insulin Initiation and Titration Regimens in People with Type 2 Diabetes. Canadian Journal of Diabetes. 2013;37, Supplement 1:S200-S201. doi:10.1016/j.jcjd.2013.02.041

Appendix 4: Smarter Step Count Prescription. Canadian Journal of Diabetes. 2018;42:S311. doi:10.1016/j.jcjd.2017.12.005

Appendix 5: Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Health-Care Providers. Canadian Journal of Diabetes. 2018;42:S312-S313. doi:10.1016/j.jcjd.2017.10.043

Appendix 6: Therapeutic Considerations for Renal Impairment. Canadian Journal of Diabetes. 2013;37, Supplement 1:S207-S208. doi:10.1016/j.jcjd.2013.02.044

Diabetes Canada. Appendix 6: Types of Insulin. Canadian Journal of Diabetes. 2018;42:S314. doi:10.1016/j.jcjd.2017.12.006

Appendix 8: Sick-Day Medication List. Canadian Journal of Diabetes. 2018;42:S316. doi:10.1016/j.jcjd.2017.10.045

Diabetes Canada. Appendix 9: Examples of Insulin Initiation and Titration Regimens in People With Type 2 Diabetes. Accessed April 11, 2025. https://guidelines.diabetes.ca/appendices/appendix9

Appendix 10: Sample Diabetes and Driving Assessment Form. Canadian Journal of Diabetes. 2018;42:S319. doi:10.1016/j.jcjd.2017.10.050

Appendix 11A: Rapid Screening for Diabetic Neuropathy Using the 10 g Semmes-Weinstein Monofilament. Canadian Journal of Diabetes. 2018;42:S320. doi:10.1016/j.jcjd.2017.10.046

Appendix 11B: Rapid Screening for Diabetic Neuropathy Using the 128 Hz Vibration Tuning Fork (the “On-Off” Method). Canadian Journal of Diabetes. 2018;42:S321. doi:10.1016/j.jcjd.2017.10.054

Appendix 12: Monofilament Testing in the Diabetic Foot. Canadian Journal of Diabetes. 2018;42:S322. doi:10.1016/j.jcjd.2017.10.047

Appendix 13: Diabetes and Foot Care: A Checklist. Canadian Journal of Diabetes. 2018;42:S323. doi:10.1016/j.jcjd.2017.10.048

Appendix 14: Diabetic Foot Ulcers—Essentials of Management. Canadian Journal of Diabetes. 2018;42:S324. doi:10.1016/j.jcjd.2017.10.049

Appendix 15: Glycated Hemoglobin Conversion Chart. Canadian Journal of Diabetes. 2018;42:S325. doi:10.1016/j.jcjd.2017.10.051

Tags CDE, Diabetes

CDE Diabetes

Flashcards: Diabetes and MASLD (Chapter 42)

Post author By Michael Boivin
Post date December 27, 2025

Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD)—formerly NAFLD—is a highly prevalent comorbidity in Type 2 diabetes that significantly increases the risk of cirrhosis, hepatocellular carcinoma, and cardiovascular death. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2024 Clinical Practice Guidelines Update regarding the new nomenclature, the two-step screening algorithm for fibrosis, and the emerging pharmacotherapeutic options.

Key Topics Covered:

New Terminology: Understanding the transition from NAFLD to MASLD (Metabolic Dysfunction-associated Steatotic Liver Disease) and MASH (Metabolic Dysfunction-associated Steatohepatitis) [cite: Ch42-Diabetes-and-Metabolic-Dysfunction-associated-Steatotic-Liver-Disease-in-Adults.pdf].
Screening Protocol: Memorizing the two-step algorithm: starting with the FIB-4 index (age, AST, ALT, platelets) every 3 years to rule out advanced fibrosis in patients with Type 2 diabetes [cite: Ch42-Diabetes-and-Metabolic-Dysfunction-associated-Steatotic-Liver-Disease-in-Adults.pdf].
Risk Stratification: Identifying the thresholds for referral: knowing that a low FIB-4 score (<1.3) allows for continued primary care management, while higher scores require second-line testing (e.g., FibroScan).
Pharmacotherapy: Recalling that GLP-1 receptor agonists and SGLT2 inhibitors are the preferred antihyperglycemic agents for patients with MASLD, and that pioglitazone has specific benefits for MASH.
Statin Use: Reinforcing that statins are safe and essential for cardiovascular protection in this population, despite potential mild elevations in liver enzymes.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Diabetes and MASLD (Chapter 42)

Post author By Michael Boivin
Post date December 27, 2025

Formerly known as Non-Alcoholic Fatty Liver Disease (NAFLD), Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) affects up to 70% of people with Type 2 diabetes. The 2024 Clinical Practice Guidelines Update introduces a major paradigm shift: moving from passive observation to active screening for liver fibrosis to prevent cirrhosis and liver-related mortality.

