Addressing Metabolic Dysfunction‑Associated Steatotic Liver Disease (MASLD) in Endocrinology Settings in Canada: From Prevalence to Patient-Centered Management
Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent in Canadian endocrinology, affecting up to 70% of those with type 2 diabetes and 75% with obesity. Despite this, routine screening is rare, leading to missed detection and intervention. Advanced fibrosis, observed in 15% of cases, increases the risk of liver and cardiovascular complications. This article addresses the burden of MASLD and the need for systemic screening and patient-centred care to improve outcomes and reduce Canada’s disease burden.
Copyright (c) 2025 Canadian Diabetes & Endocrinology Today https://creativecommons.org/licenses/by-nc-nd/4.0
Optimizing the Use of Automated Insulin Delivery (AID) Systems in Routine Clinical Care of People with Type 1 Diabetes
With the updated Diabetes Canada Clinical Practice Guidelines recognizing automated insulin delivery (AID) as the standard of care for people with type 1 diabetes (PwT1D), clinicians play a vital role in supporting individuals to adopt and optimize use of this technology. AID systems integrate insulin pump therapy (IPT) and real-time continuous glucose monitors (rtCGM) in conjunction with a control algorithm to automate various aspects of insulin delivery. The recommendation to adopt AID is supported by robust evidence from both randomized-controlled trials and real-world studies across diverse populations, including all ages, previous experience with technology, baseline glycemia, and self-management behaviours. Glycemic benefits include consistent improvements in time in range (TIR) (often by >10%), and reductions in A1C, mean glucose levels, and hypoglycemia. Additionally, AID use has shown important improvements in person-reported outcomes, including reduced diabetes distress, reduced fear of hypoglycemia, improved quality of life, and improved sleep.
Type 2 diabetes (T2D) was once considered a disease of adults. However, the obesity pandemic has helped its transition to the pediatric population. While type 1 diabetes remains the most common type of pediatric diabetes in Canada, the incidence of youth-onset T2D has increased by 60% in recent years. Canada has one of the highest prevalences of youth-onset T2D in the world, with approximately 50% of new cases annually occurring in Indigenous children, with the remaining 50% of cases occurring in other ethnic groups, including Caucasians. As a relatively new disease in youth, there is a lack of natural history data for youth-onset T2D to predict long-term outcomes. However, its aggressive nature in youth suggests that these patients will likely have a significant burden of disease related to cardiometabolic risk, comorbidities, and complications. In this paper, we highlight current knowledge on the pathophysiology of youth-onset T2D, diagnostic criteria, the impact of obesity on diabetes risk, comorbidities and complications, and current treatments.
Running a Trans-Welcoming Clinical Practice
A wide range of terms are used to describe gender-diverse people, including transgender, gender-fluid, gender-queer, non-binary, and two‑spirit, reflecting the diversity of the community itself. Transgender and gender-diverse patients (TGDP) may experience gender dysphoria—the distress that arises when their gender identity does not align with the sex assigned at birth. TGDP are estimated to represent between 0.1% and 2% of the global population; in Canada, the 2019 census reported a prevalence of 0.35%. Access to gender-affirming care is strongly linked to improved health outcomes. One study found that suicidal ideation decreased from 67% prior to transition to just 3% afterward. Yet, despite the clear benefits, TGDP continue to face major barriers to care. According to the Trans PULSE survey, as of 2019, only 35% of respondents had completed their medical transition. Even in general healthcare, access remains inequitable: while 81% of respondents reported having a primary care provider (PCP), only 52% felt comfortable discussing trans‑related health issues with their PCP, and over 40% reported having an unmet healthcare need. These disparities reflect the ongoing impact of transphobia and prior trauma within healthcare systems, and as a result, TGDP face disproportionate health burdens compared to the general population, including lower rates of cancer screening, higher rates of mental health disorders, and sexually transmitted infections (Figure 1). Addressing these inequities requires urgent action to expand access to gender-affirming hormone therapy, surgery, and mental health care. Equally important, healthcare systems must adopt inclusive policies and practices that improve access to all forms of care for TGDP. This article outlines practical measures that any healthcare practice can implement to create a more welcoming and affirming environment.
