APPENDIX B-1

CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 1 of 85

1.0 PURPOSE: To standardize the diagnosis and management of Type1 and Type2 Diabetes Mellitus in
adult patients as well as during pregnancy in outpatient visit.
This guideline is consisting of three chapters as following:
A- The diagnosis and management of type 2 diabetes in adults
B- The diagnosis and management of type 1 diabetes mellitus in adults
C- The diagnosis and management of diabetes mellitus in pregnancy

2.0 DEFINITIONS:
The general categories of diabetes are classified as follows:

2.1 Type 1 diabetes mellitus (T1DM) arises as the result of beta-cell destruction, usually leading
to absolute insulin deficiency.

2.2 Type 2 diabetes (T2DM) arises as the result of progressive loss of insulin secretion on the
background of insulin resistance.

2.3 Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance of variable

severity with onset or first recognition during pregnancy, that is neither pre-existing T1DM or
T2DM.
Diabetes mellitus may predate conception and be either known to the patient or discovered
during pregnancy. Women who are discovered to have diabetes in the first trimester of
pregnancy are classified as having diabetes, rather than GDM.

2.4 Specific types of diabetes due to other causes, such as:

2.4.1 Monogenic diabetes syndromes e.g.:
2.4.2 Neonatal diabetes.
2.4.3 Maturity-onset diabetes of the young.

2.5 Secondary diabetes includes:

Diseases of the exocrine pancreas e.g.:
2.5.1 Any process that extensively injures the pancreas can cause diabetes e.g., cystic
fibrosis, haemochromatosis.
2.5.2 Pancreatitis.
2.5.3 Trauma.
2.5.4 Infection.
2.5.5 Pancreatectomy.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 2 of 85

2.5.6 Pancreatic carcinoma.

2.6 Drug- or chemical-induced diabetes e.g.:

2.6.1 With glucocorticoid use.
2.6.2 In HIV/AIDS treatment.
2.6.3 After organ transplantation.

2.7 Endocrinopathies:
2.7.1 Acromegaly.
2.7.2 Cushing’s syndrome or disease.
2.7.3 Glucagonoma.
2.7.4 Pheochromocytoma.
2.7.5 Hyperthyroidism.

Evidence grading and recommendations: Appendix A

Abbreviations used in this guideline:

ACC/AHA American College of Cardiology / American Heart Association

ACE Angiotensin converting enzyme
ACR Albumin-creatinine ratio
ADL Activities of daily living
AIDS Acquired Immune Deficiency Syndrome
ALT Alanine aminotransferase
Anti-TPO Anti-thyroid peroxidase antibody
ARB Angiotensin receptor blocker
ASCVD Atherosclerotic cardiovascular disease
BG Blood glucose
BMI Body mass index
BP Blood pressure
CCB Calcium channel blocker
CGM Continuous glucose monitoring
CKD Chronic kidney disease
CSII Continuous subcutaneous insulin infusion
CTG Cardiotocography
DAFNE Dose Adjustment For Normal Eating

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 3 of 85

DESMOND Diabetes Education and Self-Management for Ongoing and Newly Diagnosed
DKA Diabetic ketoacidosis
DPP-4 Dipeptidyl peptidase-4
DSME Diabetes self-management education
DSMS Diabetes self-management support
eGFR Estimated glomerular filtration rate
FBS Fasting blood sugar
GADA Glutamic acid decarboxylase antibodies
GDM Gestational diabetes mellitus
GLP-1 Glucagon-like peptide-1
HAAF Hypoglycaemia-associated autonomic failure
HBA1C Glycated haemoglobin
HDL-C High-density lipoprotein cholesterol
HIV Human Immunodeficiency Virus
HHS Hyperglycaemic hyperosmolar state
IFG Impaired fasting glucose
IGT Impaired glucose tolerance
IOL Induction of labour
IUFD Intrauterine fetal death
IUGR Intrauterine growth retardation
IV Intravenous route
LDL-C Low density lipoprotein-cholesterol
MDI Multiple-dose insulin injections
MDT Multidisciplinary team
MOPH Ministry of Public Health of Qatar
MNT Medical nutrition therapy
NAFLD Non-alcoholic fatty liver disease
NPH Neutral protamine Hagedorn
OGTT Oral glucose tolerance test
PCOS Polycystic ovary syndrome
PCV13 13-valent pneumococcal conjugate vaccine
PHQ Patient health questionnaire
PHQ-2 2-question Patient Health Questionnaire
PHQ-9 9-question Patient Health Questionnaire
PPSV23 23-valent pneumococcal polysaccharide vaccine

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 4 of 85

SSI Sliding scale insulin

SMBG Self-monitoring of blood glucose
SGLT-2 Sodium glucose cotransporter-2
SU Sulfonylurea
T1DM Type 1 diabetes mellitus
T2DM Type 2 diabetes mellitus
TDD Total daily dose
TSH Thyroid stimulating hormone
TZD Thiazolidinedione
VRII Variable rate insulin infusion

3.0 APPLIES TO:

Physicians, Nurses, Diabetes Educators and other allied health care professional

4.0 PATIENT GROUP:

4.1 The diagnosis and management of T2 DM in adults:
Adult, non-pregnant T2 DM patients.
4.2 The diagnosis and management of type 1 diabetes mellitus in adults.
Adult, non-pregnant T1DM patients.
4.3 The diagnosis and management of diabetes mellitus in pregnancy
Adult, pregnant DM patients.

5.0 EXCEPTIONS:
Patient less than 14 years of age.

6.0 TARGET AREAS:

Outpatient area.

7.0 GUIDELINES:
Section: 1

7.1 THE DIAGNOSIS AND MANAGEMENT OF T2DM IN ADULTS

7.1.1 PURPOSE: The purpose of this guideline is to define the appropriate diagnosis,
management and Patient’s referrals of T2DM in adults. To unify the following:
7.1.2 Prediabetes diagnosis
7.1.3 T2DM diagnostic criteria

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 5 of 85

7.1.4 Risk factors of T2DM

7.1.5 Screening for type 2 diabetes and pre-diabetes in asymptomatic people
7.1.6 T2DM patient’s referral from primary/generalist care to secondary/specialist care
7.1.7 Components of the comprehensive initial diabetes evaluation
7.1.8 Maintenance and reassessment of diabetes management
7.1.9 Glucose monitoring and treatment targets
7.1.10 Pharmacological therapy
7.1.11 Atherosclerotic cardiovascular disease (ASCVD) risk management
7.1.12 Diabetes mellitus in special circumstances
7.1.13 Hypoglycemia
7.1.14 Transitions of Care

7.1.2 Prediabetes Diagnosis:

Pre-diabetes is diagnosed if any of the following criteria are met:
Test Diagnosis criteria
Impaired fasting glucose (IFG): -Fasting plasma glucose 5.6 - 6.9 mmol/L (100 – 125 mg/dL)
-Where fasting is for at least 8 hours.
Impaired glucose tolerance (IGT): 2-hour plasma glucose 7.8 - 11.0 mmol/L (140 – 199 mg/dL)
during OGTT performed using a glucose load containing the
equivalent of 75g anhydrous glucose dissolved in water.
HBA1C HBA1C of 5.7 - 6.4%.

7.1.3 T2DM Diagnostic Criteria:

7.1.3.1 Diagnostic criteria for the diagnosis of T2DM requires one of the following:

Test Diagnosis criteria of DM

Fasting plasma glucose (where fasting is for at least 8 hours). ≥7.0 mmol/L (126 mg/dL)
2-hour plasma glucose during an oral glucose tolerance test ≥11.1 mmol/L (200 mg/dL)
(OGTT) performed using a glucose load containing the
equivalent of 75g anhydrous glucose dissolved in water
a random plasma glucose (In patients with classic symptoms of ≥11.1 mmol/L (200 mg/dL).
hyperglycaemic crisis or hyperglycaemia)
HBA1C * ≥6.5%.
*NB: Does not require the patient to fast.
*Some haemoglobinopathies and anaemias may make interpretation difficult:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 6 of 85

For patients with abnormal haemoglobin but normal red blood cell turnover, an HBA1C assay
without interference from abnormal haemoglobins should be used [L2].

7.1.3.2 A second diagnostic test is required to confirm the diagnosis, unless [L2].:
a. Patient is in hyperglycaemic crisis.
b. Patient has classic symptoms of hyperglycaemia and a random plasma glucose
≥11.1 mmol/L (200 mg/dL).

7.1.3.3 The results are unequivocal [R-GDG]:

7.1.3.3.1 If a second test is required, the same diagnostic test should be used with
a new blood sample.
7.1.3.3.2 If a patient has had inconsistent results from two diagnostic tests, the test
result that is above the diagnostic threshold should be repeated without
delay.
7.1.3.3.3 If a repeat test is below the diagnostic threshold, the test should be
repeated again after 3-6 months.
7.1.3.3.4 Only blood glucose (BG) criteria should be used to diagnose diabetes in
conditions associated with increased red blood cell turnover, e.g.:
 Erythropoietin therapy.
 Pregnancy (second and third trimesters).
 Recent blood loss or transfusion.
 Haemolysis.

7.1.4 Risk Factors of T2DM

Risk factors for T2DM Risk factors for T2DM
Overweight or obesity. Age ≥40 years without other risk factors
Smoking Family history of T2DM
Physical inactivity/sedentary lifestyle Previous history of GDM or previous delivery of a
baby weighing ≥4 kg (9 lb)
Hypertension, dyslipidaemia or Member of an at-risk racial or ethnic subgroup
atherosclerotic cardiovascular disease
(ASCVD)
Prediabetes and/or metabolic syndrome Sleep disorders
Polycystic ovary syndrome (PCOS), Certain medications, e.g.: Glucocorticoids,
acanthosis nigricans, non-alcoholic fatty liver Thiazide diuretics, Antipsychotics
disease (NAFLD).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 7 of 85

7.1.5 Screening for T2DM and Pre-Diabetes in Asymptomatic People

Any of the following tests are appropriate for screening asymptomatic people for T2DM and pre-diabetes:
 Fasting plasma glucose.
 2-hour post-glucose level on a 75g OGTT.
 HBA1C.

Consider screening for T2DM and pre-diabetes:

 In all adults with a body mass index (BMI) ≥25 kg/m2 and one additional risk factor for T2DM [L2,
RGA1]. (see table A3)
o Use lower BMI thresholds in South-Asian people [R-GDG].
 All adults aged ≥40 years and above.
 If tests are negative, repeat screening every 3 years [L3, RGA2].

7.1.6 T2DM Patients Referral from Primary/Generalist Care to Secondary/Specialist Care:

Appendix B

7.1.7 Components of The Comprehensive Initial Diabetes Evaluation [L2]:

History
Medical History  Confirmation of the diagnosis.
 Age and features of onset of diabetes, e.g.:
o Asymptomatic laboratory finding; or
o Symptomatic presentation.
 Review of previous treatment regimens, if any; and response to
therapy.
 Results of glucose monitoring.
 Diet and physical activity assessment.
 History of acute complications e.g.:
o Diabetic ketoacidosis (DKA):
o Hypoglycaemia.
o Hyperglycaemic hyperosmolar state.
 History of microvascular complications:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 8 of 85

o Retinopathy.
o Nephropathy.
o Neuropathy
o Diabetic foot problems.
o Erectile dysfunction.
o Gastroparesis.

