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Diabetes Canada Guidelines 2018 - Vaccinations

>> Monday, June 18, 2018





The 2018 Guidelines have expanded the vaccination chapter to now include recommendations for not only the flu shot and the pneumococcal vaccine, but also information regarding hepatitis B and shingles.


Key Messages For People With Diabetes:

You should receive routine vaccinations as recommended for anyone with or without diabetes.
Check if you are up to date with your vaccinations.

You should receive:
  • the flu shot, every year
  • the pneumococcal vaccine initially when you are over age 18; and again, when you are over age 65 IF your first vaccination was given under age 65 and it's been more than 5 years since you had it

It is now recognized that people with diabetes are at a higher risk of hepatitis B infection compared to people without diabetes.  Outbreaks can happen in places where there is assisted glucose monitoring if hygiene protocols are not adhered to - for example, there have been cases of outbreaks reported in long term care facilities.   The Guidelines do not officially recommend Hepatitis B vaccinations, but do go through some of the pros and cons to consider. 

Though the data is scarce, the existing information suggests that people with diabetes are at an increased risk of getting shingles (herpes zoster), which is a reactivation of the chicken pox virus.  The Diabetes Canada Guidelines list the recommendations for Canadians as a whole for shingles vaccination, with the point of making sure that people with diabetes are vaccinated according to these recommendations. 



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www.drsue.ca © 2018




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Diabetes Canada Guidelines 2018 - Driving Safety

>> Sunday, June 10, 2018





Yes, it’s finally here!  The Diabetes Canada Guidelines now has a full chapter dedicated to the important topic of driving safety in people with diabetes.  

Diabetes can affect driving performance because of the risk of low blood sugars with some medications (see below), because low blood sugars can delay reflexes, cause confusion, or loss of consciousness.  Complications of diabetes can also affect driving safety, including eye complications affecting vision; nerve complications (can affect sensory and/or muscle function); amputation;  and vascular disease (heart disease or history of stroke). 


Here are some of the Key Messages For People With Diabetes from this chapter: 

1. If you take insulin, or a diabetes medication that can cause low blood sugar [sulphonylureas: eg. gliclazide (Diamicron), glyburide; or meglitinides (repaglinide (Gluconorm)], check your blood sugar: 

  • immediately before driving
  • if you develop symptoms of low blood sugar while driving (pull over immediately in a safe location)
  • at least every 4 hours while driving, or more frequently if there are factors that may increase your risk of low blood sugar (eg recent activity, missing a meal)
  • at least every 2 hours while driving if you have a history of recurrent severe hypoglycemia or if you have hypoglycemia unawareness (you don't feel it when your sugars are low)
2.  Do not drive if your blood sugar is less than 4 mmol/L.  If your sugar is less than 4, do not start driving until you have ingested 15 grams of carbohydrate, retested, and blood sugar is at least 5.  Wait 40 minutes before driving as it takes time for judgement and reflexes to the brain to fully recover from a low blood sugar. 

An easy way to remember (it rhymes!): ABOVE 5 BEFORE YOU DRIVE


3.  If a low blood sugar develops while driving:
  • STOP the vehicle in a safe location
  • REMOVE the keys from the ignition
  • TREAT the low blood sugar and WAIT before driving again (see above)

4.  Always keep a glucose meter, supplies, and a source of fast acting carbohydrate (eg dextrose tabs) with you, and within easy reach, if you take any of the above medications or insulin.

5.  On longer journeys, take regular meals, snacks, and periods of rest.


There are also important messages about notifying your doctor and your driving licensing body if you've had severe hypoglycemia, frequency of assessments for fitness to drive, reporting procedures for health care professionals when patients have conditions that impair their driving abilities, and special considerations for commercial drivers.

For health care providers, there is also excellent information on how, when, and what needs to be assessed for fitness of people with diabetes to drive.  This includes a discussion of hypoglycemia risk, glycemic control, and assessment of diabetes complications to identify whether any of these factors could significantly increase the risk of a car accident for your patient.

This entire chapter is a must-read for any health care professional who has patients in their practice with diabetes treated with insulin, sulfonylureas, or meglitinides.


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www.drsue.ca © 2018









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Diabetes Canada Guidelines 2018 - Diabetes In Older People

>> Sunday, June 3, 2018






The goals of diabetes management in older people (defined by the Guidelines as about age 70 or older) is distinct from diabetes in younger people, especially for those who are frail or dependent on others for care.

One of the highest priorities in the older person with diabetes (as for all people with diabetes) is the avoidance of hypoglycemia (low blood sugars), which can be a side effect of some diabetes medications.  Older people are less likely to feel symptoms of low sugars, and their bodies are less able to respond to low sugars (due to reduced glucagon secretion), putting them at even higher risk of severe hypoglycemia.  

Many of the recommendations in this chapter of the 2018 Guidelines are focused on the principle of avoiding low sugars in older people with diabetes, upping the emphasis on this even above what was already stated in the last edition of the Guidelines.  

Here are some highlights from this chapter

NEW: There is now more guidance as to what A1C target may be considered, depending on a patient’s level of independence and frailty. 

The recommended targets for older people with diabetes are: 
  • Functionally independent: A1C 7% or less, premeal sugars 4-7 mmol/L, post meal 5-10
  • Functionally dependent: A1C less than 8%, premeal 5-8, post meal less than 12
  • Frail and/or with dementia: A1C less than 8.5%, premeal 6-9, post meal less than 14
  • End of life: avoid low sugars, and avoid symptomatic high sugars
The 2018 Guidelines continue to advise caution in using sulphonylureas in the elderly because of risk of hypoglycemia.  Now, there is a NEW Key Recommendation that DPP4 inhibitors should be used over sulphonlyureas because of a lower risk of hypoglycemia.

