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Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes. Diabetes care should be delivered using as many elements as possible of the chronic care model. The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including selfmanagement support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination. Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. HELPFUL HINTS BOX: ORGANIZATION OF CARERecognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.Register: Develop a registry for all of your patients with diabetes.Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists.Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes.Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.

It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.

In recent years, the development of basal insulin therapies has focused on insulin analogues that have longer durations of action and more predictable pharmacokinetic/pharmacodynamic (PK/PD) profiles than their human insulin-based predecessors, such as neutral protamine Hagedorn (NPH) insulin. Dosed once-daily, such analogues can provide a more stable glucose-lowering action, which translates clinically into a reduced risk of hypoglycemia. Insulin degludec (degludec) became available in Canada in 2017 and is the first basal insulin analogue to have a half-life exceeding the dosing interval. As well as offering the promise of an exceptionally flat PK/PD profile when at steady state, this characteristic means that insulin degludec can be dosed with some flexibility with regard to time of day and that it need not be taken at the same time each day. However, the approximately 25-h half-life also has some implications concerning dose titration. This article provides an up-to-date review of the study data describing the clinical profile of degludec, and aims to give helpful and practical advice to prescribers about its use. While the clinical benefits of degludec are described, it is also acknowledged that further study is required to better understand how its clinical performance compares with that of insulin glargine 300 units/mL.

Introduction: Needle reuse and repeated injection of insulin into the same site encourage lipohypertrophy. We explored the potential of coupling a novel pen needle strategy with community pharmacists to improve injection site rotation. Methods: Between October 2018 and January 2019, adult insulin users with type 1 or 2 diabetes were enrolled by 16 community pharmacists across 7 Canadian provinces and randomized to their usual pen needles (control) or coloured pen needles packaged with education materials in boxes with reminder sound chips (intervention [mCPN]). A total of 203 individuals completed all requirements of the 30-day study. The primary outcome was a composite of the number of zones injected, the use of new injection zones if the number of zones equaled that at baseline, and the change in size of the injection area from baseline. The pharmacists completed two questionnaires, which provided insights into whether study participation elevated their comfort and confidence in providing injection site rotation counselling. Results: Compared to the control group, more participants in the mCPN arm improved their site rotation practices (54.1% vs. 33.7%; P = 0.005), 15 more increased the number of injection zones used (P = 0.03), and there was less needle reuse (25% vs. 12% reduction). The pharmacists reported improved knowledge of the consequences of lipohypertrophy and the proportion who were ''very comfortable'' with pen needle tip selection and use rose from 31.3% pre-study to 93.8% post-study. Conclusion: The coloured pen needles with their education materials are a novel means of encouraging injection site rotation. Community pharmacists represent an untapped resource for improving injection self-care practices.