Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

ABSTRACT: Type 2 diabetes is a common metabolic condition that requires a multifaceted approach to reduce associated complications. Management is challenging because of the progressive nature of the condition and the growing availability of different classes of antihyperglycemic agents. Unfortunately, general practitioners and specialists looking for guidance in the complex pharmacological management of type 2 diabetes in BC can find themselves frustrated by contradictory recommendations from these three bodies: Diabetes Canada, the British Columbia Guidelines and Protocols Advisory Committee, and the Therapeutics Initiative. These three bodies differ in composition and the methodology that they use to prepare recommendations. Diabetes Canada is a national organization supporting a large number of volunteers from many health professions as they develop clinical practice guidelines. The Guidelines and Protocols Advisory Committee consists of representatives from the Ministry of Health and Doctors of BC who oversee working groups that develop BC-specific guidelines on important clinical topics, including diabetes care. The Therapeutics Initiative is an organization funded by the Ministry of Health and the University of British Columbia that completes assessments of drug therapy and publishes the findings in bulletin form. Receiving conflicting information is difficult for physicians and can result in a wide variability in quality of care, as well as clinical inertia, such as failure to implement or intensify a beneficial therapy. Furthermore, despite growing evidence of significant clinical benefits for many diabetes drugs, most require special authority approval or, in the case of newer agents, are not covered at all by BC Pharmacare, which makes it difficult for physicians to manage their patients with diabetes using the most up-to-date and robust evidence.

Contradictory recommendations and formulary restrictions make it difficult for BC physicians to manage their patients with diabetes using the most robust and up-to-date evidence.

Diabetes is a chronic metabolic disease that is becoming more common in British Columbia, with predicted prevalence rates rising from 8.3% in 2013 to 10.3% in 2020.[1] The complications of diabetes contribute significantly to morbidity and mortality, and increase the cost burden to patients, our medical system, and society as a whole.[2,3] Primary care physicians manage the majority of people living with diabetes, and more than 20% of a typical physician’s caseload will likely involve caring for people with either diabetes or prediabetes.[4] Not only is the prevalence of diabetes increasing,[5] but the management of patients with diabetes is becoming more complicated as patients live longer and require additional care for frailty and comorbid conditions. There are now nine classes of antihyperglycemic agents, which often need to be used in combination owing to the progressive nature of diabetes,[6,7] a situation that increases the complexity of therapeutic decision making.

Diabetes requires a multifaceted approach to reduce both microvascular and macrovascular complications.[8] Glycemic control is an important risk factor for microvascular disease, including retinopathy, nephropathy, and peripheral neuropathy.[9-13] Early improved glucose control slows progression to these endpoints.[9,14-17] An association between macrovascular disease and aggressive glycemic control is less clear.[16,18,19] Cardiovascular (CV) benefit, most likely from better glucose control, has been seen in long-term (10- to 20-year) observational studies such as EDIC,[20] long-term follow-up of the UKPDS,[21] and a subset of VADT (although no overall survival benefit was seen in this group with established cardiovascular disease),[22] suggesting that good glycemic control achieved with less hypoglycemia, if initiated early in the course of the disease, reduces long-term CV risk.

Worldwide, clinical practice guidelines based on the best available evidence support the use of antihyperglycemic agents to reduce the risk of long-term complications of diabetes.[2,23-25] In large, randomized controlled CV safety studies, agents such as empagliflozin,[26] liraglutide,[27] semaglutide,[28] and canagliflozin[29] have demonstrated CV benefits. Conflicting information regarding appropriate use of these and other antihyperglycemic agents can confuse physicians and may result in widely variable quality of care as well as clinical inertia, which can mean physicians fail to implement or intensify a beneficial therapy.

Sources of recommendations

British Columbia physicians’ management of diabetes is guided by recommendations from three principle sources:

  • Diabetes Canada (DC), formerly known as the Canadian Diabetes Association, which publishes clinical practice guidelines for the prevention and management of diabetes in Canada[2,3] and updates these as necessary.[23]
  • The Guidelines and Protocols Advisory Committee (GPAC), which publishes clinical practice guidelines for use in BC on many topics, including diabetes care.[30]
  • The Therapeutics Initiative (TI), which publishes recommendations regarding drug therapy for managing diabetes in their regular Therapeutics Letters.[31]

Table 1 summarizes the composition and methodology of the bodies and shows how they vary in their guideline development and publishing processes. The recommendations produced by all three are widely disseminated.

