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CDE Diabetes

Study Guide: Glycemic Management Across the Lifespan for People With Type 1 Diabetes (2025 Update)

1. Overview & Scope

This is a major update that replaces the 2018 “Glycemic Management in Adults with Type 1 Diabetes” chapter and updates the glycemic sections of the “Type 1 Diabetes in Children and Adolescents” chapter.

  • Goal: To support individuals in living well with type 1 diabetes throughout their lifespan, balancing glycemic optimization with hypoglycemia risk and quality of life.
  • Key Shift: Universal access to advanced insulin therapies (second-generation analogues) and technologies (Automated Insulin Delivery) is advocated for all individuals.

2. Updated Terminology

The guidelines have updated the language to reflect modern clinical practice.

New TermPrevious/
Related Terms		Description
BBI (Basal Bolus Injection)MDI (Multiple Daily Injections)Subcutaneous delivery of rapid and long-acting insulin via pens/syringes.
IPT (Insulin Pump Therapy)CSII (Continuous Subcutaneous Insulin Infusion)Pump therapy without automation.
IPT + PLGSSAP + PLGS (Sensor Augmented Pump)Pump + CGM with Predictive Low Glucose Suspend (automated basal suspension).
AID (Automated Insulin Delivery)Hybrid Closed Loop / Artificial PancreasPump + CGM with automated increases, decreases, and suspensions of basal insulin (and sometimes automated boluses).

3. Glycemic Targets

  • Universal Target: An A1C target of < 7.0% is now recommended for ALL age groups, including children (previously, children had higher targets).
    • Rationale: Evidence suggests chronic hyperglycemia in young children (4–10 years) impacts brain development/cognition. New technologies (AID/CGM) make lower targets safer.
  • Person-Centered: Targets must be individualized. If <7.0% is not attainable without severe hypoglycemia or significant burden, a higher target is appropriate.

4. Insulin Therapy (Formulations)

The guidelines express a clear preference for modern analogues over older insulins to improve A1C and reduce hypoglycemia.

  • Rapid-Acting Analogues (Aspart, Lispro, Glulisine): Preferred over Regular insulin for BBI and IPT.
  • Ultrarapid-Acting Analogues (FiAsp, Lyumjev):
    • Recommendation: Should be considered in place of rapid analogues for BBI (to lower post-prandial glucose) and IPT (to improve Time in Range).
    • Timing: Ideally administered 10–20 minutes prior to meals.
  • Long-Acting Basal Analogues (Glargine U-100, Detemir): Preferred over NPH due to lower hypoglycemia risk.
  • Ultralong-Acting Basal Analogues (Glargine U-300, Degludec):
    • Recommendation: Should be considered in place of long-acting analogues to further minimize hypoglycemia (especially nocturnal) and glycemic variability.
    • Weekly Insulin: Once-weekly Icodec is not generally preferred for T1D due to a 2-fold increase in hypoglycemia risk compared to daily basal.

5. Insulin Delivery Hierarchy (The "Choice" Recommendations)

For the CDE exam, know the hierarchy of preferred treatments based on efficacy:

  1. Automated Insulin Delivery (AID):
    • Gold Standard: Preferred for ALL individuals (adults and children) willing/able to use it.
    • Benefits: Improves A1C, Time in Range (TIR), and Quality of Life; reduces hypoglycemia, diabetes distress, and sleep interruption.
  2. IPT + PLGS (Predictive Low Glucose Suspend):
    • Recommended if AID is not used, specifically to reduce hypoglycemia.
  3. Insulin Pump Therapy (IPT):
    • Preferred over BBI to improve A1C and lifestyle flexibility.
  4. Basal Bolus Injection (BBI):
    • Standard injection therapy. Use of smart apps/bolus calculators is recommended to improve outcomes.

6. Adjunctive Therapies (Adults Only)

Using non-insulin agents to help with weight, insulin dose, and glycemia.

  • Status: Conditional recommendation for Adults only. (Insufficient evidence for children).
  • Classes:
    • Metformin: Reduces weight and insulin dose; minimal A1C effect.
    • GLP-1 RAs: Reduces A1C, weight, and insulin dose. Risk: GI side effects, ketosis.
    • SGLT2 Inhibitors: Reduces A1C, weight, and variability. Risk: Euglycemic DKA and genital infections.
  • Safety: Requires careful monitoring. SGLT2i use requires the STOP DKA protocol (ketone monitoring even if glucose is normal).