 History of macrovascular complications:

o Coronary artery disease.
o Cerebrovascular disease.
o Peripheral vascular disease.
 Diabetes education, self-management, and support history and
needs.

Comorbidities for assessment and consideration in T2DM include [L2]:

 Hypertension.
 Dyslipidaemia.
 Obesity *.
 Fatty liver disease.
 Heart failure.
 Obstructive sleep apnoea.
 Low testosterone in men.
 Depression.

Allergy A list of medication and/or food to which patient is allergic

Habit Smoking, alcohol consumption, illicit drug use
Immunization All adults with T2DM should receive the routine vaccinations in line with
general recommendations for the adult population. In addition, the
MOPH Public Health department recommends the following:
 Annual influenza vaccination prior to the start of the influenza season.
 Pneumococcal vaccination: see figure (1) Appendix C
If not received the vaccination then patient to be directed to PHCC
Family History History of diabetes, hypertension, hyperlipidemia, coronary artery
disease, chronic kidney disease.
Social and Type of job and social factors influencing diabetes care

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 9 of 85

psychological History
PHYSICAL EXAMINATION
Vital Sign Height, weight, Body Mass Index (BMI), Blood pressure (BP) including
orthostatic BP when indicated.
Another organs Exam Neck, Chest, heart and abdomen exam when indicated
Skin Examination Acanthosis nigricans, insulin injection sites, skin tags
INITIAL LABORATORY EVALUATION
A1C If not available within the past 3 months
If not performed Fasting lipid profile, including total cholesterol, LDL, HDL and
/available within past Triglyceride.
year Liver function test
Spot urinary albumin-creatinine ratio (ACR).
Serum creatinine
Thyroid stimulating hormone in patients with dyslipidemia or in women
aged over 50 years
REFERRAL (annual or if otherwise indicated)
Eye care professional for annual dilated eye exam
Registered dietician for Each member of the healthcare team should be knowledgeable about
Medical Nutrition the principles of MNT and encourage their implementation.
Therapy (MNT)
All patients with diabetes should receive individualized MNT, preferably
delivered by a registered dietician. This should include the following:
 Effectiveness of nutrition therapy.
 Energy balance.
 Eating patterns and both micronutrient and macronutrient
distribution.
 If alcohol is consumed, discourage excessive intake.

Diabetes self- (DSME) is the process of facilitating the knowledge and skills needed
management for diabetes self-care.
education (DSME/S) (DSMES) refer to the support that is required for implementing and
sustaining coping skills and behaviors needed to self-management such
providing the patients with meters for example.
All T2DM patients should receive DSME and DSMS in a consistent
manner.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 10 of 85

The DSME/S are designed to address the patient’s beliefs, cultural

needs, current knowledge, physical limitations, emotional concerns,
family support, financial status, medical history and other factors that
may influence each person’s ability to meet the challenges of self-
management.
- Providing the DSME/S through written and formal curriculum for
individuals approved by Diabetes Education Lead according to National
Diabetes Education Standard from AADE this curriculum should be
reviewed and updated.
And should be provided by experts in educational process with clear
communication such as Educator, Dietitian, pharmacist or other health
care provider who received intensive training and education and certified
as diabetes educator.
All T2 DM should be referred to DSME/S programs for individuals or
group sitting as needed and evaluated by referred physician:

 At diagnosis or referred to NDC.

 At time of change of treatment.

 At acute episodes of illness like surgery or flu.
 At major lifestyle changes e.g. puberty, marriage, etc.
 At onset of co- morbidities.
 At onset of complications.
- For group of patients DSME/S provided through DESMOND
program (Diabetes Self-Management Education for On-
going and Newly Diagnosed) is the only internationally
recognised evidence based self-management structured
education programme for people with type 2 diabetes. The
DESMOND curriculum was revised to include adaptation to
local cultures, beliefs and other health issues, and it’s
delivered only by DESMOND certified educators.
 Smoking cessation
Encourage all patients not to use cigarettes, shisha or other tobacco
products [L1, RGA1]:
 Include smoking cessation counselling and other forms of treatment
as a routine component of diabetes care.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 11 of 85

 Physical activity and exercise

Advise patients on physical activity levels [L2]:
 The exercise programme should be individualised to the patient.
 Encourage patients to set short and long-term goals.
 Adults with diabetes should be advised to:
o Reduce sedentary time, and break up long periods (i.e. >90 mins)
spent sitting.
o Undertake basic activity for >30 mins every day.
 Basic activity is defined as exercise that raises the heart
and respiratory rates but the patient is still able to talk.
o Undertake aerobic fitness exercise for 20-60 mins over
a 24-hour period, 3-5 times per week.
 Aerobic fitness is defined as exercise that raises the
heart and respiratory rates until the patient is out of
breath and unable to talk.
o Undertake strength exercises, 2-3 times per week, until near
muscle exhaustion is reached.

 Contraindications to physical activity [L2]:

Providers should assess patients for conditions that might contraindicate
certain types of exercise, such as:
 Hypertension.
 Coronary artery disease.
 Autonomic neuropathy.
 Peripheral neuropathy.
 Foot lesions.
 Untreated proliferative retinopathy.
 Albuminuria and nephropathy.

 Hypoglycemia risk
Risk of hypoglycemia:
 Patients who take insulin and/or insulin secretagogues are at
increased risk of hypoglycaemia as a result of exercise.
 Medication dose or carbohydrate intake must be altered in line with

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 12 of 85

the amount of physical exercise if pre-exercise glucose levels are

<5.6 mmol/L (100 mg/dL).
 Intense activities may raise BG levels instead of lowering them.
 Further risk factors for exertional hypoglycaemia include:
o Prolonged exercise time.
o Exercise intensity the patient is not used to.
o Inadequate supply of energy in relation to blood insulin levels.
 Post-exertional hypoglycaemia can be prevented or minimised by
careful glucose monitoring before and after exercise:
o Snacks should be consumed prior to exercise if BG levels are
falling.
 Patients should carry a readily absorbable source of carbohydrates
when exercising, including sporadic housework or outdoor work.
 It may be useful to alter the insulin dose on days with planned
exercise:
o Especially in patients with well controlled diabetes and a history
of exercise-induced hypoglycaemia.

Podiatry Screening For Comprehensive foot examination

Clinic - Inspection
- Palpation of dorsalis pedis and posterior tibial pulses
- Presence/absence of patellar and Achilles reflexes
-Determination of proprioception, vibration, and monofilament sensation
Mental health Consider the patient’s psychosocial circumstances while managing
professional patients with T2DM:
(psychologists) if
indicated  Psychosocial screening, includes consideration of:
o Attitude about the illness.
o Expectations surrounding medical management and outcomes.
o Mood.
o Quality of life.
o Resources:
 Financial.
 Social.
 Emotional.
o Psychiatric history.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 13 of 85

 Routinely screen for psychosocial problems, using the PHQ-2

questions:
o If positive, assess for depression using the PHQ-9 scoring
system.

Referral to an appropriate mental health specialist should be considered

if:
o Self-harm or suicidal ideation.
o Gross disregard for the medical regimen.
o Depression.
o Debilitating anxiety (alone or with depression).
o Indications of an eating disorder.
o Cognitive function that significantly impairs judgement.

7.1.7.1 Weight Management:

7.1.7.1.1 Assess BMI:

 Overweight and obesity should be diagnosed using BMI:
o Overweight: 25 -30 kg/m2.
o Obese: ≥30 kg/m2.
 Assess at every patient visit and document the result in the medical record.

7.1.7.1.2 Consider measuring waist circumference:

 In patients with a BMI of 25-35 kg/m2.
 Patients with values of >102 cm (40 in) for males; and >88 cm (35 in) for females
are at increased risk of metabolic disease.

7.1.7.1.3 Weight management:

 Clinicians should determine each patient’s willingness to achieve weight loss.
 Strategies include:
o Diet.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 14 of 85

o Physical activity.
o Behavioural therapy.
o Pharmacological therapy:
 May be used in combination to diet, physical activity, and behavioural
therapy for carefully selected patients.
o Bariatric surgery.
 May be used in combination to diet, physical activity, and behavioural
therapy for carefully selected patients.

7.1.8 Maintenance and Reassessment of Diabetes Management

Regular review every 3 to 6 months

 Blood pressure and weight should be measured at every routine visit
 A1C
 Lipid Profile (total cholesterol, LDL, HDL, Triglyceride) and LFT if patient on statin
 Serum creatinine, calculated glomerular filtration rate (GFR) and serum electrolyte.
 Review medication
Annual Review
 Spot urinary albumin-creatinine ratio (ACR).
 Thyroid function Test (if indicated)
 Vitamin B12 level for patients on Metformin
 Retina Examination
 podiatry clinic
 Dietary and DSME
 Mental health review if indicated
 Immunization

7.1.9 GLUCOSE MONITORING AND TREATMENT TARGETS

7.1.9.1 HBA1C Testing and Goals

HBA1C Testing APPROPRIATE PATIENTS

At least twice a year -In patients who are achieving their treatment goals; and
-Who have stable glycaemic control.
- Once the HBA1C level and BG lowering therapy are stable.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 15 of 85

Quarterly -Have undergone a change in therapy

-Who are not meeting their glycaemic targets
- Tailored to individual needs, until the HBA1C is stable on unchanging
therapy.

7.1.9.2 HBA1C targets:

HbA1C Target Appropriate patients

HBA1C ≤7.0%. A reasonable HBA1C goal for non-pregnant adults
Lower HBA1C goals e.g. ≤6.5% may be considered if it can be achieved without problematic
hypoglycaemia.
A higher HBA1C of ≤8.0% may -A history of severe hypoglycaemia.
be acceptable for patients with -Limited life expectancy.
-Advanced microvascular or macrovascular complications.
-Extensive comorbidities.
-Poor engagement despite multiple attempts to improve
glycaemic control.

*NB: 1- Involve patients in decisions and individualize HBA1C targets.

2- Encourage patients to achieve their target, unless they are experiencing adverse effects or their
efforts to achieve their target adversely affect their quality of life.
3- Clinicians should be aware that there are other causes of low HBA1C level, such as:
o Deteriorating renal function.
o Sudden weight loss.

7.1.9.3 SELF-MONITORING OF BLOOD GLUCOSE

Self-monitoring of blood glucose (SMBG):

 SMBG may provide feedback about the effects of their lifestyle and pharmacologic therapy.
 Patients who do not require insulin therapy may also benefit from SMBG.
 Frequency of testing should be individualised to the patient.
 SMBG should be used in the following groups:
o Insulin-treated diabetics.
o Patients with a history or symptoms of hypoglycaemic episodes.
o Patients taking medication associated with increased risks of hypoglycaemia (e.g. a
sulfonylurea).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 16 of 85

o Patients who are pregnant or planning pregnancy.

