Diabetes Canada Clinical Practice Tools Study Guide: 2025 Update

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