Please click here for the current time in Calgary– https://time.is/Calgary . Make sure you are familiar with how to use Zoom BEFORE the Q and A sessions. Once the session has started I will be busy with admitting people from the wait room, moving the screen to show questions and monitoring the chat. I wont have time to help you with Zoom.

Note there is a max of 100 people per Zoom meeting so it is first come first serve.

For the Q and A session with general endocrinologist Dr Stuart Ross- All questions for Dr Ross must be sent to cdestudycourse@gmail.com by October 11th. Note that diabetes in pregnancy and pediatrics are a sub specialty and are generally not answered. Please follow the Zoom link below.

Esmond Wong is inviting you to a scheduled Zoom meeting.

Topic: Oct 18-  Q and A with Dr Stuart Ross
Time: Oct 18, 2021 05:00 PM Mountain Time (US and Canada)

For the Q and A session with Esmond, it is much more casual you can just ask questions without sending them in before. This session will be recorded and once uploaded you can view it here. Because of the Friday test writers the Q and A session has been moved to Thursday at 6:30 pm. Please follow the Zoom link below.

Esmond Wong is inviting you to a scheduled Zoom meeting.

Topic: Oct 21- Q and A with Esmond
Time: Oct 21, 2021 06:30 PM Mountain Time (US and Canada)

QUESTIONS

A For ecg screening. Is it repeated every 2 years or every 3-5?
B for arb/ace you are meant to start them if you have micro vascular
complications or if you are over 55 with cardiac risk factors
including albuminemia.  But if you have albuminemia wouldn’t that mean
you already  had microvascular complications?
I find the various criteria for cardiac risk factors very confusing as
they are often similar but not the same .
Thanks for taking the time to review these questions !
Jonathan

-Hi Johnathan, ECG screening is repeated every 3-5 years. Another student mentioned the the Essentials recommends every 2 years. For real life you could go with either but for the exam go with 3-5 years.
Yes that diagram can be confusing.

Hi Esmond,
Could you/Dr. Ross please explain the processes behind hyperglycemia
in DM1 during intense exercise?  I recall it has to do with glucagon,
but would like to understand it a bit better, and the guidelines don’t
go into this.
Thank you!
Karen

-Hi Karen, for people with or without diabetes during intense exercise there is a marked increase in glucose due to release of catecholamines like adrenaline which also suppresses insulin secretion. Think back to the flight and fight response. Intense exercise is like that, your body wants to break down glycogen into glucose for fight or flight.

2. Can you reconfirm the blood sugar range that a person on insulin
should aim for before bed? In your Q&A session you said 4-7 but in
Chapter 12 they suggest no less than 7 (which is what I have usually
gone with if someone is on a basal insulin. I am curious because I am
imagining if someone is closer to 4 when going to bed, their blood
sugar could easily drop below 4.

Hello,  I think you are referring to this paragraph

Adding bedtime snacks may be helpful to prevent nocturnal hypoglycemia among those taking NPH as the basal insulin or in those individuals at high risk of severe hypoglycemia (regardless of insulin type), particularly when bedtime plasma glucose (PG) levels are <7.0 mmol/L (54,55).

Hello, its important to remember two things 1) There is no official bedtime glucose range recommended by the Diabetes Canada guidelines so it wont show up as a question on the exam. and 2) you aren’t treating hyperglycemia with basal insulin. The ideal with basal insulin is to have their sugars flat throughout the night so if they go to sleep with 4 they wake up with 4. If they are having lows you can increase that number.

Actual example of QI strategy – I think I am getting confused – is it the measuring of something, or is it the outcome from measuring something (an improvement that comes from the measure)?

Hello, you can think of QI strategy is the process of improving diabetes care or making it more efficient. That involves measuring the outcome and then trying to improve it.

You can find examples of QI in the study below: 

 

Please clarify the following – 50% of A1C value represents glycemia over the last 30 days and 10% is the 90-120 days – does this mean that the difference (40%) represents glycemia between days 30 and 90? Or do I have this wrong?

That is my understanding as well

 

Re: Screening for CVD chapter The CPG recommends screening with a resting ECG at DM diagnosis.  Is this for all patients or just for patients with risk factors? How often should we follow up with ECG?  (some places say q2years, some say q3 to 5 years) and At what point should someone be referred for a stress test?   (Eg. the CPG lists unexplained dyspnea and PAD as criteria… so what would we be looking for when we are following up with patients?) What are some of the other tests done for DM patients to evaluate CVD risk and are they done routinely here in Alberta? The resting ECG is for all patients with or without risk factors but I know that is not always done in real life practice.

Hello, the answer would be q3-5 years as that is in the grey/Recommendations area.