7. Acute Complications: Pediatric Updates

New protocols for Hypoglycemia and DKA in children differ from historical teaching.

A. Hypoglycemia Treatment (Children/Adolescents)

  • Dose: 0.3 g/kg of carbohydrate.

    • Age < 5: 5 g

    • Age 5–10: 10 g

    • Age > 10: 15 g.

  • AID Users: May require LESS carbohydrate (e.g., 5–10 g) because the pump has already suspended insulin.
  • Severe Hypoglycemia:
    • Intranasal Glucagon: Recommended for age 4 years.
    • Injectable Glucagon: Standard for all ages; preferred over nasal for < 4 years.

B. Diabetic Ketoacidosis (DKA) Management

  • Fluids: Isotonic fluids (Normal Saline or Balanced Crystalloids) are safe. Aggressive fluid resuscitation does not increase cerebral edema risk in mild/moderate DKA.
  • Insulin: Subcutaneous insulin (rapid-acting analogues every 1–2 hours) is a safe alternative to IV insulin for mild to moderate DKA in both adults and children. This can avoid ICU admission.

8. Diabetes Canada 2025 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Pages 14-15).

  1. Targets: A1C < 7.0% for all ages to reduce microvascular complications, individualized based on context [Grade A/D].
  2. AID Systems: Should be used in all individuals with T1D to improve A1C, TIR, and Quality of Life [Grade A, Level 1A].
  3. Insulin Choice:
    • Ultrarapid analogues should be considered over rapid analogues to lower post-prandial glucose [Grade A, Level 1A].
    • Ultralong basal analogues should be considered over long-acting to minimize hypoglycemia [Grade C].
  4. Adjunctive Therapy (Adults): Metformin, GLP-1RA, or SGLT2i may be used in adults to achieve specific outcomes (weight/A1C) with careful safety review [Grade D, Consensus].
  5. Pediatric DKA: Use isotonic fluids [Grade B] and consider frequent subcutaneous insulin for mild/moderate cases [Grade B].

Reference:

Halperin IJ, Wicklow B, Amed S, et al. Glycemic Management Across the Lifespan for People With Type 1 Diabetes: A Clinical Practice Guideline. Canadian Journal of Diabetes. 2025;49(1):5-18. doi:10.1016/j.jcjd.2025.01.001
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CDE Diabetes

Flashcards: Remission of Type 2 Diabetes (Chapter 39)

he 2022 Guidelines Update introduced a transformative concept: Type 2 diabetes is not necessarily a permanent, progressive condition. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the evidence-based criteria for remission, the specific interventions (lifestyle and surgical) that drive it, and the safety protocols required for deprescribing medications.

Key Topics Covered:

  • Defining Remission: Memorizing the diagnostic criteria: an A1C <6.0% (on two tests) after at least 3 months without any glucose-lowering pharmacotherapy.

  • Intervention Strategies: Identifying Low-Energy Diets (LED) (800–1000 kcal/day, often using meal replacements) and bariatric surgery as the most effective methods for achieving remission.

  • Deprescribing Protocols: Reviewing the safety steps for stopping insulin, sulfonylureas, and SGLT2 inhibitors at the start of an intervention to prevent hypoglycemia and euglycemic DKA.

  • Terminology: Understanding why the term “remission” is used instead of “reversal” or “cure”—signaling that the risk of relapse remains and ongoing monitoring is essential.

  • Predictors of Success: Recalling that a shorter duration of diabetes (<6 years), younger age, and significant weight loss are strong predictors of achieving remission.

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CDE Diabetes

Practice Exam: Remission of Type 2 Diabetes (Chapter 39)

For decades, Type 2 diabetes was viewed as a progressive, lifelong condition. The updated Clinical Practice Guidelines challenge this paradigm, confirming that remission—restoring healthy blood glucose levels without the use of antihyperglycemic medications—is a viable goal for many people.

