dm saudi guidelines by dr. wedad bardisi.pptx
TRANSCRIPT
The National Saudi Diabetic Guidelines for PHC
Quick Reference For The National Saudi Diabetic Guidelines
For Primary Health care
Dr Wedad BardisiABFM amp SBFM
Chief editor
The National Saudi Diabetic Guidelines for PHC
Introduction
bull The Challenge of Diabetes
bull Diabetes mellitus is a serious condition with potentially devastating complications that affects all age groups worldwide
bull There is a huge increase in number of diabetics by 2030
bull Saudi Arabia the sixth of the Top Ten
The National Saudi Diabetic Guidelines for PHC
Saudi Studies
bull The different national studies for the epidemiology of diabetes
mellitus type 2 found that the incidence increased annually
bull A study at (Riyadh- 2011) found that the overall crude
prevalence of DMT2 was 231
bull Another study at (Jeddah-2011) estimated the prevalence
diabetes was 341 in males and 276 in females
The National Saudi Diabetic Guidelines for PHC
The Cost of diabetes
bull Diabetes and its complications increase costs and service pressures
on Ministry of Health
bull 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 ($3686 vs $380)
than what expenditures would be in the absence of diabetes
bull The impact of diabetes is significant not only for individuals but also
for their families and for society as a whole
The National Saudi Diabetic Guidelines for PHC
bull The Saudi population can be regarded as a moderate risk population for
diabetes mellitus
bull The present management is unsatisfactory since those who are controlled
(HbA1C lt7) are only 20 of diabetic patients
bull It is suggested that steps must be taken to improve awareness of the disease
and to take measures to improve diabetes care
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Introduction
bull The Challenge of Diabetes
bull Diabetes mellitus is a serious condition with potentially devastating complications that affects all age groups worldwide
bull There is a huge increase in number of diabetics by 2030
bull Saudi Arabia the sixth of the Top Ten
The National Saudi Diabetic Guidelines for PHC
Saudi Studies
bull The different national studies for the epidemiology of diabetes
mellitus type 2 found that the incidence increased annually
bull A study at (Riyadh- 2011) found that the overall crude
prevalence of DMT2 was 231
bull Another study at (Jeddah-2011) estimated the prevalence
diabetes was 341 in males and 276 in females
The National Saudi Diabetic Guidelines for PHC
The Cost of diabetes
bull Diabetes and its complications increase costs and service pressures
on Ministry of Health
bull 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 ($3686 vs $380)
than what expenditures would be in the absence of diabetes
bull The impact of diabetes is significant not only for individuals but also
for their families and for society as a whole
The National Saudi Diabetic Guidelines for PHC
bull The Saudi population can be regarded as a moderate risk population for
diabetes mellitus
bull The present management is unsatisfactory since those who are controlled
(HbA1C lt7) are only 20 of diabetic patients
bull It is suggested that steps must be taken to improve awareness of the disease
and to take measures to improve diabetes care
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Saudi Studies
bull The different national studies for the epidemiology of diabetes
mellitus type 2 found that the incidence increased annually
bull A study at (Riyadh- 2011) found that the overall crude
prevalence of DMT2 was 231
bull Another study at (Jeddah-2011) estimated the prevalence
diabetes was 341 in males and 276 in females
The National Saudi Diabetic Guidelines for PHC
The Cost of diabetes
bull Diabetes and its complications increase costs and service pressures
on Ministry of Health
bull 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 ($3686 vs $380)
than what expenditures would be in the absence of diabetes
bull The impact of diabetes is significant not only for individuals but also
for their families and for society as a whole
The National Saudi Diabetic Guidelines for PHC
bull The Saudi population can be regarded as a moderate risk population for
diabetes mellitus
bull The present management is unsatisfactory since those who are controlled
(HbA1C lt7) are only 20 of diabetic patients
bull It is suggested that steps must be taken to improve awareness of the disease
and to take measures to improve diabetes care
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
The Cost of diabetes
bull Diabetes and its complications increase costs and service pressures
on Ministry of Health
bull 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 ($3686 vs $380)
than what expenditures would be in the absence of diabetes
bull The impact of diabetes is significant not only for individuals but also
for their families and for society as a whole
The National Saudi Diabetic Guidelines for PHC
bull The Saudi population can be regarded as a moderate risk population for
diabetes mellitus
bull The present management is unsatisfactory since those who are controlled
(HbA1C lt7) are only 20 of diabetic patients
bull It is suggested that steps must be taken to improve awareness of the disease
and to take measures to improve diabetes care
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull The Saudi population can be regarded as a moderate risk population for
diabetes mellitus
bull The present management is unsatisfactory since those who are controlled
(HbA1C lt7) are only 20 of diabetic patients
bull It is suggested that steps must be taken to improve awareness of the disease
and to take measures to improve diabetes care
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Definition
Diabetes mellitus is a metabolic disorder characterized by the
presence of hyperglycemia due to defective insulin secretion
defective insulin action or both
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
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 toketoacidosis This form includes cases due to an auto- immune 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 apparenttype 2 diabetes who appear to have immune-mediated loss of pancreatic beta cells
