What are the Canadian guidelines for managing chronic diseases such as diabetes or hypertension in a patient?

Canadian Guidelines for Managing Chronic Diseases: Diabetes and Hypertension

Blood Pressure Targets

For patients with diabetes and hypertension, target a systolic blood pressure <140 mmHg and diastolic blood pressure <80 mmHg. 1, 2 Lower targets of 120-129 mmHg systolic may be appropriate for younger patients who tolerate treatment well, but avoid going below 120 mmHg. 2 For older adults ≥65 years with diabetes, aim for systolic BP 130-139 mmHg. 2

• Confirm hypertension diagnosis on a separate day if initial readings show SBP ≥130 mmHg or DBP ≥80 mmHg. 3
• Measure BP at every routine diabetes visit with proper technique: seated position, feet on floor, arm supported at heart level, after 5 minutes of rest. 3
• Screen for orthostatic hypotension before initiating or intensifying BP medications by measuring BP after 5 minutes sitting/lying, then 1 and/or 3 minutes after standing. 3

Pharmacological Treatment Algorithm

Initiate ACE inhibitors or ARBs immediately as first-line therapy for all patients with diabetes and confirmed BP ≥140/90 mmHg, alongside lifestyle modifications. 1, 2 If one class is not tolerated, substitute with the other. 3, 2

Treatment Thresholds:

• BP ≥140/90 mmHg: Start pharmacotherapy immediately plus lifestyle therapy. 3, 1
• BP 130-139/80-89 mmHg: Attempt lifestyle therapy alone for maximum 3 months, then add pharmacotherapy if targets not achieved. 3, 1

Medication Selection Priority:

1. First-line: ACE inhibitor or ARB (especially with albuminuria, proteinuria, or left ventricular hypertrophy). 1, 2
2. Second-line: Add thiazide or thiazide-like diuretic in fixed-dose combination with ACE inhibitor/ARB. 4
3. Third-line: Add calcium channel blocker (dihydropyridine preferred). 4
4. Fourth-line: Consider mineralocorticoid receptor antagonist. 4

• Multiple drugs (two or more at maximal doses) are typically required to achieve BP targets. 3
• Administer one or more antihypertensive medications at bedtime. 3
• Avoid combining ACE inhibitors with ARBs—this combination should not be used. 4
• Beta-blockers are not first-line agents unless the patient has heart failure or previous myocardial infarction. 4

Monitoring Requirements:

• Monitor serum creatinine/eGFR and serum potassium when using ACE inhibitors, ARBs, or diuretics. 3, 2

Glycemic Control Targets

Target HbA1c <7.5% for most adults with diabetes, relaxing to <8.0-8.5% for older adults with multiple comorbidities or limited life expectancy. 1

• Use metformin as first-line pharmacotherapy for type 2 diabetes unless contraindicated. 1
• Consider SGLT2 inhibitors for patients with CKD (eGFR >20 mL/min/1.73 m²) to improve outcomes and provide modest BP-lowering effects. 3
• GLP-1 receptor agonists and SGLT2 inhibitors offer additional benefits for weight reduction and cardiovascular risk reduction. 3

Lifestyle Modifications (Mandatory for All Patients)

Initiate lifestyle interventions for all patients with BP >120/80 mmHg or diabetes, regardless of medication status. 1

Specific Interventions:

• Weight loss: Target BMI 18.5-25 kg/m² if overweight or obese. 2
• DASH dietary pattern: Reduce sodium to <2,300 mg/day, increase potassium intake, consume 8-10 servings of fruits and vegetables daily. 3, 1, 2
• Physical activity: 30-60 minutes of moderate activity on >5 days per week. 2
• Alcohol moderation: Maximum 2 drinks/day for men, 1 drink/day for women. 2
• Smoking cessation: Provide pharmacological support (nicotine replacement, bupropion, or varenicline) plus behavioral counseling. 2

Cardiovascular Risk Factor Management

Target LDL cholesterol <1.4 mmol/L (<55 mg/dL) or ≥50% reduction for patients with diabetes and very high cardiovascular risk. 1, 2

• Add statin therapy to lifestyle modifications regardless of baseline lipid levels for all diabetic patients. 2
• Measure fasting lipid profile at least annually. 2
• Implement comprehensive cardiovascular risk reduction including antiplatelet therapy when indicated. 3

Screening and Monitoring Protocols

Screen annually for diabetic kidney disease by assessing eGFR and urinary albumin-to-creatinine ratio. 1

• Avoid routine cardiac screening in asymptomatic patients with diabetes; instead perform careful cardiovascular risk factor assessment. 1
• ACE inhibitors or ARBs are preferred first-line therapy especially when urinary albumin-to-creatinine ratio ≥30 mg/g. 2

Team-Based Care Implementation

Implement team-based care models with structured protocols as the primary delivery system, designating specific team members to execute medication titration algorithms under physician supervision. 1

• Create protocols for timely patient contact through telephone, secure messaging, or urgent appointments. 1
• Use patient-centered communication incorporating patient preferences, literacy assessment, and cultural considerations. 1

Special Populations

Pregnant Patients:

• Target BP 110-129/65-79 mmHg for long-term maternal health while minimizing impaired fetal growth. 3, 2
• ACE inhibitors and ARBs are absolutely contraindicated during pregnancy. 3, 2

Older and Frail Patients:

• For patients ≥85 years or with moderate-to-severe frailty, consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors, followed by low-dose diuretics if tolerated. 3
• Avoid beta-blockers or alpha-blockers unless compelling indications exist. 3
• Consider deprescription of BP-lowering medications if BP drops with progressing frailty. 3

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for patients with BP ≥140/90 mmHg—initiate immediately alongside lifestyle changes. 1
• Do not combine ACE inhibitors with ARBs—increased risk without additional benefit. 4
• Do not use beta-blockers as first-line unless specific cardiac indications exist. 4
• Do not target BP <120 mmHg systolic even in younger patients—excessive treatment burden without proven benefit. 2
• Do not forget to monitor renal function and potassium when using RAS blockers or diuretics. 3, 2