This practice exam tests your ability to define remission, identify eligible candidates, and manage the intensive interventions (both lifestyle and surgical) required to achieve and maintain this state.

Key Concepts Covered in This Exam:

  • Defining Remission: Memorizing the specific criteria for remission: an A1C <6.0% measured at least 3 months after stopping all glucose-lowering pharmacotherapy.

  • Structured Interventions: Understanding the role of Low-Energy Diets (LED) (800–1000 kcal/day, typically using meal replacements) and bariatric surgery as the most effective evidence-based methods for achieving remission.

  • Deprescribing Safety: Applying protocols for safely tapering or stopping insulin, sulfonylureas, and SGLT2 inhibitors (to prevent euglycemic DKA) at the start of a remission intervention.

  • Terminology: Recognizing why the term “remission” is preferred over “reversal” or “cure,” emphasizing that the underlying physiology remains and hyperglycemia can return.

  • Long-Term Monitoring: Acknowledging that patients in remission still require regular screening for complications (such as retinopathy and nephropathy) and ongoing cardiovascular risk management.

1. A patient with type 2 diabetes, established ASCVD, and CKD asks about pursuing remission. According to the guideline, what is the most appropriate response?

2. If a person pursuing remission achieves modest weight loss (5-10% of initial body weight) but does not meet remission criteria, what benefits might they still experience?

3. According to the guideline, bariatric surgery should be recommended as an option to potentially induce type 2 diabetes remission in nonpregnant adults with type 2 diabetes and a BMI of at least:

4. At what time points should lab evaluation be performed after stopping antihyperglycemic medications to determine if remission criteria are met?

5. Low-calorie (∼800 to 850 kcal/day) diets with meal replacement products are recommended for remission in nonpregnant adults meeting which of the following criteria?

6. After remission criteria have been met, how frequently should A1C testing be performed to evaluate for persistence of remission versus relapse?

7. According to the guideline, what is the target weight loss for the low-calorie diet approach to induce remission?

8. A patient with type 2 diabetes for 20 years who is on basal-bolus insulin asks about remission. What is the most appropriate approach?

9. According to Diabetes Canada, ‘remission to prediabetes’ is defined as achieving an A1C in which range without antihyperglycemic medications?

10. If an individual achieves remission but subsequently has an A1C ≥6.5%, what is their classification according to Diabetes Canada terminology?

11. According to the guideline, why are no recommendations formulated for pharmacological interventions to induce type 2 diabetes remission?

12. A 55-year-old woman with type 2 diabetes for 3 years, BMI 30 kg/m², on metformin only, achieves an A1C of 5.5% after 6 months without medications. Her perindopril was stopped due to low BP. According to the case studies, should her statin be continued?

13. According to the User’s Guide, what is the duration of Phase 1 (Total Dietary Replacement) in the low-calorie diet protocol?

14. For the exercise training recommendation (Grade C, Level 2), what is the target exercise duration per week?

15. Which of the following is a predictor of late relapse after bariatric surgery?

16. The approach to deprescribing antihyperglycemic agents should incorporate which principles?

17. The Diabetes Canada guideline prefers the term ‘remission’ over ‘reversal’ or ‘regression’ to signify which characteristic of glucose improvement?

18. According to the User’s Guide, during Phase 1 of the low-calorie diet protocol, exercise is:

19. According to Diabetes Canada, what is the minimum duration without antihyperglycemic medications required to meet the definition of type 2 diabetes remission?

20. According to the literature cited in the guideline, what is the median remission period following Roux-en-Y gastric bypass surgery?

21. According to the guideline, what is a potential harm of setting a management plan of remission for patients at high cardiovascular risk?

22. A patient achieves remission criteria but is then started on empagliflozin for heart failure management. According to Diabetes Canada definitions, this patient’s diabetes status would be classified as:

23. According to the Diabetes Canada definitions, what A1C threshold defines ‘remission to normal glucose levels’?

24. In the “Shared Decision-Making Checklist for Remission of Type 2 Diabetes,” which statement about remission is emphasized for patients to understand?

25. A 45-year-old patient with type 2 diabetes for 4 years, BMI 32 kg/m², A1C 8.5%, on metformin only, asks about remission. According to the guideline, which intervention would be most appropriate to recommend?