Novel Treatment Options For Menopausal Symptoms
The world of menopause is undergoing a renaissance. In recent years, medical experts have taken to social media, igniting a long overdue surge of information on the subject that helps debunk the fear of menopausal hormone therapy (MHT), which stems from the 2002 Women’s Health Initiative (WHI) study.1 The devastating consequences on health and wellness were profound: an entire generation of women was suddenly deprived of symptom relief and quality of life (QOL) due to the marked decline in hormone prescriptions in North America. These effects continue to echo today. The near extinction of medical education on mature women’s health and wellness in our academic institutions since 2002 has left healthcare professionals ill-equipped to guide the next generation of menopausal women who seek contemporary medical advice and refuse to “live their mothers’ menopause.” The creation of the Menopause Foundation of Canada in 2022, recent sold-out menopause conferences, and renewed interest from pharmaceutical companies is convincing evidence that menopause is finally receiving the recognition and attention it deserves.
Type 1 diabetes (T1D) is an autoimmune disease characterized by progressive destruction of pancreatic β cells. This process is mediated by both cellular (T lymphocyte) and humoral (autoantibody) immune responses. Although T cells play a central pathogenic role, autoantibodies are the earliest detectable markers of β cell autoimmunity and are instrumental in diagnosing and predicting disease progression. Although T1D develops on a background of genetic risk, most individuals with genetic risk never develop type 1 diabetes. In contrast, virtually all individuals with 2 or more islet autoantibodies eventually develop type 1 diabetes.
Current and Emerging Treatments For the Management of Hypoparathyroidism
Chronic hypoparathyroidism is a rare endocrine disorder marked by parathyroid hormone (PTH) deficiency, leading to hypocalcemia and its associated complications. Conventional therapy with oral calcium and active vitamin D fails to address the hormonal deficit and poses risks such as hypercalciuria and nephrocalcinosis. Recent advances in PTH replacement therapy have shifted the treatment paradigm. Palopegteriparatide, a long-acting prodrug of PTH (1–34), is now U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA)-approved, demonstrating effective calcium homeostasis, reduced reliance on conventional therapy, and potential renal benefits. Discontinuation of rhPTH (1–84) has accelerated interest in emerging alternatives such as eneboparatide, calcilytics (e.g., encaleret), MBX2109, and oral PTH1 receptor agonists. These novel therapies target PTH signalling through diverse mechanisms—offering injectable and oral options with improved safety, efficacy, and quality-of-life outcomes. This review synthesizes current evidence on approved and investigational treatments, underscoring their mechanisms, clinical impacts, and roles in personalized care for chronic hypoparathyroidism.
Vaccinating Your Adult Diabetic Patient: What Vaccines Would You Recommend?
Adults with diabetes (type 1 or type 2) are at substantially higher risk of infections and complications from vaccine-preventable diseases. As a result, persons with diabetes experience higher rates of serious illnesses such as influenza, pneumonia, and other infections. Epidemiological studies show that during flu epidemics, persons with diabetes are hospitalized at much higher rates and are more likely to suffer serious complications (e.g., myocardial infarction, heart failure, stroke) than their non‐diabetic peers. Globally, diabetes is one of the most common comorbidities among patients with severe COVID-19. In short, diabetes—especially when poorly controlled or long-standing—is a risk factor for viral, bacterial, and fungal infections. People with diabetes are more likely to be hospitalized or die from illnesses such as influenza, pneumonia, and COVID-19. Clinicians should understand that diabetes itself impairs immunity, making timely immunization critical. Notably, the Canadian Immunization Guide confirms that there is no evidence suggesting that vaccines adversely affect blood glucose control.