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Diagnosis of diabetes1 HBA1Cge65
OR
2 FPG ge 126 mgdl (70 mmoll)
OR
2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)
OR
3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT
In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Categories of increased risk for diabetes (prediabetes)
1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)
OR
2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)
OR
3- A1C 57ndash64
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
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Risk factors for pre-diabetes and diabetes
bull Overweight (BMI ge25 kgm2) and have additional risk factors
bull Physical inactivity
bull Family history
bull High-risk raceethnicity
bull Women who delivered a baby weighing 9 lb or had GDM
bull Hypertension
bull HDL cholesterol level
bull polycystic ovary syndrome
bull A1C ge57 IGT or IFG
bull History of CVD
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
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 ge65
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 56-69 mmolL(100-125mhdl) andor an A1C of 57-64
in order to identify individuals with diabetes
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
PreventionDelay of Diabetes
bull 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
bull Progression from prediabetes to type 2 diabetes can also be
reduced by pharmacologic therapy with metformin (30
reduction) acarbose ( 30 reduction)
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Monitoring Glycemic Control
bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control
bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control
bull The frequency of SMBG should be determined individually
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C
Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis
Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin
Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants
Altered glycation AlcoholismHemoglobinopathies
Chronic renal failureDecreased erythrocyte pH
Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH
Erythrocyte destruction Increased erythrocyte lifespanSplenectomy
Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone
Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use
Hypertriglyceridemia Hemoglobinopathies
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Targets for Glycemic Control
bull A1C 70
bull FBS or Pre-prandial capillary plasma glucose
70ndash130mgdL (39ndash72mmolL)
bull Peak postprandial capillary plasma glucose
180 mgdL(100 mmolL)
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Optimal glycemic control
bull Individual patient considerations
bull More or less stringent glycemic goals may be appropriate for
individual patients
bull Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
bull Postprandial glucose measurements should be made 1ndash2 h after
the beginning of the meal generally peak levels in patients with
diabetes
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Recommended Targets for Glycemic Control
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Pharmacologic Management of Type 2 Diabetes
bull Lifestyle modification including nutritional therapy and
physical activity should continue to be emphasized while
pharmacotherapy is being used
bull Diabetic treatment must be dynamic
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull 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
bull Due to the progressive nature of type 2 diabetes insulin therapy is
eventually indicated for many patients with type 2 diabetes
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Treatment Recommendations
bull Metformin is the preferred initial pharmacological agent for type 2 diabetes
bull In newly diagnosed type 2 diabetic patients with markedly symptomatic andor elevated blood glucose levels or A1C consider insulin therapy with or without additional agents from the outset
bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull A long acting insulin analogue is added to oral antihyperglycemic agents
bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin
bull 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
bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective
bull As type 2 diabetes progresses additional doses of basal insulin may also be required
bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Insulin Therapy
bull When to initiate insulin therapy
bull Use a structured programme upon insulin initiation
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Initiate Insulin Therapy from a choice of a number of insulin types and regimens
bull Begin with human NPH insulin injected at bed-time or twice daily according to need
bull Consider as an alternative using a long-acting insulin analogue (insulin detemir insulin glargine)
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)
bull 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
bull Monitor persons on insulin frequently for any modifications
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
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
Important
Counsel all diabetics about the recognition and prevention of
drug-induced hypoglycemia
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Anti-platelet therapy for people with diabetes
bull The role of antiplatelet therapy in primary and secondary prevention of cardiovascular disease in diabetics is variable and should be individualized
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Recommendations
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg
bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg
bull 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)
bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Identification of Individuals at High Risk of Coronary Events
bull 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
bull For the younger person (male lt45 years or female lt50 years) with diabetes
the risk of developing CAD may be assessed from the evaluation of risk
factors for CAD (both classical and diabetes related)
bull 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
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Treatment of Hypertension