 Consider short-term SMBG:
o When starting treatment with oral or intravenous corticosteroids; or
o To confirm suspected hypoglycaemia.

SMBG in patients using insulin:

 SMBG should be used by patients on insulin:
o Minimum twice a day, and
o Ideally before insulin injections.
o More frequent monitoring after meals, or in the middle of the night, may be needed in
patients:
 With frequent hypoglycaemia.
 Suspected hypoglycaemia unawareness.
 Those not yet achieving their HBA1C target.
 Should be used in all patients on intensive insulin regimens:
o Before meals and snacks.
o Occasionally post-prandially if hypoglycaemia is frequent.
o At bedtime.
o Before exercise.
o When the patient suspects low BG.
o After treating low BG until they are normoglycaemic.
o Before critical tasks such as driving.

Assessment of SMBG in all patients who are testing their BG:

 Should be carried out at least annually as part of the annual review of the patient.
 Should include an assessment of:
o The patient’s self-monitoring skills.
o The quality and frequency of testing.
o Checking that the patient knows how to interpret the BG results and what action to take.
o The impact on the patient’s quality of life.
o The continued benefit to the patient.
o The equipment used.

7.1.9.4 Continuous glucose monitoring

Continuous glucose monitoring (CGM):
 Is not routinely used for people with T2DM.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 17 of 85

 May be used in addition to SMBG in patients with hypoglycaemia unawareness or frequent

hypoglycaemic episodes.
 Should be considered in patients using basal-bolus therapy.
 Before prescribing CGM:
o Assess the patient’s readiness for continuing to use CGM.
o Educate and support the patient in order to optimise CGM implementation and ongoing
use.

7.1.10 Pharmacological Therapy

The risks and benefits of drug treatment and the options available should be discussed with the
patient. The choice of drug should be based on the following [L2, RGA2]:
 Safety and tolerability of the drug.
 The patient’s individual clinical circumstances, e.g.:
o Comorbidities.
o Risk of polypharmacy.
 The patient’s individual employment circumstances e.g. whether:
o Driving for work.
o Working at heights.
o Operating heavy machinery.

 Relative cost:
o If two drugs in the same class are appropriate, choose the option with the lowest cost.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 18 of 85

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 19 of 85

Table (1): Comparison of drugs used for glycemic control in T2DM [Adapted from Standards of Medical Care in Diabetes 2017].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 20 of 85

7.1.10.1 Monotherapy
If tolerated and not contraindicated, metformin monotherapy is the usual initial treatment [L1]:
 Gradually increase the dose of standard-release metformin over several weeks to
minimise the risk of gastrointestinal side effects [L2]:
o In patients who experience gastrointestinal side effects consider a trial of modified-
release metformin [L2, RGA2].
 Review the dose of metformin If the eGFR is <45 ml/min/1.73m2 [L2].
 Stop metformin if the eGFR is ≤30 ml/min/1.73m2 [9,17].
 Prescribe metformin with caution in patients at risk of sudden deterioration in kidney
function and those at risk of eGFR falling <45 ml/min/1.73m2 [L2].
 Patients on metformin should be monitored for vitamin B12 deficiency [L2]:
o Vitamin B12 supplements should be given to patients with deficiency.

If metformin is not tolerated or contraindicated:

 Consider monotherapy with any of the following:
o Sulfonylurea (SU).
o Thiazolidinedione (TZD).
o Dipeptidyl peptidase-4 (DPP-4) inhibitor.
o Sodium glucose cotransporter-2 (SGLT2) inhibitor.
o Glucagon-like peptide-1 (GLP-1) receptor agonist.
o Basal insulin.

7.1.10.2 Dual therapy

If the patient’s HBA1C target is not achieved after approximately 3 months of monotherapy or the
patient’s HBA1C is ≥9.0%, commence dual therapy. The choice of drugs dependent on variety of
patient- and disease-specific factors.

Dual therapy comprises of:

 Metformin plus one of:
o SU.
o TZD.
o DPP-4 inhibitor.
o SGLT2 inhibitor.
o GLP-1 receptor agonist.
o Basal insulin.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 21 of 85

7.1.10.3 Triple therapy

If the HBA1C target is not achieved after approximately 3 months of dual therapy, commence triple
drug therapy with the choice dependent on variety of patient- and disease-specific factors.

Triple therapy comprises of any combination of the following drugs:

 Metformin plus any two of:
o SU.
o TZD.
o DPP-4 inhibitor.
o Either a SGLT2 inhibitor or a GLP-1 receptor agonist.
o Basal insulin.
 NB: Do not use a SGLT2 inhibitor in combination with a GLP-1 receptor agonist.
 Use of a GLP-1 receptor agonist with insulin, should only be offered on specialist advice
and with the ongoing support from a consultant-led MDT [L3, RGA2].

Other medications:
 Rapid-acting secretagogues (meglitinides) may be used instead of sulfonylureas in
patients:
o With irregular meal schedules, or
o Who develop late post-prandial hypoglycaemia on a sulfonylurea.
 Alpha-glucosidase inhibitors, may be prescribed in certain cases, however, they are
generally not preferred because of modest efficacy, frequency of administration and/or
side effects [R-GDG].

7.1.10.4 Combination injectable therapy

Combination injectable therapy:

 Comprises of:
o Metformin; with
o Basal insulin; with either
o Mealtime insulin or a GLP-1 receptor agonist.
 Consider starting combination injectable therapy when HBA1C is ≥10%, especially if
symptomatic.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 22 of 85

7.1.10.5 Insulin therapy

Consider insulin therapy (with or without additional medications) in newly diagnosed patients [L2,
RGA2]:
 Who are markedly symptomatic and/or have elevated BG or HBA1C.
 Clinicians should not use insulin as a threat or describe it as a failure or punishment.
 Patients may benefit from being provided with an algorithm for self-titration of insulin
doses based on SMBG.

Consider insulin in patients who are not newly diagnosed [L1]:

 When non-insulin anti-hyperglycaemic therapy fails to attain glycaemic control.
 When a patient has symptomatic hyperglycaemia.
 NB: Insulin therapy should not be delayed in patients with T2DM who are not attaining
glucose goals.

When initiating insulin therapy, use a structured program employing active insulin dose titration
that encompasses:
 Injection technique, including:
o Rotating injection sites and avoiding repeated injections at the same point within
sites.
 Dose titration to target levels.
 SMBG.
 Dietary understanding.
 Guidance on driving.
 Management of hypoglycaemia.
 Management of acute changes in plasma glucose control.
 Continuing telephone support.
 Support from an appropriately trained and experienced healthcare professional.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 23 of 85

Table (2) Common insulin options available [R-GDG].

Insulin Type Onset of Action Duration of action

Lispro
Aspart 5-15 minutes 2-4 hours
Glulisine
Human Regular 30 minutes 5-8 hours
Human NPH 1-3 hours 12-18 hours
Glargine 1-2 hours 20-24 hours
Glargine U300 1-2 hours Up to 36 hours
Detemir 1-3 hours 6-24 hours
Degludec 1-2 hours up to 42 hours
Human regular/NPH Variable Variable
Lispro/lispro protamine Variable Variable
Lispro/lispro protamine Variable Variable
Aspart/aspart protamine Variable Variable
Aspart/aspart protamine Variable Variable

NPH: Neutral protamine Hagedorn

A-Initiating insulin therapy

Step 1: Basal insulin:

 Initially prescribe 10 Units/day (or 0.1-0.2 Units/kg/day).
 Adjust by or 2-4 Units (or 10-15%), once or twice weekly to reach the fasting blood glucose (FBG)
target.
o If hypoglycaemia occurs, determine and address the cause, and decrease the
corresponding dose by 2-4 Units (or 10-20%).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 24 of 85

Step 2: Consider additional insulin injections or GLP-1 trial:

If SMBG is not controlled after FBG target has been reached (or if the dose is >0.5 Units/kg/day):
 Treat post-prandial glucose excursions with mealtime insulin with one of the following:
o Option 1: Add a rapid-insulin injection before the largest meal.
o Option 2: Consider changing to a premixed insulin twice a day.
o Move to Step 3 (see below).
 Use of a GLP-1 receptor agonist with insulin, should only be offered on specialist advice and with
the ongoing support from a consultant-led MDT [L3, RGA2].

Option 1: Add a rapid-insulin injection before the largest meal:

 Start with 4 Units, (or 0.1 Units/kg), or 10% of the basal dose:
o If HBA1C is <8.0%, consider decreasing the basal dose by the same amount.
 Increase the dose by 1-2 Units (or 10-15%) once to twice weekly until the BG target is reached.
o If hypoglycaemia occurs, determine and address the cause, and decrease the
corresponding dose by 2-4 Units (or 10-20%).
 If not controlled, move to Step 3.

Option 2: Change to a premixed insulin twice daily:

 Divide the current basal dose into either:
o 2/3 in the morning, 1/3 in the evening; or
o 1/2 in the morning, 1/2 in the evening.
 Increase the dose by 1-2 Units (or 10-15%), once to twice weekly until the BG target is reached.
o If hypoglycaemia occurs, determine and address the cause, and decrease the
corresponding dose by 2-4 Units (or 10-20%).
 If not controlled, move to Step 3.

Step 3: Changing to a basal-bolus regimen:

 Add ≥2 rapid insulin injections before meals.
 Administer 4 Units, (or 0.1 Units/kg), or 10% of the basal dose per meal:
o If HBA1C is <8.0%, consider decreasing basal insulin by the same amount.
 Increase the dose by 1-2 Units (or 10-15%) once to twice weekly until the BG target is reached.
o If hypoglycaemia occurs, determine and address the cause, and decrease the
corresponding dose by 2-4 Units (or 10-20%).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 25 of 85

7.1.10.6 Continuous subcutaneous insulin infusion

Continuous subcutaneous insulin infusion (CSII) [L1]:

 Patients with T2DM who are insulin-treated, are candidates for CSII, if all other measures have
failed to adequately improve glycaemic control.
 CSII should only be used in patients who are knowledgeable and motivated in self-care, including
insulin adjustment.
 Patients using CSII must receive DSME and be periodically re-evaluated.
 For patients who are at risk of hypoglycaemia, consider sensor-augmented CSII including those
with a threshold-suspend function.
 Prescribing physicians must have expertise in CSII therapy, which should be started in a specialist
centre [R-GDG]:

7.1.10.7 Additional considerations

Additional considerations when prescribing insulin:

 Only offer a GLP-1 mimetic in combination with insulin on specialist care advice and with ongoing
support from a consultant-led MDT [L3, RGA2].
 When starting insulin therapy, continue to offer metformin for people without contraindications or
intolerance:
o Review the continued need for other BG lowering therapies.
 Patients receiving insulin therapy typically gain around 1-3 kg of weight in comparison to those
receiving other agents.