This practice exam tests your ability to apply the new nomenclature, utilize the recommended two-step screening algorithm, and select appropriate pharmacotherapy that addresses both metabolic and hepatic health.

Key Concepts Covered in This Exam:

New Nomenclature: Recognizing the shift from NAFLD to MASLD to more accurately reflect the pathophysiology driven by metabolic dysfunction.
Screening Algorithm: Mastering the two-step screening strategy for adults with Type 2 diabetes: utilizing the FIB-4 index (based on age, AST, ALT, and platelet count) as the initial triage tool every 3 years.
Advanced Assessment: Knowing when to refer for second-line non-invasive testing, such as Vibration Controlled Transient Elastography (VCTE/FibroScan) or the Enhanced Liver Fibrosis (ELF) test, for patients with indeterminate or high FIB-4 scores.
Pharmacotherapy: Identifying GLP-1 receptor agonists (semaglutide, liraglutide) and SGLT2 inhibitors as preferred agents for patients with T2D and MASLD, and the specific role of pioglitazone in improving liver histology in confirmed steatohepatitis (MASH).
Statin Safety: Reinforcing that statins are safe and indicated for cardiovascular risk reduction in patients with MASLD and should not be withheld due to mild liver enzyme elevations.

Please go to Practice Exam: Diabetes and MASLD (Chapter 42) to view this quiz

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Diabetes and Metabolic Dysfunction-associated Steatotic Liver Disease (Chapter 42)

Post author By Michael Boivin
Post date December 27, 2025

1. New Nomenclature & Definitions

The terminology has shifted from “Non-alcoholic” to “Metabolic” to reduce stigma and better reflect the pathophysiology.

MASLD (Metabolic dysfunction-associated Steatotic Liver Disease): Replaces NAFLD. Defined as hepatic steatosis with at least one cardiometabolic risk factor (Diabetes/Prediabetes, Obesity, Hypertension, Dyslipidemia) and without harmful alcohol intake.
MASH (Metabolic dysfunction-associated Steatohepatitis): Replaces NASH. The progressive form characterized by inflammation and hepatocyte injury (ballooning).
MetALD: A new category for individuals with MASLD who also consume increased alcohol (140–350 g/week for women, 210–420 g/week for men). This highlights the synergistic damage of metabolic disease and alcohol .

2. Epidemiology & Risk

Prevalence:
- Type 2 Diabetes (T2D): ~70% have MASLD.
- Type 1 Diabetes (T1D): ~22% have MASLD.
Primary Risk Driver: Liver Fibrosis (scarring) is the primary determinant of adverse outcomes (hepatic and non-hepatic).
Mortality: The leading cause of death in people with MASLD is Cardiovascular Disease (CVD), followed by extrahepatic cancers and liver-related complications.

3. Screening & Diagnosis (The FIB-4 Index)

Because steatosis is so common in T2D, screening focuses on identifying advanced fibrosis (F3–F4) rather than just fatty liver.

Who to Screen: All adults with Prediabetes or Type 2 Diabetes.
Screening Tool: Fibrosis-4 Index (FIB-4).
- Inputs: Age, AST, ALT, Platelet Count.
Interpretation & Action:
- Low Risk (FIB-4 < 1.3): Unlikely to have advanced fibrosis. Manage in primary care; repeat screening in 1–3 years.
- Indeterminate Risk (FIB-4 1.3 – 2.67): Requires “second-line” testing (e.g., transient elastography/FibroScan® or ELF test) to clarify risk.
- High Risk (FIB-4 > 2.67): High probability of advanced fibrosis. Refer to Hepatology.

4. Management Strategies

A. Lifestyle Interventions (Cornerstone)

Weight Loss:
- $\ge$ 5%: Required to reduce liver fat.
- $\ge$ 7-10%: Required to resolve MASH (inflammation) and improve fibrosis.
Diet: The Mediterranean Diet is specifically recommended to reduce liver fat and improve outcomes.
Alcohol: Abstinence or minimization of alcohol intake is crucial.

B. Pharmacotherapy

Agents used for diabetes can have dual benefits for the liver.

Pioglitazone: Improves MASH resolution and improves fibrosis scores. (Watch for weight gain/heart failure).
GLP-1 Receptor Agonists (Semaglutide, Liraglutide): Improve MASH resolution but have not consistently shown improvement in fibrosis stage in trials as of time of guideline developement.
SGLT2 Inhibitors: Reduce liver fat content and liver enzymes; effects on histology (fibrosis) are less established but they provide cardiorenal protection.
Statins: Safe to use in MASLD. Do not discontinue statins due to mild liver enzyme elevations; they reduce cardiovascular risk, which is the leading cause of death in this population.

