Diabetes Tool

1) Comorbidities

2) Insurance

3) Medication options

4) Recomendations

5) Third line medication patient handouts

6) Fair Pharmacare estimate

7) Non invasive liver fibrosis screen

The medication management of type 2 diabetes is determined by multiple variables:

1) Drug benefits and side effects
2) Drug cost and insurance coverage
3) Renal function

This tool is designed to help inform and simplify medication choice decision making.
Starting in the Home screen, for the tool to be helpful you need to complete the information needed under:
1) Comorbities and 2) Insurance.

All the medication options are listed in the Formulary in the top bar, and if you use a different medication than what is offered to you, you can adjust this preferrence in the Formulary screen.
Once the eGFR is updated the Formulary screen can be very helpful to see which of the medications can be used at this level of renal function.

Estimating the cost to the patient can be complicated. Not all medications are eligible for coverage and if under the Fair Pharmacare program may require special authorisation.
Private insurance normally covers a percentage, often 80% but can differ between plans.

Fair Pharmacare uses a Deductible and Family Maximum that is based off the net household income.
Practically what this means is that the patient pays the full amount for medications at the beginning of the year until they reach their Deductible, at this point the cost is reduced to 30% until they reach their Family Maximum at which time the medications are free for the remainder of the year.
However the cycle starts Jan 1 every year and for patients on a fixed income can be difficult.
Pharmacare does offer a Monthly Deduction Payment Option but the patient has to apply for this (see link in Formulary). Depending on the patients Deductible, adding on an expensive medication like an SGLT-2 or GLP-1 may appear to cost more initially but when worked out over the year the added cost to the patient can be minimal.

Disclaimer
The use of this tool is at your own risk and clinical discretion.

Diabetes tool by David Page licensed under a GPL

Medication selection:

Step one: Next

SGLT-2/GLT-1 specific recommendations UK 🇬🇧 CA 🇨🇦 Link

The Diabetes Tool by Dr D.Page is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Disclaimer:Use this tool at your own risk. Always use your own clinical judgement. See the resources section for more information.

A1C                   Target A1C:      6.5      7.0      7.5     8.0     8.5     >8.5
eGFR

CHF (Class 2/3/4 and EF <40%)                 HFpEF

CVD (CAD or Stroke)

CKD (eGFR ≤ 60 or ACR ≥ 3mg/mmol)

CVD risk

       Age ≥60
       HBP (on Rx or BP ≥ 140/90)
       Dyslipidemia (On Rx or TC >5.2, HDL <1(1.3 females), LDL >3.4 TG > 2.3)
       Smoker
       Male sex
       A1C >6.5%
       Race: Asian/African/Hispanic
       Family history of CVD or CKD

       Obesity (BMI ≥ 35)

Age ≥65

Frailty

Fatty Liver

Diabetic retinopathy

Bladder cancer

Previous amputation

A1C:        A1C Target:        eGFR:       Age:

OSCAR VALUES:
Sex      BMI      Smoking status
ACR
LDL      HDL      TG      TC
Disease registry

Meds

Click on the class header to open/close for more detailed information.Hover over the pink box for more information.
Check the box next to the class header to exclude this class (eg. for prior adverse reaction).
Click on the underlined medication to open a pharmacare special authority form.

Avoid due to renal function     Medical Concerns     General Pharmacare     SPA Pharmacare
Physican hotline: 1-877-657 1188 Option #5
Patient hotline to set up MDPO (Monthly deduction payment option)
Fair Pharmacare Income Review

Biguanide
Generally the first medication prescribed for type 2 diabetes.
Mode of action:
Works primarily by lowering glucose production in the liver and improving sensitivity to insulin
Side effects: (often improve with time or consider extended formulation)
Nausea / Abdominal pain / Bloating / Diarrhea / Possible B-12 deficiency
Benefits:
Diabetes prevention in high risk pateints :Absolute risk reduction for diabetes progression ranging from 4.4% to 14.3% and a number needed to treat between 7 and 14 over a 3 year period.
Although there is no prospective, randomized controlled clinical trial evaluating the CV effects of metformin, available data suggest that metformin has favorable CV effects in patients with T2DM.
Renal:
eGFR > 15

