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The National Saudi Diabetic Guidelines
For Primary care
Dr. Wedad Bardisi
ABFM. & ABFM
Chief editor
Reference:
Introduction
The Challenge of Diabetes:
Diabetes mellitus is a serious condition with potentially
devastating complications that affects all age groups
worldwide
There is a huge increase in number of diabetics by 2030.
Saudi Arabia the sixth of the Top Ten.
Reference : IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030
Reference:
Saudi Studies
The different national studies for the epidemiology of diabetes mellitus type 2,
found that the incidence increased annually.
A study at (Riyadh- 2011), found that, the overall crude prevalence of DMT2 was
23.1%.
Another study at (Jeddah-2011) estimated the prevalence diabetes was 34.1% in
males and 27.6% in females
Referrence :
Diabetes Impact in Saudi Health, Health minister,,Alruba,an et al - initial report 2008
Prevalence of diabetes mellitus in a Saudi community 2011
Khalid A. Alqurashi, Khalid S. Aljabi, and Samia A. Bokhari
Reference:
The Cost of diabetes

Diabetes and its complications increase costs and service pressures on Ministry of Health.
A study Economic costs of diabetes in Saudi Arabia (2013) found that People diagnosed with
diabetes, on average, have medical healthcare expenditures that are ten times higher ($3,686 vs.
$380) than what expenditures would be in the absence of diabetes.
The impact of diabetes is significant not only for individuals but also for their families and for society
as a whole

Referrence :Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish
Family Community Med. 2013 Jan-Apr; 20(1): 17.

Reference:
The Saudi population can be regarded as a moderate risk population for diabetes mellitus.

The present management is unsatisfactory since those who are controlled (HbA1C <7%) are only 20% of
diabetic patients.

It is suggested that steps must be taken to improve awareness of the disease and to take measures to improve
diabetes care

Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish

Reference:
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion,
defective insulin action or both

Ref :National Saudi diabetic guidelines 2014
American diabetes standard of care 2013
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Classification of Diabetes
Table. 1 Classification of diabetes
Type 1 diabetes* is diabetes that is primarily a result of pancreatic beta cell destruction and is prone to
ketoacidosis. This form includes cases due to an autoimmune process and those for which the etiology
of beta cell destruction is unknown.
Type 2 diabetes may range from predominant insulin resistance with relative insulin deficiency to a
predominant secretory defect with insulin resistance.
Gestational diabetes mellitus refers to glucose intolerance with onset or first recognition during
pregnancy.
Other specific types*
*Includes latent autoimmune diabetes in adults (LADA), and includes the small number of people with apparent type 2
diabetes who appear to have immune-mediated loss of pancreatic beta cells
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Diagnosis of diabetes
1. HBA1C6.5%
OR
2. FPG 126 mg/dl (7.0 mmol/l)..
OR
2. Symptoms of hyperglycemia or hyperglycemic crisis, and a casual (random) plasma
glucose 200 mg/dl (11.1 mmol/l).
OR
3. 2-hours plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT.

*In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeated testing.
Ref : American diabetes standard of care 2013

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Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mg/dL (5.6 mmol/L) to 125 mg/d (6.9 mmol/L) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0
mmol/L)(IGT)
OR
3- A1C 5.76.4%

*For all three tests, risk is continuous, extending below the lower limit of the range and
becoming disproportionately greater at higher ends of the range.

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Risk factors for pre-diabetes and diabetes
Overweight (BMI 25 kg/m2*) and have additional risk factors:
Physical inactivity
Family history
High-risk race/ethnicity
Women who delivered a baby weighing .9 lb or had GDM
Hypertension
HDL cholesterol level
polycystic ovary syndrome
A1C 5.7%, IGT, or IFG
History of CVD

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Screening for Type 2 Diabetes
Screening for type 2 diabetes using fasting plasma glucose (FPG) should be performed every
3 years in individuals 40 years of age. or in individuals at high risk using a risk calculator.
Diabetes will be diagnosed if A1C is 6.5%.
Testing with a 2-hour plasma glucose (2hPG) in a 75 g oral glucose tolerance test (OGTT)
should be undertaken in individuals with an FPG of 5.6-6.9 mmol/L(100-125mh/dl) and/or
an A1C of 5.7%-6.4% in order to identify individuals with diabetes.

