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

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

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

5.0 < 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

78%

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

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




2013

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.



guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%


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

NO

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]

2013

2013


CDA Clinical Practice Guidelines

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

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

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

Documents

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