26. According to the guideline, sustained weight loss of what amount is associated with the greatest probability of type 2 diabetes remission?

27. In the meta-analysis comparing RYGB to sleeve gastrectomy, what were the remission rates at 1 year?

28. If A1C is unreliable (e.g., hemoglobinopathy), what alternative criteria can be used to define remission to normal glucose levels?

29. In the 5As framework for remission counselling, what does the first ‘A’ represent?

30. In the low-calorie diet for remission protocol, how often should the HCP follow up during Phase 1 (Total Dietary Replacement)?


 

Categories
CDE Diabetes

Study Guide: Remission of Type 2 Diabetes (2022 Update)

1. Definition & Terminology

This is a new topic in the guidelines. Understanding the specific definitions is crucial for the exam.

  • Definition: Remission is defined as achieving healthy glucose levels without any antihyperglycemic medications for a minimum of 3 months.

  • Why “Remission”? The terms “Reversal” or “Cure” are discouraged because glucose improvement may be temporary, and the risk of relapse remains.

  • Classification:

    • Remission to Prediabetes: A1C between 6.0% and 6.4% (off meds > 3 months).
    • Remission to Normoglycemia: A1C < 6.0% (off meds > 3 months).

Testing Protocol:

  • Primary Test: A1C is the preferred criteria.

  • Alternative: If A1C is unreliable, use Fasting Plasma Glucose (FPG) or OGTT.

  • Timing: Test at 3 months and 6 months after stopping medications or starting the intervention. If remission is achieved, monitor at least every 6 months thereafter .

2. Candidate Selection (Who is Eligible?)

Not everyone is a candidate. Remission strategies usually involve significant weight loss or surgery.

Ideal Candidates:

  • Duration: Early Type 2 diabetes (diagnosed < 6 years ago).

  • Body weight: Overweight or obesity.

  • Treatment: Not currently taking insulin.

  • Motivation: Inclination to engage in intensive weight loss behaviors.

Exclusions / Caution:

  • Comorbidities: People with established ASCVD, Heart Failure (HF), or Chronic Kidney Disease (CKD) who require organ-protective medications (SGLT2i, GLP-1 RA) should not stop these agents even if glucose normalizes.

  • Mental Health: Those with significant eating disorders or severe mental health disorders.

  • Pregnancy: Recommendations apply to non-pregnant adults.

3. Interventions for Remission

The guidelines reviewed Surgical, Behavioural, Pharmacological, and Digital interventions. Only Surgery and Health Behavioural interventions have graded recommendations.

A. Bariatric Surgery

  • Recommendation: Recommended for adults with T2D and BMI > 35 kg/m²

  • Efficacy: High remission rates (30–63% at 1–5 years).

  • Relapse: 35–50% may eventually relapse.

B. Low-Calorie Diet (The “DiRECT” Protocol)

  • Method:

    • Phase 1: Total diet replacement with low-calorie formula (800–900 kcal/day) for 3–5 months.

    • Phase 2: Structured food reintroduction (1–2 months).

      Phase 3: Weight maintenance with increased physical activity.

  • Target: Aim for > 15 kg weight loss.

  • Eligibility for this specific intervention: BMI 27–45 kg/m², T2D duration < 6 years, not on insulin.

C. Exercise + Calorie Restriction (The “U-TURN” Protocol)

  • Method: High-volume structured exercise (240–420 min/week) combined with calorie restriction.

  • Target: Modest weight loss (5–7%).

  • Eligibility: BMI > 25 kg/m², T2D duration < 10 years, A1C < 9%.

D. Pharmacological & Digital

  • Pharmacotherapy: Currently no recommendation for using meds solely to induce remission (evidence insufficient).

  • Digital: No specific app/tool recommended due to lack of RCT evidence.

4. Deprescribing & Safety

Stopping medications requires a safe, individualized approach.

  • Cardiorenal Protection: Do not stop SGLT2i or GLP-1 RA in patients with ASCVD, HF, or CKD, even if A1C is normal. This is considered “Pharmacologically-managed diabetes,” not remission.

  • Hypoglycemia: Minimize risk when tapering agents (especially insulin/sulfonylureas).

