Category: CDE

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

Post author By Michael Boivin
Post date December 25, 2025

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).

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].
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].
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].
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

Tags CDE, Diabetes

Flashcards: Diabetes in Older People (Chapter 37)

Post author By Michael Boivin
Post date December 25, 2025

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: $\le$ 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.

CDE Diabetes

Practice Exam: Diabetes in Older People (Chapter 37)

Post author By Michael Boivin
Post date December 25, 2025

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Diabetes in Older People (Chapter 37)

Post author By Michael Boivin
Post date December 25, 2025

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 $\ge$ 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 Status	Description / Frailty Score	A1C Target
Functionally Independent	Robust, life expectancy > 10 years.	$\le$ 7.0%
Functionally Dependent	Loss of autonomy, intermediate health.	7.1% – 8.0%
Frail and/or Dementia	Multiple comorbidities, high vulnerability.	7.1% – 8.5%
End of Life	Life 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).

Targets:
- Independent: Same as young (usually $\le$ 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].
Education: Tailor diabetes education to the individual; focus on psychological support [Grade A, Level 1A].
Exercise: Resistance training and/or aerobic exercise should be performed if not contraindicated [Grade B, Level 2].
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].
Insulin:
- Basal analogues (Detemir, Glargine, Degludec) preferred over NPH to reduce hypoglycemia [Grade B, Level 2].
- Use pre-filled pens [Grade B, Level 2].
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

Tags CDE, Diabetes

CDE Diabetes

Flashcards: Diabetes and Pregnancy (Chapter 36)

Post author By Michael Boivin
Post date December 25, 2025

Pregnancy acts as a metabolic stress test, and hyperglycemia during this critical period carries significant risks for both the mother and the developing fetus. The 2018 Clinical Practice Guidelines provide rigorous standards for pre-conception counseling, screening protocols, and tight glycemic targets to ensure the best possible start for the next generation.

This practice exam tests your ability to navigate the specific diagnostic algorithms for Gestational Diabetes Mellitus (GDM), manage complex insulin regimens during changing physiology, and ensure appropriate postpartum follow-up.

Key Concepts Covered in This Exam:

Pre-conception Care: Mastering the checklist for women with pre-existing diabetes, including the recommendation for 1 mg of folic acid daily and achieving an A1C target of $\le$ 7.0% (optimally $\le$ 6.5%) prior to conception.
Screening & Diagnosis: Differentiating between the “Preferred” Two-Step Approach (50g screening followed by 75g diagnostic OGTT) and the “Alternative” One-Step Approach.
Glycemic Targets: Memorizing the strict targets during pregnancy: Fasting/preprandial <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L, and 2-hour postprandial <6.7 mmol/L.
Pharmacotherapy: Identifying insulin as the first-line therapy for GDM and understanding the specific limitations and placental transfer of oral agents like metformin and glyburide.
Postpartum Follow-up: Recognizing that women with GDM are at high risk for developing Type 2 diabetes and require screening with a 75g OGTT between 6 weeks and 6 months postpartum.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Diabetes and Pregnancy (Chapter 36)

Post author By Michael Boivin
Post date December 25, 2025

Key Concepts Covered in This Exam:

Pre-conception Care: Mastering the checklist for women with pre-existing diabetes, including the recommendation for 1 mg of folic acid daily and achieving an A1C target of $\le$ 7.0% (optimally $\le$ 6.5%) prior to conception.
Screening & Diagnosis: Differentiating between the “Preferred” Two-Step Approach (50g screening followed by 75g diagnostic OGTT) and the “Alternative” One-Step Approach.
Glycemic Targets: Memorizing the strict targets during pregnancy: Fasting/preprandial <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L, and 2-hour postprandial <6.7 mmol/L.
Pharmacotherapy: Identifying insulin as the first-line therapy for GDM and understanding the specific limitations and placental transfer of oral agents like metformin and glyburide.
Postpartum Follow-up: Recognizing that women with GDM are at high risk for developing Type 2 diabetes and require screening with a 75g OGTT between 6 weeks and 6 months postpartum.

