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Diabetes Canada Guidelines 2018 - Complementary And Alternative Medicine

>> Monday, June 25, 2018

Many people turn to natural health remedies in an effort to improve their health, and diabetes is no exception.  There is a lot of confusing information on the internet about these products, so I'm thrilled that the 2018 Diabetes Canada Clinical Practice Guidelines has systematically updated their review of the available medical literature on herbal remedies for diabetes, and summarized this in a fantastic chapter that also includes evaluation of other therapies such as yoga, acupuncture, and reflexology.

People with diabetes: if you are taking a natural approach as part of your diabetes management, read on!

Health care providers:  anywhere from 25% to 57% of people with diabetes report using complementary medicine or alternative medicine - so this discussion will be highly relevant to anyone's practice.

Check out the lists in the chapter to look for data on a particular remedy.  Here's a summary:

  • About 30 natural health products have been shown to improve type 2 diabetes control - but - noting that these are mostly single and small trials, it is premature to recommend their widespread use, and further research is needed.  This includes ginger, nettle, and a list of Chinese herbs, amongst others.
  • A list of supplements that did NOT show improvement in type 2 diabetes control, or had studies less than 3 months, or were non randomized or non controlled.  This includes ginseng, flaxseed oil, soy phytoestrogens, vitamin C, vitamin E, vitamin D, and others.
  • A list of supplements that have shown conflicting results for diabetes control, including cinnamon, coenzyme Q10, omega 3, probiotics, and zinc
  • Chromium gets special attention due to its popularity - with studies being small, short, with most not showing a benefit to improve diabetes control. Studies of vanadium are too short to tell if it improves diabetes control or not.

The chapter goes on to review data on natural products for treatment of complications of diabetes and other cardiovascular risk factors like cholesterol and blood pressure. While there is some interesting data, the studies are again short and small, making strong conclusions difficult.

Importantly, the Guidelines warn us that side effects and toxicities have been reported with some natural remedies, giving examples ranging from diarrhea to liver failure to inducing abortion.  Concerns exist about standardization and purity of these compounds. Some natural health products contain pharmaceutical ingredients, and even toxic substances. Herbs can also interact with prescription medications, which can be dangerous. Again, the theme is that studies are too small and short to really understand safety of natural remedies in general.

Yoga has shown some benefit in diabetes control, but acupuncture and tactile massage have not. The chapter also reviews a smattering of data that exist looking at tai chi and reflexology - have a read of the whole chapter to get into these details.

Key Messages: 

Some natural products have reported a lowering of A1C of 0.5% or more in trials lasting at least 3 months in adults with type 2 diabetes, but most of these are single, small trials that require further large scale evaluations before they can be recommended for widespread use in diabetes.

A few more commonly used natural health products for diabetes have been studied in larger randomized controlled trials and/or meta analyses, and have refuted the popular belief of the benefits of these compounds.

Health care providers should always ask about the use of complementary and alternative medicine as some may result in unexpected side effects and/or interactions with traditional medicines.

Key Messages For People With Diabetes: 

Although some complementary and alternative medicines may have the potential to be effective, they have not been sufficiently studied, and others can be ineffective or even harmful.

It is important to let your health care provider know if you are using complementary and/or alternative medicines for your diabetes.

Follow me on twitter! @drsuepedersen © 2018


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. 

Follow me on twitter! @drsuepedersen © 2018


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.

Follow me on twitter! @drsuepedersen © 2018


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. 

Follow me on twitter! @drsuepedersen © 2018



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