Thyroid Nodules: Reducing Overdiagnosis and Investigations
Thyroid nodules (TN) are incredibly common, with approximately 5% of the population presenting with palpable TN. However, the widespread utilization of sensitive imaging techniques over the past few decades has led to a rapid increase in their prevalence. Notwithstanding the clinically palpable TN, the rate of incidental nodules picked up on imaging studies varies remarkably with the underlying imaging modality. For instance, the prevalence of TNs on computed tomography (CT) scans of the neck is reported to be 16.5%,3 FDG-PET to be 2% and on neck ultrasounds (US) well over 50%. The prevalence of TN is higher in females and increases with age, and while there has been little change in the overall reported incidence of palpable TNs, the rising prevalence can be almost exclusively attributed to the expanded use of imaging, particularly the widespread availability of sensitive US. It is estimated that over 60% of the population may have at least one TN.
Monogenic and Syndromic Obesity: Therapeutic Implications
Obesity is a complex, progressive and relapsing neuroendocrine condition, characterized by disordered communication between the gastrointestinal tract, adipocytes and the hypothalamus. It is a heterogeneous condition with unique etiologies, broadly classified as: polygenic obesity, monogenic obesity, syndromic obesity and secondary obesity.2 The most common form of obesity is polygenic, a highly hereditable condition that involves the clustering of genes that increase the risk for obesity. This inherited genetic risk is exploited by socio-biologic exposures. Monogenic and syndromic obesity result from rare genetic mutations and are characterized by early onset severe obesity and hyperphagia. Secondary obesity may occur as a result of medication exposures, hypothalamic damage or primary endocrine disorders. Accurate classification of obesity is critical to inform surveillance and management strategies, decrease health risk and improve quality of life through newly available targeted therapies.
Copyright (c) 2024 Canadian Diabetes & Endocrinology Today https://creativecommons.org/licenses/by-nc-nd/4.0
Addressing Inositol Use in PCOS Management
Polycystic ovary syndrome (PCOS) is a heterogeneous complex endocrine disorder characterized by oligo-ovulation, insulin resistance, and hyperandrogenism. Treatment should be individualized based on each patient’s symptoms and reproductive goals. Unfortunately, there is no pharmacologic medication that simultaneously promotes ovulation, improves metabolic health, and reduces clinical hyperandrogenism. Metformin is a well accepted, evidence-based pharmacologic therapy that targets the insulin resistance pathway and improves ovulatory frequency, but it has limited effects on clinical hyperandrogenism as well as poor tolerability for some patients. The growing interest in complementary therapies has highlighted the need for more tolerable and ‘non-pharmacologic’ treatment options. Inositol, a naturally occurring compound, has gained attention as a promising therapeutic agent for managing PCOS. This review aims to support shared decision-making between clinicians and patients by exploring the roll of inositol as a complementary therapy for PCOS management.
Type 2 diabetes (T2D) poses a substantial global health burden. In 2023, we published an overview on the remission of T2D. Since then, additional long-term data has emerged regarding the outcomes associated with T2D remission, highlighting the importance of revisiting this topic. This article synthesizes findings from the landmark Diabetes Remission Clinical Trial (DiRECT), its 5-year follow-up, and recent studies exploring the enduring benefits of both short-term and sustained remission.
Glucagon-like Peptide-1 Receptor Agonists and Thyroid Cancer: Myth or Reality?
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are being used increasingly for the management of type 2 diabetes mellitus (T2DM) or obesity because of their association with robust glucose lowering, weight loss, and cardiorenal benefits. The association between GLP-1RA treatments and thyroid cancer has been a topic of discussion since their early development with the understanding that GLP-1 receptors are present on rodent thyroid parafollicular cells (C-cells), and that GLP-1RAs can cause an increase in calcitonin, and both C-cell hyperplasia and medullary thyroid carcinoma (MTC). This data from rodent studies has led to GLP-1RAs being contraindicated in patients with a personal or family history of MTC or with multiple endocrine neoplasia syndrome type 2. Despite this contraindication, the human relevance of GLP-1RA induced MTC in rodents has not been proven. Normal or hyperplastic C-cells in humans may not express the GLP-1 receptor, and studies of human MTCs have shown variable expression of the GLP-1 receptor. Studies have shown conflicting evidence regarding the expression of the GLP-1 receptor in human papillary thyroid cancer (PTC) cell lines: however, GLP-1RAs did not have significant effects on the proliferation of PTC cells. Because of the data that potentially links GLP-1RAs to an increased risk of thyroid cancer, clinical studies in humans are important in addressing this issue. I will review the relevant data from human studies that have analyzed the potential link between GLP-1RA treatment and thyroid cancer, including pharmacovigilance and observational studies as well as randomized controlled trials (RCTs).
