Canadian Diabetes Association
2013 Clinical Practice Guidelines
The Case of Victor
(Updated July 2015)
2015
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Learning Objectives
By the end of this session, participants will be able to:
1. Understand the major changes within the 2013 CDA
clinical practice guidelines
2. Understand the rationale behind these changes
3. Apply the recommendations in clinical practice
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Faculty for slide deck development
•
•
•
•
•
•
•
•
Jonathan Dawrant, BSc, MSc, MD, FRCPC
Zoe Lysy, MDCM, FRCPC
Geetha Mukerji, MD, FACP, FRCPC
Dina Reiss, MD, FACP, FRCPC
Steven Sovran, BSc, MD, MA, FRCPC
Alice Y.Y. Cheng, MD, FRCPC
Peter J. Lin, MD, CCFP
Catherine Yu, MD, FRCPC, MHSc
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Victor
59 years old
FBS 6.7 mmol/L
A1C 6.2%
Does he have diabetes?
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Diagnosis of Diabetes
2013
FPG ≥7.0 mmol/L
Fasting = no caloric intake for at least 8 hours
or
A1C ≥6.5% (in adults)
Using a standardized, validated assay, in the absence of factors that affect the
accuracy of the A1C and not for suspected type 1 diabetes
or
2hPG in a 75-g OGTT ≥11.1 mmol/L
or
Random PG ≥11.1 mmol/L
Random= any time of the day, without regard to the interval since the last meal
2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose
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Diagnosis of Prediabetes*
2013
Test
Result
Prediabetes Category
Fasting Plasma
Glucose
(mmol/L)
6.1 - 6.9
Impaired fasting glucose
(IFG)
7.8 – 11.0
Impaired glucose tolerance
(IGT)
6.0 - 6.4
Prediabetes
2-hr Plasma Glucose in
a 75-g Oral Glucose
Tolerance Test (mmol/L)
Glycated
Hemoglobin
(A1C) (%)
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM
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Can we delay the onset of
his Type 2 Diabetes?
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Diabetes Prevention Program (DPP)
•
•
Benefit of diet and exercise or Metformin on diabetes prevention in
at-risk patients
N = 3234 with IFG and IGT, without diabetes
40
Placebo
Metformin
31%
30
Cumulative
incidence of
diabetes
20
(%)
Lifestyle
58%
P*
< 0.001
< 0.001
10
0
0
1.0
2.0
Years
3.0
4.0
Diabetes Prevention Program (DPP) Research Group. N Engl J Med 2002;346:393-403.
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*vs placebo
IFG = impaired fasting glucose,
IGT = impaired glucose tolerance
What do you tell him about
exercise?
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Physical Activity Checklist
2013
 DO a minimum of 150 minutes of moderate-to
vigorous-intensity aerobic exercise per week
 INCLUDE resistance exercise ≥ 2 times a week
 SET physical activity goals and INVOLVE a multidisciplinary team
 ASSESS patient’s health before prescribing an
exercise regimen
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Pre-exercise Assessment
•
Assess for conditions that can predispose to injury
before prescribing an exercise regimen:
–
Neuropathy (autonomic and peripheral)
–
Retinopathy
–
Coronary artery disease – resting ECG +/exercise stress test (see CPG Chapter 23)
–
Peripheral arterial disease
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Who Should be Screened with ECG?
Age >40 years
Duration of DM >15years
+
Age >30 years
End organ damage
–
–
Microvascular
Macrovascular
Cardiac risk factors
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Baseline resting
ECG
Repeat every 2 years
Who Should have Stress Testing and/or
Functional Imaging to Screen for CAD?
Typical or atypical cardiac
symptoms
Associated diseases:
–
–
–
–
PAD
Carotid bruits
TIA
Stroke
Resting ECG
abnormalities (e.g. Q waves)
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Exercise ECG
stress testing
If cannot exercise or
resting ECG abnormality
present:
–
–
Pharmacologic stress
echo
Pharmacologic stress
nuclear imaging
What do you tell him about
his diet?
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Macronutrient Distribution (% Total Energy)
% of total
energy
Calories per
gram
Grams for 2000
calorie/day diet
Carbohydrates
Protein
Fat
45-60%
15-20%
20-35%
(or 1-1.5g / kg BW)
4
4
9
225-300
75-100
44-78
BW = body weight
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Choose low glycemic index carbohydrates
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Victor
Lost to follow up and shows up 3
years later
FBS 9.0 mmol/L
A1C 8.3%
What are the A1C targets for Victor?
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2013
Targets Checklist
 A1C
≤ 7.0% for MOST people with diabetes

