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Quick Reference ForThe National Saudi Diabetic Guideli

For Primary care

Dr. Wedad BardisiABFM. & ABFMChief editor

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Introduction The Challenge of Diabetes: Diabetes mellitus is a serious condition with potentially

devastating complications that affects all age groupsworldwide

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

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Saudi Studies The different national studies for the epidemiology of diabetes mellitus typ

found that the incidence increased annually.

A study at (Riyadh- 2011), found that, the overall crude prevalence of DMT

23.1%.

Another study at (Jeddah-2011) estimated the prevalence diabetes was 34.1

males and 27.6% in femalesReferrence : 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

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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 v

$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 fo

as a whole

Referrence :Economic costs of diabetes in Saudi Arabia Abdulkarim K. AlhowaishFamily Community Med. 2013 Jan-Apr; 20(1): 1 7.

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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

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Definition

Diabetes mellitus is a metabolic disorder characterized bypresence of hyperglycemia due to defective insulin secret

defective insulin action or both

Ref :National Saudi diabetic guidelines 2014American diabetes standard of care 2013

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Classification of DiabetesTable. 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 etiologyof beta cell destruction is unknown.

Type 2 diabetes may range from predominant insulin resistance with relative insulin deficiency to apredominant secretory defect with insulin resistance.

Gestational diabetes mellitus refers to glucose intolerance with onset or first recognition duringpregnancy.

Other specific types*

*Includes latent autoimmune diabetes in adults (LADA), and includes the small number of people with apparent type 2diabetes who appear to have immune-mediated loss of pancreatic beta cells

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Diagnosis of diabetes1. HBA1C6.5%

OR

2. FPG 126 mg/dl (7.0 mmol/l )..

OR

2. Symptoms of hyperglycemia or hyperglycemic crisis, and a casual (random) pglucose 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)

OR2- 2-h plasma glucose in the 75-gOGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dLmmol/L)(IGT)

OR3- A1C 5.7 6.4%

*For all three tests, risk is continuous, extending below the lower limit of the ranbecoming disproportionately greater at higher ends of the range. Ref : American diabetes standard of care 2013

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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 Ref : American diabetes standard of care 2013

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Screening for Type 2 Diabetes

Screening for type 2 diabetes using fasting plasma glucose (FPG) should be performe

3 years in individuals 40 years of age. or in individuals at high risk using a risk calcul

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 (OG

should be undertaken in individuals with an FPG of 5.6-6.9 mmol/L(100-125mh/dl) a

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 2013Canadian 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 progre

from impaired glucose tolerance to type 2 diabetes by almost 60%.

Progression from prediabetes to type 2 diabetes can also be reduced b

pharmacologic therapy with metformin (30% reduction), acarbose ( 3reduction).

Ref :National Saudi diabetic guidelines first update.2014

Canadian Clinical Practice guidelines 2013

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Monitoring Glycemic Control Glycated hemoglobin (A1C) is a valuable indicator of gly

control.

Self monitoring of blood glucose (SMBG) results andA1C,provides the best to assess glycemic control.

Ref :National Saudi diabetic guidelines first update.2014 Canadian Clinical Practice guidelines 2013

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The frequency of SMBG should be determined individual

Ref :National Saudi diabetic guidelines first update.2014 Canadian Clinical Practice guidelines 2013

Table 2: Factors that can affect A1C

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Table 2: Factors that can affect A1CFactor Increased A1C Decreased A1C Variabl

Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis

Use of erythropoietin, iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin

Fetal heHemoglMethemGenetic

Altered glycation AlcoholismHemoglobinopathies

Chronic renal failureDecreased erythrocyte pH

Ingestion of aspirin, vitamin C orvitamin EIncreased erythrocyte pH

Erythrocyte destruction Increased erythrocyte lifespan:Splenectomy

Decreased erythrocyte lifespan:Chronic renal failureHemoglobinopathiesSplenomegalyRheumatoid arthritisAntiretroviralsRibavirinDapsone

Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use

Hypertriglyceridemia Hemogl

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Targets for Glycemic Control A1C 7.0% FBS or Pre-prandial capillary plasma glucose 70 130

(3.9 7.2mmol/L) Peak postprandial capillary plasma glucose, 180 mg

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 pa Postprandial glucose may be targeted if A1C goals are not met despite rea

pre-prandial glucose goals

*Postprandial glucose measurements should be made 1 2 h after th

of the meal, generally peak levels in patients with diabetes. American Diabetes Association2013

Standards of Medical Care in Diabetes

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Recommended Targets for Glycemic Control

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Pharmacologic Management of Type 2 Diabete

Lifestyle modification, including nutritional therapy and physi

activity, should continue to be emphasized while pharmacothe

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

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A patient-centered approach should be used to guide choice of pharmacolo

agents; considerations include efficacy, cost, potential side effects, effects

weight, comorbidities, hypoglycemia risk, and patient preferences.

Due to the progressive nature of type 2 diabetes, insulin therapy is eventua

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 symptoma

and/or elevated blood glucose levels or A1C, consider insulin therapyor without additional agents, from the outset.

If noninsulin monotherapy at maximal tolerated dose does not achievmaintain the A1C target over 3 6 months, add a second oral agentreceptor agonist, or insulin.


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A long acting insulin analogue is added to oral antihyperglycemic ag The addition of bedtime insulin to metformin therapy leads to less we

gain than insulin plus a sulfonylurea or twice daily NPH insulin . As type 2 diabetes progresses, doses of basal insulin (intermediate ac

or long acting analogues) will need increasing, pre-prandial insulin (sacting or rapid acting analogues) may be required.

A combination of oral antihyperglycemic agents and insulin ofteneffectively controls glucose levels.


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DPP-4 inhibitors and GLP-1 receptor agonists have been sto be effective.