Ref : National Saudi diabetic guidelines first update.2014
Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1

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Prevention/Delay of Diabetes
Intensive and structured lifestyle modification that results in loss of
approximately 5% of initial body weight can reduce the risk of progression
from impaired glucose tolerance to type 2 diabetes by almost 60%.
Progression from prediabetes to type 2 diabetes can also be reduced by
pharmacologic therapy with metformin (30% reduction), acarbose ( 30%
reduction).
Ref :National Saudi diabetic guidelines first update.2014

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Monitoring Glycemic Control
Glycated hemoglobin (A1C) is a valuable indicator of glycemic
control.

Self monitoring of blood glucose (SMBG) results and
A1C,provides the best to assess glycemic control.


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The frequency of SMBG should be determined individually.


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Table 2: Factors that can affect A1C
Factor Increased A1C Decreased A1C
Variable change in A1C
Erythropoiesis

Iron deficiency
B12 deficiency
Decreased erythropoiesis

Use of erythropoietin, iron or B12
Reticulocytosis
Chronic liver disease
Altered hemoglobin
Fetal hemoglobin
Hemoglobinopathies
Methemoglobin
Genetic determinants
Altered glycation Alcoholism
Hemoglobinopathies

Chronic renal failure
Decreased erythrocyte pH

Ingestion of aspirin, vitamin C or
vitamin E
Increased erythrocyte pH

Erythrocyte destruction Increased erythrocyte lifespan:
Splenectomy

Decreased erythrocyte lifespan:
Chronic renal failure
Hemoglobinopathies
Splenomegaly
Rheumatoid arthritis
Antiretrovirals
Ribavirin
Dapsone

Assays Hyperbilirubinemia Carbamylated hemoglobin
Alcoholism
Large doses of aspirin
Chronic opiate use
Hypertriglyceridemia Hemoglobinopathies
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Targets for Glycemic Control
A1C 7.0%
FBS or Pre-prandial capillary plasma glucose 70130mg/dL
(3.97.2mmol/L)
Peak postprandial capillary plasma glucose, 180 mg/dL*(10.0
mmol/L)

American Diabetes Association2013
Standards of Medical Care in Diabetes

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Optimal glycemic control
Individual patient considerations
More or less stringent glycemic goals may be appropriate for individual patients
Postprandial glucose may be targeted if A1C goals are not met despite reaching
pre-prandial glucose goals
*Postprandial glucose measurements should be made 12 h after the beginning
of the meal, generally peak levels in patients with diabetes.
American Diabetes Association2013

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Recommended Targets for Glycemic Control
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Pharmacologic Management of Type 2 Diabetes
Lifestyle modification, including nutritional therapy and physical
activity, should continue to be emphasized while pharmacotherapy
is being used.
Diabetic treatment must be dynamic.

National Saudi diabetic guidelines 2014.
American Diabetes Association2013 , Standards of Medical Care in Diabetes
CG66 in NICE clinical guideline 87 ,September 2010 European Medicines

Reference:
A patient-centered approach should be used to guide choice of pharmacological
agents; considerations include efficacy, cost, potential side effects, effects on
weight, comorbidities, hypoglycemia risk, and patient preferences.

Due to the progressive nature of type 2 diabetes, insulin therapy is eventually
indicated for many patients with type 2 diabetes.


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Treatment Recommendations
Metformin, is the preferred initial pharmacological agent for type 2
diabetes .

In newly diagnosed type 2 diabetic patients with markedly symptomatic
and/or elevated blood glucose levels or A1C, consider insulin therapy, with
or without additional agents, from the outset.

If noninsulin monotherapy at maximal tolerated dose does not achieve or
maintain the A1C target over 36 months, add a second oral agent, a GLP-1
receptor agonist, or insulin.

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A long acting insulin analogue is added to oral antihyperglycemic agents.
The addition of bedtime insulin to metformin therapy leads to less weight
gain than insulin plus a sulfonylurea or twice daily NPH insulin .
As type 2 diabetes progresses, doses of basal insulin (intermediate acting
or long acting analogues) will need increasing, pre-prandial insulin (short
acting or rapid acting analogues) may be required.
A combination of oral antihyperglycemic agents and insulin often
effectively controls glucose levels.


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DPP-4 inhibitors and GLP-1 receptor agonists have been shown
to be effective.
As type 2 diabetes progresses, additional doses of basal insulin
may also be required.
Insulin regimens based on basal or bolus insulin appear to be
equally effective and superior to biphasic insulin-based
regimens.

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Insulin Therapy

When to initiate insulin therapy?

Use a structured programme upon insulin initiation.