A1C ≤ 6.5% for SOME people with T2DM

A1C 7.1-8.5% in people with specific features
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Macro and Microvascular Benefits?
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Legacy Effect of Earlier Glucose Control
After median 8.5 years post-trial follow-up
Aggregate Endpoint
1997
Any diabetes related endpoint
RRR: 12%
P: 0.029
2007
9%
0.040
Microvascular disease
RRR:
25%
P: 0.0099
Myocardial infarction
RRR:
P:
16%
0.052
15%
0.014
All-cause mortality
RRR:
P:
6%
0.44
13%
0.007
Holman R, et al. N Engl J Med 2008;359.
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24%
0.001
Legacy Effect of Earlier Glucose Control
After median 8.5 years post-trial follow-up
Aggregate Endpoint
1997
Any diabetes related endpoint
RRR: 12%
P: 0.029
2007
9%
0.040
Microvascular disease
RRR:
25%
P: 0.0099
Myocardial infarction
RRR:
P:
16%
0.052
15%
0.014
All-cause mortality
RRR:
P:
6%
0.44
13%
0.007
Holman R, et al. N Engl J Med 2008;359.
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24%
0.001
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ADVANCE: Glucose Control
10.0
9.0
Standard control
7.3%
8.0
Mean
A1C (%)
7.0
p < 0.001
6.0
Intensive control
6.5%
5.0
0.0
0
6
12
18
24
30 36
42
Follow-up (months)
ADVANCE Collaborative Group. N Engl J Med 2008;358:24.
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48
54
60
66
ADVANCE: Treatment Effect on the Primary
Microvascular Outcomes
•
25
New/worsening nephropathy, retinopathy
20
HR 0.86 (0.77-0.97)
p = 0.01
15
Cumulative
incidence (%)
Standard
control
10
Intensive
control
5
0
0
6
12
18
24
30
36
42
48
54
60
66
Follow-up (months)
Intensive
Standard
HR
p
Nephropathy/retinopathy (%)
9.4
10.9
0.86
0.01
Nephropathy (%)
4.1
5.2
0.79
0.006
Retinopathy (%)
6.0
6.3
0.95
NS
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2013 CanadianGroup.
Diabetes
Association
ADVANCE
N Engl
J Med 2008;358:24.
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Consider A1C 7.1-8.5% if …
•
•
•
•
•
•
•
Limited life expectancy
High level of functional dependency
Extensive coronary artery disease at high risk of
ischemic events
Multiple co-morbidities
History of recurrent severe hypoglycemia
Hypoglycemia unawareness
Longstanding diabetes for whom is it difficult to
achieve an A1C ≤ 7%, despite effective doses of
multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy
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2013
Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia
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What do you prescribe for
his glucose control?
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AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
2015
A1C <8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C 8.5%
Symptomatic hyperglycemia with
metabolic decompensation
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
Add an agent best suited to the individual:
Patient Characteristics
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Comorbidities (renal, cardiac, hepatic)
Preferences & access to treatment
Other
Agent Characteristics
BG lowering efficacy and durability
Risk of inducing hypoglycemia
Effect on weight
Contraindications & side-effects
Cost and coverage
Other
See next page…
From prior page…
L
I
F
E
S
T
Y
L
E
If not at glycemic target
• Add another agent from a different class
• Add/Intensify insulin regimen
2015
Make timely adjustments to attain target A1C within 3-6 months
AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
2015
A1C < 8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C  8.5%
Symptomatic hyperglycemia with
metabolic decompensation
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
Add an agent best suited to the individual:
Patient Characteristics
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Comorbidities (renal, cardiac, hepatic)
Preferences & access to treatment
Other
Agent Characteristics
BG lowering efficacy and durability
Risk of inducing hypoglycemia
Effect on weight
Contraindications & side-effects
Cost and coverage
Other
See next page…
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2015
Antihyperglycemic agents and Renal Function
2015
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Adapted
from:©Product
Monographs
as of July
2015; Harper W et al. Can J Diab 2015;39:250-252; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.
Copyright
2013 Canadian
Diabetes
Association
.
Victor’s friend passed out
because of low sugars
What do you tell Victor
about Hypoglycemia?
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Recognize Risk Factors for Severe
Hypoglycemia
Risk factors in Type 1 DM
patients
Risk factors in Type 2 DM
patients
Adolescence
Elderly
Children unable to detect and/or
treat mild hypoglycemia
Poor health literacy, Food
insecurity
A1C <6.0%
Increased A1C
Long duration of diabetes
Duration of insulin therapy
Prior episode of severe
hypoglycemia
Severe cognitive impairment
Hypoglycemia unawareness
Renal impairment
Autonomic neuropathy
Neuropathy
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Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to
relieve symptoms
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and
retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a
snack with 15 g carbohydrate plus protein
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Hypoglycemia and Driving
Safe blood glucose (BG)
prior to driving
•
•
BG ≥ 5.0 mmol/L
If BG <5.0 mmol/L prior to driving:
–
Take 15 g carbohydrate
–
Re-check in 15 minutes
–
When BG >5 mmol/L for at least 45 minutes  safe to drive
Need to re-check BG every 4 hours of continuous
driving and carry simple carbohydrate snacks
Iain S. Begg et al . Canadian Journal of Diabetes. 2003;27(2):128-140.
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“Do I need to poke my
fingers 8 times a day?”
What do you tell Victor
about SMBG?
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Regular SMBG is Required for:
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Increased frequency of SMBG may be required:
Daily SMBG is not usually required if patient:
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Should Victor get:
Statin
ACE-inhibitor or ARB
ASA
for Vascular Protection
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Vascular Protection Checklist
2013