The Role of GLP-1R and GIPR Agonism in Heart Failure
Heart failure (HF) is a clinical syndrome characterized by signs and symptoms of structural and functional cardiac abnormalities. It is corroborated by elevated N-terminal pro‑B‑type natriuretic peptide (NT-proBNP) levels and objective evidence of pulmonary or systemic congestion. More than 100,000 Canadians are diagnosed with HF annually. For years, HF has been classified based on left ventricular ejection fraction (LVEF). HF with reduced ejection fraction (HFrEF) refers to symptomatic HF with an LVEF <40%. However, if the LVEF is >50%, this is known as HF with preserved ejection fraction (HFpEF). In HFpEF, obesity is commonly implicated in the disease pathophysiology, and is present in up to 80% of people with this condition. Obesity contributes to concentric heart remodelling through mechanisms such as insulin resistance, diabetes, hyperlipidemia, visceral adipose tissue expansion, and myocardial steatosis. Additionally, obesity leads to a pro-inflammatory state which affects the vasculature and visceral organs.2 Glucagon‑like peptide-1 receptor agonists (GLP‑1RAs), such as semaglutide, have shown promise in weight reduction across multiple Phase 3 clinical trials. Agents combining GLP-1RA and glucose-dependent insulinotropic peptide receptor (GIPR) agonism, such as tirzepatide, have also contributed to clinically significant weight loss. As such, their impact in addressing obesity‑related HFpEF is under investigation. This paper reviews the data on GLP-1RAs and tirzepatide in patients with HF across the LVEF spectrum, with a particular focus on those with HFpEF.
As of 2018 data, 30–60% of reproductive‑aged women in Canada were affected by overweight (body mass index [BMI] 25.9–29.9) and obesity (BMI >30.0), and these rates are increasing. Obesity during pregnancy is associated with higher rates of preeclampsia, gestational diabetes, macrosomia, stillbirth, post‑term pregnancy, and increased caesarean delivery rates. Obesity is also associated with higher rates of diabetes, which has well‑known consequences for pregnancy, and ovulatory dysfunction, which impacts fertility, such as in polycystic ovarian syndrome (PCOS). Addressing obesity and its associated metabolic impacts could have a profound effect on reproductive and fetal health. Since the 2000s, incretin-based therapies for diabetes and obesity have become the focus of research and clinical practice. Glucagon‑like‑peptide 1 (GLP-1), an endogenous incretin hormone secreted by intestinal L-cells in response to food intake, and its agonists, have been available for clinical use in Canada since the introduction of liraglutide in 2011. Recently, pharmacologic agonists of glucose-dependent insulinotropic polypeptide (GIP), an incretin synthesized in the K-cells of the duodenum and jejunum, have also become available. Dual agonism of these hormones is associated with more significant reductions in blood glucose and weight. The currently available incretin-based therapies are listed in Table 1, and their physiologic effects are summarized in Figure 1. Active research is underway on new molecules, for example agonists of amylin and glucagon, in various combinations with GLP‑1 and GIP, to maximize clinical benefits. These combinations have shown weight loss effects rivalling those of metabolic surgery. Considering their potential, this medication class has taken the world by storm. Canada's Drug Agency (CDA) found that expenditure on injectable semaglutide, under the brand-name Ozempic™, increased from $13.5 million in 2019 to $227 million in 2021, with 20% of the claims being for non-type 2 diabetes use. The metabolic improvements and weight loss achieved with incretin-based therapies are associated with improved fertility. While product monographs warn against use in pregnancy and lactation, conception while on these treatments is becoming more common. Considering this increasing reality, this review aims to summarize what is currently known about GLP-1 and GIP agonists and their effects during pregnancy.