C. Surgical Management

Bariatric (Metabolic) Surgery: Can result in resolution of MASH and improvement in fibrosis in a high percentage of patients (up to 80-90%).

5. Diabetes Canada 2025 Clinical Practice Guidelines Recommendations

Key takeaways for the exam.

Screening: Screen all adults with T2D or prediabetes for MASLD with the FIB-4 Index (every 1-3 years) [Grade D, Consensus].
Pathway:
- If FIB-4 < 1.3: Manage standard CV risks [Grade C, Level 3].
- If FIB-4 > 2.67: Refer to specialist/hepatologist [Grade C, Level 3].
Lifestyle: Aim for 7-10% weight loss to improve liver fibrosis/inflammation [Grade B, Level 2].
Pharmacotherapy: Consider Pioglitazone or GLP-1 RAs (Semaglutide/Liraglutide) for patients with biopsy-proven MASH or those at high risk to improve liver health [Grade A/B].
Statins: Statins are safe and should be used to reduce CV risk in patients with MASLD [Grade B, Level 2].

Reference:

Kim J, Bajaj HS, Ramji A, Bemeur C, Sebastiani G. Diabetes and Metabolic Dysfunction–associated Steatotic Liver Disease in Adults: A Clinical Practice Guideline. Canadian Journal of Diabetes. 2025;49(4):222-236. doi:10.1016/j.jcjd.2025.04.003

Tags CDE, Diabetes

CDE Diabetes

Flashcards: Glycemic Management in Type 1 Diabetes (Chapter 41)

Post author By Michael Boivin
Post date December 27, 2025

This module covers the critical paradigm shifts in the management of Type 1 Diabetes (T1D) for both adults and children. These guidelines replace the previous 2018 chapters on Glycemic Management in Adults and portions of the Type 1 Diabetes in Children and Adolescents chapter.

Key Concepts Covered in These Flashcards:

Unified Glycemic Targets: The shift to an A1C target of <7.0% for all ages, including children, to protect brain development and reduce long-term complications.
Technology First: The new recommendation establishing Automated Insulin Delivery (AID) systems as the preferred treatment method for all individuals willing and able to use them.
Advanced Therapeutics: The role of ultrarapid and ultra-long-acting insulin analogues in minimizing hypoglycemia and improving Time in Range (TIR).
Adjunctive Therapies: Evidence-based guidance on the use of non-insulin agents like Metformin, GLP-1RAs, and SGLT2 inhibitors in adults.
Emergency Management: Updated protocols for treating hypoglycemia (including adjustments for AID users) and managing Diabetic Ketoacidosis (DKA) with fluids and subcutaneous insulin.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Glycemic Management in Type 1 Diabetes (Chapter 41)

Post author By Michael Boivin
Post date December 27, 2025

This new “Special Article” and Clinical Practice Guideline (Chapter 41) represents a significant consolidation in the Diabetes Canada guidelines. It replaces the previous separate chapters for Adults (2018, Ch. 12) and Children/Adolescents (2018, Ch. 34).

For the CDE candidate, this chapter is high-yield. It moves away from age-stratified silos and towards a lifespan approach that prioritizes technology, mental burden reduction, and aggressive complication prevention.

Before you jump into the practice questions, here are the 5 Key Practice Changes you need to know:

AID is the New Gold Standard The guidelines no longer present insulin pumps as a second-line option for specific candidates. Automated Insulin Delivery (AID) systems are now the preferred treatment method for all individuals (adults and children) to optimize glycemia and improve person-reported outcomes. If AID is not possible, CGM should be used with pump therapy or basal-bolus injections.
Pediatric Targets Have Tightened Historically, A1C targets for children were higher to avoid hypoglycemia. However, new evidence links chronic hyperglycemia in young children to white matter structural changes in the brain. Consequently, the recommended A1C target for the pediatric population is now <7.0% across all age groups.
“Ultra” Insulins are Preferred To minimize hypoglycemia and improve outcomes, ultra-rapid and ultra-long-acting insulin analogues should be considered in place of standard rapid- or long-acting analogues for both adults and children.
Adjunctive Therapies (Non-Insulin) The guidelines now open the door for adjunctive therapies in adults, such as Metformin, GLP-1 RAs, or SGLT2 inhibitors, to help meet goals. However, this comes with strict safety warnings, particularly regarding the risk of euglycemic DKA with SGLT2i use.
Managing Emergencies There are updated protocols for hypoglycemia and DKA:
- Hypoglycemia: Intranasal glucagon is recommended for adults and children.
- DKA: Subcutaneous insulin can be safely used to manage non-severe DKA , and fluid resuscitation in children can be more aggressive than previously feared.

Please go to Practice Exam: Glycemic Management in Type 1 Diabetes (Chapter 41) to view this quiz

Tags CDE, Diabetes