7.1.10.8 Medication adjustment

Medication adjustments:
 A thorough review of BG patterns throughout the day may indicate vulnerable periods that warrant
medication adjustments.
 Adjustments include:
o Substitution of regular insulin by rapid-acting insulin analogues.
o Substitution of intermediate-acting insulin by basal insulin analogues.
o CSII offers flexibility for adjusting the dose and dosing pattern in order to counteract
iatrogenic hypoglycaemia.
 Sulfonylureas are the oral agents that pose the greatest risk for iatrogenic hypoglycaemia:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 26 of 85

o Consider substituting for other classes of oral agents or GLP-1 analogues in the event of
troublesome hypoglycaemia.

7.1.10.9 Pharmacotherapy in obese patients

Pharmacotherapy in obese patients:

May be considered if lifestyle modifications have failed to result in weight loss goals being achieved.

 When prescribing glucose lowering agents in overweight or obese patients, consider their effect on
weight:
o Insulin secretagogues, TZD and insulin have been linked to weight gain.
o DPP-4 inhibitors are weight-neutral.
 Minimise the prescribing of medications for comorbidities that are associated with weight gain [L3,
RGA2], such as:
o Atypical antipsychotics.
o Antidepressants.
o Glucocorticoids.
o Oral contraceptives that contain progestins.
o Anticonvulsants.

7.1.10.10 Weight loss medication:

The following drugs are available in Qatar but should be administered by a multi-disciplinary weight loss
service [R-GDG]:

Name Primary Mode of Action

Single dose
Phentermine* Appetite Suppression
Orlistat Malabsorption
Lorcaerin Appetite Suppression
Liraglutide Appetite Suppression and delay gastric emptying
Combination drugs
Phentermine & topiramate Appetite Suppression
 Drugs not presently available in the private sector

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 27 of 85

7.1.11 Atherosclerotic Cardiovascular Disease (ASCVD) Risk Management

7.1.11.1 Management of hypertension

For patients with T2DM without known hypertension, review Blood Pressure (BP) at every visit and at least
annually. Provide and emphasize lifestyle advice to all diabetic patients.

Table (3): Aim to achieve a clinic BP of:

Blood pressure target Appropriate patients
<140/90 mmHg all diabetic patients
<130/80 mmHg - Younger patients.
- Those with albuminuria.
- Those with hypertension and one or more additional ASCVD risk
factors, if the target can be achieved without undue treatment burden.

Note: If BP remains above target levels following lifestyle improvement, add medication to reduce BP to
target levels.

Medication to control BP in T2 DM:

Treatment Medication
First-line medication*  A once daily angiotensin converting enzyme (ACE) inhibitor; or
 For people of African or Afro-Caribbean consider using an ACE
inhibitor plus either a diuretic or calcium channel blocker (CCB).
 For women who may become pregnant, start with a CCB:
- Avoid the use of ACE inhibitors and angiotensin II-receptor
antagonists.
 If there is ongoing intolerance to an ACE inhibitor, other than renal
deterioration or hyperkalaemia, an angiotensin receptor blocker ARB
may be used instead.
 NB: Unless contraindicated, for diabetic patients with hypertension
and renal impairment, an ACE inhibitor or ARB must be the first line
drug.
Second line treatment If With first-line therapy, add a CCB or a diuretic (usually thiazide or
BP is not adequately thiazide-like diuretic).
controlled to the agreed

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 28 of 85

target level
Third-line treatment If BP With dual therapy, add the other drug, i.e. either a CCB; or a diuretic.
is not adequately
controlled to the agreed
target level

Fourth-line treatment If With triple therapy, add either an alpha-blocker; or a beta-blocker; or a

BP is not adequately potassium-sparing diuretic
controlled to the agreed
target level

If BP is not adequately controlled to the agreed target level:

*Advise patients to monitor BP every 1-2 months and intensify therapy until BP is consistently
within target range. Continue to reinforce lifestyle advice. If BP is consistently attained at the target
level, continue to monitor the patient's BP at every clinic visits and check for adverse effects
including risks of hypotension.

*NB: Antihypertensive medications can increase the likelihood of side effects, e.g. orthostatic hypotension
in a patient with autonomic neuropathy.
Note the following key points:
 Use potassium-sparing diuretics with caution if the patient is already taking an ACE inhibitor or
ARB.
 Do not combine an ACE inhibitor with an ARB.
 Refer to specialist care if BP remains above target levels following triple therapy including a
diuretic.

7.1.11.2 Lipid management

Table (4): High-intensity and moderate-intensity statin therapy

High-intensity statin therapy Moderate-intensity statin therapy

(lowers LDL cholesterol by >50%) (lowers LDL cholesterol by 30% to <50%)
Atorvastatin 40–80 mg Atorvastatin 10–20 mg
Rosuvastatin 20–40 mg Rosuvastatin 5–10 mg
Simvastatin 20–40 mg

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 29 of 85

Pravastatin 40–80 mg
Fluvastatin XL 80 mg (XL is once daily dose-
extended release).

Table (5): when to start High-intensity and moderate-intensity statin therapy: American College of
Cardiology/American Heart Association guideline on the treatment of blood cholesterol 2013

Table (6)-When Ezetimibe is a recommended option for hypercholesterolemia in adults

Condition Appropriate in the following circumstances

In conjunction with initial Serum total cholesterol or LDL-C levels are not appropriately
statin treatment controlled after titration of the statin treatment; or dosing is limited
by intolerance to the statin
As monotherapy - A contraindication to initial statin treatment.
- Intolerance to statin treatment

PCSK9 Inhibitors:
PCSK9 Inhibitors may be considered as adjunctive therapy for patients with diabetes at high risk for
ASCVD events who require additional lowering of LDL cholesterol or who require but are intolerant to high-
intensity statin therapy

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 30 of 85

7.1.11.3 Antiplatelet therapy

Aspirin and other antiplatelet are not routinely recommended for patients with T2DM in the absence of
established ASCVD.
However, the American Diabetes Association recommends initiating low-dose aspirin use for the primary
prevention of ASCVD in adults aged 50-59 years, who have a 10-year ASCVD risk of a ≥10%, using the
ACC/AHA Pooled Cohort Equations (http://www.cvriskcalculator.com/). Patients must not be at increased
risk for bleeding, have a life expectancy of at least 10 years and be willing to take low-dose aspirin daily for
at least 10 years.

7.1.12 Diabetes Mellitus in Special Circumstances:

7.1.12.1 Managing diabetes during Ramadan

7.1.12.1.1 Risk stratification

All patients with T2DM, are considered exempt from fasting on medical and religious grounds, however
fasting may be permitted if the patient is at low-risk of complications. The following risk stratification,
classifies patients into risk groups. In low risk patients, fasting may be possible, where insisted upon by
the patient.

Table (7): Risk stratification of patients with T2DM who wish to fast.

Moderate/low risk: High risk: Very high risk:

May be allowed to fast Should not fast MUST not fast
Well-controlled T2DM treated One or more of the following: One or more of the following:
with one or more  T2DM with sustained poor  Severe hypoglycaemia
of the following: glycaemic control*. within the 3 months prior to
 Lifestyle therapy.  Well-controlled T2DM on Ramadan.
 Metformin. multi-dose injections or  DKA within the 3 months
 TZD. mixed insulin. prior to Ramadan.
 Second-generation SUs.  Pregnant T2DM or GDM  Hyperosmolar
 Incretin-based therapy. controlled by diet only hyperglycaemic coma within
 SGLT-2 inhibitors.  or metformin. the 3 months prior to
 Basal insulin.  CKD stage 3. Ramadan.
 Stable macrovascular  History of recurrent

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 31 of 85

complications. hypoglycaemia.
 Patients with comorbid  History of hypoglycaemia
conditions that present unawareness.
additional risk factors.  Acute illness.
 People with T2DM  Pregnancy in pre-existing
performing intense physical diabetes, or GDM treated
labour. with insulin or SUs.
 Treatment with drugs that  Chronic dialysis or CKD
may affect cognitive stage 4 or 5.
function.  Advanced macrovascular
complications.
 Old age with ill health.

*The level of glycaemia control should be agreed between the patient and their physician.

7.1.12.1.2 If patients insist on fasting during Ramadan, then they should:

 Receive structured pre-Ramadan education.
 Be followed by a qualified diabetes team.
 Perform Self-monitoring of blood glucose (SMBG) regularly.
 Adjust medication dose according to the recommendations outlined below.
 Be prepared to break the fast if hypoglycaemia or hyperglycaemia develop.
 Be prepared to stop fasting if frequent hypoglycaemia or hyperglycaemia occur, or there is
worsening of other related medical conditions.

7.1.12.1.3 Structured pre-Ramadan education:

The objective of Ramadan-focused education is to raise awareness of the risks associated with diabetes
and fasting, and to provide strategies to minimize them. Education should be simple, engaging, and
delivered with cultural sensitivity by well-informed individuals.

Table (8): Pre-Ramadan education should comprise of the following:

CATEGORY INSTRUCTION
Pre-Ramadan assessment, 6-
8 weeks before Ramadan
begins to risk stratify the

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 32 of 85

patient and determine

whether the patient intends
to fast.

SMBG -Measuring blood glucose does not invalidate or break the fast.
-All patients should measure BG after iftar and if experiencing
symptoms of either hypoglycaemia, hyperglycaemia or feeling
unwell.
-Patients at moderate-low risk of complications: Measure 1-2
times/day.
-Patients at high-very high risk (or those taking insulin or
sulfonylureas): Measure several times/day.
-Patients should always check their BG level before driving,
especially while fasting.
-Provide education on when patients should break their fast:
 Blood Glucose (BG) <70 mg/dL (3.9 mmol/L).

Recheck within 1 hour if BG  BG >300 mg/dL (16.6 mmol/L).

70-90mg/dL (3.9-5.0 mmol/L).  Symptoms of hypoglycaemia, hyperglycaemia,
dehydration or acute illness occur.
Dietary advice -Divide daily calories between suhoor and iftar, plus 1–2 snacks
if necessary.
-Ensure meals are well balanced:
 45–50% carbohydrate.
 20–30% protein.
 <35% fat (preferably mono- and polyunsaturated).
-Include low glycaemic index, high fibre foods that release
energy slowly before and after fasting, e.g. granary bread,
beans, rice.
-Include plenty of fruit, vegetables and salads.
-Minimise foods that are high in saturated fats, e.g. ghee,
samosas, pakoras etc.
-Avoid sugary desserts.
-Use small amounts of oil when cooking, e.g. olive oil, rapeseed
oil.
-Keep hydrated between sunset and sunrise by drinking water or
other non-sweetened beverages.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 33 of 85

-Avoid caffeinated and sweetened drinks.