A Practical Approach to the Incidental Adrenal Mass
With modern use of abdominal imaging, incidental detection of adrenal masses is increasingly common. These lesions are estimated to be present in 4% of all patients and in up to 10% of the elderly population. Fortunately, most adrenal masses are benign non‑functioning adenomas. However, some of these lesions are hyperfunctioning or harbour malignancy. A familiarity with the evaluation and management of incidental adrenal masses is of interest to endocrinologists as well as surgeons and primary care providers who order abdominal imaging tests. In 2023 a multidisciplinary working group of Canadian radiologists, endocrinologists, and radiologists published an updated guideline on the diagnosis, management, and follow‑up of the incidentally discovered adrenal mass.4 This publication has helped clarify the necessary imaging and biochemical testing required prior to creating a management plan for a patient with an incidental adrenal lesion. When faced with an adrenal mass, the clinician must answer 3 essential questions: 1) Is the mass benign or malignant? 2) Is the mass hormonally functional or non-functional? 3) How should the mass be managed?
Diabetic kidney disease (DKD) affects 40% of individuals with diabetes mellitus (T2DM) and is associated with an increased risk of cardiovascular events, hospitalization for heart failure, and premature death. Existing treatments focus on lifestyle measures, glycemic control, blood pressure and lipid management, inhibition of the renin‑angiotensin‑aldosterone system (RAAS), and the use of sodium glucose cotransporter 2 inhibitors (SGLT2-i). However, substantial residual risk of progression to end-stage kidney disease (ESKD) or cardiovascular complications remain despite optimal therapy. Finerenone, a non-steroidal mineralocorticoid antagonist (MRA), has been shown to reduce important outcomes when added to evidence-based therapies, and is approved by Health Canada as an adjunct to standard of care therapy in adults with chronic kidney disease (CKD) and T2DM to reduce the risk of ESKD and a sustained decrease in estimated glomerular filtration rate (eGFR), cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure.
Cardiovascular Safety of Testosterone Replacement Therapy in Hypogonadal Men
Testosterone replacement therapy (TRT) aims to restore serum testosterone levels in men with hypogonadism. Symptoms associated with hypogonadism include reduced libido, erectile dysfunction, fatigue, depression, and loss of muscle mass and bone density. The primary purpose of TRT is to alleviate these symptoms and improve quality of life by restoring serum testosterone levels to the physiological range. The prevalence of hypogonadism in men increases with age, affecting approximately 2–5% of middle-aged and older men and up to 20% of elderly men. Despite its therapeutic benefits, the cardiovascular safety of TRT remains a topic of debate and investigation. Cardiovascular disease is a leading cause of morbidity and mortality among men, and any therapy that might influence cardiovascular risk requires careful evaluation. Early observational studies raised concerns about potential adverse cardiovascular outcomes associated with TRT. These findings prompted regulatory agencies to issue warnings and recommend further research. In response, more recent trials, including the TRAVERSE Study, have provided new insights into the relationship between TRT and cardiovascular health. This article aims to provide a review of recent evidence on the cardiovascular safety of TRT.