Please go to Practice Exam: Diabetes and Pregnancy (Chapter 36) to view this quiz

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Diabetes and Pregnancy (Chapter 36)

Post author By Michael Boivin
Post date December 25, 2025

1. Overview & Classification

Pregnancy is a state of increased insulin resistance. Hyperglycemia during pregnancy increases risks for both mother (preeclampsia, C-section) and baby (macrosomia, shoulder dystocia, neonatal hypoglycemia).

Classification:

Pre-existing Diabetes: Type 1 or Type 2 diabetes diagnosed before pregnancy.
Gestational Diabetes Mellitus (GDM): Glucose intolerance first recognized during pregnancy.

2. Pre-Conception Care (Pre-Existing Diabetes)

For women with Type 1 or Type 2 diabetes, care begins before conception to minimize congenital malformations (which occur in the first few weeks).

A1C Target: Aim for $\le$ 7.0% (ideally $\le$ 6.5%) prior to conception.
Supplements: Start Folic Acid (1 mg/day) 3 months pre-conception to prevent neural tube defects.
Medication Review: Stop potentially teratogenic drugs:
- ACE Inhibitors / ARBs.
- Statins.
Screening: Assess for complications (retinopathy, nephropathy) as pregnancy can worsen them.

3. Diagnosis of GDM (The "Preferred" vs. "Alternative" Approach)

This is a high-yield exam topic. Canada suggests a “Preferred” 2-step approach but allows an “Alternative” 1-step approach. Screening typically occurs at 24–28 weeks gestation.

A. Preferred Approach (Sequential 2-Step)

Step 1 (Screen): 50g Oral Glucose Challenge Test (non-fasting).
- < 7.8 mmol/L: Normal.
- 7.8 – 11.0 mmol/L: Indeterminate $\rightarrow$ Go to Step 2.
- $\ge$ 11.1 mmol/L: GDM Diagnosed (No further testing needed).
Step 2 (Diagnostic): 75g Oral Glucose Tolerance Test (fasting).
- Diagnosis of GDM is made if ONE value is met or exceeded:
  - Fasting $\ge$ 5.3 mmol/L
  - 1 hour $\ge$ 10.6 mmol/L
  - 2 hour $\ge$ 9.0 mmol/L

B. Alternative Approach (1-Step)

Test: 75g Oral Glucose Tolerance Test (fasting).
Diagnosis of GDM is made if ONE value is met or exceeded:
- Fasting $\ge$ 5.1 mmol/L
- 1 hour $\ge$ 10.0 mmol/L
- 2 hour $\ge$ 8.5 mmol/L

4. Management Targets During Pregnancy

Targets are tighter during pregnancy to prevent macrosomia.

Parameter	Target (mmol/L)
Fasting / Pre-prandial	< 5.3
1-hour Post-prandial	< 7.8
2-hour Post-prandial	< 6.7
A1C	$\le$ 6.5% (ideally $\le$ 6.1% if safe)

5. Management Strategies

A. Lifestyle (First Line)

Nutritional therapy is the primary intervention for GDM.
Weight Gain: Monitor gestational weight gain based on pre-pregnancy BMI (e.g., Normal BMI 18.5–24.9 should gain 11.5–16 kg).
Ketones: Avoid ketosis (starvation ketones) as it may harm the fetus.

B. Pharmacotherapy

Insulin: The Gold Standard and first-line pharmacotherapy if lifestyle fails to reach targets within 2 weeks.
- Safe Insulins: Aspart, Lispro, Glargine, Detemir, NPH, Regular. (Glulisine and Degludec were not standard at time of 2018 guidelines for pregnancy).
- Dosing: Needs increase dramatically in the 2nd and 3rd trimesters due to placental hormones causing insulin resistance.
Metformin: Can be used as an alternative or adjunct. It crosses the placenta.
Glyburide: Generally not recommended as first-line due to higher rates of neonatal hypoglycemia and macrosomia compared to insulin or metformin.