bull 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
bull People with diabetes and elevated BP should be aggressively treated to achieve
a target BP of lt14080 mm Hg to reduce the risk of both micro- and
macrovascular complications
bull Patients with diabetes should be treated to a diastolic blood pressure lt80
mmHg
bull Most people with diabetes will require more than one BP lowering medications
to achieve BP targets
bull
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
JNC (American) classification OF Blood Pressure
Category Systolic Diastolic
Optimal lt120 And lt80Normal lt130 And or lt85
Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)
140-159 And or 90-99
Stage 2 (moderate to severe
hypertension)
ge160 And or ge100
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Screening And Diagnosis
bull Blood pressure should be measured at every routine visit
bull Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Goals
bull The goal is 140 for systolic and 80 for diastolic
bull Some cases the systolic is recommended to be 130 for systolic
and 80 for diastolic
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Treatment
bull Life style therapy low sodium high potassium DASH diet
Exercise
bull ACE inhibitors or ARBS
bull If ACE inhibitors ARBs or diuretics are used monitor serum
creatinineestimated glomerular filtration rate (eGFR) and
serum potassium levels
bull Alpha-blockers are not recommended
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman who ay get pregnant
bull For diabetes and albuminuria an ACE inhibitor or an ARB is recommended as initial therapy
bull
bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP
bull 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
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Dyslipidemia in Diabetes
bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)
bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Nephropathy
bull Screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR
bull
bull Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter
bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull 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 gt100 mgmmol)
Haematuria is present
Glomerular filtration rate has worsened rapidly
The person is systemically ill
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull Adults with diabetes and persistent albuminuria (ACR gt2 0
mgmmol in males and females) should receive an ACE
inhibitor or an ARB to delay progression of CKD even in the
absence of hypertension
bull For a person with an abnormal albumin creatinine ratio
maintain blood pressure below 13080mmHg
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Retinopathy
bull Screening is important for early detection of treatable disease
bull Screening intervals for diabetic retinopathy vary according to
the individualrsquos age and type of diabetes
bull Tight glycemic BP and lipid control reduces the onset and
progression of sight-threatening diabetic retinopathy
bull Laser therapy reduces the risk of significant visual loss
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Neuropathy
bull 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
bull Tests are monofilament vibration with 128 tuning fork and
reflexes
bull Management of neuropathy include a trial of duloxetine
gabapentin or pregabalin
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Erectile Dysfunction
bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes
bull All adult men with diabetes should be regularly screened for EDwith a sexual function history
bull The current mainstays of therapy are phosphor diesterase type5 inhibitors
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
RecommendationsMedical Nutrition Therapy (MNT)
bull Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals
preferably provided by a diabetic dietitian
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Foot care
bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
ndash Inspection
ndash Assessment of foot pulses
ndash Test for loss of protective sensation 10-g monofilament plus testing any one of
bull Vibration using 128-Hz tuning fork
bull Pinprick sensation
bull Ankle reflexes
bull Vibration perception threshold
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Upper panel
bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles
bull Hold in place for 1 second and then release
Lower panel
bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
Foot care
bull Provide general foot self-care education
bull Use multidisciplinary approach
ndash Individuals with foot ulcers high-risk feet especially prior ulcer or
amputation
bull Refer patients to foot care specialists for ongoing preventive care
life-long surveillance
ndash Smokers
ndash Loss of protective sensation or structural abnormalities
ndash History of prior lower-extremity complications
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
bull Initial screening for peripheral arterial disease (PAD)
ndash Include a history for claudication assessment of pedal pulses
ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD
are asymptomatic
bull Refer patients with significant claudication or a positive ABI for
further vascular assessment
ndash Consider exercise medications surgical options
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
In Summary
bull 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
bull Diabetes care is complex and requires multifactorial risk
reduction strategies beyond glycemic control
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
References
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 ministerAlrubaan 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
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines
The National Saudi Diabetic Guidelines for PHC
References
7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish
Family Community Med 2013 Jan-Apr 20(1) 1ndash7
8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
9--Canadian Clinical Practice guidelines 2013
Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1
10-American Diabetes Association2013
Standards of Medical Care in Diabetes
11- CG66 in NICE clinical guideline 87
September 2010 European Medicines