Table 7:

Treatment targets: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*

RecommendationSource guideline (key supporting reference)
All individuals with diabetes should follow a comprehensive, multifaceted approach to reduce CV risk, including:
  • A1C ≤ 7.0% implemented early in the course of diabetes

  • SBP of < 130 mm Hg and DBP of < 80 mm Hg

  • Additional vascular-protective medications in the majority of adult people with diabetes

  • Achievement and maintenance of healthy weight goals

  • Healthy eating

  • Regular physical activity

  • Smoking cessation

Therapy in most individuals with type 1 or type 2 diabetes should be targeted to achieve an A1C ≤ 7.0% to reduce the risk of microvascular and, if implemented early in the course of disease, CV complications.DC36
In people with type 2 diabetes, an A1C ≤ 6.5% may be targeted to reduce the risk of chronic kidney disease and retinopathy if they are assessed to be at low risk of hypoglycemia based on class of antihyperglycemic medication(s) used, and the person’s characteristics.DC37
A higher A1C target may be considered in people with diabetes with the goals of avoiding hypoglycemia and overtreatment related to antihyperglycemic therapy, with any of the following:
  • Functionally dependent: 7.1%–8.0%

  • History of recurrent severe hypoglycemia, especially if accompanied by hypoglycemia unawareness: 7.1%–8.5%

  • Limited life expectancy: 7.1%–8.5%

  • Frail, older age or with dementia: 7.1%–8.5%

  • End of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.

An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk.DC38
We recommend a target LDL-C consistently < 2.0 mmol/L or > 50% reduction of LDL-C in individuals for whom treatment is begun, to decrease the risk of CVD events. Alternative target variables are apoB < 0.8 g/L or non–HDL-C < 2.6 mmol/L.CCS39
We recommend a > 50% reduction of LDL-C for patients with LDL-C > 5.0 mmol/L in individuals for whom treatment is begun, to decrease the risk of CVD events and mortality.CCS39
For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30–60 min of moderate intensity dynamic exercise (e.g., walking, jogging, cycling or swimming) 4–7 d/wk in addition to the routine activities of daily living.HC
For high-risk patients aged 50 yr or older, with SBP levels ≥ 130 mm Hg, intensive management to target an SBP of ≤ 120 mm Hg should be considered. Intensive management should be guided by AOBP measurements. Patient selection for intensive management is recommended and caution should be taken in certain high-risk groups.HC40
Antihypertensive therapy should be prescribed for average DBP measurements of ≥ 100 mm Hg or average SBP measurements of ≥ 160 mm Hg in patients without macrovascular target organ damage or other cardiovascular risk factors. Antihypertensive therapy should be strongly considered for average DBP readings ≥ 90 mm Hg or for average SBP readings ≥ 140 mm Hg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors.HC41,42
People with diabetes mellitus should be treated to attain SBP of < 130 mm Hg and DBP of < 80 mm Hg (these target BP levels are the same as BP treatment thresholds).DC43
All those considering beginning a vigorous exercise program are encouraged to consult their physician or health care team professionals.Obesity44
  • Note: A1C = glycosylated hemoglobin, AOBP = automated office blood pressure, apoB = apolipoprotein B-100, BP = blood pressure, C-CHANGE = Canadian Cardiovascular Harmonized National Guideline Endeavour, CCS = Canadian Cardiovascular Society – Dyslipidemia, CV = cardiovascular, CVD = cardiovascular disease, DBP = diastolic blood pressure, DC = Diabetes Canada (formerly Canadian Diabetes Association), HC = Hypertension Canada, HDL-C = high-density liproprotein cholesterol, HF = Canadian Cardiovascular Society – Heart Failure, LDL-C = low-density liproprotein cholesterol, Obesity = Obesity Canada, SBP = systolic blood pressure.

  • * All recommendations are considered strong recommendations (Box 1); the quality of evidence supporting each recommendation varies (see Appendix 1 for a detailed discussion of the supporting evidence. Key references are indicated in this table.)

  • Based on consensus opinion.