Diabetes Canada

In 1998 the Canadian Diabetes Association published one of the first evidence-based guidelines for the management of diabetes in Canada.[32] In this and subsequent publications an independent expert committee developed and graded recommendations based on the quality of evidence from key studies. Updates were published in 2003, 2008, 2013, and 2018.[3] These guidelines are ranked among the best in the world with respect to quality, rigor, and process[33] as assessed using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation).[34] Each recommendation addresses a clinically important question related to the management of diabetes and its sequelae. Health benefits of interventions as well as risks and side effects are considered in formulating the recommendations. Patient preferences and values are considered by consulting people with diabetes and reviewing the literature. Each recommendation is justified using the strongest clinically relevant, empirical evidence that can be identified. Sources of evidence are cited and the strength of this evidence is indicated based on criteria from the epidemiological literature and other guidelines processes. Recommendations based on biological or mechanistic reasoning, expert opinion, or consensus are explicitly identified and graded as such. Finally, harmonization is sought with guidelines issued by other bodies, including the Canadian Cardiovascular Society, the Canadian Hypertension Education Program, the Canadian Cardiovascular Harmonization of National Guidelines Endeavour, and the Society of Obstetricians and Gynecologists of Canada.

Guidelines and Protocols Advisory Committee

The Guidelines and Protocols Advisory Committee consists of representatives from the BC Ministry of Health and Doctors of BC. The committee advises the Medical Services Commission regarding both the effective utilization of medical services and high-quality, appropriate patient care,[35,36] and oversees a number of working groups responsible for developing guidelines and protocols on almost 100 topics (see The diabetes care guideline does not include an independent literature review but instead relies heavily on existing documents, including the Diabetes Canada clinical practice guidelines. The diabetes care guideline also addresses circumstances in BC and includes BC-specific information such as Medical Service Plan billing rules and incentive fees, lab test availability, Pharmacare coverage, referral pathways, and local resources. A handbook outlining the process for guideline development indicates that “For guidelines published after 2014, lists of contributors may be published on the website.”[36]

Therapeutics Initiative

The Therapeutics Initiative was established in 1994 by the Department of Pharmacology and Therapeutics in cooperation with the Department of Family Practice at the University of British Columbia “to provide physicians, pharmacists, allied health professionals and the public with up-to-date, evidence-based, practical information on prescription drug therapy.”[31] Funding is provided by the BC Ministry of Health through a grant to UBC. Four TI working groups are engaged in the development of recommendations that are published bimonthly in Therapeutics Letters and distributed as unsolicited mail to physicians and pharmacists in BC. Each letter commonly focuses on adverse outcomes found in trials as opposed to the primary or secondary objectives of the trials reviewed. Authors of the letters are not named and there is no stated methodology for literature selection or review or grading of recommendations, nor a predefined schedule for discussion of specific therapeutic areas. Since 2010, 18 drugs or classes of drugs have been reviewed in detail in 27 Therapeutics Letters and only one drug has been given a full recommendation (intravenous iron in appropriately selected people with chronic severe iron deficiency).[37]

Recommendations compared

Both Diabetes Canada and the Guidelines and Protocols Advisory Committee identify a process, structure, and timeline for their work in advance. The recommendations produced by both are more comprehensive in scope than those of the Therapeutics Initiative, which focuses mainly on drug therapies and aims to “improve prescription habits.”

The composition of DC guidelines committees is broad-based and interprofessional, including people with diabetes as well as experts in various specialties from across Canada. The GPAC working groups responsible for developing guidelines are smaller than the DC committees, but also include medical experts and a Pharmacare pharmacist. The members of TI working groups include salaried employees and other health care professionals and academics who are identified on the organization’s website. While the authors of DC guidelines are named, authors of GPAC guidelines and Therapeutics Letters are not.