A • A1C – optimal glycemic control (usually ≤7%)

B • BP – optimal blood pressure control (<130/80)

C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat

D • Drugs to protect the heart
A – ACEi or ARB │ S – Statin │ A – ASA if indicated

E • Exercise / Eating healthily – regular physical
activity, achieve and maintain healthy body weight

S • Smoking cessation
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Who Should Receive Statins?
(regardless of baseline LDL-C)
•
•
•
•
•
2013
≥40 yrs old or
Macrovascular disease or
Microvascular disease or
DM >15 yrs duration and age >30 years or
Warrants therapy based on the 2012 Canadian
Cardiovascular Society lipid guidelines
Among women with childbearing potential, statins should only
be used in the presence of proper preconception counseling &
reliable contraception. Stop statins prior to conception.
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What if baseline LDL-C ≤2.0 mmol/L?
•
Within CARDS and HPS, the subgroups that started
with lower baseline LDL-C still benefited to the same
degree as the whole population
•
If the patient qualifies for statin therapy based on the
algorithm, use the statin regardless of the baseline
LDL-C and then target an LDL reduction of ≥50%
HPS Lancet 2002;360:7-22
Colhoun HM, et al. Lancet 2004;364:685.
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2013
Who Should Receive ACEi or ARB Therapy?
(regardless of baseline blood pressure)
•
≥55 years of age or
•
Macrovascular disease or
•
Microvascular disease
At doses that have shown vascular protection
[perindopril 8 mg daily (EUROPA), ramipril 10 mg daily
(HOPE), telmisartan 80 mg daily (ONTARGET)]
Among women with childbearing potential, ACEi or ARB should
only be used in the presence of proper preconception
counseling & reliable contraception. Stop ACEi or ARB either
prior to conception or immediately upon detection of pregnancy
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EUROPA Investigators, Lancet 2003;362(9386):782-788.
HOPE study investigators. Lancet. 2000;355:253-59.
ONTARGET study investigators. NEJM. 2008:358:1547-59
Recommendation
2013
ASA should not be routinely used for the primary
prevention of cardiovascular disease in people with
diabetes [Grade B, Level 2]
ASA may be used in the presence of additional
cardiovascular risk factors [Grade D, Consensus]
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X
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What is Victor’s BP Target?
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Hypertension Checklist
2013

ASSESS for hypertension (≥ 130/80 mmHg)

TREAT to target < 130/80 mmHg

USE multiple antihypertensive medications if
needed to achieve target (often necessary)