  • Blood Pressure/Lipids: Do not automatically stop statins or ACEi/ARBs. Continue if indicated for CV protection (e.g., Age > 40, established disease) .

5. Managing Expectations & Relapse

  • Shared Decision Making: Use tools like the COM-B Model (Capability, Opportunity, Motivation) and 5As (Ask, Assess, Advise, Agree, Assist) to guide conversations .

  • Relapse Management: Remission is often temporary. If weight regain > 2 kg occurs, consider “rescue” plans (e.g., brief return to meal replacements).

  • Language: Avoid terms like “Failure.” Frame remission as a journey where any weight loss/A1C reduction yields health benefits.

6. Diabetes Canada 2022 Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page 759).

  1. Goal: Remission may be considered for interested individuals without eating disorders or compelling indications for specific organ-protective meds [Grade D, Consensus] .

  2. Monitoring: Test A1C every 6 months to assess for persistence or relapse.

  3. Surgery: Recommend bariatric surgery for T2D + BMI > 35 kg/m² [Grade A, Level 1A].

  4. Low-Calorie Diet: Recommend 800–850 kcal/day meal replacement diet for 3–5 months (target > 15 kg loss) for BMI 27–45, duration < 6 years, non-insulin users [Grade A, Level 1A].

  5. Exercise: Recommend intensive exercise (240–420 min/week) + diet for BMI > 25, duration < 10 years [Grade C, Level 2]

References:

Jin S, Bajaj HS, Brazeau AS, et al. Remission of Type 2 Diabetes: User’s Guide. Canadian Journal of Diabetes. 2022;46(8):762-774. doi:10.1016/j.jcjd.2022.10.005
 
MacKay D, Chan C, Dasgupta K, et al. Remission of Type 2 Diabetes. Canadian Journal of Diabetes. 2022;46(8):753-761.e8. doi:10.1016/j.jcjd.2022.10.004
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CDE Diabetes

Flashcards: Type 2 Diabetes and Indigenous Peoples (Chapter 38)

Indigenous peoples in Canada face a prevalence of Type 2 diabetes that is 3 to 5 times higher than the general population, a disparity rooted in the legacy of colonization and the disruption of traditional lifestyles. These flashcards are designed to help pharmacists and healthcare professionals memorize the 2018 Clinical Practice Guidelines regarding aggressive screening protocols, the specific risks for early-onset complications, and the essential principles of cultural safety.

Key Topics Covered:

  • Screening Protocols: Recalling the recommendation to screen all Indigenous adults for Type 2 diabetes starting at age 18 (or earlier with risk factors) and repeating every 6 to 12 months.

  • Social Determinants: Understanding the impact of colonization, residential schools, and food insecurity as primary drivers of the diabetes epidemic in this population.

  • Complication Risks: Identifying end-stage renal disease (ESRD) and lower limb amputation as complications that occur more frequently and at younger ages in Indigenous patients.

  • Maternal Health: Memorizing the need for postpartum screening in women with gestational diabetes to break the cycle of intergenerational transmission.

  • Cultural Safety: Defining culturally safe care as an approach that acknowledges power imbalances, respects traditional knowledge, and requires self-reflection by the provider.

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CDE Diabetes

Practice Exam: Type 2 Diabetes and Indigenous Peoples (Chapter 38)

Indigenous peoples in Canada face a disproportionate burden of Type 2 diabetes, with prevalence rates 3 to 5 times higher than the general population. The 2018 Clinical Practice Guidelines emphasize that this disparity is not inherent but is deeply rooted in the legacy of colonization, residential schools, and the resulting loss of traditional lifestyles.

This practice exam tests your ability to provide culturally safe care, apply aggressive screening protocols, and address the specific complications that affect this population at younger ages.

Key Concepts Covered in This Exam:

  • Screening Protocols: Mastering the recommendation to screen asymptomatic Indigenous adults for Type 2 diabetes starting at age 18 (or younger if risk factors are present) and repeating every 6 to 12 months.

  • Social Determinants: Recognizing colonization, residential school experiences, and food insecurity as critical determinants of health that directly impact diabetes management and outcomes.

  • Complication Risks: Understanding that Indigenous peoples experience higher rates of severe complications, particularly end-stage renal disease and lower limb amputations, often at a younger age.