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Initiate Insulin Therapy
from a choice of a number of insulin types and regimens
Begin with human NPH insulin injected at bed-time or twice
daily according to need.

Consider, as an alternative, using a long-acting insulin analogue
(insulin detemir, insulin glargine).


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Consider twice-daily pre-mixed (biphasic) human insulin
(particularly if HbA1c 9.0%).

Consider pre-mixed preparations that include short-acting insulin
analogues, rather than pre-mixed preparations that include short-
acting human insulin preparations, in some cases.


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Monitor persons on insulin frequently for any modifications.


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To lower post prandial blood glucose, use either of these

a)- Alph-glucosidase inhibitor.
b)- premixed insulin analogues.
c)- meglitinides.
d)- rapid-acting insulin analogues.


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Important:
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia.


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Anti-platelet therapy for people with diabetes

The role of antiplatelet therapy in primary and secondary
prevention of cardiovascular disease in diabetics is variable, and
should be individualized.

Ref: National Saudi diabetic guidelines 2014

Reference:
Recommendations
Offer low-dose aspirin, (75-162) mg daily, to a person who is (male aged >50 years / female
aged >60 years) if blood pressure is below 145/90 mmHg.
Offer low-dose aspirin, (75-162) mg daily, to a person who is (male aged <50 years /female
aged <60 years) and has significant other cardiovascular risk factors if blood pressure is
below 145/90 mmHg.

Clopidogrel (75mg) should be used instead of aspirin only in those with clear aspirin
intolerance. (except in the context of acute cardiovascular events and procedures).
*Combination therapy with aspirin(75162 mg/day) and clopidogrel (75mg/day) is
reasonable for up to a year after an acute coronary syndrome.


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Identification of Individuals at High Risk of Coronary Events
People with diabetes should be considered to have a high 10-year risk of CAD events if 45
years and male, or 50 years and female.
For the younger person (male <45 years or female <50 years) with diabetes, the risk of
developing CAD may be assessed from the evaluation of risk factors for CAD (both classical
and diabetes related).
When assessing the need for pharmacologic measures to reduce risk in the younger person
with diabetes, it is important to consider his or her high lifetime risk of developing CAD.

Reference:
Treatment of Hypertension

In the prevention of diabetes-related complications, vascular protection is the first priority,
followed by control of hypertension in those whose blood pressure (BP) levels remain above
target, then nephroprotection for those with proteinuria.
People with diabetes and elevated BP should be aggressively treated to achieve a target BP
of <140/80 mm Hg to reduce the risk of both micro- and macrovascular complications.
Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg
Most people with diabetes will require more than one BP lowering medications to achieve
BP targets,

Reference:
JNC (American) classification OF Blood Pressure
Category Systolic

Diastolic
Optimal <120 And <80
Normal <130 And /or <85
Prehypertension 130-139 And /or 85-89
Stage 1 (mild
hypertension)
140-159 And /or 90-99
Stage 2 (moderate
to severe
hypertension)
160 And /or 100
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Screening And Diagnosis

Blood pressure should be measured at every routine visit.

Patients found to have elevated blood pressure should have blood
pressure confirmed on a separate day.


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Goals
The goal is 140 for systolic and 80 for diastolic.

Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic.
American Diabetes Association2013 ,Standards of Medical Care in Diabetes

Reference:
Treatment
Life style therapy: low sodium , high potassium, DASH diet
Exercise.
ACE inhibitors, or ARBS.
If ACE inhibitors, ARBs, or diuretics are used, monitor serum
creatinine/estimated glomerular filtration rate (eGFR) and serum
potassium levels.

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Alpha-blockers are not recommended

A calcium channel blocker should be the first-line blood
pressure-lowering therapy for a woman who ay get pregnant.


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For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as
initial therapy.

If BP remains 140/80 mm Hg additional antihypertensive drugs should be
used to obtain target BP.

For persons with diabetes and a normal urinary albumin excretion rate, with no
chronic kidney disease and with isolated systolic hypertension, a long-acting DHP
CCB is an initial choice.


Reference:
Dyslipidemia in Diabetes

The primary treatment goal for people with diabetes is LDL-C
mmol/L(100mg/dl)HDL-c (50 mg/dl),TG 150 mg/dl)

Achievement of the primary goal may require intensification of
lifestyle changes and/or statin therapy.

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Nephropathy
Screening for CKD in diabetes should be conducted using a random urine
ACR and a serum creatinine converted into an eGFR.

Screening should commence at diagnosis of diabetes in individuals with
type 2 diabetes and yearly thereafter.