Metformin          Cost:2g $17/month SE:GIT upset   Benefits:?🡇CVD     Cost:2g $17/month
Meformin ER     Cost:2g $79/month SE:GIT upset     Benefits:?🡇CVD     Cost:2g $79/month

Sulfonylurea/Meglitinide
Mode of action:
Stimulates the pancreas to secrete more insulin
Glinides are faster acting than sulfonylureas, and the duration of their effect in the body is shorter.
Side effects:
Low blood sugar / Weight gain
Meta-analyses suggest that sulphonylurea use may elevate the risk of cardiovascular disease among patients with diabetes.
Benefits:
Potent glucose lowering
Generally less expensive
Differences:
Glicazide (Diamicron) can be used down to eGFR 30, Glimpiride (Amaryl) shorter acting and less hypoglycemia, Repaglinide (Gluconorm)can be used in renal failure with any eGFR.
Renal:
eGFR > 0-30

Glyburide (Diabeta)              Cost:20mg $22/month SE:🡇BS/🠝Wt     Benefits:Cheap    Cost:20mg $22/month
Glicazide (Diamicron)           Cost:120mg $14/month SE:🡇BS/🠝Wt     Benefits:Cheap/Use in CKD    Cost:IR 160mg/MR 120mg $14/month
Repaglinide (Gluconorm)        Cost:3mg $38/month SE:🡇BS/🠝Wt    Benefits:Use in CKD    Cost:3mg $38/month
Glimepiride (Amaryl)              Cost:4mg $41/month SE:🡇BS/🠝Wt     Benefits:Less 🡇BS     Cost:4mg $41/month

SGLT-2 Inhibitor
Mode of action:
Works by blocking glucose from being reabsorbed by the kidneys. With normal renal function this leads to 50–80g of glucose being excreted per day (200-300 Calorie loss).
Side effects:
Urinary tract infections / Yeast infections / Rare,serious genital infection
Benefits:
May promote weight loss and may lower blood pressure.
Primary prevention:
Mortality 🡇1.5% (NNT 66), CVD mortality 🡇0.7% (NNT 143), Non-fatal MI 🡇0.7% (NNT 143), Kidney failure 🡇0.3% (NNT 333), HF admit 🡇0.9% (NNT 111)
Secondary prevention:
Mortality 🡇2.5% (NNT 40), CVD mortality 🡇1.2% (NNT 83), Non-fatal MI 🡇1.3% (NNT 76), Kidney failure 🡇0.6% (NNT 166), HF admit 🡇2.3% (NNT 43)
Renal:
eGFR > 30

Empagliflozin (Jardiance)       Cost:12.5mg/25mg $49/$98/month SE:UTI/Vag yeast/🡇BP/🠝Lipids   Benefits:🡇CVD/🡇CHF/🡇CKD/🡇Wt    Cost:25mg $98/month
Canagliflozin (Invokana)         Cost:300mg $103/month SE:UTI/Vag yeast/🡇BP/🠝Lipids/Amputations    Benefits:🡇CVD/🡇CHF/🡇CKD/🡇Wt    Cost:300mg $103/month
Dapagliflozin (Forxiga)            Cost:10mg $98/month SE:UTI/Vag yeast/🡇BP/🠝Lipids   Benefits:🡇CVD/🡇CHF/🡇CKD/🡇Wt    Cost:10mg $98/month
Ertugliflozin (Steglatrol)            Cost:15mg $104/month SE:UTI/Vag yeast/🡇BP/🠝Lipids   Benefits:🡇CVD/🡇CHF/🡇CKD/🡇Wt    Cost:15mg $104/month