  • Maternal Health: Identifying the elevated risk of diabetes in pregnancy (both pre-existing and gestational) and the critical importance of postpartum screening to prevent intergenerational transmission.

  • Cultural Safety: Applying the principles of culturally safe care, which prioritizes building trust, respecting traditional knowledge, and acknowledging the power imbalances in healthcare.

Please go to Practice Exam: Type 2 Diabetes and Indigenous Peoples (Chapter 38) to view this quiz

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CDE Diabetes

Study Guide: Type 2 Diabetes and Indigenous Peoples (Chapter 38)

1. Overview & Epidemiology

Indigenous peoples in Canada (First Nations, Inuit, and Métis) experience a disproportionately high burden of Type 2 diabetes compared to the general population.

  • Prevalence: The age-standardized prevalence of diabetes is significantly higher in Indigenous populations (e.g., 17.2% among First Nations individuals living on-reserve vs. 5.0% in the general population).

  • Earlier Onset: Diabetes is diagnosed at a younger age in Indigenous peoples, leading to longer disease duration and higher rates of complications (renal failure, lower limb amputation, cardiovascular disease).

  • Etiology: The high prevalence is linked to a complex interplay of genetic susceptibility, environmental factors, and the social determinants of health resulting from colonization.

2. The Impact of Colonization

Understanding the root causes is a critical competency for CDEs working with this population.

  • Colonization as a Driver: The guidelines explicitly identify colonization as a key determinant of health.

    • Policies like residential schools, forced relocation, and the reservation system disrupted traditional lifestyles, food systems, and cultural practices.

  • Trauma-Informed Care: Health-care providers must practice “trauma-informed care,” recognizing the impact of intergenerational trauma and avoidance of re-traumatization in the healthcare setting.

  • Food Insecurity: High rates of food insecurity (especially in northern/remote communities) contribute significantly to obesity and diabetes risk.

3. Screening Recommendations

Due to the high risk and earlier onset, standard adult screening guidelines (starting at age 40) are insufficient.

  • Adults: Screening should be considered earlier and at more frequent intervals in Indigenous adults.

    • Note: While a specific age isn’t strictly defined in the “Recommendations” box of this specific chapter, other chapters (Screening) typically suggest starting at age 18 or earlier if additional risk factors are present.

  • Children & Adolescents: Screening should be targeted at those with risk factors. (Refer to Chapter 35: Screening usually starts at puberty or age 10).

4. Prevention & Management Strategies

Effective management requires cultural safety and addressing the specific metabolic profile.

A. Prevention (Prediabetes)

  • Lifestyle: Culturally appropriate healthy behaviour interventions are the cornerstone.

  • Pharmacotherapy: Metformin should be considered for Indigenous adults with prediabetes to prevent/delay progression to Type 2 diabetes.

B. Management of Type 2 Diabetes

  • Holistic Approach: Management plans should incorporate traditional knowledge, foods, and activities where possible.

  • Barriers: Be aware of geographical barriers (remote access), cost of healthy food, and lack of clean drinking water in some communities.

C. Pregnancy & Women of Childbearing Age

  • High Risk: Indigenous women have high rates of gestational diabetes (GDM) and pre-existing Type 2 diabetes in pregnancy.

  • Cycle of Risk: In utero exposure to hyperglycemia increases the child’s risk of developing obesity and Type 2 diabetes early in life, perpetuating the epidemic.

  • Screening:

    • Early Screening: Screen for overt diabetes early in pregnancy.

    • Postpartum: Mandatory screening for Type 2 diabetes in women with a history of GDM to allow for early intervention.

5. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S303).

  1. Screening: Screening for diabetes in Indigenous peoples should be carried out earlier and at more frequent intervals than in the general population [Grade D, Consensus].

  2. Prevention:

    • Culturally appropriate healthy behaviour interventions should be initiated for those at risk [Grade B, Level 2].

    • Metformin may be used in Indigenous adults with prediabetes to prevent or delay type 2 diabetes [Grade D, Consensus].

  3. Pregnancy:

    • Screening for diabetes in pregnancy should be performed early (before the standard 24-28 weeks) to detect pre-existing diabetes [Grade D, Consensus].

