Canadian clinical practice guidelines play a crucial role in the PEBC Qualifying Examination Part 1, as they often form the basis for determining the correct answers to clinical scenario questions. This article highlights key Canadian guidelines that are frequently tested on the exam and how they may differ from international guidelines.

Cardiovascular Guidelines

Canadian cardiovascular guidelines have several important differences from those used in other countries, particularly regarding hypertension management and lipid therapy.

Hypertension Canada Guidelines:

• Blood Pressure Targets: Generally aim for <140/90 mmHg for most patients, and <130/80 mmHg for those with diabetes or high cardiovascular risk
• First-line Agents: Thiazide diuretics, ACE inhibitors, ARBs, or long-acting CCBs are all considered appropriate first-line options
• Combination Therapy: Initial combination therapy is recommended for patients with BP ≥20/10 mmHg above target
• Home BP Monitoring: Emphasized as an important component of hypertension management

Canadian Cardiovascular Society Lipid Guidelines:

• Risk Assessment: Uses the Framingham Risk Score modified for family history
• Primary Prevention: Statin therapy recommended for high-risk individuals (≥20% 10-year risk) or those with LDL-C ≥3.5 mmol/L
• Secondary Prevention: High-intensity statin therapy for all patients with established cardiovascular disease
• Non-statin Therapy: Ezetimibe and PCSK9 inhibitors recommended for those not reaching targets on maximum tolerated statin therapy

Diabetes Management

Diabetes Canada Clinical Practice Guidelines provide comprehensive recommendations for the management of diabetes that may differ from international guidelines.

Key Recommendations:

• Glycemic Targets: A1C ≤7.0% for most patients, with individualized targets based on age, comorbidities, and hypoglycemia risk
• Pharmacotherapy: Metformin remains first-line, but second-line therapy selection is based on presence of cardiovascular or renal disease
• CV Risk Reduction: SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit are recommended for patients with established cardiovascular disease
• Renal Protection: SGLT2 inhibitors recommended for patients with CKD and albuminuria
• Screening: Fasting plasma glucose or A1C for screening, with specific recommendations for high-risk ethnic groups

The Canadian guidelines place strong emphasis on a patient-centered approach and shared decision-making, considering factors such as hypoglycemia risk, weight effects, cost, and patient preferences when selecting therapy.

Infectious Disease Guidelines

Canadian infectious disease guidelines often reflect local resistance patterns and formulary considerations.

Community-Acquired Pneumonia:

• Outpatient treatment typically includes a respiratory fluoroquinolone or amoxicillin plus a macrolide
• Severity assessment using the CURB-65 or Pneumonia Severity Index to guide site of care decisions
• Specific recommendations for patients with COPD, bronchiectasis, or other comorbidities

Urinary Tract Infections:

• First-line agents for uncomplicated UTIs include nitrofurantoin, TMP-SMX, or fosfomycin
• Fluoroquinolones generally reserved for complicated infections due to resistance concerns
• Duration of therapy often shorter than in some international guidelines

Antimicrobial Stewardship:

• Strong emphasis on appropriate antibiotic selection and duration
• Recommendations for delayed prescribing strategies for certain conditions
• Focus on reducing unnecessary fluoroquinolone and macrolide use

Mental Health Guidelines

Canadian Psychiatric Association and CANMAT guidelines provide evidence-based recommendations for mental health disorders.

Depression Management:

• SSRIs and SNRIs as first-line agents for major depressive disorder
• Stepped approach to treatment with specific recommendations for treatment-resistant depression
• Integration of psychotherapy with pharmacotherapy
• Specific recommendations for special populations (elderly, pregnant women, adolescents)

Anxiety Disorders:

• SSRIs and SNRIs as first-line pharmacotherapy
• Cognitive-behavioral therapy as an effective non-pharmacological option
• Limited role for benzodiazepines due to dependence concerns

Bipolar Disorder:

• Mood stabilizers (lithium, valproate) and atypical antipsychotics for acute mania
• Lithium, lamotrigine, or certain atypical antipsychotics for maintenance therapy
• Comprehensive approach including psychoeducation and lifestyle modifications

Respiratory Disorders

Canadian Thoracic Society guidelines provide recommendations for asthma and COPD management.

Asthma Management:

• Stepped approach to therapy based on symptom control and risk factors
• Low-dose ICS as first-line controller therapy for most patients
• LABA/ICS combinations for patients not controlled on ICS alone
• Specific recommendations for severe asthma, including biologics

COPD Management:

• Pharmacotherapy based on symptom burden and exacerbation history
• LAMA or LABA as initial therapy for most patients
• LAMA/LABA combinations for patients with persistent symptoms
• ICS addition primarily for patients with history of exacerbations and elevated eosinophils
• Pulmonary rehabilitation as a key non-pharmacological intervention

Key Resources for Canadian Guidelines

To prepare effectively for the PEBC Qualifying Examination Part 1, familiarize yourself with these essential resources:

• RxTx (formerly e-CPS): Comprehensive Canadian drug information
• Therapeutic Choices: Evidence-based recommendations for common conditions
• Canadian Medical Association Journal: Often publishes Canadian guidelines
• Choosing Wisely Canada: Recommendations to reduce unnecessary tests and treatments
• Health Canada Drug Product Database: Official information on approved medications

The passMCQ app includes specific modules on Canadian clinical practice guidelines to help you prepare for the PEBC Qualifying Examination Part 1.