GLP-1 Agonist
Mode of action:
Works by activating GLP-1 receptors in the pancreas, which leads to enhanced insulin release and reduced glucagon release. Effects on GLP-1 receptors in the CNS and the gastrointestinal tract cause reduced appetite and delayed glucose absorption due to slower gastric emptying.
Side effects:
Nausea / Pancreatitis /Cholecystitis / AKI /Thyroid cancer
Concerns about increased diabetic retinopathy particularly with semaglutide.
Benefits:
Significant A1C lowering and promotes weight loss with low risk for hypoglycemia.
** Liraglutide, subcutaneous semaglutide, albigultide and dulaglutide have shown reductions in composite cardiovascular outcomes.
Oral semaglutide has not demonstrated cardiovascular benefit.GLP-1 agonists have also demonstrated a reduction in non fatal strokes.
Primary prevention:
Mortality 🡇0.8% (NNT 125), CVD mortality 🡇0.5% (NNT 200), Non-fatal MI 🡇0.4% (NNT 250), Non-fatal stroke 🡇0.9% (NNT 111), Kidney failure 🡇0.2% (NNT 500)
Secondary prevention:
Mortality 🡇1.3% (NNT 76), CVD mortality 🡇0.9% (NNT 111), Non-fatal MI 🡇0.8% (NNT 125), Non-fatal stroke 🡇1.6% (NNT 62), Kidney failure 🡇0.4% (NNT 250)
Renal:
eGFR > 0-30

SemaglutideSC (Ozempic)**          Cost: $295/month SE:GIT upset/Pancreatitis/DM Retinopathy/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt/🡇CVA/🡇CVD     Cost: $295/month

Liraglutide (Victoza)**                    Cost: $339/month SE:GIT upset/Pancreatitis/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt/🡇CVA/🡇CVD     Cost: $339/month

Dulaglutide (Trulicity)**                    Cost: $258/month SE:GIT upset/Pancreatitis/DM Retinopathy/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt/🡇CVA/🡇CVD     Cost: $258/month

Exenatide (Byetta)                      Cost: $181/month SE:GIT upset/Pancreatitis/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt/Cheapest GLP1     Cost: $181/month

Exenatide QW (Bydureon)          Cost: $250/month SE:GIT upset/Pancreatitis/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt     Cost: $250/month

Lixisenatide (Adlyxine)                Cost: $146/month SE:GIT upset/Pancreatitis/AKI/Cholecystitis/Hypersensitivity
Benefits:🡇🡇A1C/🡇Wt/Cheapest GLP1    Cost: $146/month

SemaglutidePO (Rybelsus)         Cost: $333/month SE:GIT upset/Pancreatitis/DM Retinopathy/AKI/Thyroid Ca/Cholecystitis/Hypersensitivity
Benefits:🡇A1C/🡇Wt   Cost: $333/month

DPP4
Mode of action:
DPP-4 is a ubiquitous enzyme that acts on incretin hormones, mainly GLP-1 (glucagon-like peptide-1) and GIP (gastric inhibitory peptide), which maintain glucose homeostasis by increasing insulin secretion and decreasing glucagon secretion.
These incretins are released within minutes of food intake, and DPP-4 degrades these hormones immediately due to their short half-life. By inhibiting the DPP-4 enzyme, DPP-4 inhibitors increase the levels of GLP-1 and GIP
Side effects:
Well tolerated, side effects similar to placebo (GIT upset/rash),
Benefits:
Can be dose adjusted in renal failure
Low risk of hypoglycemia
Weight neutral
Renal:
eGFR > 0-15

Linagliptin (Trajenta)     Cost:5mg $95/month SE:Pancreatitis/Joint pain/Modest🡇BS    Benefits:Use in CKD    Cost:5mg $95/month
Saxagliptin (Onglyza)     Cost:5mg $68/month SE:Pancreatitis/Joint pain/Modest🡇BS    Benefits:Cheapest DPP4     Cost:5mg $68/month
Sitagliptin (Januvia)     Cost:100mg $116/month SE:Pancreatitis/Joint pain/Modest🡇BS    Benefits:Use in CKD     Cost:100mg $116/month
Alogliptin (Nesina)     Cost:25mg $69/month SE:Pancreatitis/Joint pain/Modest🡇BS    Benefits:Use in CKD     Cost:25mg $69/month