6. Intrapartum & Postpartum Care

Labor: Maintain maternal glucose between 4.0 – 7.0 mmol/L to prevent neonatal hypoglycemia.
Breastfeeding: Strongly encouraged. It reduces the risk of the child developing obesity/diabetes and helps maternal weight loss.
- Metformin & Glyburide: Considered safe during breastfeeding.
Postpartum Screening (GDM):
- Women with GDM are at high risk for Type 2 diabetes.
- Test: 75g OGTT between 6 weeks and 6 months postpartum.

7. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S277).

Pre-conception: Women with diabetes should receive pre-conception care (A1C $\le$ 7.0%, Folic Acid 1 mg) [Grade D, Consensus].
Screening GDM: Screen all pregnant women at 24–28 weeks [Grade C, Level 3].
Diagnosis: Use the Preferred 2-step approach (50g screen $\rightarrow$ 75g diagnostic) OR the Alternative 1-step approach (75g diagnostic) [Grade B, Level 2].
Glycemic Targets: Fasting < 5.3 mmol/L, 1h < 7.8 mmol/L, 2h < 6.7 mmol/L [Grade D, Consensus].
Treatment:
- Insulin is first-line [Grade A, Level 1].
- Metformin may be used as an alternative [Grade A, Level 1A].
Postpartum: Screen women with GDM for diabetes between 6 weeks and 6 months postpartum using a 75g OGTT [Grade D, Consensus].

Reference:

Feig DS, Berger H, Donovan L, et al. Diabetes and Pregnancy. Canadian Journal of Diabetes. 2018;42:S255-S282. doi:10.1016/j.jcjd.2017.10.038

Tags CDE, Diabetes

CDE Diabetes

Flashcards: Type 2 Diabetes in Children and Adolescents (Chapter 35)

Post author By Michael Boivin
Post date December 25, 2025

Type 2 diabetes in children and adolescents is distinct from the adult-onset form, characterized by a rapid decline in beta-cell function and the early appearance of complications. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding targeted screening criteria, diagnostic differentiation, and the specific pharmacologic limitations in the pediatric population.

Key Topics Covered:

Screening Criteria: Memorizing the indications for screening: every 2 years starting at age 8 (or puberty) in children with multiple risk factors.
Disease Trajectory: Understanding that Type 2 diabetes in youth is more aggressive than in adults, often presenting with hypertension, dyslipidemia, or MASLD at diagnosis.
Pharmacotherapy: Identifying metformin as the preferred oral agent for youth in Canada and knowing when to initiate insulin (e.g., for ketosis or severe hyperglycemia).
Differential Diagnosis: Recalling when to test for diabetes autoantibodies to distinguish between Type 1, Type 2, and monogenic diabetes.
Prevention: Reviewing anticipatory guidance strategies regarding sleep, screen time, and activity to reduce risk.

Tags CDE, Diabetes

CDE Diabetes

Practice Exam: Type 2 Diabetes in Children and Adolescents (Chapter 35)

Post author By Michael Boivin
Post date December 25, 2025

The incidence of Type 2 diabetes in youth is rising at an alarming rate, presenting a distinct and aggressive clinical challenge compared to the adult-onset form. The 2018 Clinical Practice Guidelines highlight that adolescents with Type 2 diabetes face a more rapid decline in beta-cell function and a higher risk of early complications, necessitating prompt diagnosis and intensive management.

This practice exam tests your ability to identify at-risk youth, apply specific screening algorithms, and implement appropriate pharmacologic and lifestyle interventions.

Key Concepts Covered in This Exam:

Targeted Screening: Identifying the specific criteria for screening (e.g., age $\ge$ 8 with $\ge$ 3 risk factors or post-puberty with $\ge$ 2 risk factors) and the recommended interval of every 2 years.
Diagnostic Differentiation: Understanding how to distinguish Type 2 diabetes from Type 1 diabetes and monogenic diabetes in the pediatric population.
Pharmacotherapy: Identifying metformin as the first-line medication in combination with lifestyle intervention, and knowing when the addition of insulin is mandatory (e.g., severe metabolic decompensation or ketosis).
Comorbidity Management: Recognizing the high prevalence of associated conditions such as Polycystic Ovary Syndrome (PCOS), Nonalcoholic Fatty Liver Disease (NAFLD), and dyslipidemia.
Psychosocial Care: Acknowledging the critical need for mental health support, as youth with Type 2 diabetes have higher rates of depression and distress compared to their peers.