Exercise -Avoid vigorous exercise.
-Take light-to-moderate exercise during Ramadan (including
Tarawih prayers).
7.1.12.1.4 Pharmacological management during Ramadan:

A- Oral Hypoglycemic Agent

Class Adjustment when Fasting Ramadan

Metformin Immediate-release preparations:
o If taking once/day: Take usual dose at iftar.
o If taking twice/day: Take usual doses at iftar and suhoor
o If taking 3 times/day: Take the morning dose before suhoor and Take
afternoon and evening doses together at iftar
Modified-release preparation:
o Take usual dose at iftar.
Thiazolidinediones No adjustment to TZD medication is needed during Ramadan and doses
can be taken with iftar or suhoor
Sulfonylureas (SUs) Use of older SUs (e.g. glyburide/glibenclamide) should be avoided.
Second-generation SUs should be used instead (e.g. glicazide,
glimepiride).
-If taking once/day: Take at iftar and Dosing may be reduced if BG levels
are well-controlled.
- If taking twice/day: Take the usual evening dose at iftar and Reduce the
suhoor dose, if BG levels are well controlled.
Short-acting insulin The daily dose of short-acting insulin analogues (based on a three-meal
analogues dosing) may be reduced or redistributed to two doses during Ramadan
according to the patient’s meal size
SGLT2 inhibitors Take the usual dose at iftar.
Use with caution and consume additional fluids during the evening after a
fast to reduce the risk of dehydration.

DPP-4 inhibitors No treatment modification is required during Ramadan

GLP-1 receptor No treatment modification is required during Ramadan, as long as the
agonists dose has been adequately titrated at least 6 weeks prior to Ramadan
beginning

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 34 of 85

B- Insulin:
Insulin Modification
Long-acting (basal insulin) Basal insulin:
and short-acting insulin -If using NPH/detemir/glargine/degludec once daily:
regimens A- Reduce dose by 15-30% and take at iftar.
B- If using NPH/detemir/glargine twice daily:
- Take the usual morning dose at iftar.
- Reduce the usual evening dose by 50% and take at
suhoor.

Short-acting insulin:
-Take the normal dose at iftar.
-Omit the lunchtime dose.
-Reduce the suhoor doe by 25-50%.

Pre-mixed insulin dosing Once-daily dosing: Take the normal dosing at iftar.
regimen Twice-daily dosing: Take the normal dose at iftar and Reduce the
suhoor dose by 25-50%.
3times/day dosing: - Omit the afternoon dose.
- Adjust iftar and suhoor doses.
- Titrate doses every 3 days (see Table A-21 )

NB: Patients with T2DM and poor glycaemic control despite multiple daily injections of insulin may benefit
from an insulin pump system with CSII, which can be used safely in patients who fast.

Titration Insulin Dose during Ramadan:

The following table outlines recommended dose adjustments according to SMBG in patients prescribed
long and short acting insulin regimens and appropriate dose titration in patients taking pre-mixed insulin.

Table (9): Dose adjustment and titration in insulin regimens

Fasting/ pre-iftar/ pre- Pre-iftar Post-iftar/ post -suhoor Dose titration

suhoor BG result Basal insulin Short-acting insulin Pre-mixed insulin
<70 mg/dL (3.9 mmol/L) Reduce by 4 units Reduce by 4 units Reduce by 4 units
or symptoms

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 35 of 85

70–90 mg/dL (3.9–5.0 Reduce by 2 units Reduce by 2 units Reduce by 2 units

mmol/L)
90–130 mg/dL (5.0–7.2 No change required No change required No change required
mmol/L)
130–200 mg/dL (7.2– Increase by 2 units Increase by 2 units Increase by 2 units
11.1 mmol/L)
>200 mg/dL (11.1 Increase by 4 units/ Increase by 4 units Increase by 4 units
mmol/L)

7.1.13 Hypoglycemia

7.1.13.1 Definition and Treatment

A- Definition:
Hypoglycemia is defined as:
 Plasma glucose concentration of <3.9 mmol/L (70 mg/dL).

Mild to moderate hypoglycemia is defined as:

 Plasma glucose concentration of 2.2 - 3.9 mmol/L (40 - 70 mg/dL).
 Which does not require assistance from another person.

Severe hypoglycemia is defined as:

 Plasma glucose concentration of <2.2 mmol/L (40 mg/dL).
 Hypoglycaemia requiring assistance from another person.
 It is characterised by cognitive impairment that may be recognised or unrecognised and can
progress to loss of consciousness, seizure, coma or death.

Patients at risk for hypoglycaemia should be asked about symptomatic and asymptomatic hypoglycaemia
at each encounter. Patients should also be aware of situations in which they have an increased risk of
hypoglycaemia, including:
 Fasting.
o For medical tests or procedures.
o During Ramadan or for other religious purposes.
 During or after intense exercise.
 During sleep.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 36 of 85

B- Treatment:
 Glucose (15–20g) is the preferred treatment for the conscious individual with hypoglycaemia,
although any form of carbohydrate that contains glucose may be used.
 If SMBG shows continued hypoglycaemia 15 mins after treatment, the treatment should be
repeated.
 Once SMBG returns to normal, the individual should consume a meal or snack to prevent
recurrence of hypoglycaemia.
 Glucagon should be prescribed for all individuals at increased risk of severe hypoglycaemia.
 Caregivers, school personnel, or family members of these individuals should be instructed in its
administration. Glucagon administration is not limited to health care professionals.

7.1.13.2 Hypoglycemia Unawareness

7.1.13.2.1 Hypoglycemia unawareness is:

 Caused by an attenuated increase in sympatho-adrenal activity.
 The first sign of hypoglycaemia in these patients is confusion.
 Patients will heavily rely on others to recognise and treat hypoglycaemia.
7.1.13.2.2 Hypoglycemia-associated autonomic failure (HAAF) :
 Is the combination of defective glucose counter-regulation and hypoglycaemia
unawareness.
 Often caused by recent iatrogenic hypoglycaemia.
 Is partially reversible by avoiding hypoglycaemia.
 Is associated with a ≥25-fold increase in the risk of severe hypoglycaemia during
intensive glycaemic therapy.
 It is important to distinguish HAAF from classical autonomic neuropathy, which
may occur as one form of diabetic neuropathy.

7.1.13.2.3 Restore recognition of hypoglycemia in patients with HAAF:

How to Restore recognition of hypoglycemia Consider the following

Monitoring and goal setting o Encourage SMBG before meals, at bedtime, and
when symptoms occur.
o Encourage SMBG between 02:00 and 05:00, at
least three times a week.
o Set a pre-prandial glucose target of 100-150
mg/dL (5.6-8.3 mmol/L).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 37 of 85

Patient education o Explain to the patient the symptoms of

hypoglycaemia and the role of repeated
hypoglycaemia in the development of
hypoglycaemia unawareness.
o Ensure that the patient understands that
hypoglycaemia unawareness is reversible
through avoidance of hypoglycaemia
Dietary intervention o Ensure adequate calorie intake.
o Recommend the consumption of interprandial
and bedtime snacks.
o Ensure that the patient has access to readily
absorbable carbohydrates at all times.

Exercise counselling oEncourage SMBG before, during, and after

exercise.
oIf BG is <140 mg/dL (7.8mmol/L), advise:
 That the patient consumes additional
calories before, during, and after exercise.
Medication adjustment o Consider adjusting the insulin regimen to attain
target glucose levels.
o To reduce the risk of inter-prandial
hypoglycaemia:
 Use rapid-acting insulin analogues.
o To reduce the risk of nocturnal hypoglycaemia:
 Use basal insulin analogues.
o Consider using a CSII pump.
o Consider a CGM device.

7.1.14 Transitions of Care

Management during transitions of care:
 Care transitions are important times to revisit diabetes management targets.
 Consider the following:
o Perform a medication reconciliation.
o Provide patient and caregiver education.
o Re-evaluate the patient’s ability to perform diabetes self-care behaviours.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 38 of 85

o Have close communication between transferring and receiving care teams to ensure
patient safety and reduce readmission rates.
 At the time of admission to a new facility, transitional care documentation may include:
o The current meal plan.
o Activity levels.
o Prior treatment regimen.
o Prior self-care education.
o Laboratory tests, including:
 HBA1C.
 Lipid profile results.
 Renal function.
o Hydration status.
o Previous episodes of hypoglycaemia (including symptoms and patient’s ability to
recognise and self-treat).

Section 2:

7.2-THE DIAGNOSIS AND MANAGEMENT OF T1DM IN ADULTS

7.2.1- PURPOSE:
The purpose of this guideline is to define the appropriate diagnosis and management of type 1
diabetes mellitus in adults. In addition to improve the appropriateness of investigation, medication
prescription and T1DM patient’s referrals.
Also, to unify the following:

7.2.2 Risk Factors of T1DM

7.2.3 Clinical Presentation and Diagnosis
7.2.4 Initial Assessment
7.2.5 Multidisciplinary Approach
7.2.6 Pharmacological Therapy
7.2.7 ASCVD Risk Management
7.2.8 Hypoglycemia Prevention and Management
7.2.9 Advice for Fasting During Ramadan

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 39 of 85

7.2.2- Risk Factors of T1 DM:

Risk factors:
 Family member with T1DM (15-fold increase in risk).
 Genetics:
o Predisposing haplotypes include:
 DRB1*0401-DQB1*0302.
 DRB1*0301-DQB1*0201.
 Viral infections.
 Psychological trauma.

7.2.3- Clinical Presentation and Diagnosis

7.2.3.1 Presentation

T1DM is typically diagnosed on the basis of clinical symptoms associated with insulin deficiency:
 Polyuria.
 Polydipsia.
 Weight loss.
 Marked hyperglycaemia that is not responding to oral agents.
 Acute onset includes:
o Classic symptoms of hyperglycaemia or hyperglycaemic crisis.
o Random plasma glucose of ≥ 11.1 mmol/L (200 mg/dL).

7.2.3.2 Clinical Presentation in Adults:

 Typically has a more gradual onset than in children, with slower destruction of beta-cells.
 May initially appear consistent with type 2 diabetes mellitus (T2DM), and differentiating between
T1DM and T2DM may be challenging.
 Clinical clues suggestive of T1DM may include: A lean individual with:
o Clinical symptoms of hyperglycaemia.
o Without a first-degree relative with diabetes.
o But often with a history of distant relatives with T1DM or other autoimmune disease.
o It should be noted that obesity does not rule out autoimmunity.
 Adults may retain sufficient beta-cell function to prevent ketoacidosis for many years.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 40 of 85

Diagnose T1DM on clinical grounds in adults presenting with hyperglycemia, whilst considering that
patients will often have one or more of the following:
 Ketosis.
 Rapid weight loss.
 BMI below 25 kg/m2.
 Personal and/or family history of autoimmune disease.