Thiazolidinedione
Mode of action:
Works by the improvement of insulin sensitivity using a mechanism that involves activation of PPAR gamma, a nuclear receptor. This alters the transcription of several genes involved in glucose and lipid metabolism and energy balance and reduces insulin resistance in adipose tissue, muscle and the liver.
Side effects:
Edema /weight gain / CHF / Increased fracture risk / Bladder cancer
The net benefit of thiazolidinedione therapy is unclear. Given that there are other effective drugs to control glycemia that are associated with fewer adverse events, thiazolidinediones should not be considered appropriate as first-line therapy for type 2 diabetes mellitus. If a patient is unable to take other therapies or if other therapies have failed, there may be a role for thiazolidinediones in carefully selected patients duly informed of the potential adverse effects.(CMAJ. 2009 Jan 6; 180(1): 16–17.)
Benefits:
Improved glycemic control without hypoglycemia and decrease in insulin resistance
Renal:
eGFR > 0-30

Pioglitazone (Actos)     Cost:45mg $40/month SE:CHF/Bladder Ca/Fractures/🠝Wt     Benefits:Use in CKD     Cost:45mg $40/month
Rosiglitazone (Avandia)     Cost:8mg $97/month SE:CHF/Fractures/🠝Wt/Anemia/MI     Benefits:Use in CKD     Cost:8mg $97/month

Alpha-glucosidase inhibitor
Mode of action:
Work by inhibiting the absorption of carbohydrates from the small intestine. They competitively inhibit enzymes that convert complex non-absorbable carbohydrates into simple absorbable carbohydrates. These enzymes include glucoamylase, sucrase, maltase, and isomaltase. By delaying carbohydrate absorption, they reduce the rise in postprandial blood glucose concentrations by about 3 mmol/l.
Side effects:
Gastrointestinal disturbances resulting from the degradation of undigested carbohydrates by bacteria in the colon, which causes excessive gas formation leading to flatulence in about 78% of the cases. Diarrhea and abdominal pain may also occur.
Benefits:
Reduce post meal blood sugars
Weight neutral
Renal:
eGFR > 25

Acarbose (Glucobay)     Cost:300mg $48/month SE:GIT upset/Liver/Drug interactions    Benefits:🡇CVD/🡇BP    Cost:300mg $48/month
Miglitol (Glyset)     Cost:300mg $300/month SE:GIT upset/Hypoglycemia/Drug interactions    Benefits:    Cost:300mg $300/month

Insulin
Mode of action:
Insulin initiates its action by binding to a glycoprotein receptor on the surface of the cell which generates a signal that eventually results in insulin's action on glucose, lipid, and protein metabolism.
Side effects:
Hypoglycemia / weight gain / lipoatrophy and lipohypertrophy
Benefits:
Lowers blood sugar
Renal:
eGFR > 0

NPH     Cost:1500u $50/month SE:Hypoglycemia/ weight gain/ lipoatrophy and lipohypertrophy     Cost:1500u $50/month
Basaglar     Cost:1500u $75/month SE:Hypoglycemia/ weight gain/ lipoatrophy and lipohypertrophy     Cost:1500u $75/month
Lantus     Cost:1500u $100/month SE:Hypoglycemia/ weight gain/ lipoatrophy and lipohypertrophy     Cost:1500u $100/month
Levemir     Cost:1500u $120/month SE:Hypoglycemia/ weight gain/ lipoatrophy and lipohypertrophy     Cost:1500u $120/month

Fair Pharmacare Private Insurance Income Assistance/First Nations/RCMP

Pharmacare patient contact numbers: 1-800-663-7100 or 1-604-683-7151

Option 1 Option 2 Option 3

Deductible:

1) What is your pharmacare deductible?: $

2) What was last years annual household cost of pharmacare eligible medications?: $

3) Is at least one family member born before 1940?:

Net Household Income:

1) What was last years annual household cost of pharmacare eligible medications?: $

2) What is your approximate net household income?:

     $30 000
     $40 000
     $50 000
     $60 000
     $70 000
     $80 000
     $90 000

3) Is at least one family member born before 1940?