The Role of Bisphosphonate Drug Holidays in the Management of Osteoporosis
Osteoporosis is a chronic skeletal disorder of compromised bone strength leading to an increased risk of fragility fractures, particularly with advancing age. More than 2 million Canadians are living with osteoporosis, and osteoporotic fractures are associated with considerable morbidity, increased mortality, and high economic burden to the healthcare system. The ultimate goal of osteoporosis pharmacotherapy is to reduce the risk of fragility fractures. Bisphosphonates are the most widely used first-line medications for osteoporosis due to their robust anti-fracture efficacy and favourable safety profile, as demonstrated in short-term randomized placebo-controlled trials of 3-years duration with fracture outcome assessed as the primary endpoint. However, the optimal duration of bisphosphonate therapy has been questioned regarding their long‑term efficacy and safety given their long half‑life in bone. Prolonged use is associated with very rare but serious adverse complications such as atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ). Moreover, while extension trials indicate that long‑term bisphosphonate therapy helps maintain bone density, the evidence supporting further fracture risk reduction with prolonged treatment is less convincing. Regarding concerns about rare adverse effects and the attenuated benefit-to-risk ratio with long‑term use, several professional organizations have issued guidelines suggesting bisphosphonate drug holidays. This approach aims to minimize prolonged exposure and mitigate rare risks while preserving some residual anti-fracture benefits from the persistent drug in the skeleton. Here, we review the role of bisphosphonate drug holidays in the long-term management of osteoporosis, the supporting evidence, recommended guidelines on treatment duration, along with key considerations for implementing a bisphosphonate drug holiday.
Treatment of Obesity in Individuals with Type 1 Diabetes
The prevalence of obesity (OB) is increasing among individuals with type 1 diabetes (T1D), posing unique challenges for managing their blood sugar levels and long-term health. Unlike type 2 diabetes (T2D), which is closely linked to OB and insulin resistance (IR), addressing OB in T1D requires careful consideration, because patients rely on external insulin, which can contribute to weight gain. In this review, we will discuss the causes and complications of OB in individuals with T1D, current approaches to treatment, potential lifestyle, and medical, and surgical interventions to manage weight while effectively maintaining optimal blood sugar control.
Glucagon-like Peptide Receptor Agonists (GLP-1 receptor agonists): A Powerful Addition to Foundational Therapy Kidney Care in Patients with Type 2 Diabetes Mellitus
There has been a veritable explosion in therapeutic options for patients with chronic kidney disease (CKD) and Type 2 diabetes mellitus (T2DM). For the past several decades, therapy for this condition has been limited to glycemic control, blood pressure control and utilization of angiotensin converting enzyme inhibitors (ACEi’s) or angiotensin 2 receptor blockers (ARBs). Recently, the emergence of therapies with organ protective effects has completely altered the landscape of therapy and outcomes for CKD in T2DM. Specifically, several large randomized clinical trials have demonstrated the positive impact of sodium glucose luminal transporter 2(SGLT2) inhibitors on the progression of kidney disease, end-stage kidney disease (ESKD), major adverse cardiovascular events (MACE), cardiovascular (CV) death, hospitalization for heart failure(HHF), all‑cause hospitalization, and all-cause mortality. Furthermore, finerenone, a non-steroidal mineralocorticoid receptor (nsMRA), has also been established as a component of foundational kidney therapy in patients with T2DM. A robust clinical trial program demonstrated kidney protection, CV protection and reductions in HHF in patients with CKD and T2DM. International guidelines have been updated to incorporate these agents as standards of care in this group of patients. CKD in T2DM is a complex disease and it stands to reason that multi‑targeted therapy could result in better outcomes for patients, similar to the management of patients with chronic heart failure. Those who follow this field will have noted that GLP-1 receptor agonists are listed as a component of guideline-directed management. However, these recommendations are based on the CV protective effect of these agents. Until recently, it was not clear if GLP‑1RA’s possessed kidney protective properties. The recent publication of the FLOW trial confirms that GLP-1 receptor agonists are, in fact, kidney protective.
