Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-

3b. TREAT TO INDIVIDUALIZED A1C TARGET (refer to Figure 1) [2020 update]

At diagnosis of type 2 diabetes (T2D), through shared decision-making and individualized SMART goal-setting. the person with T2D should be engaged in their diabetes management plan to attain their individualized A1C target by 3 months. • If A1C less than 1.5% above individual target (with no evidence of metabolic decompensation and/or symptoms of hyperglycemia). o Treatment Plan: Initiate healthy lifestyle changes expected to reduce blood glucose levels o Metformin may (or may not) be started at diagnosis when A1C is less than 1.5 % above individual target.

o Goal: Achieve A1C target within three months. o If A1C NOT at individual target at 3 months

→ if metformin has not already been started, start metformin → if metformin HAS already been started, revisit healthy behaviour interventions, consider uptitrate metformin dose to the lesser of maximally-tolerated dose or 2 g metformin and see “Adjust or Advance Therapy”

• If A1C greater than 1.5% above individual target. o Treatment Plan: Initiate healthy lifestyle changes expected to reduce blood glucose levels and antihyperglycemic pharmacotherapy

▪ First-line treatment: Initiate and uptitrate metformin unless contraindicated as can reduce A1C by 1.0%. (refer to Figure 1).

▪ Start a second agent concurrently: Each agent will decrease A1C by 0.5 1.5% depending on the agent and the degree of hyperglycemia. A more robust lowering of A1C is often seen with higher baseline A1C, see “Adjust or Advance Therapy” o Goal: Achieve A1C target within three months.

Type 2 diabetes — PRE-EXISTING Type 2 diabetes

The ongoing assessment and management plan for people with type 2 diabetes is outlined in the Diabetes Canada Quick Reference Guide figures 2, 2.1, 2.2, and figure 3. Of note, building from the 2018 Clinical Practice Guidelines, in the 2020 update, the assessment of the person with pre-existing type 2 diabetes begins with consideration of glycemic control, cardiovascular and renal status, recent dietary patterns and weight change, rather than primarily looking at A1C.