As type 2 diabetes progresses, additional doses of basal imay also be required.

Insulin regimens based on basal or bolus insulin appear toequally effective and superior to biphasic insulin-based

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

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Insulin Therapy

When to initiate insulin therapy?

Use a structured programme upon insulin initiation. National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes CG66 in NICE clinical guideline 87 ,September 2010 European Medicines

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Initiate Insulin Therapyfrom a choice of a number of insulin types and regimens

Begin with human NPH insulin injected at bed-time or twdaily according to need.

Consider, as an alternative, using a long-acting insulin ana(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 insanalogues, rather than pre-mixed preparations that include shacting human insulin preparations, in some cases.


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Monitor persons on insulin frequently for any modificatio


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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

drug-induced hypoglycemia.


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Anti-platelet therapy for people with diabetes

The role of antiplatelet therapy in primary and secondaryprevention of cardiovascular disease in diabetics is variable, anshould be individualized.

Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013

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Recommendations Offer low-dose aspirin, (75-162) mg daily, to a person who is (male aged >50 years /

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

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Identification of Individuals at High Risk of Coronary Even

People with diabetes should be considered to have a high 10-year risk of CAD events

years and male, or 50 years and female. For the younger person (male

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Treatment of Hypertension In the prevention of diabetes-related complications, vascular protection is the first p

followed by control of hypertension in those whose blood pressure (BP) levels remaintarget, then nephroprotection for those with proteinuria.

People with diabetes and elevated BP should be aggressively treated to achieve a tar

of

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JNC (American) classification OF Blood Pressu

Category Systolic Diastolic Optimal

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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 syst

and 80 for diastolic. Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013

American Diabetes Association2013 ,Standards of Medical Care in Diabetes

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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 seru

potassium levels. Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes

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Alpha-blockers are not recommended

A calcium channel blocker should be the first-line bloodpressure-lowering therapy for a woman who ay get pregna

Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes

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For diabetes and albuminuria an ACE inhibitor or an ARB is recommendeinitial therapy.

If BP remains 140/80 mm Hg additional antihypertensive drugs shouldused to obtain target BP.

For persons with diabetes and a normal urinary albumin excretion rate, witchronic kidney disease and with isolated systolic hypertension, a long-actinCCB is an initial choice.


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Dyslipidemia in Diabetes

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

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



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Nephropathy Screening for CKD in diabetes should be conducted using a random u

ACR and a serum creatinine converted into an eGFR. Screening should commence at diagnosis of diabetes in individuals w

type 2 diabetes and yearly thereafter.

A diagnosis of CKD should be made in patients with a random urine

>2.0 mg/mmol and/or an eGFR

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Suspect renal disease, when the albumin: creatinine ratio (ACR) is raised of the following apply:No retinopathy

High BP or resistant to treatmenthad a documented normal ACR and develops heavy proteinuria (ACR >1mg/mmol)Haematuria is presentGlomerular filtration rate has worsened rapidlyThe person is systemically ill.


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Adults with diabetes and persistent albuminuria (ACR >2

mg/mmol in males, and females) should receive an ACEinhibitor or an ARB to delay progression of CKD, even inabsence of hypertension.

For a person with an abnormal albumin: creatinine ratio,

maintain blood pressure below 130/80mmHg. Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013


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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 progressio

sight-threatening diabetic retinopathy.

Laser therapy reduces the risk of significant visual loss. Ref: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes

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Neuropathy Screening for distal symmetric polyneuropathy (DPN) starting at diagnosis of type 2

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 EDwith a sexual function history.

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

Ref: National Saudi diabetic guidelines 2014

Canadian Clinical Practice guidelines 2013


Recommendations:

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Recommendations:Medical Nutrition Therapy (MNT)

Individuals who have prediabetes or diabetes should receive individualized MNT as nto 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 amputatio Inspection Assessment of foot pulses Test for loss of protective sensation: 10-g monofilament plus testing any o

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 tothe 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 siteswhile the patients eyes are closed

Ref: National Saudi diabetic guidelines 2014 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 surveillan Smokers

Loss of protective sensation or structural abnormalities

History of prior lower-extremity complications

Ref: National Saudi diabetic guidelines 2014 American Diabetes Association2013 , Standards of Medical Care in Diabetes

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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 areasymptomatic

Refer patients with significant claudication or a positive ABI for further v

assessment.

Consider exercise, medications, surgical options. Ref: National Saudi diabetic guidelines 2014 American Diabetes Association2013 ,Standards of Medical Care in Diabetes

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In Summary

Diabetes mellitus is a chronic illness that requires continu

medical care and ongoing patient self-management educat

and support to prevent acute complications and to reduce t

risk of long-term complications.

Diabetes care is complex and requires multifactorial risk

reduction strategies beyond glycemic control.

f

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Reference1- the Saudi national diabetic guideline for primary care 20142-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-MaAbdullah M , Attas O , Al-Shahid MS, Al-Mobeireek A . 2004.3- Diabetes Impact in Saudi Health, Health minister,,Alruba,an et al - initial report 20084- Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (riyadh coh

decade of an epidemic Nasser M Al-Daghri 12*, Omar S Al-Attas 12, Majed S Alokail 12, Khalid M Alkharfy12Shaun Louie Sabico 1 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; acceOctober 2011. published online 14 November 2011

7-Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish Family Community Med. 2013 Jan-Apr; 20(1): 1 7.

8- Canadian journal of diabetes April 2013 - Volume 37 - Supp lement 1

R f
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Reference:

Reference9--Canadian Clinical Practice guidelines 2013Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1

10-American Diabetes Association2013Standards of Medical Care in Diabetes

11- CG66 in NICE clinical guideline 87

September 2010 European Medicines.

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Wedad DM[1] (1).pptx