1) How much do you pay each month for pharmacare eligible medications?: $

2) What month does pharmacare support kick in?
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

3) Is at least one family member born before 1940?:

Deductible: $ Family Maximum: $ Annual drug cost: $

Percentage coverage of eligible medications: % 80% 100%

Percentage coverage of eligible medications: 100%

3 or less risk factors More than 3 risk factors Established CVD Established Renal disease Established CVD AND Renal disease

BMJ Rapid Recommendations:
We suggest not using SGLT-2 inhibitors or GLP-1 receptor agonists unless patient wanting to further reduce their risk for cardiovasular and renal outcomes and then we suggest SGLT-2 inhibitors rather than GLP-1 receptor agonists . We suggest using SGLT-2 inhibitors and not using GLP-1 receptor agonists. We suggest SGLT-2 inhibitors or GLP-1 receptor agonists. We suggest SGLT-2 inhibitors or GLP-1 receptor agonists. We recommend SGLT-2 inhibitors or suggest using GLP-1 receptor agonists as an alternative.

SGLT-2 GLP-1

SGLT-2 inhibitors are a new class of diabetic agents that include Empagliflozin (Jardiance), Canagliflozin (Invokana), Dapagliflozin (Forxiga) and Ertugliflozin (Steglatrol). Apart from their ability to lower blood sugars, they offer benefits to kidney function and reduction of cardiac risk and also help with potential weight loss.

Given your particular risk profile:
Over a 5 year period in 1000 people like you taking an SGLT-2 inhibitor
Reduction of all cause mortality (deaths) from 20 to 17 people (3 fewer deaths)
Reduction of non fatal heart attacks from 30 to 26 people (4 fewer heart attacks)
Reduction of end stage kidney disease from 2 to 1 people (1 fewer renal failures)
Reduction of hospitalisation for heart failure from 5 to 3 people (2 fewer patients hospitalised)

Reduction of all cause mortality (deaths) from 70 to 60 people (10 fewer deaths)
Reduction of non fatal heart attacks from 58 to 51 people (7 fewer heart attacks)
Reduction of end stage kidney disease from 10 to 7 people (3 fewer renal failures)
Reduction of hospitalisation for heart failure from 30 to 21 people (9 fewer patients hospitalised)

Reduction of all cause mortality (deaths) from 120 to 104 people (16 fewer deaths)
Reduction of non fatal heart attacks from 108 to 95 people (13 fewer heart attacks)
Reduction of end stage kidney disease from 20 to 14 people (6 fewer renal failures)
Reduction of hospitalisation for heart failure from 80 to 57 people (23 fewer patients hospitalised)

Reduction of all cause mortality (deaths) from 170 to 148 people (22 fewer deaths)
Reduction of non fatal heart attacks from 120 to 106 people (14 fewer heart attacks)
Reduction of end stage kidney disease from 92 to 67 people (25 fewer renal failures)
Reduction of hospitalisation for heart failure from 105 to 76 people (29 fewer patients hospitalised)

Reduction of all cause mortality (deaths) from 265 to 235 people (30 fewer deaths)
Reduction of non fatal heart attacks from 190 to 169 people (21 fewer heart attacks)
Reduction of end stage kidney disease from 148 to 110 people (38 fewer renal failures)
Reduction of hospitalisation for heart failure from 235 to 177 people (58 fewer patients hospitalised)

The most common side effects from this class of drug are increased risk for urinary tract infections and genital yeast infections.

Because these are new medications they are expensive and cost around $100 per month/ $1200 per year but are potentially eligible for pharmacare and private medication coverage.