7.2.4 Initial Assessment

7.2.4.1 History
Take a comprehensive medical history, including [L2]:
 Age and features of onset of diabetes, e.g.:
o Diabetic ketoacidosis (DKA), asymptomatic laboratory finding etc.
 Eating patterns.
 Nutritional status.
 Weight history.
 Physical activity habits.
 Nutrition education and behavioural support history and needs.
 Presence of co-morbidities including depression.
 History of smoking, alcohol consumption, substance use.
 History of diabetes education and self-management plans
 Review of previous treatment regimens
 Review of previous response to diabetic medications
 Results of previous glucose monitoring.
 History of DKA:
o Frequency.
o Severity.
o Cause.
 History of hypoglycaemic episodes:
o Awareness.
o Frequency.
o Causes.
 History of hypertension.
 History of hypercholesterolaemia.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 41 of 85

 Microvascular complications:
o Retinopathy.
o Nephropathy.
o Neuropathy:
 Sensory, including history of foot lesions.
 Autonomic, including sexual dysfunction and gastroparesis.
 Macrovascular complications:
o Coronary heart disease.
o Cerebrovascular disease.
o Peripheral arterial disease.

7.2.4.2 Physical examination

Conduct a general physical examination noting in particular the following [L2]:

 Height, weight and body mass index (BMI).
 Blood pressure (BP), including orthostatic BP, if indicated.
 Head and neck examination including:
o Thyroid enlargement.
 Skin stigmata (e.g. striae, acanthosis nigricans, hyperpigmentation, alopecia or vitiligo).
 Hepatomegaly.

7.2.4.3 Complications and comorbidity assessment

Complications of T1DM include:

 Diabetic kidney disease.
 Diabetic retinopathy.
 Neuropathy.
 Foot ulcers.
 Charcot foot.
 Foot amputations.

Commonly associated conditions include.:

 Atherosclerotic cardiovascular disease (ASCVD)
 Fatty liver disease.
 Fractures due to osteoporosis.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 42 of 85

 Low serum levels of testosterone in men.

 Periodontal disease.
 Cognitive impairment in long-standing and poorly controlled T1DM.

Patients with autoimmune T1DM are also prone to other autoimmune disorders, such as:
 Hashimoto’s thyroiditis.
 Coeliac disease.
 Graves’ disease.
 Addison’s disease.
 Vitiligo.
 Autoimmune hepatitis.
 Myasthenia gravis.
 Pernicious anaemia.
7.2.4.4 Investigation

7.2.4.4.1 Initial tests

Diagnostic criteria for the diagnosis of T1DM requires one of the following:
 Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) (where fasting is for at least 8 hours).
 2-hour plasma glucose ≥11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test (OGTT)
performed using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in
water.
 In patients with classic symptoms of hyperglycaemic or hyperglycaemia crisis, a random plasma
glucose of ≥11.1 mmol/L (200 mg/dL).
 HBA1C of ≥6.5%:
o Does not require the patient to fast.
o Some haemoglobinopathies and anaemias may make interpretation difficult:
 For patients with abnormal haemoglobin but normal red blood cell turnover, an
HBA1C assay without interference from abnormal haemoglobins should be used
[L2].
NB:
 A second diagnostic test is required to confirm the diagnosis, unless [L2]:
o Patient is in hyperglycaemic crisis.
o Patient has classic symptoms of hyperglycaemia and a random plasma glucose ≥11.1
mmol/L (200 mg/dL).
o The results are unequivocal [R-GDG].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 43 of 85

 If a second test is required, should be done with a new blood sample.

 If a patient has had inconsistent results from two diagnostic tests, the test result that is above the
diagnostic threshold should be repeated without delay.
 If a repeat test is below the diagnostic threshold, the test should be repeated again after 3-6
months.
 Only blood glucose (BG) criteria should be used to diagnose diabetes in conditions associated
with increased red blood cell turnover, e.g.:
o Erythropoietin therapy.
o Pregnancy (second and third trimesters).
o Recent blood loss or transfusion.
o Haemolysis.
A diagnosis of T1DM should be considered, if hyperglycaemia and/or osmotic symptoms (i.e.
polyuria, polydipsia) persists in a patient, suspected to have T2DM treated with non-insulin agents
[L2].

7.2.4.4.2 Further laboratory evaluation can include:

 HBA1C: If a result from the past 3 months is not available.

 If not performed in the last 12 months:
o Fasting lipid profile.
o Liver function tests.
o Spot urinary albumin-creatinine ratio (ACR).
o Serum creatinine + estimated glomerular filtration rate (eGFR).
o Thyroid stimulating hormone (TSH):
 If abnormal, consider testing for anti-thyroid peroxidase antibody (Anti-TPO).
 Screening for autoimmune markers:
o Autoimmune markers of immune-mediated diabetes include :
 Islet cell autoantibodies.
 Insulin autoantibodies.
 Glutamic acid decarboxylase antibodies (GADA).
o Autoantibody titres diminish as time passes from diagnosis [2].
o The lowest false-positive rate is at the time of diagnosis, the rate of false positives
increases thereafter:
 The false negative rate can be reduced by conducting two different tests.
 C-peptide levels measurement:
o A surrogate marker for insulin secretion.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 44 of 85

o Occasionally needed to confirm T1DM in a patient on insulin.

o May be detected over 40 years after the initial diagnosis, irrespective of whether the
diagnosis was made in childhood or adulthood.
o The more time that has passed since diagnosis, the higher the discriminative value of C-
peptide testing.

C-peptide and/or diabetes-specific autoantibody titres should:

 Not be routinely used to confirm T1DM in adults.

 Should be considered if [L2]:
o T1DM is suspected, but features are atypical, e.g.:
 Patient is aged ≥50 years.
 BMI of ≥30 kg/m2 [R-GDG].
 Slow evolution of hyperglycaemia.
 Long prodrome.
o If there is a clinical suspicion of a monogenic form of diabetes.
o The classification is uncertain, and confirmation of the diagnosis would alter the therapy

7.2.5 Multidisciplinary Approach

All adults diagnosed with type 1 DM should be referred to a secondary/specialist diabetology service and
receive care within a multidisciplinary team (MDT), which includes the following [R-GDG]:
 Physicians.
 Nurses.
 Diabetes educator.
 Dieticians.
 Podiatrists.
 Clinical pharmacists, if available.
 Other professionals which may form part of the team may include:
o Exercise therapists.
o Mental health professionals (psychologists).
o Ophthalmologists.

The management plan should be individualized to the patient [L2]:

 Taking patient and family’s needs, circumstances and preferences into account.
 People with diabetes must also take an active role in their care.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 45 of 85

 Health care providers must take into account:

o The patient’s age.
o Comorbidities and diabetes-related complications.
o Life expectancy.
o School/work conditions.
o Lifestyle choices.
o Social situation.
o Cultural factors.
o Polypharmacy.

7.2.5.1 Referrals for initial care management

If unavailable within the MDT, consider referral for the following specialty services, after initial diagnosis
[L2]:
 Ophthalmologist for dilated eye exam within 5 years of diagnosis and annual review thereafter.
 Diabetes educator for structured education and support.
 Registered dietician for medical nutrition therapy (MNT).
 Podiatry screening clinic For Comprehensive foot examination
- Inspection
- Palpation of dorsalis pedis and posterior tibial pulses
- Presence/absence of patellar and Achilles reflexes
- Determination of proprioception, vibration, and monofilament sensation
 Refer to preventive care service when appropriate:
- Refer to PHCC for Immunisation.
- Referral for smoking cessation clinic, Naufar for drugs and alcohol abuse.

7.2.5.2 Multidisc-plenary care Management:

Diabetes self-management education and support

All people with diabetes should participate in DSME and DSMS [L1, RGA1]:
 DSME helps patients to gain the knowledge, skills, and abilities needed for self-care (e.g. Dose
Adjustment for Normal Eating (DAFNE)).
 DSMS helps the patient implement and sustain skills and behaviours required for ongoing self-
management.
 Measure and monitor effective self-management, improved clinical outcomes, health status, and
quality of life as part of care [L2].
 Programmes should be:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 46 of 85

o Patient centred, respectful, and responsive to individual patient preferences, needs, and
values, which should guide clinical decisions [L1].
o Reviewed by trained, competent and independent assessors who measure it against
criteria that ensure consistency

For DSME in older adults:

 Involve care partners (family, friends, or other caregivers).
 Patients may have low health literacy and numeracy skills, and be overwhelmed due to many
coexisting conditions.
There are five critical time points for DSME and DSMS delivery :
 At diagnosis.
 An annual assessment to include assessment of diabetes education, nutrition, and psychological
support
 When new complicating factors arise that influence self-management.
 When transitions in care occur.
 Special occasions e.g. Ramadan and Hajj [R-GDG].

Adult patients should be offered a structured education programme 6-12 months following diagnosis.

7.2.5.2 MNT:
 Should be individualised to the patient.
 Implementation should be supported by each member of the care team all of whom should be
knowledgeable about the principles of MNT [L2].
 Should be preferably delivered by a registered dietician [L1, RGA1].

Goals of MNT include:

 Effectiveness of nutrition therapy.
 Energy balance.
 Eating patterns and both micronutrient and macronutrient distribution.
 If alcohol is consumed, discourage excessive intake.

Nutrition considerations in older adults:

 Older adults living in long term care facilities may have:
o Irregular meal consumption.
o Undernutrition.
o Anorexia.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 47 of 85

o Impaired swallowing.
 Therapeutic diets should be avoided, as they may lead to decreased food intake resulting in
weight loss and undernutrition.
 Diets considering the patient’s culture, preferences, and personal goals may
increase quality of life, nutritional status, and satisfaction with meals.

7.2.5.3 Smoking cessation

All patients should be advised not to smoke cigarettes, or use other tobacco products [L1]. Ensure that
smoking cessation counselling, or referral to a smoking cessation service, is provided to patients as a
routine part of diabetes management.

7.2.5.4 Physical activity

Physical activity:
 Is recommended for all patients [L3, RGA2].
 Regimens should be individualised to each patient:
o Recommendations may need to be altered in the presence of macro- and microvascular
complications [L3, RGA2].

7.2.5.4.1 Pre-exercise evaluation:

Prior to initiation of physical exercise, completion of the PAR-Q questionnaire is advised (available from:
http://www.csep.ca/view.asp?ccid=517). The questionnaire should be completed by patients before starting
a moderate to vigorous physical activity program. If patients answer ‘yes’ to one or more questions on the
form, clearance from a physician should be sought prior to commencement of a physical activity program.

Pre-exercise evaluation:
 Take a careful history considering the possibility of an atypical presentation of coronary artery
disease.
 Assess for cardiovascular risk factors.
 Assess for conditions that may contraindicate certain types of exercise or predispose the patient to
injury, such as:
o Uncontrolled hypertension.
o Autonomic neuropathy.
o Peripheral neuropathy.
o A history of foot lesions.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 48 of 85

o Untreated proliferative retinopathy.

 Consider the patient’s age and previous physical activity levels.
 Patients with complications may require a more in-depth evaluation.

7.2.5.4.2 Exercise recommendations:

Adults with diabetes should be advised:
 To participate in at least 150 minutes of physical activity per week, reaching 50-70% of maximum
heart rate [L1, RGA1].
 Physical activity should be spread over at least 3 days per week with no more than 2 consecutive
days without exercise [L1, RGA1].
 To take part in muscle strengthening training activities that involve all major muscle groups on 2 or
more days/week [L2].
 To reduce the amount of time they spend sitting [L1, RGA1]:
o Extended periods of time spent sitting (more than 90 minutes) should be avoided, advise
that these are broken up by briefly standing or walking [L1].
High risk patients should be encouraged to start with short periods of low-intensity exercise and slowly
increase the duration and intensity [L2].