Please go to Practice Exam: Type 2 Diabetes in Children and Adolescents (Chapter 35) to view this quiz

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Type 2 Diabetes in Children and Adolescents (Chapter 35)

Post author By Michael Boivin
Post date December 25, 2025

1. Overview & Epidemiology

Type 2 diabetes (T2D) in youth is a growing epidemic, disproportionately affecting specific ethnic groups. It is an aggressive disease with early onset of complications.

High-Risk Populations: Incidence is highest among children of Indigenous, African, Arab, Asian, Hispanic, and South Asian descent.
Pathophysiology: Characterized by insulin resistance (usually obesity-related) combined with rapid beta-cell failure.
Complications: Microvascular and macrovascular complications (nephropathy, hypertension, dyslipidemia) appear earlier and progress faster in youth-onset T2D compared to type 1 diabetes or adult-onset T2D.

2. Screening & Diagnosis

Screening is targeted at high-risk individuals rather than universal screening.

Who to Screen? Screening should be considered every 2 years using A1C (or FPG) in children who have:

$\ge$ 3 risk factors in prepubertal children.
$\ge$ 2 risk factors in pubertal children.

The Risk Factors:

Obesity (BMI $\ge$ 95th percentile).
High-risk ethnic group (Indigenous, African, Arab, Asian, Hispanic, South Asian).
Family history of type 2 diabetes (first or second degree) or exposure to diabetes in utero.
Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, NAFLD, PCOS).
Note: Screening typically begins at onset of puberty or age 10 years, whichever is earlier.

3. Management Strategies

Management requires an interprofessional approach involving lifestyle and pharmacotherapy.

A. Lifestyle Intervention

Goal: Healthy behaviour changes for the entire family, not just the child.
Activity: Aim for 60 minutes of moderate-to-vigorous activity daily.
Diet: Limit sugar-sweetened beverages, increase fiber, regular meals.
Screen Time: Limit recreational screen time to < 2 hours/day.

B. Pharmacotherapy

First Line: Metformin is the drug of choice.
Insulin:
- Start insulin immediately with metformin if there is metabolic decompensation (DKA, severe hyperglycemia, unexpected weight loss) or if the diagnosis (T1D vs T2D) is unclear.
- Once metabolic stability is achieved, wean insulin while introducing metformin.
Targets: A1C target is $\le$ 7.0% for most adolescents.

4. Comorbidities Surveillance

Youth with T2D are at very high risk for comorbidities. Screening should occur at diagnosis and regularly thereafter.

Comorbidity	Screening Tool	Frequency
Hypertension	BP Measurement	Every visit
Dyslipidemia	Lipid Profile (Fasting)	At diagnosis, then annually
Nephropathy	Urine ACR	At diagnosis, then annually
Retinopathy	Dilated Eye Exam	At diagnosis, then annually
Neuropathy	Foot Exam	At diagnosis, then annually
Fatty Liver (NAFLD)	ALT (Enzymes)	At diagnosis, then annually
PCOS	Menstrual History	Every visit
OSA	Sleep History	Every visit

Note: This differs from T1D (where screening often starts 5 years post-diagnosis). In T2D, you screen at diagnosis.

5. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S253).

Screening: Targeted screening (A1C/FPG) every 2 years for children with risk factors (pubertal + 2 factors, or prepubertal + 3 factors) [Grade D, Consensus].
Management:
- Metformin is the first-line oral agent [Grade A, Level 1A].
- Insulin should be used for severe metabolic decompensation (DKA, A1C $\ge$ 9.0%) [Grade D, Consensus].
Complications: Screen for nephropathy, retinopathy, neuropathy, dyslipidemia, and hypertension at diagnosis and annually thereafter [Grade D, Consensus].
Mental Health: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].
PCOS: Adolescent females with T2D should be assessed for menstrual irregularities and hyperandrogenism [Grade D, Consensus].

Reference:

Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes. 2018;42 Suppl 1:S234-S246. doi:10.1016/j.jcjd.2017.10.036

Tags CDE, Diabetes