Based on the information you have provided it is estimated that it would cost you on average an extra $ per month/ $ per year to be on this medication with the remainder covered by your insurance.

This estimate is based on your pharmacare deductible being $ and your current annual pharmacare eligible medication costs being $.

You can confirm your pharmacare deductible or enrol in pharmacare by contacting pharmacare at 1-800-663-7100 or 1-604-683-7151 or you can use the calculator at: https://www.health.gov.bc.ca/pharmacare/plani/calculator/calculator.html
You can confirm your current annual pharmacare eligible medication costs by speaking with your pharmacist-ask for the total cost of your medications for last year (how much you paid plus how much pharmacare contributed) minus the cost of non insured medications.

How pharmacare works is you pay the full amount until you reach your deductible, then you pay 30% of pharmacare eligible costs until you reach your family maximum and then for the rest of the year pharmacare eligible costs are free.

Adding an expensive pharmacare eligible medication will mean that you will pay more at the beginning of the year but you will reach your deductible and family maximum sooner and pay less for the remainder of the year so it is important to look at your annual medication cost and not your monthly cost.
If you are unable to afford the initial higher monthly costs, pharmacare does offer a monthly deduction payment option (MDPO) to average out these costs over the year.
Go to https://www2.gov.bc.ca/assets/gov/health/health-drug-coverage/pharmacare/fpc04.pdf for the application form.

Your pharmacare deductible is based on your income in your last two income tax returns.
If you have had a recent change in your income(eg you have just retired), you can request an income review.
Go to https://www2.gov.bc.ca/assets/gov/health/health-drug-coverage/pharmacare/fpc03.pdf This estimate is based on your private insurance covering % of the cost.

This estimate is based on your provincial insurance covering 100% of the cost.

GLP-1 agonists are a new class of diabetic agents that include SemaglutideSC (Ozempic), Liraglutide (Victoza) and Dulaglutide (Trulicity). Apart from their ability to lower blood sugars, they offer potential reduction of cardiac risk and non fatal strokes and also potential help with weight loss.

Given your particular risk profile:
Over a 5 year period in 1000 people like you taking a 'glutide' GLP-1 agonist
Reduction of all cause mortality (deaths) from 20 to 18 people (2 fewer deaths)
Reduction of non fatal heart attacks from 30 to 28 people (2 fewer heart attacks)
Reduction of non fatal strokes from 30 to 25 people (5 fewer strokes)

Reduction of all cause mortality (deaths) from 70 to 62 people (8 fewer deaths)
Reduction of non fatal heart attacks from 58 to 54 people (4 fewer heart attacks)
Reduction of non fatal strokes from 58 to 49 people (9 fewer strokes)

Reduction of all cause mortality (deaths) from 120 to 107 people (13 fewer deaths)
Reduction of non fatal heart attacks from 108 to 100 people (8 fewer heart attacks)
Reduction of non fatal strokes from 108 to 92 people (16 fewer strokes)
Reduction of end stage kidney disease from 108 to 100 people (8 fewer renal failures)

Reduction of all cause mortality (deaths) from 170 to 153 people (17 fewer deaths)
Reduction of non fatal heart attacks from 120 to 111 people (9 fewer heart attacks)
Reduction of non fatal strokes from 120 to 103 people (17 fewer strokes)
Reduction of end stage kidney disease from 92 to 73 people (9 fewer renal failures)

Reduction of all cause mortality (deaths) from 265 to 241 people (24 fewer deaths)
Reduction of non fatal heart attacks from 190 to 177 people (13 fewer heart attacks)
Reduction of non fatal strokes from 190 to 165 people (25 fewer strokes)
Reduction of end stage kidney disease from 148 to 119 people (29 fewer renal failures)

The most common side effects from this class of drug is nausea although there has been an increase noted for pancreatitis and cholecystitis.

Because these are new medications they are expensive and cost around $300 per month/ $3600 per year but are potentially eligible for pharmacare and private medication coverage.