NB: Intensive physical activity may increase BG levels rather than lowering them [L2].

7.2.5.5 Psychosocial care (if indicated):

Consider the patient’s psychosocial circumstances while managing patients with T2DM:
 Psychosocial screening, includes consideration of [L2]:
o Attitude about the illness.
o Expectations surrounding medical management and outcomes.
o Mood.
o Quality of life.
o Resources:
 Financial.
 Social.
 Emotional.
o Psychiatric history.
 Routinely screen for psychosocial problems, using the PHQ-2 questions:
o If positive, assess for depression using the PHQ-9 scoring system.

Referral to an appropriate mental health specialist should be considered if:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 49 of 85

o Depression, self-harm or suicidal ideation.

o Gross disregard for the medical regimen.
o Debilitating anxiety (alone or with depression).
o Indications of an eating disorder.
o Cognitive function that significantly impairs judgement.
7.2.5.6Self-monitoring of blood glucose and HBA1C

7.2.5.6.1 Patients with T1DM:

 Should perform self-monitoring of blood glucose (SMBG) [L2, RGA1]

o At a minimum, 3-4 times per day, prior to meals and at bedtime.
o At other times, including:
 Postprandial.
 Mid-sleep (c.3-4am), if risk of hypoglycaemia during sleep.
 Prior to, during, and/or after exercise.
 When low BG is suspected.
 After treating low BG until normoglycaemia has been restored.
 When correcting a high BG level.
 Prior to critical tasks such as driving and during prolonged journeys of ≥2 hours
duration [R-GDG].
 At more frequent intervals during illness or stress.

Make sure that patients receive ongoing instruction and evaluation of their [L3, RGA2]:
 SMBG technique.
 SMBG results.
 Their ability to use their SMBG results to adjust therapy [L3].
 These skills should be reviewed at least annually .

NB: SMBG should not be routinely carried out using sites other than the fingertips.

7.2.5.6.2 HBA1C testing:

 Perform HBA1C testing every 3 months.
 Consider point of care testing in order to provide quicker treatment changes [L3, RGA2].

7.2.5.7 Continuous glucose monitoring

Continuous glucose monitoring (CGM):

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 50 of 85

 It could be useful tool to lower HBA1C in conjunction with intensive insulin regimens in adults with
T1DM.
 May be used as a supplemental tool to SMBG in patients with hypoglycaemia unawareness and/or
frequent hypoglycaemic episodes [L2].
 Prior to prescribing CGM assess the patient’s individual readiness for continuing CGM[L3].
 Education, training, and support are needed for optimal CGM initiation and maintenance [L3].
 Patients should be willing to commit to using it at least 70% of the time and have it calibrated if
needed.

7.2.5.8 Glycemic targets and testing

For patients with T1DM, a combination of frequent SMBG levels (including CGM), in addition to HBA1C, is
the most accurate way of evaluating glycemic control [L2, RGA1].

Glycemic treatment targets:

 Individualise treatment targets based on patient circumstances including:
o Duration of diabetes.
o Age/life expectancy.
o Comorbid conditions.
o Known CVD or advanced microvascular complications.
o Hypoglycaemia unawareness.
o Individual patient considerations.
 Agree individualised bedtime and waking plasma glucose goals with each adult patient,
considering timing of their last meal and corresponding insulin dose .

The target BG and HBA1C levels for non-pregnant adults are as follows (if could be achieved without
hypoglycemia):
 Before meals: 4.4 – 7.2 mmol/L (80 – 130 mg/dL).
 Peak post-prandial: <10.0 mmol/L (<180 mg/dL).
 HBA1C: <7.0%.

Note:
 Measure post-prandial BG 1-2 hours after the start of the meal.
 Post-prandial measures may be targeted if pre-prandial values have been attained, but HBA1C
remains above the target level.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 51 of 85

7.2.6 Pharmacological Therapy

7.2.6.1 Insulin types:

Table 1: Common insulin options available [R-GDG].

Insulin Type Onset of Action Duration of action
Lispro
Aspart 5-15 minutes 2-4 hours
Glulisine
Human Regular 30 minutes 5-8 hours
Human NPH 1-3 hours 12-18 hours
Glargine 1-2 hours 20-24 hours
Glargine U300 1-2 hours Up to 36 hours
Detemir 1-3 hours 6-24 hours
Degludec 1-2 hours up to 42 hours
Human regular/NPH Variable Variable
Lispro/lispro protamine Variable Variable
Lispro/lispro protamine Variable Variable
Aspart/aspart protamine Variable Variable
Aspart/aspart protamine Variable Variable

NPH: Neutral protamine Hagedorn

7.2.6.2 Insulin regimens

Treatment for T1DM consists of the following:

 Intensive insulin therapy consisting of multiple-dose insulin injections (MDI) or
continuous subcutaneous insulin infusion (CSII) therapy, i.e. insulin pump [L1, RGA1]:
o MDI should include three or more injections of prandial insulin per day, and
one or two injections of basal insulin [L1].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 52 of 85

 Match prandial insulin to carbohydrate intake, pre-meal BG, and expected physical
activity [L3, RGA2].
 Insulin analogues should be used for most patients, especially those at elevated risk
of hypoglycaemia to reduce hypoglycaemia risk [L1, RGA1].
 A sensor-augmented low-glucose threshold-suspend pump, may be considered for
patients with [L2]:
o Frequent nocturnal hypoglycaemia.
o Recurrent severe hypoglycaemia; and/or
o Hypoglycaemia unawareness.

Use the principles of flexible insulin therapy in adults who use real-time CGM, using one of :
 MDI regimen.
 CSII (i.e. insulin pump).

7.2.6.3 Insulin administration

Initiation of insulin [R-GDG]:

 The recommended total daily dose (TDD) of insulin is approximately 0.5 units/kg.
 50% of TDD should be from basal insulin and 50% from bolus insulin.

NB: Recommendations on optimal prandial insulin dose administration should be individualised to each
patient.

Basal insulin [R-GDG]:

 Is usually injected on a once-daily basis (consider twice daily if detemir is used).
 Preferably injected in the evening, approximately one hour before bedtime, but can also be given
in the morning, according to the patient’s preference.
 Titrate the dose according to the pre-prandial (fasting) glucose level.

The optimal time to inject prandial insulin is based on the following [L2]:
 The type of insulin used:
o Offer rapid-acting insulin analogues (rather than rapid-acting soluble human or animal
insulins) for mealtime insulin replacement.
o Do not advise rapid-acting insulin analogues for routine use after meals .
 The measured BG level.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 53 of 85

 Timing of meals.
 Carbohydrate consumption.
 Anticipated physical activity.

7.2.6.5 Intercurrent illness

Patients and their relatives should be advised of the following general measures to manage intercurrent
illness and prevent DKA or hypoglycemia (i.e. sick-day management):

7.2.6.5.1 Monitoring:
 Increase the frequency of observation of the patient.
 Measure BG every 2-3 hours and ketones every 4 hours.

7.2.6.5.2 Food and fluid intake:

 Encourage fluids and rest.
 Encourage normal meals but encourage carbohydrate intake.

7.2.6.6 Patients on multi-dose injection regimens

Insulin management [R-GDG]:
 Basal insulin should always be continued, but doses should be modified if food consumption is
less than usual [15].
 If BG is >250 mg/dL (13.9 mmol/L), or ketones are detected in urine:
o Give additional correction doses of rapid-acing insulin analogues.
o Encourage eating between doses of rapid-acting insulin analogues.
o NB:
 Omit additional doses if the BG is not elevated, even if ketones are present in
blood or urine.
 Ketones should decrease within 8 hours from the first dose of additional insulin.

7.2.6.7 Specialist advice and support [R-GDG]:

 Advise the patient and their family/carer to seek additional advice from the diabetes team.
 Emergency Department attendance is warranted if:
o Ketones remain elevated despite two additional doses of rapid-acting insulin analogues.
o Symptoms of DKA develop.
o The patient or their relatives are concerned about the illness or BG control.
o BG is persistently >300 mg/dL (16.5 mmol/L), despite additional insulin.
o BG is persistently <70 mg/dL (3.9 mmol/L).

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 54 of 85

7.2.6.8 Injection site monitoring

Advise patients to:
 Rotate their insulin injection site.
 Avoid repeated injections at the same point within sites.
 Have injection sites checked at least annually, or if new problems with BG control arise.

7.2.6.9 Insulin delivery devices

Insulin delivery devices:
 Provide an insulin injection delivery device that helps patients optimise wellbeing; one or more
types of insulin injection pen may be needed.
 Patients with special visual or psychological needs require injection devices or needle-free
systems that can be used independently for accurate dosing.
 Provide needles of different lengths to patients experiencing problems like pain, local skin
reactions and injection site leakages.
 Arrangements should be made to allow the safe disposal of used needles, e.g. the provision of
sharps containers and their disposal.

7.2.6.10 Metformin
The addition of metformin to insulin therapy, can be considered as an adjunct if an adult patient has a BMI
of ≥30 kg/m2, to improve BG control while minimizing their effective insulin dose.

7.2.7 ASCVD RISK MANAGEMENT

7.2.7.1 Management of hypertension

For patients with T1DM without known hypertension, review Blood Pressure (BP) at every visit and at least
annually. Provide and emphasize lifestyle advice to all diabetic patients.

Table (3): Aim to achieve a clinic BP of:

Blood pressure target Appropriate patients
<140/90 mmHg all diabetic patients
<130/80 mmHg - Younger patients.
- Those with albuminuria.
- Those with hypertension and one or more additional ASCVD risk
factors, if the target can be achieved without undue treatment burden.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 55 of 85

Note: If BP remains above target levels following lifestyle improvement, add medication to reduce BP to
target levels.
Medication to control BP in T1 DM:
Treatment Medication
First-line medication*  A once daily angiotensin converting enzyme (ACE) inhibitor; or
 For people of African or Afro-Caribbean consider using an ACE
inhibitor plus either a diuretic or calcium channel blocker (CCB).
 For women who may become pregnant, start with a CCB:
- Avoid the use of ACE inhibitors and angiotensin II-receptor
antagonists.
 If there is ongoing intolerance to an ACE inhibitor, other than renal
deterioration or hyperkalaemia, an angiotensin receptor blocker ARB
may be used instead.
 NB: Unless contraindicated, for diabetic patients with hypertension
and renal impairment, an ACE inhibitor or ARB must be the first line
drug.
Second line treatment If With first-line therapy, add a CCB or a diuretic (usually thiazide or
BP is not adequately thiazide-like diuretic).
controlled to the agreed
target level
Third-line treatment If BP With dual therapy, add the other drug, i.e. either a CCB; or a diuretic.
is not adequately
controlled to the agreed
target level

Fourth-line treatment If With triple therapy, add either an alpha-blocker; or a beta-blocker; or a

BP is not adequately potassium-sparing diuretic
controlled to the agreed
target level

If BP is not adequately controlled to the agreed target level:

*Advise patients to monitor BP every 1-2 months and intensify therapy until BP is consistently
within target range. Continue to reinforce lifestyle advice. If BP is consistently attained at the target
level, continue to monitor the patient's BP at every clinic visits and check for adverse effects
including risks of hypotension.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 56 of 85

*NB: Antihypertensive medications can increase the likelihood of side effects, e.g. orthostatic hypotension
in a patient with autonomic neuropathy.