    • Postpartum screening should be performed in women with a history of GDM [Grade D, Consensus].

  4. Management Programs: Management programs should be culturally safe, community-based, and address the social determinants of health [Grade D, Consensus].

Reference:

Crowshoe L, Dannenbaum D, Green M, Henderson R, Hayward MN, Toth E. Type 2 Diabetes and Indigenous Peoples. Canadian Journal of Diabetes. 2018;42:S296-S306. doi:10.1016/j.jcjd.2017.10.022
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CDE Diabetes

Flashcards: Diabetes in Older People (Chapter 37)

The management of diabetes in older adults requires a nuanced approach that prioritizes quality of life and safety over intensive glycemic targets. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding functional status assessment, the risks of overtreatment, and the specific pharmacologic adjustments needed to protect the aging brain and body.

Key Topics Covered:

  • Personalized Targets: Memorizing the A1C targets based on frailty: 7.0% for functionally independent adults versus 7.1%–8.5% for those who are frail or have dementia.

  • Hypoglycemia & Dementia: Understanding the dangerous bidirectional relationship between severe hypoglycemia and cognitive decline.

  • Medication Safety: Identifying glyburide as a medication to avoid due to prolonged hypoglycemia risk and recognizing the preference for DPP-4 inhibitors or shorter-acting agents.

  • De-intensification: Knowing when and how to simplify insulin regimens or reduce pill burdens to prevent adverse events in complex patients.

  • Institutional Care: Recalling that for residents in long-term care, the primary goals are maintaining comfort, preventing symptomatic hyperglycemia, and avoiding hypoglycemia rather than achieving strict metabolic targets.

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CDE Diabetes

Practice Exam: Diabetes in Older People (Chapter 37)

Managing diabetes in older adults requires a fundamental shift from a “one-size-fits-all” approach to highly personalized care. The 2018 Clinical Practice Guidelines emphasize that this population is incredibly heterogeneous—ranging from robust, functionally independent individuals to those with frailty and dementia. Consequently, treatment goals must balance the benefits of glycemic control against the heightened risks of hypoglycemia, falls, and cognitive decline.

This practice exam tests your ability to stratify risk, select appropriate glycemic targets based on functional status, and safely de-intensify therapy when necessary.

Key Concepts Covered in This Exam:

  • Personalized Targets: Distinguishing between functionally independent older adults (who may aim for an A1C 7.0%) and frail individuals (where an A1C of 7.1%–8.5% is appropriate to prioritize safety).

  • Hypoglycemia & Cognition: Understanding the bidirectional relationship between severe hypoglycemia and dementia, where each increases the risk of the other, necessitating regular cognitive screening.

  • De-intensification: Recognizing when to simplify complex insulin regimens or stop high-risk oral agents (such as sulfonylureas) to reduce the risk of adverse events without compromising quality of life.

  • Safe Pharmacotherapy: Identifying glyburide as a medication to avoid in older adults due to its prolonged risk of hypoglycemia, and selecting safer alternatives like DPP-4 inhibitors.

  • Institutional Care: Applying specific management strategies for residents in long-term care facilities, where the primary goal is symptom management and preservation of comfort rather than strict metabolic control.

Please go to Practice Exam: Diabetes in Older People (Chapter 37) to view this quiz

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CDE Diabetes

Study Guide: Diabetes in Older People (Chapter 37)

1. Overview & Philosophy

Management of diabetes in older adults requires a paradigm shift from the approach used in younger adults. The focus shifts from strict prevention of long-term complications to preservation of function, quality of life, and safety (avoidance of hypoglycemia).

  • Heterogeneity: The “older person” category (generally age 70) includes a spectrum from robust/fit individuals to those who are frail or at the end of life.
  • Frailty: A multidimensional syndrome of increased vulnerability. It is a better predictor of complications and death than chronological age.
  • The “Clock Drawing Test”: A simple cognitive tool that can predict which older individuals will have difficulty learning to inject insulin.