A resting ECG, repeated every 3 to 5 years, should be performed in individuals with diabetes with any of the following [Grade D, Consensus for all of the following]: Age >40 years
Duration of diabetes >15 years and age >30 years
End organ damage (microvascular, CV)
≥1 CVD risk factor(s) (current smoking, hypertension, family history of premature CVD in first degree relative [men <55 years, women <65years], CKD, obesity [BMI >30 kg/m2], erectile dysfunction)
Age >40 years and planning to undertake very vigorous or prolonged exercise, such as competitive running, long-distance running, or high-intensity interval training (see Physical Activity and Diabetes chapter, p. S54).

Hello, for the stress test, something that detailed wont be on the exam and I would follow the guidelines here

People with diabetes should undergo investigation for CAD by exercise ECG stress testing as the initial test in the presence of any of the following:

Typical or atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort) [Grade C, Level 3 (13)]
Signs or symptoms of associated diseases
PAD (abnormal ankle-brachial index) [Grade D, Level 4 (18)]
Carotid bruits [Grade D, Consensus]
Transient ischemic attack [Grade D, Consensus]
Stroke [Grade D, Consensus]
Resting abnormalities on ECG (e.g. Q waves) [Grade D, Consensus]
CAC score >400 Agatston score [Grade D, Consensus]

Some other tests that are done in Alberta. Dr James Stone a cardiologist in Alberta advocates for the calcium coronary test. I’m not familiar with it but supposedly its becoming more popular and its a better predictor of CV risk than the Framingham.

RE: PVD screening
The CPG recommends palpatation of peripheral pulses as part of a
routine clinical examination for patients with T2DM.  Could you please
describe how this is done and what a diabetes educator would be
looking for?

Basically it’s feeling for a pulse. For foot checks the two places to palpate pulses is the dorsal pedis pulse on top of the foot and the tibial pedal pulse below the ankle. Please see this Alberta Health Services be video on foot checks-

https://www.youtube.com/watch?v=AtaQKs2jTTI&t=198s&ab_channel=AHSChannel

Re: Statins
There is a lot of evidence of the CV protective effect of statins.
Should our goal be to max out the tolerable dose of statins in our DM
patients or is a target of LDL-C < 2 adequate?  Is there a statin that
you prefer over another?

That is a matter of considerable debate. I have heard some endos like Dr David Lau say we should be getting LDL to as close to zero as possible. For the exam go with LDL less than 2 in real life that is more grey. In terms of statins no I don’t have a preference based on efficacy however patients will think you are better health care professional if you use a lower dose. For example a patient who complains I have to increase his atorvastatin from 40 to max dose 80mg is delighted when I change him to rosuvastatin max dose 40mg instead. Its a stupid idea but it works like a charm on real patients.

Guidelines imply that treatment protocol for hypoglycemia when BG less
than 4 is intended for people on insulin and SUs – would like to know
whether same treatment applies for someone on non-insulin/SU e.g.
SGLT2 in combo with metformin?

Yes, all treatment for hypoglycemia regardless of cause is the same except acarbose and alcohol. Please see pg S106 for details.

Do we treat with same protocol e.g.
15-20g CHO and glucagon if needed, or advise otherwise – since insulin
is not part of the MOA in these drugs???

I know that these situations
are rare but monographs caution hypoglycemia can occur in combo with
other agents, so we should know how to treat if and when it occurs and
whether we should be having patients keep a fast acting CHO on hand
just in case. If protocol is intended for any cause (combo of
non-insulin meds where co administration may increase hypo risk) why
is this not written into the protocol? Protocol is intended for any cause

Yes all the same treatment except for acarbose and alcohol. I’m reading the paragraphs on pg S106-107 and I don’t see where it says that treatment is only for insulin and SU.

1.     Table 1 of Chapter 9 (Monitoring Glycemic Control:
http://guidelines.diabetes.ca/cpg/chapter9) in the DC 2018 Guidelines
states that Alcoholism can increase A1C. What is the mechanism/reason
behind this?

Remember that those examples in Table 1 are for things that falsely elevate or falsely decrease A1c. Its like a mercury thermometer and room temperature. A1c measures blood glucose but isn’t blood glucose, A1c is the glycation of hemoglobin and things that affect glycation of hemoglobin can falsely elevate or decrease A1c. Alcohol affects hemoglobin glycation which affects A1c. I tried to find an exact reason but all I could find was complicated biochemical reactions that I dont understand.

I’m wondering why SQ Semaglutide received a Grade B Level 2 and not
the higher rating that liraglutide and dulaglutide received? Same
question for canagliflozin: How come it received the lower rating
compared to empagliflozin?

The semaglutide study SUSTAIN was a non-inferiority study compared with the liraglutide study LEADER which was designed as a cardiovascular study. LEADER proved that liraglutide prevents cardiovascular events while SUSTAIN showed that semaglutide was non-inferior to liraglutide. So the example I would like to use is You have one guy that proves you have a gold mine under your house and guarantee he can get you the gold. The other guy says he has non-inferior confidence that there is a gold mine under your house and can give you a non inferior guarantee that he can get you the gold

For SGLT-2, For the empagliflozin study EMPA-REG they used close to 100% secondary prevention whereas the canagliflozin CANVAS only used ~2/3 secondary prevention. I as assuming this is the reason they gave EMPA-REG higher evidence. The guidelines committee does not publish their rationale for assigning specific evidence grades.