A diagnosis of CKD should be made in patients with a random urine ACR
>2.0 mg/mmol and/or an eGFR<60 mL/min on at least 2 of 3 samples over
a 3-month period.

Reference:
Suspect renal disease, when the albumin: creatinine ratio (ACR) is raised and any
of the following apply:
No retinopathy
High BP or resistant to treatment
had a documented normal ACR and develops heavy proteinuria (ACR >100
mg/mmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill.

Reference:
Adults with diabetes and persistent albuminuria (ACR >2. 0
mg/mmol in males, and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD, even in the
absence of hypertension.
For a person with an abnormal albumin: creatinine ratio,
maintain blood pressure below 130/80mmHg.

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Retinopathy
Screening is important for early detection of treatable disease.
Screening intervals for diabetic retinopathy vary according to the
individuals age and type of diabetes.
Tight glycemic, BP, and lipid control reduces the onset and progression of
sight-threatening diabetic retinopathy.
Laser therapy reduces the risk of significant visual loss.

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Neuropathy
Screening for distal symmetric polyneuropathy (DPN) starting at diagnosis of type 2 diabetes
and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter.
Tests are, monofilament , vibration with 128 tuning fork, and reflexes.
Management of neuropathy include a trial of duloxetine, gabapentin, or pregabalin.


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Erectile Dysfunction
Erectile dysfunction (ED) affects approximately 34 to 45% of men
with diabetes.

All adult men with diabetes should be regularly screened for ED
with a sexual function history.

The current mainstays of therapy are phosphor diesterase type 5
inhibitors.

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Recommendations:
Medical Nutrition Therapy (MNT)
Individuals who have prediabetes or diabetes should receive individualized MNT as needed
to achieve treatment goals, preferably provided by a diabetic dietitian.


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Foot care
For all patients with diabetes, perform an annual comprehensive foot
examination to identify risk factors predictive of ulcers and amputations
Inspection
Assessment of foot pulses
Test for loss of protective sensation: 10-g monofilament plus testing any one of
Vibration using 128-Hz tuning fork
Pinprick sensation
Ankle reflexes
Vibration perception threshold

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Upper panel
To perform the 10-g monofilament
test, place the device perpendicular to
the skin, with pressure applied until
the monofilament buckles
Hold in place for 1 second and then
release
Lower panel
The monofilament test should be
performed at the highlighted sites
while the patients eyes are closed

American Diabetes Association2013 ,Standards
of Medical Care in Diabetes

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Foot care
Provide general foot self-care education
Use multidisciplinary approach
Individuals with foot ulcers, high-risk feet; especially prior ulcer or amputation
Refer patients to foot care specialists for ongoing preventive care, life-long surveillance
Smokers
Loss of protective sensation or structural abnormalities
History of prior lower-extremity complications


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Initial screening for peripheral arterial disease (PAD)
Include a history for claudication, assessment of pedal pulses
Consider obtaining an ankle-brachial index (ABI); many patients with PAD are
asymptomatic
Refer patients with significant claudication or a positive ABI for further vascular
assessment.
Consider exercise, medications, surgical options.

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In Summary
Diabetes mellitus is a chronic illness that requires continuing
medical care and ongoing patient self-management education
and support to prevent acute complications and to reduce the
risk of long-term complications.
Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control.
Reference:
Reference
1- the Saudi national diabetic guideline for primary care 2014
2-Diabetes mellitus in Saudi Arabia.
Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, Khan NB, Al-Khadra A, Al-Marzouki K, Nouh MS,
Abdullah M, Attas O, Al-Shahid MS, Al-Mobeireek A. 2004.
3- Diabetes Impact in Saudi Health, Health minister,,Alruba,an et al - initial report 2008
4- Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (riyadh cohort 2): a
decade of an epidemic Nasser M Al-Daghri12*, Omar S Al-Attas12, Majed S Alokail12, Khalid M Alkharfy123, Mansour Yousef4,
Shaun Louie Sabico1 and George P Chrousos Al-Daghri et al; licensee BioMed Central Ltd 2011
5- Prevalence of diabetes mellitus in a Saudi community 2011
Khalid A. Alqurashi, Khalid S. Aljabri, and Samia A. Bokhari
6-IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030 Received 19 October 2011; accepted 20
October 2011. published online 14 November 2011
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1

Reference:
Reference
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1

10-American Diabetes Association2013

11- CG66 in NICE clinical guideline 87
September 2010 European Medicines.

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