2. Diagnosis and Screening

  • A1C Limitations: Normal aging is associated with a progressive increase in A1C. There is often discordance between glucose-based and A1C-based diagnosis in this age group.
  • Recommendation: Screen with BOTH a Fasting Plasma Glucose (FPG) and an A1C, as they are complementary.
  • Over Age 80: Screening is unlikely to be beneficial in most people over age 80; decisions should be individualized.

3. Glycemic Targets (The Functional Status Approach)

This is the most critical section for the CDE exam. Targets are stratified by health status.

Functional StatusDescription /
Frailty Score		A1C Target
Functionally IndependentRobust, life expectancy > 10 years.

7.0%

 
Functionally DependentLoss of autonomy, intermediate health.

7.1% – 8.0%

 
Frail and/or DementiaMultiple comorbidities, high vulnerability.

7.1% – 8.5%

 
End of LifeLife expectancy < 6 months.

Avoid symptomatic hyperglycemia and any hypoglycemia. A1C measurement not recommended.

 

4. Pharmacotherapy Considerations

Older adults are highly susceptible to hypoglycemia due to reduced glucagon secretion and impaired awareness.

A. Oral Agents
  • Metformin: First-line. Monitor Vitamin B12 levels as deficiency is associated with long-term use.
  • Sulfonylureas (Caution):
    • Glyburide: Avoid. High risk of severe hypoglycemia.
    • Gliclazide/Glimepiride: Preferred over glyburide if a sulfonylurea must be used.
    • Dosing: Start at half the regular dose.
  • DPP-4 Inhibitors: Preferred as second-line therapy over sulfonylureas due to lower risk of hypoglycemia and weight neutrality.
  • SGLT2 Inhibitors: Use with caution. High risk of dehydration (volume depletion) and potential fracture risk. Benefits for CV outcomes seen in empagliflozin/canagliflozin trials for older cohorts.

B. Insulin Therapy

  • Basal Analogues: Glargine (U-100/U-300), Detemir, and Degludec are preferred over NPH or Humulin 30/70 because they cause less hypoglycemia.
  • Simplification: In frail elderly, complex regimens (e.g., MDI/Basal-Bolus) should be simplified to once-daily basal insulin to reduce error and hypoglycemia risk.
  • Delivery: Use pre-filled pens instead of syringes to improve dosing accuracy.

C. Deprescribing

  • In people with limited life expectancy or frailty, agents that cause hypoglycemia (sulfonylureas, insulin) or have long-term preventive goals (statins) should be considered for discontinuation.

5. Long-Term Care (LTC) Management

  • Diet: “Diabetic diets” or specialized formulas are generally not recommended. A regular diet is preferred to prevent undernutrition and improve quality of life.
  • Sliding Scale Insulin: Should be avoided. It is associated with worse control and higher hypoglycemia risk.
  • Overtreatment: Many LTC residents are overtreated (A1C < 7.0%), putting them at dangerous risk for falls and cognitive decline.

6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page 5289).

  1. Targets:

    • Independent: Same as young (usually 7.0%) [Grade D].

    • Dependent: 7.1–8.0% [Grade D].

    • Frail/Dementia: 7.1–8.5% [Grade D].

    • End of Life: Avoid symptoms, no A1C [Grade D].

  2. Education: Tailor diabetes education to the individual; focus on psychological support [Grade A, Level 1A].

  3. Exercise: Resistance training and/or aerobic exercise should be performed if not contraindicated [Grade B, Level 2].

  4. Sulfonylureas:

    • Use with caution [Grade D].

    • DPP-4 inhibitors should be used over sulfonylureas because of lower hypoglycemia risk [Grade B, Level 2].

    • Gliclazide/Glimepiride preferred over Glyburide [Grade B/C].

  5. Insulin:

    • Basal analogues (Detemir, Glargine, Degludec) preferred over NPH to reduce hypoglycemia [Grade B, Level 2].

    • Use pre-filled pens [Grade B, Level 2].

  6. LTC: Avoid sliding scale insulin [Grade C, Level 3]. Use regular diets [Grade D, Level 4].

Reference: 

Meneilly GS, Knip A, Miller DB, Sherifali D, Tessier D, Zahedi A. Diabetes in Older People. Canadian Journal of Diabetes. 2018;42:S283-S295. doi:10.1016/j.jcjd.2017.10.021