Recommendations issued by the TI are notable for not aligning with those of other bodies, while recommendations issued by DC and GPAC align closely with American and European guidelines for diabetes management[24,25] and those of the United Kingdom’s National Institute for Health and Care Excellence (NICE), which produces the only guidelines to receive a higher rating than the DC diabetes guidelines[33] and is cited in one Therapeutics Letter as a source of “independent information.”[38]

DC, GPAC, and these international bodies recommend monitoring patients with diabetes using a glycated hemoglobin (HbA1c) level, and that the target A1c should be individualized, with a reasonable level for most adults being less than 7.0% and a target for those who are younger being 6.5% so they may benefit from more years of excellent glycemic control to avoid microvascular complications. Algorithms in DC, GPAC, and other international guidelines provide diabetes care teams with direction for management. No such direction is provided by the TI other than a preference for lifestyle intervention: “While we await the trial evidence, it is rational to emphasize lifestyle measures in these patients: weight loss, low carbohydrate diets and exercise.”[39] This recommendation is made despite the statement in another Therapeutics Letter that “weight loss is difficult to maintain”[40] and a lack of any references to support emphasizing “low carbohydrate diets,” which a literature review by Diabetes Canada found no evidence to support.[3] In the comments section of the TI website, a request for clarification regarding exactly what kind of carbohydrates such a diet would include is answered as follows: “We [the TI] are not experts on evidence about diet” (reply to Dr Virendra Sharma by Thomas L. Perry, MD, FRCPC, Chair, TI Education Working Group, 21 March 2017, 9:05 p.m.).

BC Pharmacare coverage

The most recent Diabetes Canada clinical practice guidelines recommend that antihyperglycemic agents should be chosen based on both patient and agent characteristics.[2,3] While all agents named by DC have been evaluated and approved for use in Canada, in BC only a few (generally older and less-expensive agents such as glyburide, metformin, and human insulins) are fully covered under the provincial formulary.[41] This makes it much more difficult for physicians to use up-to-date evidence when managing their patients with diabetes.

Table 2 and Table 3 illustrate the extent to which BC restricts Pharmacare coverage compared with three other provinces: Alberta and Ontario (each historically considered a have province) and Nova Scotia (considered a have-not province). Although drug evaluation is now performed nationally by the Common Drug Review and the Canadian Agency for Drugs and Technologies in Health (CADTH), it appears that recommendations from the TI rather than those from the much more robust DC guidelines are determining BC Pharmacare policy. BC is the only province to require special authority for gliclazide (for use after hypoglycemia with glyburide),[41,42] and is the only province to not list empagliflozin. The rejection of empagliflozin appears to be influenced largely by cost and supported by the TI’s criticisms of the EMPA-REG OUTCOME trial.[43] These criticisms, however, do not accord with most interpretations of the trial and other recent CV safety trials[26-29] such as the LEADER trial of liraglutide,[27] which demonstrated benefit for people with type 2 diabetes and clinical cardiovascular disease.

As a result of TI conclusions, BC residents with diabetes are at a disadvantage when compared with Canadians in other jurisdictions. Essentially, BC has become a have-not province for people with diabetes, a problem likely to worsen as the rates of diabetes in BC continue to rise.[44]

Key recommendations considered

Clear, high-quality, evidence-based recommendations are the cornerstone of medical training and subsequent decision making for health care providers. Physicians and patients expect and deserve the best care possible based on transparent processes and unbiased sources.

In BC, comparing key recommendations on important clinical issues such as A1c targets and pharmacological therapy[45-55] reveals significant discord. The TI is at odds with DC and GPAC on a number of topics, as shown in Table 4. In an example regarding cardiovascular outcomes and the use of empagliflozin, the Therapeutics Letter of July/August 2017 disputes the conclusions of the EMPA-REG OUTCOME trial.[43] The TI authors question the design of the trial, which is one mandated by the FDA, and the “aggressive” use of insulin, sulfonylureas, and DPP4s in the control group, which are the very medications BC Pharmacare covers. The TI authors also focus on genital infections experienced by some study subjects, and emphasize these harms in a table. Despite these concerns, the Therapeutics Letter of September/October 2017 names canagliflozin and dapagliflozin as “drugs to avoid”[55] but does not name empagliflozin.

