Screening for Type 1 and Type 2 Diabetes Chapter 4 Jean-Marie Ekoé, Zubin Punthakee, Thomas Ransom, Ally PH Prebtani, Ron Goldenberg Canadian Diabetes.

Screening for Type 1 and Type 2 Diabetes

Chapter 4

Jean-Marie Ekoé, Zubin Punthakee, Thomas Ransom,

Ally PH Prebtani, Ron Goldenberg

Canadian Diabetes Association 2013 Clinical Practice Guidelines

Screening Checklist

ASSESS all adults clinically every year for risk of type 2 diabetes (T2DM)

SCREEN every 3 years if ≥ 40 years or high risk on risk calculator

SCREEN earlier and more frequently if very high risk on risk calculator or additional risk factors present

USE fasting plasma glucose (FPG) and/or A1C as initial screening tests

Diabetes in Canada: Prevalence by Province and Territory

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.

NL6.5%

ON 6.0%

QC 5.1%

PE5.6%

NB5.9%

NS 6.1%

MB 5.9%

SK 5.4%

AB 4.9%

BC 5.4%

NT 5.5%

YT 5.4%

NU 4.4%

† Age-standardized to the 1991 Canadian population.

Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09

NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest.

5.0 < 5.5

5.5 < 6.0

6.0 < 6.5

≥ 6.5

DIASCAN: Canadian Screening for T2DM in those age > 40 Years in Primary Care

Known DM16%

Probable DM

0.4%IGT 0.6%

IFG 2.5%New DM

2.2%Normal

5.7% undiagnosed

glucose abnormalities

Leiter LA et al. Diabetes Care 2001;24:1038-43.

ADDITION-Cambridge: No Mortality Benefit of Screening for T2DM in United Kingdom

Simmons RK et al. Lancet 2012;380:1741-48.

ADDITION-Cambridge: Prevalence of Diabetes

• Prevalence of diabetes only 3.0-3.3% in this study

• Prevalence of diabetes in Canada 6.8%

Can the results of ADDITION-Cambridge be applied to Canada?

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.Simmons RK et al. Lancet 2012;380:1741-48.

Assessing Risk: Risk Factors for T2DM

Personal factors:

• First-degree relative with T2DM

• Member of high-risk population (e.g. Aboriginal,

African, Asian, Hispanic or South Asian)

• History of prediabetes

• History of gestational diabetes (GDM)

• History of delivery of macrosomic infant

Presence of associated problems:• End organ damage complications associated with

diabetes – Microvascular (retinopathy, neuropathy, nephropathy)– Macrovascular (coronary, cerebrovascular, peripheral

arterial)• Vascular risk factors

– Low HDL-cholesterol (< 1.0 mmol/L males, 1.3 mmol/L females)

– Triglycerides ≥ 1.7 mmol/L– Hypertension, overweight, abdominal obesity

Presence of associated problems (continued):• Associated diseases

– Polycystic ovarian syndrome, acanthosis nigricans, obstructive sleep apnea, psychiatric disorders (bipolar, depression, schizophrenia), HIV infection

Presence of secondary causes:• Use of drugs associated with diabetes

– Glucocorticoids– Atypical antipsychotics– Highly active antiretroviral therapy (HAART)– Others (see Appendix 1 in CPG document)

• Other secondary causes (see Appendix 1 in CPG document)

If you choose to use a diabetes risk calculator …• Public Health Agency of Canada CANRISK calculator

http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/canrisk/index-eng.php

• For people 40 - 74 years old• Components

– Age, sex, BMI, waist circumference– Physical activity level, eating veg and fruits– Hypertension, history of dysglycemia (GDM, acute illness

etc.) macrosomia– Family history, ethnicity, level of education

• Calculates low, moderate or high risk groups

• Similar to CANRISK• Does not include:

– Macrosomia– Ethnicity – Level of education

• Risk categories differ:– Low-moderate– High– Very high

• http://canadiantaskforce.ca/guidelines/2012-diabetes/

FINRISK calculator

Screening for Type 2 Diabetes in Adults

Algorithm presented on next slides

Screening for Type 2 Diabetes in Adults (continued)

*If both FPG and A1C are available, but discordant, use the test that appears furthest to the right side of the algorithm.

‡ In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.

‡ Diabetes: In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.

Do we need to screen for Type 1 diabetes (T1DM)?

There is insufficient evidence for interventions to prevent or delay T1DM.

Recommendation 1

1. All individuals should be evaluated annually for

type 2 diabetes risk on the basis of demographic

and clinical criteria [Grade D, Consensus].

Recommendation 2

2. Screening for diabetes using a FPG and/or A1C

should be performed every 3 years in individuals

40 years of age or at high risk using a risk

calculator [Grade D, Consensus]. More frequent and/or

earlier testing with either a FPG and/or A1c or a

2h PG in a 75 g OGTT should be considered in

those at very high risk using a risk calculator or in

people with additional risk factors for diabetes [Grade D, Consensus].

2. Risk factors include:

– First-degree relative with T2DM

– Member of high-risk population (e.g. Aboriginal,

African, Asian, Hispanic, or South Asian)

– History of prediabetes

– History of gestational diabetes (GDM)

– History of delivery of macrosomic infant

Recommendation 2 (continued)

Presence of associated problems– End organ damage complications associated with

diabetes • Microvascular (retinopathy, neuropathy, nephropathy)• Macrovascular (coronary, cerebrovascular, peripheral

arterial)– Vascular risk factors

• Low HDL-cholesterol (< 1.0 mmol/L males, 1.3 mmol/L females)

• Triglycerides ≥ 1.7 mmol/L• Hypertension, overweight, abdominal obesity

Presence of associated problems (continued)– Associated diseases

• Polycystic ovarian syndrome, acanthosis nigricans, obstructive sleep apnea, psychiatric disorders (bipolar, depression, schizophrenia), HIV infection

– Use of drugs associated with diabetes• Glucocorticoids• Atypical antipsychotics• Highly active antiretroviral therapy (HAART)• Others (See Appendix 1 in the full document)

– Other secondary causes (See Appendix 1 in the full document)

Recommendation 3 and 4

3. Testing with a 2hrPG in a 75-g OGTT should be

undertaken in individuals with FPG of 6.1 to 6.9

mmol/L and/or A1C 6.0 to 6.4% in order to identify

individuals with IGT or diabetes [Grade D, Consensus]

4. Testing with a 2hPG in a 75-g OGTT may be

undertaken in individuals with a FPG of 5.6 to 6.0

mmol/L and/or A1C 5.5 to 5.9% and >1 risk

factor(s) in order to identify individuals with IGT or

diabetes [Grade D, Consensus]

CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

Screening for Type 1 and Type 2 Diabetes Chapter 4 Jean-Marie Ekoé, Zubin Punthakee, Thomas Ransom, Ally PH Prebtani, Ron Goldenberg Canadian Diabetes.

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