Based on the information you have provided it is estimated that it would cost you on average an extra $ per month/ $ per year to be on this medication with the remainder covered by your insurance.

This estimate is based on your pharmacare deductible being $ and your current annual pharmacare eligible medication costs being $.

You can confirm your pharmacare deductible or enrol in pharmacare by contacting pharmacare at 1-800-663-7100 or 1-604-683-7151 or you can use the calculator at: https://www.health.gov.bc.ca/pharmacare/plani/calculator/calculator.html
You can confirm your current annual pharmacare eligible medication costs by speaking with your pharmacist-ask for the total cost of your medications for last year (how much you paid plus how much pharmacare contributed) minus the cost of non insured medications.

How pharmacare works is you pay the full amount until you reach your deductible, then you pay 30% of pharmacare eligible costs until you reach your family maximum and then for the rest of the year pharmacare eligible costs are free.

Adding an expensive pharmacare eligible medication will mean that you will pay more at the beginning of the year but you will reach your deductible and family maximum sooner and pay less for the remainder of the year so it is important to look at your annual medication cost and not your monthly cost.
If you are unable to afford the initial higher monthly costs, pharmacare does offer a monthly deduction payment option (MDPO) to average out these costs over the year.
Go to https://www2.gov.bc.ca/assets/gov/health/health-drug-coverage/pharmacare/fpc04.pdf for the application form.

Your pharmacare deductible is based on your income in your last two income tax returns.
If you have had a recent change in your income(eg you have just retired), you can request an income review.
Go to https://www2.gov.bc.ca/assets/gov/health/health-drug-coverage/pharmacare/fpc03.pdf This estimate is based on your private insurance covering % of the cost.

This estimate is based on your provincial insurance covering 100% of the cost.

This worksheet provides a monthly estimate of the financial impact that adding a new pharmacare eligible medication will make.
Deductible: $
Family Maximum: $
Current annual cost of medication before pharmacare subsidy: $

Cost of new medication per month: $

Current situation: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total cost $ $ $ $ $ $ $ $ $ $ $ $ $ Impact of starting a medication costing $ for next year: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total cost $ $ $ $ $ $ $ $ $ $ $ $ $ Impact of starting a medication costing $ for next year enrolled in the Pharmacare MDPO plan: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total cost $ $ $ $ $ $ $ $ $ $ $ $ $

Summary:
Adding a new medication costing $ per year
Your actual annual cost for this will be $.

FIB-4: Fibrosis stage:

FIB-4 INPUTS: Age ALT AST Plt

Renal dosing
Dr JF Yale Endocrinologist McGill: Look at "Antihyperglycemic Agents and Renal Failure, pdf version"
Diabetes Canada Renal Dosing

Medication costs (updated March 2022)
Current medication costs: DrugSearch.ca
Insulin costs:PAD newsletter
Fair Pharmacare Tables: Regular
Fair Pharmacare Tables: Enhanced

Diabetic management guidelines
BC Guidelines
Diabetes Canada
ADA: American Diabetic Association
UK:NICE Guidelines
NICE Guideline: DM with CVD
Australian Guidelines

Benefits of SGLT-2 and GLP-1 medications
BMJ Rapid Guidelines
Comparison of benefits SGLT-2 and GLP-1
GLP1 studies and outcomes regarding cardiovascular risk reduction: 2019
Risk equations for complications of Diabetes (RECODe)

NAFLD Primary Care Pathway/FIB-4 screening
Alberta NAFLD Guidelines
Use of the FIB-4 index for non-invasive evaluation of fibrosis in NAFLD (Gastro2009)
The use of the FIB-4 scoring system to rule out advanced fibrosis (BMJ2017)
Low Accuracy of FIB-4 and NAFLD Fibrosis Scores for Screening for Liver Fibrosis in the Population (Gastro2021)

TZD for NAFLD
Pioglitazone for NAFLD Patients With Prediabetes or Type 2 Diabetes Mellitus(Endo2021)

Lipid Guidelines
Simplified Lipid Guidelines(cfp 2015)