USE initial combination therapy if systolic blood
pressure > 20 mmHg or diastolic blood
pressure > 10 mmHg above target
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Summary of Pharmacotherapy for Hypertension
in Patients with Diabetes
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
With
Nephropathy,
CVD or CV
risk factors
ACE Inhibitor
or ARB
Diabetes
Without
the above
1. ACE Inhibitor
or ARB or
2. Thiazide diuretic
or DHP-CCB
Combination of 2 first line
drugs may be considered
as initial therapy if the
blood pressure is >20
mmHg systolic or >10
mmHg diastolic above
target
> 2-drug
combinations
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI
or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of
proteinuria
More than 3 drugs may be needed to reach target values
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop
if control of volume is desired
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diuretic
should
be substituted
for a thiazide diuretic
Copyright
© 2013
Canadian
Diabetes Association
What is Victor’s LDL target?
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If on therapy, target
LDL ≤ 2.0 mmol/L
Increase the statin dose and continue to monitor
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Drug Class
Generic name (Trade
name)
Principal effects
Other considerations
Bile Acid Sequestrant
Lowers LDL-C
Gastrointestinal intolerability
TG elevation
Colesevelam: A1C lowering effect
Lowers LDL-C
Effective in combination with statin
Lowers TG
Variable LDL-C
effect
Variable HDL-C
effect
May creatinine + homocysteine (but
long term fenofibrate use has
favorable renal effects)
Do not combine gemfibrozil + statin
Lower TG + LDL-C
Raise HDL-C
Dose related deterioration in glycemia
ER Niacin more tolerable than IR
Long-acting niacin should NOT be
used
•Cholestyramine resin (Questran)
•Colestipol HCl (Colestid)
•Colesevalam (Lodalis)
Cholesterol Absorption
Inhibitor
•Ezetimibe (Ezetrol)
Fibrate
•Bezafibrate (Bezalip SR)
•Fenofibrate (Lipidil)
•Gemfibrozil (Lopid)
Nicotinic Acid
•ER Niacin (Niaspan, Niaspan
FCT)
•IR Niacin (non-prescription)
•LA (“no-flush”) Niacin – not
recommended
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ER Copyright
= extended
release;
IR = immediate
release; LA=long acting; TG=triglycerides; FCT=film coated tablet; SR=sustained release
© 2013
Canadian
Diabetes Association
“Why do you keep testing
my urine?”
What do you tell Victor?
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2013
Chronic Kidney Disease (CKD) Checklist
 SCREEN regularly with random urine albumin creatinine
ratio (ACR) and serum creatinine for estimated glomerular
filtration rate (eGFR)
 DIAGNOSE with repeat confirmed ACR ≥ 2.0 mg/mmol
and/or eGFR < 60 mL/min
 DELAY onset and/or progression with glycemic and blood
pressure control and ACE inhibitor or angiotensin receptor
blocker (ARB)
 PREVENT complications with “sick day management”
counselling and referral when appropriate
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Counsel all
Patients
About
Sick Day
Medication
List
2015
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When to Refer…..
•
Chronic, progressive loss of kidney function
•
ACR persistently >60 mg/mmol
•
eGFR <30 mL/min
•
Unable to remain on renal-protective therapies due to
adverse effects such as hyperkalemia or a >30%
increase in serum Cr within 3 months of starting ACEi
or ARB
•
Unable to achieve target BP (could be referred to any
specialist in hypertension)
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“My grandmother went blind
from diabetes – I am afraid
of that.”
What do you tell Victor?
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Retinopathy Checklist
2013
 SCREEN regularly
 DELAY onset and progression with glycemic
and blood pressure control ± fibrate
 TREAT established disease with laser
photocoagulation, intra-ocular injection of
medications or vitreoretinal surgery
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Delaying Retinopathy
1.
Glycemic control: target A1C ≤7%
2.
Blood pressure control: target BP <130/80
3.
Lipid-lowering therapy: fibrates have been
shown to decrease progression and may be
considered
2013
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Victor heard that
amputations are highest in
people with diabetes
What do you tell Victor?
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Patients with DM are 20X More Likely to be
Hospitalized for Non-traumatic Limb Amputation
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Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).
Educate patients on proper foot care – The “DO’s”
DO …
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual
markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet – seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. Wipe off excess.
Change your socks every day
Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
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See a foot care specialist if you need advice or treatment
Educate patients on proper foot care – The “DON’Ts”
DO NOT …
Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak your feet
Take very hot baths
Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
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Smoke
“I get numbness in my toes.”
What do you tell Victor?
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40-50% of people with DM will have
detectable neuropathy within 10 years
• Sensorimotor poly- or mono-neuropathy
• Increased risk for:




Foot ulceration and amputation
Neuropathic pain
Significant morbidity
Usage of health care resources
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Neuropathy Checklist
2013