Contradictory recommendations serve to confuse medical care providers, and restrictive Pharmacare coverage only adds to this confusion and promotes clinical inertia. A recent evidence-based review of formulary coverage for diabetes and cardiovascular disease concluded that glucose-lowering agents that reduce mortality in patients at very high cardiovascular risk are now available, and that empagliflozin has been shown to be highly cost-effective. The authors urge all provincial formularies to “re-examine their access requirements for SGLT-2 inhibitors and to consider adding GLP-1 agonists to reflect current evidence and clinical guideline recommendations.”[56]

Patients in BC living with type 2 diabetes deserve care that meets nationally vetted standards and provincial support for the most up-to-date evidence-based approach to diabetes management.


Type 2 diabetes is a common disease and its management is becoming increasingly complex. Management recommendations used in BC come primarily from Diabetes Canada, the Guidelines and Protocols Advisory Committee, and the Therapeutics Initiative.

The use of antihyperglycemic therapy has been shown to reduce complications and save lives. Physicians in BC are receiving contradictory information and facing formulary restrictions not seen in other provinces. Better alignment of evidence-based recommendations and appropriate drug coverage is needed to improve clinical outcomes and the lives of people in BC living with diabetes, and to make the management of diabetes less challenging for physicians and patients alike.


The authors wish to acknowledge the editorial assistance of Cynthia N. Lank (Halifax, NS) and the logistical support of Aleta Allen (Division of Endocrinology, UBC) for their part in supporting the publication of this theme issue.

Competing interests

This and the other articles in the theme issue were developed under the auspices of the Division of Endocrinology at the University of British Columbia and supported by an educational grant from AstraZeneca Canada Inc., Merck & Co. Inc., Novo Nordisk Canada Inc., Boehringer Ingelheim Canada Ltd., and Janssen Inc., a Division of Johnson & Johnson. The authors were volunteers and received no remuneration for their time or efforts. With the exception of Dr Ur, all authors were unaware of the sponsors’ identities until after this article was submitted to the BCMJ. Funds were used exclusively for travel and logistical support. Sponsors were not involved in any aspect of the decision to develop this article, in the content of the article, in the selection of authors, or in any aspect of the editorial process. In the past, all authors of this article (except for Dr Mudaliar) have received fees and honoraria from pharmaceutical companies for a variety of activities, including speaking, attending meetings, and organizing education. Details are available upon request.

This article has been peer reviewed.


1.    Canadian Diabetes Association. At the tipping point: Diabetes in British Columbia. Accessed 23 August 2018.

2.    2013 Clinical Practice Guidelines Committees. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. Accessed 23 August 2018.

3.    2018 Clinical Practice Guidelines Committees. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2018;42(suppl 1):S1-S325. Accessed 19 April 2018.

4.    Leiter LA, Barr A, Bélanger A, et al. Diabetes screening in Canada (DIASCAN) study: Prevalence of undiagnosed diabetes and glucose intolerance in family physician offices. Diabetes Care 2001;24:1038-1043.

5.    Gregg EW, Li Y, Wang, J, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med 2014;370:1514-1523.

6.    Thrasher J. Pharmacologic management of type 2 diabetes mellitus: Available therapies. Am J Cardiol 2017;120:S4-S16.

7.    DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care 2013;36(suppl 2):S127-S138.

8.    Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383-393.

9.    Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes 1995;44:968-983.

10.    Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 2000;321:405-412.

11.    Cohen RA, Hennekens CH, Christen WG, et al. Determinants of retinopathy progression in type 1 diabetes. Am J Med 1999;107:45-51.

12.    Zoungas S, Arima H, Gerstein HC, et al; Collaborators on Trials of Lowering Glucose (CONTROL) group. Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes: A meta-analysis of individual participant data from randomised controlled trials. Lancet Diabetes Endocrinol 2017;5:431-437.

13.    Ismail-Beigi F, Craven T, Banerji MA, et al.; ACCORD trial group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial. Lancet 2010;376(9739):419-430.

14.    UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352(9131):837-853.

15.    UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352(9131):854-865.

16.    ADVANCE Collaborative Group, Patel A, McMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes N Engl J Med 2008;358:2560-2572.

17.    ACCORD Study Group; ACCORD Eye Study Group, Chew EY, Ambrosius WT, Davis MD, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010;363:233-244.

18.    Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-2559.

19.    Duckworth W, Abraira C, Moritz T, et al.; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129-139.

20.    Nathan D; DCCT/EDIC Research Group. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study at 30 years: Overview. Diabetes Care 2014;37:9-16.