Good morning,
Just a couple quick questions:
1. Why is a 6mm needle with a 45 degree injection angel recommended for lean children? I’d think a 4mm with a 90 degree angle would be best.
2. Are there diabetes medications that are preferred for an elderly population? I see a lot of elderly people who take gliclazide. I worry about the risk of hypoglycaemia. I’d think SGLT2 and DPP4s would be safer. Thoughts?

Hope you can help.
Thanks. 
Brittany Miller RD

Hey Brittany,
1) A 6mm needle for lean children may cause an intramuscular (and thus have erratic absorption) if given 90 degrees. If you have a 4mm needle you would use that instead. Please see pg 31 of the 4th Edition FIT guidelines for details.
2) Metformin is still the first line but DPP-4s seem to be preferred as well. Please see chapter 37 for details. I would guess that a lot of elderly were diagnosed years ago and were put on SUs before the more recent explosion in different diabetes medications. For Alberta Blue Cross, an SU is required before special auth coverage will be provided for DPP-4s and SGLT-2s. SLGT-2 are a bit trickier as elderly patients often have poor renal function.
I will post these questions in the Q and A so everyone can benefit. Thanks
Esmond

Hi Esmond,

On Thursday, can you talk about the following (one is a question you already answered but I just needed further clarification).

1. Will there be questions on the 2021 BG monitoring update recommendations? Do we need to study this or leave it until after the exam (to avoid any last minute cramming).

2. I still have question about treating lows in someone not taking insulin and/or SU. You provided an answer already after Monday’s session but said that you could not see where the guidelines specifically refers to insulin/SU treatments.

Here is the definition in the guideline;
Hypoglycemia is defined by: 1) the development of autonomic or neuroglycopenic symptoms (Table 1); 2) a low plasma glucose (PG) level (<4.0 mmol/L for people with diabetes treated with insulin or an insulin secretagogue); and 3) symptoms responding to the administration of carbohydrate (7). The severity of hypoglycemia is defined by clinical manifestations (Table 2). Hypoglycemia is most frequent in people with type 1 diabetes, followed by people with type 2 diabetes managed by insulin, and people with type 2 diabetes managed by sulfonylureas.

Just want to be sure same protocol applies if person reports BG<4 but not on insulin or SU e.g. Metformin + SGLT2 or GLP1

Thank you,
Michele

 

Hi Esmond – for Thursday Q&A
I have a question about testing BG and Ketones –  frequency for testing ( every 2 hours, 3 hours, 2-4 hours, 1-2 hours) and insulin delivery (every 2 hours until no ketones? ). I want to ensure I have the correct information from the CPG for the exam  – finding practice, patient handouts etc have varying instructions. Thanks, Carlene

 

I can’t seem to find where it says that exercise helps improve glycemic control in Type 1 adults.
Is it only Type 2 for glycemic control but Type 1  gets reduced risk of CVD
Thanks Sue

The question arises from The Essentials quiz — question number 29 — I chose c instead of d because of Type 1 diabetes

Susan

 

Hey Esmond, a question for you.  This was one of the sample questions on the CDECB Sample Examination Questions

Claire is a 25-year-old police officer with type 1 diabetes. She alternates day and night shifts. Her latest A1C is 9.1% and she has fluctuating blood glucose levels. Currently she is taking intermediate-acting insulin 10 units BID and 10 units of short-acting insulin before breakfast and before supper. Which of the following insulin regimens should the diabetes educator recommend for Claire?

1. Take 20 units of intermediate-acting insulin at bedtime and switch to 7 units of rapid-acting insulin analogue before each meal.

1. Switch to 10 units of long-acting basal insulin analogue at breakfast and bedtime and 10 units of short-acting insulin before breakfast and supper.

1. Switch to 18 units of long-acting basal insulin analogue at bedtime and 6 units of rapid-acting insulin analogue before each meal.

1. Switch to 24 units of long-acting basal insulin analogue at bedtime and 6 units of rapid-acting insulin analogue before each meal.

The answer key answer is C.  I kind of have an idea why, but it doesn’t make too much sense to me

Konrad

Can you review the correction dose. Guidelines were clear about sliding scale are not recommended.

 

Can you explain how you usually adjust insulin with regards to exercise? Would you only consider increasing insulin when exercise is intensive and more than 1 hour?

 

Do they ask any COVID related questions? I didn’t see the webinar on COVID in your website that’s why worried?

 

In practice, I’m curious how much Vit C it would take to falsely lower A1C?

 

For communication questions, would you say that it’s most appropriate to address the psychosocial issues first and then medication or insulin adjustments even in the presence of hypoglycemia? Just wondering how much it’s worth focusing on the model of change and counselling?

 

How many diabetes study specific questions can we expect?