Glycemic control and pharmacotherapy

In the 2018 Clinical Practice Guidelines, Diabetes Canada proposes a new version of the figure that helps determine the target glycated hemoglobin (A1C) level. This figure allows for a quick overview of different targets based on specific clinical conditions, provides an understanding of why it is important to avoid an A1C level above 8.5%, and offers recommendations for end-of-life patients.

Source: Diabète Canada, http://guidelines.diabetes.ca/cpg/chapter8

In these same guidelines, Diabetes Canada has updated the therapeutic algorithm for patients with type 2 diabetes. One notable change concerns the choice of initial treatment. It now depends on each patient’s specific A1C target rather than aiming for an absolute value. Additionally, the algorithm emphasizes the importance of cardiovascular protection. Cardioprotective antidiabetic medications are introduced earlier in the treatment.

The guidelines also highlight the relevance of reducing A1C levels while ensuring the avoidance of hypoglycemia and weight gain, especially for patients at risk of hypoglycemia or who are overweight/obese. In fact, weight management has been added to lifestyle-focused interventions (upper part of the algorithm).

Furthermore, insulin treatment is initiated immediately upon diagnosis in the presence of symptomatic hyperglycemia and/or metabolic decompensation in the patient, whereas these two criteria were mandatory in the 2013 guidelines.