21.    Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-1589.

22.    Hayward RA, Reaven PD, Wiitala WL, et al.; VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372:2197-2206.

23.    Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Pharmacologic management of type 2 diabetes: 2016 interim update. Can J Diabetes 2016;40:484-486. Accessed 23 August 2018.

24.    American Diabetes Association. Standards of medical care in diabetes—2018. Diabetes Care 2018;41(suppl 1):S1-S159. Accessed 23 August 2018.

25.    Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes, 2015: A patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2015;58:429-442.

26.    Zinman B, Wanner C, Lachin JM, et al.; EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-2128.

27.    Marso SP, Daniels GH, Brown-Frandsen K, et al.; LEADER Steering Committee; LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375:311-322.

28.    Marso SP, Bain SC, Consoli A, et al.; SUSTAIN-6 Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016;375:1834-1844.

29.    Neal B, Perkovic V, Mahaffey KW, et al.; CANVAS Program Collaborative Group. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017;377:644-657.

30.    Guidelines and Protocols Advisory Committee. Diabetes care. Accessed 2 April 2018.

31.    Therapeutics Initiative. Accessed 2 April 2018.

32.    Meltzer S, Leiter L, Daneham D, et al. 1998 clinical practice guidelines for managing diabetes. Canadian Diabetes Association. CMAJ 1998;159(suppl 8):S1-29.

33.    Bennett WL, Odelola OA, Wilson LM. Evaluation of guideline recommendations on oral medications for type 2 diabetes mellitus. Ann Intern Med 2012;156:27-36.

34.    Brouwers M, Kho ME, Browman GP, et al., on behalf of the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. CMAJ 2010;182:E839-842.

35.    Guidelines and Protocols Advisory Committee. External review of guidelines. Accessed 2 April 2018.

36.    Guidelines and Protocols Advisory Committee. Guidelines and Protocols Advisory Committee handbook: How our “made in BC” clinical practice guidelines and protocols are developed. Revised March 2017. Accessed 2 April 2018.

37.    Therapeutics Initiative. Intravenous (IV) iron for severe iron deficiency. Therapeutics Letter November/December 2015. Accessed 2 April 2018.

38.    Therapeutics Initiative. Is prescribing information from sales representatives balanced? Therapeutics Letter August/September 2014. Accessed 2 April 2018.

39.    Therapeutics Initiative. Is the current “glucocentric” approach to management of type 2 diabetes misguided? Therapeutics Letter November/December 2016. Accessed 2 April 2018.

40.    Therapeutics Initiative. Management of type 2 diabetes. Therapeutics Letter January/February/March 1998. Accessed 2 April 2018.

41.    Diabetes Canada. Formulary listings for diabetes medications in Canada (April 2018). Accessed 23 August 2018.

42.    Province of British Columbia. Drug coverage. Accessed 2 April 2018.

43.    Therapeutics Initiative. EMPA-REG OUTCOME Trial – what does it mean? Therapeutics Letter July/August 2017. Accessed 2 April 2018.

44.    Diabetes Canada. 2017 report on diabetes in British Columbia. Accessed 2 April 2018.

45.    Tessier D, Dawson K, Tétrault JP, et al. Glibenclamide vs gliclazide in type 2 diabetes of the elderly. Diabet Med 1994;11:974-980.

46.    Drouin P. Diamicron MR once daily is effective and well tolerated in type 2 diabetes a double-blind, randomized, multinational study. J Diabetes Complications 2000;14:185-191.

47.    Holstein A, Plaschke A, Egberts EH. Lower incidence of severe hypoglycaemia in patients with type 2 diabetes treated with glimepiride versus glibenclamide. Diabetes Metab Res Rev 2001;17:467-473.

48.    Canadian Agency for Drugs and Technologies in Health. Common Drug Review. CADTH Canadian Drug Expert Committee final recommendation. Empagliflozin. 26 October 2016. Accessed 2 April 2018.

49.    Therapeutics Initiative. Glycemic targets in type 2 diabetes. Therapeutics Letter January/February 2008. Accessed 2 April 2018.

50.    Therapeutics Initiative. The limitations and potential hazards of using surrogate markers. Therapeutics Letter October/December 2014. Accessed 2 April 2018.