Aging In The Face of Diabetes: Severe Hypoglycemia in Older Adults
Global rates of type 1 and type 2 diabetes (T1D, T2D) continue to climb, despite medical advancements. Older adults constitute one of the fastest growing segments of the diabetes population, backed by the world’s unprecedented aging population, decreased diabetes mortality rates, and the obesity epidemic. In Canada, individuals aged ≥65 years account for more than a quarter of all prevalent diabetes cases, far exceeding the other age groups. Older adults with diabetes face the highest risks of microvascular and macrovascular complications, which, compared to younger age cohorts, can contribute to significant functional loss, frailty, and premature mortality. A considerable amount of research links intensive glucose-lowering with insulin or secretagogues to reduced cardiovascular disease. However, the consequent risk of severe hypoglycemia and related sequelae can be particularly catastrophic for older adults, exacerbated by coexisting health conditions and age-related social needs. Approximately 40% of Canadians with T2D aged ≥65 years currently use secretagogues, while 27% use insulin—alongside all those with T1D. Longitudinal evidence suggests that since the year 2000, hospital admission rates for hypoglycemia have consistently surpassed those for hyperglycemia, especially among individuals aged 75 years and above. Economic modelling estimates that the Canadian healthcare system spends $125,932 CAD per year on iatrogenic hypoglycemia, with the bulk of these costs likely allocated to people ≥65 years. Diabetes in older adults is a pressing public health issue in Canada, marked by clinical diversity and widespread use of medications that are prone to cause hypoglycemia. This review outlines recent epidemiologic findings on severe hypoglycemia among community-dwelling older adults with T1D or T2D treated with insulin or secretagogues. Understanding the complex factors contributing to severe hypoglycemia in this population is crucial for developing tailored prevention strategies that are both effective and safe.
Obstructive Sleep Apnea and Type 2 Diabetes
Obstructive sleep apnea (OSA) and type 2 diabetes (T2D) are commonly encountered diseases in clinical practice, and there appears to be a bidirectional relationship between these 2 diseases. The presence of OSA can increase the risk of developing T2D, increase the risk of micro- and macro-vascular complications, and increase the risk of mortality. Several management strategies are available that can positively impact the outcomes of patients living with co-existing T2D and OSA. Given this bidirectional relationship, the negative consequences of untreated OSA on outcomes in T2D, along with the currently available management strategies, screening for OSA in patients with T2D should be considered.
As part of our care of patients with diabetes, we monitor target organs for damage. We routinely screen for microvascular and macrovascular complications. In my opinion, the awareness of bones as a target organ of diabetes will improve the care that we provide to patients. Patients with both Type 1 (T1DM) and Type 2 (T2DM) are at increased risk of fractures. This will become a larger issue in the future as the prevalence of diabetes is rising and individuals with diabetes are living longer. In addition to skeletal factors, diabetes and its complications can increase fractures by increasing the patient’s propensity to fall. This can be due to neuropathy, visual impairment and hypoglycemia. However, there are some differences between the characteristics of bone disease between patients with T1DM and T2DM.
Diabetes Management at Time of Childbirth
Dynamic changes occur in glucose handling as well as insulin sensitivity and pharmacokinetics at the time of childbirth in pregnancies complicated by diabetes. The unpredictable timing and nature of labour and childbirth contribute to intrapartum glycemic challenges. Furthermore, there is a lack of high-quality evidence in the literature to guide glycemic targets and management in the intrapartum period. This lack of high-quality evidence contributes to the controversies about optimum intrapartum glycaemic targets, and results in wide variations between hospital protocols for intrapartum glucose monitoring and management. Despite these controversies, women with diabetes, particularly those with type 1 diabetes, are vulnerable for the development of hypoglycemia and/or diabetic ketoacidosis if their intrapartum glycemia is not appropriately managed. An in-depth discussion of the timing of delivery in women with diabetes in pregnancy is beyond the scope of this article. Briefly, communication between diabetes and obstetrical care providers is encouraged to develop an individualized plan for the optimum timing of childbirth for women experiencing diabetes in pregnancy. This plan should be based on the glycemia achieved in pregnancy, the type of diabetes, and other risk factors for stillbirth such as maternal age, smoking status, the presence of retinopathy and fetal monitoring findings.
