Background and Purpose
Diabetes Canada prepares clinical practice guidelines to provide a synthesis of the best evidence to help practitioners. Evidence-based medicine seeks to integrate the best evidence with clinical expertise and the values of persons living with diabetes. It is challenging to balance the goals of providing guidelines based on high-quality evidence with addressing the needs of practitioners who commonly face clinical scenarios for which there is no robust evidence.
The 2020 update examined whether recently published trials provided sufficient new evidence to require new or updated recommendations. We have deliberately sought to minimize the addition of consensus recommendations (i.e. Grade D). Nevertheless, this may not be sufficient to help decision-making in day-to-day clinical practice. This document seeks to help address this gap by providing some clinical perspective (in a question and answer format) that will help practitioners apply the updated recommendations with greater confidence.
A major challenge that all clinicians face is how to apply evidence to individuals who do not resemble clinical trial participants. Extrapolation may be required by practitioners in certain scenarios, and we have provided some commentary around this. Disagreements of approach may be less to do with the evidence itself, but rather the priorities and values of persons interpreting or applying the evidence. Individual treatment decisions should always be based on the principles of shared decision-making.
We hope this document will reduce uncertainty and, perhaps, also unhelpful conjecture, about the meaning of some recommendations or the rationale behind their grading. Additional clinical practice tools and resources are being developed to support persons with diabetes and to help prescribers apply the updated guidelines.
Acknowledgements
The authors gratefully acknowledge the support of Tracy Barnes for administrative support for all aspects of CPG revisions and in preparing this manuscript for submission, and Joanne Lewis for perspectives regarding future dissemination strategies.
Author Disclosures
Dr. Senior reports no personal fees for speaking, consulting or clinical trials for industry partners since 2018, but is a local Principal Investigator for clinical trials at the University of Alberta sponsored by Novo Nordisk. He has research support from the American Diabetes Association, the Juvenile Diabetes Research Foundation, the National Institutes of Health, and salary support from the Alberta Academic Medicine and Health Services Plan. Dr. Senior is also a member of the Diabetes Canada Board of Directors. Dr. Kim reports speaking fees/personal fees from Abbott, AstraZeneca, BD, Sanofi, Merck, Janssen, Novo Nordisk, Boehringer-Ingelheim, Eli Lilly, MDBriefcase, CPD Network, and research support from Novo Nordisk (pending). Dr. Bajaj reports speaking fees from AstraZeneca, Eli Lilly, Janssen, Merck, and Novo Nordisk, and research funding for serving as principal investigator on clinical trials from Amgen, AstraZeneca, Boehringer Ingelheim, Ceapro, Eli Lilly, Gilead, Janssen, Kowa Pharmaceuticals Co. Ltd, Madrigal Pharmaceuticals, Merck, Novo Nordisk, Sanofi and Tricida. Dr. Rabi reports research support from the Canadian Institutes of Health Research (CIHR), Heart & Stroke, Alberta Innovates, Alberta Health Services and the Natural Sciences and Engineering Research Council of Canada. Dr. Sherifali reports research support from CIHR, Diabetes Canada, Population Health Research Institute and Hamilton Health Sciences, and honoraria for investigator-led research (MERCK). Dr. Houlden reports speaking fees from AstraZeneca, Boehringer Ingelheim, Dexcom, Eli Lilly and Novo Nordisk, research support from AstraZeneca and Boehringer Ingelheim, and consulting fees from Dexcom, Novo Nordisk and Sanofi. Dr. Nagpal is the Vice President, Science & Policy, with Diabetes Canada and an adjunct professor at the University of Ottawa. Dr. Mackay reports speaker fees from Pepsico and research support from CIHR, Mitacs, W. Garfield Weston Foundation, Research Manitoba and the Manitoba Medical Service Foundation.