51.    Therapeutics Initiative. Self-monitoring of blood glucose in type 2 diabetes. Therapeutics Letter April/June 2011. Accessed 2 April 2018.

52.    Therapeutics Initiative. New drugs III. Therapeutics Letter July/August 1997. Accessed 2 April 2018.

53.    Therapeutics Initiative. Gliclazide for type 2 diabetes mellitus. Therapeutics Letter October 2007. Accessed 2 April 2018.

54.    Therapeutics Initiative. Questioning the basis of approval for non-insulin glucose lowering drugs. Therapeutics Letter May/June 2016. Accessed 2 April 2018.

55.    Therapeutics Initiative. Drugs to avoid. Therapeutics Letter September/October 2017. Accessed 2 April 2018.

56.    Riar SS, Fitchett D, FitzGerald J, Dehghani P. Diabetes mellitus and cardiovascular disease: An evidence based review of provincial formulary coverage. Can J Cardiol In Press, Accepted Manuscript, Available online 19 July 2018. Accessed 23 August 2018.

Dr Clement is a family physician in the Interior of British Columbia with a consulting practice in diabetes. She has been actively involved with Diabetes Canada and was a member of the expert committee, steering committee, and executive committee during development of the 2003, 2008, 2013, and 2018 Diabetes Canada clinical practice guidelines. Dr Paty is an endocrinologist and UBC clinical associate professor who specializes in diabetes and post-transplant endocrinology. Dr Mancini is professor of medicine in the UBC Division of Cardiology, director of the CardioRisk Clinic at Vancouver Hospital, staff physician in the Healthy Heart Program Prevention Clinic at St. Paul’s Hospital, and a member of the writing group for the 2018 Diabetes Canada clinical practice guidelines. Dr Miller is an endocrinologist in Victoria and a clinical associate professor, UBC and UVic. He was actively involved with the Diabetes Canada guidelines (2003–2018) and with the BC guidelines (2003–2018). Dr Mudaliar is a Vancouver family physician. Dr Shu is an endocrinologist at Royal Columbian Hospital, currently serving as the regional head of endocrinology for the Fraser Health Authority. Dr Thompson is medical director of the VGH Diabetes Centre and principal investigator for the cell implant trial. Dr White is an endocrinologist and UBC clinical assistant professor with a practice in Vancouver. Dr Ur is a professor in the Division of Endocrinology at UBC.

Maureen Clement, MD, CCFP, Breay Paty, MD, FRCPC, G.B. John Mancini, MD, FRCPC, David B. Miller, MD, FRCPC , Adi Mudaliar, MD, CCFP, Dave Shu, MD, FRCPC, David Thompson, MD, FRCPC, Adam White, MD, FRCPC, Ehud Ur, MBBS, FRCPC. Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options. BCMJ, Vol. 60, No. 9, November, 2018, Page(s) 439-450 - Clinical Articles.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit

BCMJ Guidelines for Authors

Dr. Mohammed A.... says: reply

Very educational and informative article.

Hope the policy makers heed the advice of family physicians, diabetes specialists and researchers and most importantly the patients and peer(s) like myself from the field in formulating the pharmacare, drug therapy and patient affordability policies.

My humble plea to those involved in making decisions regarding care and management of diabetic patients be guided by kindness and compassion rather than short sighted view of saving few pennies in the short term in drug costs and ending up paying many pounds in the long term in medical management of diabetes complications such as renal, retinal, cardiac, neural, and psychiatric problems and non traumatic amputations.

Please forgive me if I offended your sentiments or feelings by my honest and candid opinions.

With warm regards,



Mohammed A. Shariff, DVM, PhD, BVSc, MSc, (PhD-India)
Animal Physiology (Nutrition, Endocrinology and Metabolism) Researcher (India and Canada),
Small Animal Clinician and Surgeon, Canada (Retired)
Public Health Veterinarian (Retired) - Government of Canada

Marlene Richards says: reply

I have just read the comments you made in support of diabetic patients who are kept from accessing needed new drugs because BC Pharmacare will not cover the costs. I have experienced this first hand. Someone who is living on old age pension and minimal CPP should not be required to make choices between the necessities of daily living and their life saving prescriptions.

Leave a Reply