Other highlights from the Key Recommendations

NEW DETAILS: Functionally independent older people with diabetes who have a life expectancy of greater than 10 years should be treated to achieve the same glucose, BP and lipid targets as younger people with diabetes. 

NEW: BP targets should be individualized for older adults who are functionally dependent, or who have orthostasis, or who have a limited life expectancy.  (may wish to target a slightly higher BP than the usual target of less than 130/80)


NEW: In older people with type 2 diabetes with no other complex comorbidities but with clinical cardiovascular disease, and in whom glycemic targets are not met, consider a diabetes medication that decreases the risk of cardiovascular events (same as for the type 2 diabetes population in general, see here)


There are new Key Messages For Older People With Diabetes, which reflect the above points: that every older person with diabetes needs a customized diabetes care plan, and that your diabetes health care team will work with you to set blood sugar control targets, choose appropriate glucose lowering medication, and a program for screening and management of diabetes related complications. 

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www.drsue.ca © 2018

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Diabetes Canada Guidelines 2018 - Diabetes And Pregnancy

>> Monday, May 28, 2018





With no less than 42 (!) recommendations, this is the longest chapter in the 2018 Diabetes Canada Clinical Practice Guidelines.  That's because there is a lot to say about management of not only diabetes predating pregnancy, but also gestational diabetes (diabetes that develops in pregnancy).

As a summary of this chapter is beyond the scope of a blog post due to its length,  I have picked out some of the key pearls to share here.


1.  Key Messages for women with diabetes who are pregnant or planning a pregnancy - this is a completely new section, and a must read not only for women with diabetes, but also women at risk for gestational diabetes.

2.  Contraception for women with diabetes is ESSENTIAL, until both the woman and her health care providers agree that she is safe and ready for pregnancy. There are many steps to be taken that must be in place before any attempts at pregnancy. This includes having good and stable blood sugar control, ensuring no unsafe medications are on board, vitamin supplementation, and eye checks.

3.  A1C target pre pregnancy should be 7% or less, and ideally 6.5% or less if it can be achieved safely (without low blood sugars).

4.  A1C target during pregnancy should be 6.5%, and ideally 6.1% or less if it can be achieved safely (without low blood sugars).

5.  Folic acid 1mg should be started 3 months pre pregnancy, and continued until at least 12 weeks of pregnancy (the 2013 Guidelines recommended more)

6.  Women on metformin or glyburide for type 2 diabetes with good control can continue these medications until pregnant.  Once pregnant, it is recommended to switch to insulin. (the previous guidelines recommended that all women with type 2 diabetes should be switched to insulin and stabilized on insulin prior to pregnancy). Metformin use during pregnancy in women with type 2 diabetes is currently under active study.

7.  Recommendations for appropriate weight gain in pregnancy are based on pre pregnancy BMI.

8.  Screening for gestational diabetes is recommended for all women at 24-28 weeks of pregnancy, with the preferred method being a 50g glucose challenge as the initial test.  Women who are at increased risk of gestational diabetes should have blood testing for diabetes at the first pregnancy visit.

9. For women with gestational diabetes, testing for diabetes after pregnancy remains essential.

10.  New recommendations for fetal surveillance and timing of delivery are provided.

I emphasize again that there are many other changes and expansions of recommendations in this chapter of the guidelines - anyone practicing in this area of diabetes care is encouraged to embrace the chapter in its entirety.


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www.drsue.ca © 2018

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Sudden Death During Triathlons

>> Tuesday, May 22, 2018




Ever think that a triathlete seems invincible? They can swim, they can ride, they can run….

Well - think again. It turns out that the risk of sudden death during a triathlon is higher than the risk of sudden death in the general population. 

A recent study is the first to collect data on sudden deaths during triathlons.  (Triathlons consist of a swim, followed by cycling, followed by a run.)  The study reviewed race related deaths during 30 years of triathlons in USA, with data from over 9 million participants.  They identified 135 deaths, for a risk of death of 1.74 per 100,000 participants.  

Perhaps surprisingly, most of the sudden deaths and cardiac arrests (90) occurred during the swim (which starts the race), with 7 during cycling, 15 during the run, and 8 during the post race recovery.  Men age 60 and older were at the highest risk of death at 18.6 per 100,000.  There were also 15 trauma related deaths during cycling. 

Of the 135 deaths, 61 autopsies were performed.  At least 18 of these deaths were due to narrowing of the arteries of the heart.

Why do so many of these sudden deaths occur during the swim, which is at the start of the race?  This may be due to the adrenaline rush at the start of the race increasing the risk of heart arrhythmias, crashes in the water, and/or difficulty in identifying events and initiating rescue, defibrillation and CPR in the water.  This contrasts with data in marathoners (a race of running only), which suggests that sudden deaths in marathons most commonly occur at the end of the race.  Cardiovascular disease accounts for the the majority of marathon-related cardiac arrests.

Bottom Lines:  

1.  Screening for cardiovascular disease when appropriate is important, and triathletes are no exception.  

2.  Organization of races to reduce risk is important: eliminating mass swim starts, and having coordinated safety responses to identify and help people in trouble are key.

PS  - Regular readers - never fear ! I still have several chapter reviews of the Diabetes Canada 2018 Guidelines coming up over the next several weeks.  Stay tuned!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018


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A HEARTFELT WELCOME!

I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!


Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!




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