From the Bottom Up: Foot Care in Diabetes and the Role of the Endocrinologist
Diabetic foot ulcers (DFUs) are a common, serious, and costly complication of diabetes. By some estimates, up to a third of people living with diabetes (PWDs) will develop a DFU in their lifetime. The 5-year mortality rate in patients with a DFU is approximately 30%, and the mortality rate can be as high as 70% in patients with an above the foot amputation. In Canada, hospital admissions for DFUs are 25% more expensive than other common costly conditions such as heart failure and pneumonia, and this is prior to accounting for additional costs associated with treatment of DFUs, such as outpatient antibiotics, rehabilitation, prosthetics, therapeutic footwear, and continuing care. Endocrinologists and other diabetes specialists are well positioned to identify patients at high risk of developing DFUs. By providing early or preventive treatment for DFUs, there is perhaps nothing more impactful that one can do to improve the quality of life of patients living with diabetes.
Role of Continuous Glucose Monitoring in Non-Insulin-Requiring Type 2 Diabetes
Effective management of diabetes has always been contingent on our awareness of patients’ glucose levels. There has been a slow evolution in glucose-measurement technology over the last century. Benedict’s copper reagent test for urinary glucose became available in 1908, followed by the colorimetric technology of Dextrostix, patented in 1963 by Miles Laboratories Inc., and the electrochemical process of ExacTech introduced by Medisense in 1987, as examples. Continuous glucose monitoring (CGM) systems have evolved more rapidly with a well-established evidence base documenting their value in individuals using insulin. Their potential impact among individuals with type 2 diabetes (T2D) who are not using insulin has been the subject of a series of studies in the past few years, culminating most recently in a key Canadian randomized controlled trial, the IMMEDIATE study.
Risk Stratification to Improve Care and Outcomes in Diabetic Kidney Disease
Chronic kidney disease (CKD) is a global public health problem that affects one in eight Canadians, and nearly one in two with Type 2 diabetes (T2DM). It is widely recognized as a potent risk factor for cardiovascular (CV) outcomes, all-cause mortality, and progression to kidney failure requiring dialysis or transplant. End stage kidney disease is catastrophic for patients and families, but for most individuals who are identified as having high-risk CKD, progression is now preventable in this new era of guideline-directed medical therapy. This review will summarize a new paradigm for diagnosis, staging, and management of CKD, that is centered around risk of progression rather than kidney function (eGFR or serum creatinine alone). We will describe the heterogeneity in the progression of kidney disease, as well as the clinical utility and usability of accurate risk prediction tools that can be used today in Canadian clinical practice.
Lipoprotein (a) in Cardiovascular Risk Assessment and Management in Diabetes Mellitus
Lipoprotein (a) [Lp(a)] is an independent and genetically-determined risk factor for coronary heart disease (CHD) and stroke that is not changed by alterations in lifestyle factors. It is now recommended by Canadian and other national lipid guidelines to be measured once in a person’s lifetime as part of overall assessment for cardiovascular risk, along with family history; presence of hypercholesterolemia; Type 2 diabetes (T2DM); hypertension; and smoking. The presence of elevated Lp(a) confers additional risk to the already high cardiovascular risk in individuals with T2DM. This review summarizes the nature and association of Lp(a) with elevated cardiovascular disease (CVD) risk; the increased cardiovascular risk in individuals with T2DM; potential therapies to lower Lp(a); whether or not to measure Lp(a); and recommendations on how to respond to the finding of elevated Lp(a) in a patient with T2DM.
Copyright (c) 2023 Canadian Diabetes & Endocrinology Today https://creativecommons.org/licenses/by-nc-nd/4.0
Approach to the Management of Thyroid Eye Disease
Thyroid Eye Disease (TED), also known as Grave’s orbitopathy, is an autoimmune condition characterized by inflammation of the extraocular muscles, orbital fat and periocular tissues. As the most common orbital disease worldwide, its prevalence is estimated to be between 0.5–2% and it disproportionately affects females 4:1. Although the majority of TED cases occur in patients with Graves’ disease (80–90%), it can also be seen with patients with Hashimoto’s thyroiditis (10%), euthyroid individuals (5–10%) and thyroid cancer. At the time of initial Graves’ disease diagnosis, 25% of patients have clinically detectable orbital involvement that is often mild. The natural history of TED typically consists of an initial active inflammatory period lasting 6–36 months, which then plateaus and is followed by a quiescent fibrotic phase with stabilization of disease.