PREVENT with blood glucose control

SCREEN with monofilament or tuning fork

TREAT pain symptoms with anticonvulsants
or antidepressants
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Recommendation 4
2013
4. The following agents may be used alone or in
combination for relief of painful peripheral
neuropathy:
‡This
–
Anticonvulsants (pregabalin [Grade A, Level 1],
gabapentin‡, valproate‡) [Grade B, Level 2]
–
Antidepressants (amitriptyline‡, duloxetine,
venlafaxine‡) [Grade B, Level 2]
–
Opioid analgesics (tapentadol ER, oxycodone
ER, tramadol) [Grade B, Level 2]
–
Topical nitrate spray [Grade B, Level 2]
drug is not currently approved by Health Canada for the management of neuropathic pain associated with
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diabetic
peripheral neuropathy.
Copyright © 2013 Canadian Diabetes Association
What are the
options for Insulin?
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Copyright © 2013 Canadian Diabetes Association
2015
Types of Insulin
Insulin Type (trade name)
Onset
Peak
Duration
10 - 15 min
10 - 15 min
10 - 15 min
1 - 1.5 h
1 - 1.5 h
1-2h
3-5h
3-5h
3.5 - 4.75 h
30 min
2-3h
6.5 h
1-3h
5-8h
Up to 18 h
90 min
90 min
Up to 6 h
Not
applicable
Up to 24 h (detemir 16-24 h)
Up to 24 h (glargine 24 h)
Up to 30 h
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):
• Insulin aspart (NovoRapid®)
• Insulin glulisine (Apidra™)
• Insulin lispro (Humalog®)
Short-acting insulins (clear):
• Insulin regular (Humulin®-R)
• Insulin regular (Novolin®geToronto)
Basal Insulins
Intermediate-acting insulins (cloudy):
• Insulin NPH (Humulin®-N)
• Insulin NPH (Novolin®ge NPH)
Long-acting basal insulin analogues (clear)
• Insulin detemir (Levemir®)
• Insulin glargine (Lantus®)
• Insulin glargine U300 (Toujeo®)
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Types of Insulin (continued)
Insulin Type (trade name)
Time action profile
Premixed Insulins
Premixed regular insulin – NPH (cloudy):
• 30% insulin regular/ 70% insulin NPH
(Humulin® 30/70)
• 30% insulin regular/ 70% insulin NPH
(Novolin®ge 30/70)
• 40% insulin regular/ 60% insulin NPH
(Novolin®ge 40/60)
• 50% insulin regular/ 50% insulin NPH
(Novolin®ge 50/50)
Premixed insulin analogues (cloudy):
• 30% Insulin aspart/70% insulin aspart protamine
crystals (NovoMix® 30)
• 25% insulin lispro / 75% insulin lispro protamine
(Humalog® Mix25®)
• 50% insulin lispro / 50% insulin lispro protamine
®)
(Humalog® Mix50
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A single vial or cartridge contains a
fixed ratio of insulin
(% of rapid-acting or short-acting
insulin to % of intermediate-acting
insulin)
Serum Insulin Level
Time
Human Basal: Humulin-N, Novolin ge NPH
Analogue Basal: Lantus, Levemir
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Human Bolus: Humulin-R, Novolin ge Toronto
Analogue Bolus: Apidra, Humalog, NovoRapid
Serum Insulin Level
Time
Human Premixed: Humulin 30/70, Novolin ge 30/70
Analogue Premixed: Humalog Mix25, NovoMix 30
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Copyright © 2013 Canadian Diabetes Association
What if we do all of the
vascular protective steps
for Victor –
What will happen?
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Copyright © 2013 Canadian Diabetes Association
STENO-2: Intensive Group Achieved Targets
Gaede et al. NEJM. 2003: 348;383-393
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Intensive Group had Improved CV Outcomes
60
50
Any CV
event
P = 0.007
53 % RRR
Conventional therapy
40
Intensive therapy
30
NNT = 5
20
10
0
12
24 36
48 60
72
Months of Follow-up
RRR= relative risk reduction
Gaede et al. NEJM. 2003: 348;383-393
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84
96
STENO 2 – Microvascular Disease
Gaede et al. NEJM. 2003: 348;383-393
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How can we keep track of all
the parameters for Victor?
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Copyright © 2013 Canadian Diabetes Association
Tools to help us
keep track of our
patients
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Copyright © 2013 Canadian Diabetes Association
Tools to help us
keep track of our
patients
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Copyright © 2013 Canadian Diabetes Association
Back Page:
“Cheat Sheet” of
Targets and Goals
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Copyright © 2013 Canadian Diabetes Association
Back Page:
“Cheat Sheet” of
Targets and Goals
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Copyright © 2013 Canadian Diabetes Association
“Neither evidence nor clinical judgment alone
is sufficient.
Evidence without judgment can be applied by
a technician.
Judgment without evidence can be applied
by a friend.
But the integration of evidence and judgment
is what the healthcare provider does in
order to dispense the best clinical care.”
(Hertzel Gerstein, 2012)
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Copyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
www.diabetes.ca – for patients
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Copyright © 2013 Canadian Diabetes Association