Note the following key points:

 Use potassium-sparing diuretics with caution if the patient is already taking an ACE inhibitor or
ARB.
 Do not combine an ACE inhibitor with an ARB.
 Refer to specialist care if BP remains above target levels following triple therapy including a
diuretic.

7.2.7.2 Lipid management

Table (4): High-intensity and moderate-intensity statin therapy

High-intensity statin therapy Moderate-intensity statin therapy

(lowers LDL cholesterol by >50%) (lowers LDL cholesterol by 30% to <50%)
Atorvastatin 40–80 mg Atorvastatin 10–20 mg
Rosuvastatin 20–40 mg Rosuvastatin 5–10 mg
Simvastatin 20–40 mg
Pravastatin 40–80 mg
Fluvastatin XL 80 mg (XL is once daily dose-
extended release).

Table (5): when to start High-intensity and moderate-intensity statin therapy: American College of
Cardiology/American Heart Association guideline on the treatment of blood cholesterol 2013

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 57 of 85

Ezetimibe is a recommended option for hypercholesterolemia in adults, under the following conditions [L1,
RGA1].
Condition Appropriate in the following circumstances
In conjunction with initial statin Serum total cholesterol or LDL-C levels are not appropriately
treatment controlled after titration of the statin treatment; or dosing is
limited by intolerance to the statin
As monotherapy - A contraindication to initial statin treatment.
- Intolerance to statin treatment

PCSK9 Inhibitors:
PCSK9 Inhibitors may be considered as adjunctive therapy for patients with diabetes at high risk for
ASCVD events who require additional lowering of LDL cholesterol or who require but are intolerant to high-
intensity statin therapy

7.2.7.3 Antiplatelet therapy

Aspirin and other antiplatelet are not routinely recommended for patients with T1DM in the absence of
established ASCVD.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 58 of 85

However, the American Diabetes Association recommends initiating low-dose aspirin use for the primary
prevention of ASCVD in adults aged 50-59 years, who have a 10-year ASCVD risk of a ≥10%, using the
ACC/AHA Pooled Cohort Equations (http://www.cvriskcalculator.com/). Patients must not be at increased
risk for bleeding, have a life expectancy of at least 10 years and be willing to take low-dose aspirin daily for
at least 10 years.

7.2.8 Hypoglycemia Prevention and Management

7.2.8.1 Hypoglycemia Definitions:

Hypoglycemia is defined as:

 Plasma glucose concentration of <3.9 mmol/L (70 mg/dL).

Mild to moderate hypoglycemia is defined as [derived from [1]]:

 Plasma glucose concentration of 2.2 – 3.9 mmol/L (40-70 mg/dL).
 Which does not require assistance from another person.

Severe hypoglycemia is defined as:

 Plasma glucose concentration of <2.2 mmol/L (40 mg/dL).
 Hypoglycaemia requiring assistance from another person.
 It is characterised by cognitive impairment that may be recognised or unrecognised and can
progress to loss of consciousness, seizure, coma or death (symptoms may be non-specific in
children).

7.2.8.2 Education

Patients at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at
each encounter [L2].

Patients should understand the situations that increase their risk of hypoglycemia, such as [L2]:
 Taking insulin without eating adequately.
 Fasting (e.g. for tests or procedures or if fasting during Ramadan).
 During or after intense exercise.
 During sleep.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 59 of 85

Teaching patients how to balance their insulin use with their carbohydrate intake and exercise is required
to reduce the risk of hypoglycemia, however this method is not always sufficient for prevention [L2].

Those in close contact with hypoglycemia-prone patients should be educated in the use of glucagon kits
[L2].

7.2.8.3 Treatment of Hypoglycemia

7.2.8.3.1 Mild to moderate hypoglycemia:

Treatment of patients with mild-to-moderate hypoglycemia comprises of:
 15–20g of Glucose (juice or glucose tablets/gels) is the preferred treatment for the conscious
individual with hypoglycaemia, although any form of carbohydrate that contains glucose may be
used.
 15 mins after treatment, if SMBG shows continued hypoglycaemia, the treatment should be
repeated.
 Once SMBG returns to normal, the individual should consume a meal or snack to prevent
recurrence of hypoglycaemia.

7.2.8.3.2 Severe hypoglycemia:

Patients with a decreased level of consciousness [L1]:
 Should be administered intramuscular glucagon by a family member or friend who has been
educated on its use; and
 Then monitored for 10 minutes, if their level of consciousness is not significantly improving then
they should be administered intravenous glucose; and
 Then given oral carbohydrate when it is safe for the patient, and put under continued observation
by a third party who has been warned of the risk of relapse.
 Send the patient to the Paediatric Emergency Centre if not improving [R-GDG].

7.2.8.3.3 Hypoglycemia unawareness

Hypoglycemia unawareness is indicated by or one or more episodes of severe hypoglycemia and should
trigger re-evaluation of the treatment regimen [L3].

Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be

advised:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 60 of 85

 To raise their glycaemic targets to strictly avoid further hypoglycaemia for at least several weeks in
order to partially reverse hypoglycaemia unawareness and reduce risk of future episodes [L1].
 Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycaemia
by the clinician, patient, and caregivers if low cognition or declining cognition is found [L2].

7.2.8.3.4 Hypoglycemia-associated autonomic failure

7.2.8.3.4.1 Hypoglycemia-associated autonomic failure (HAAF):

 Is the combination of defective glucose counter-regulation and hypoglycaemia unawareness.
 Often caused by recent iatrogenic hypoglycaemia.
 Is partially reversible by avoiding hypoglycaemia.
 Is associated with a ≥25-fold increase in the risk of severe hypoglycaemia during intensive
glycaemic therapy.
 It is important to distinguish HAAF from classical autonomic neuropathy, which may occur as one
form of diabetic neuropathy.

7.2.8.3.4.2 Restore recognition of hypoglycemia in patients with HAAF [L2]:

 Monitoring and goal setting:
o Encourage SMBG before meals, at bedtime, and when symptoms occur.
o Encourage SMBG between 02:00 and 05:00, at least three times a week.
o Set a pre-prandial glucose target of 100-150 mg/dL.
 Patient education:
o Explain to the patient the symptoms of hypoglycaemia and the role of repeated
hypoglycaemia in the development of hypoglycaemia unawareness.
o Ensure that the patient understands that hypoglycaemia unawareness is reversible
through avoidance of hypoglycaemia.
 Dietary intervention:
o Ensure adequate calorie intake.
o Recommend the consumption of interprandial and bedtime snacks.
o Ensure that the patient has access to readily absorbable carbohydrates at all times.
 Exercise counselling:
o Encourage SMBG before, during, and after exercise.
o If BG is < 140 mg/dL, advise:
 That the patient consumes additional calories before, during, and after exercise.
 Medication adjustment:
o Consider adjusting the insulin regimen to attain target glucose levels.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 61 of 85

o To reduce the risk of interprandial hypoglycaemia:

 Use rapid-acting insulin analogues.
o To reduce the risk of nocturnal hypoglycaemia:
 Use basal insulin analogues.
o Consider using a CSII pump.
o Consider a CGM device.

7.2.8.3.5 Hypoglycemia during physical activity

Risk of hypoglycemia:

 Patients who take insulin and/or insulin secretagogues are at increased risk of hypoglycaemia as a
result of exercise.
 Medication dose or carbohydrate intake must be altered in line with the amount of physical
exercise if pre-exercise glucose levels are <5.6 mmol/L (100 mg/dL).
 Intense activities may raise BG levels instead of lowering them.
 Further risk factors for exertional hypoglycaemia include:
o Prolonged exercise time.
o Exercise intensity the patient is not used to.
o Inadequate supply of energy in relation to blood insulin levels.
 Post-exertional hypoglycaemia can be prevented or minimised by careful glucose monitoring
before and after exercise:
o Snacks should be consumed prior to exercise if BG levels are falling.
 Patients should carry a readily absorbable source of carbohydrates when exercising, including
sporadic housework or outdoor work.
 It may be useful to alter the insulin dose on days with planned exercise:
o Especially in patients with well controlled diabetes and a history of exercise-induced
hypoglycaemia.

7.2.8.3.6 Hypoglycemia follow up

Patients with one or more episodes of severe hypoglycemia may benefit from at least short-term relaxation
of their glycemic goals.

If hypoglycemia increases in frequency or becomes unusually problematic, consider the following causes
[L2]:
 Inappropriate insulin regimens.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 62 of 85

 Meal and activity patterns, including alcohol.

 Injection technique and skills, including insulin resuspension.
 Injection site problems.
 Possible organic causes, e.g. gastroparesis.
 Changes in insulin sensitivity.
 Psychological problems.
 Previous physical activity.
 Lack of the necessary skills and knowledge for adequate self-management.

In there is hypoglycemia unawareness with recurrent severe hypoglycemia, consider referral to a specialist
center if they are not responsive to interventions [L2].

7.2.9 Advice for Fasting During Ramadan

Fasting during Ramadan:

 All adults with T1DM are exempted from fasting on medical and religious grounds, due to the risk
of severe complications.
 In those patients who insist on fasting, strategies to ensure safety should be discussed with a
diabetes-specialist MDT and include:
o Ramadan-focused medical education.
o Pre-Ramadan medical assessment – 2-3 months prior to Ramadan[R-GDG].
o Robust assessment of hypoglycaemia awareness.
o Emphasising the importance of following a healthy diet and physical activity pattern.
o Modification of insulin regimen.
o Frequent SMBG or CGM.
o Regular follow-up with the diabetes specialist team.

Section 3

7.3-THE DIAGNOSIS AND MANAGEMENT OF DIABETES MELLITUS IN PREGNANCY

7.3.1- PURPOSE (AIM):

The purpose of this guideline is to define the appropriate diagnosis and management of diabetes
mellitus in pregnancy. The objective is to improve the appropriateness of investigation, prescribing
and referral of patients to national Diabetes Center (NDC).
Also, to unify the following:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 63 of 85

7.3.2 Preconception counselling and care

7.3.3 Screening for diabetes in pregnancy
7.3.4 Referral criteria to NDC
7.3.5 Management of gestational diabetes mellitus
7.3.6 Management of type 1 and type 2 diabetes mellitus in pregnancy
7.3.7 Special considerations
7.3.8 Post-natal care

7.3.2- Preconception Counselling and Care

7.3.2.1 Preconceptual care

Women of childbearing age with known diabetes should receive pre-conceptual care [L2, RGA1].
Pre-pregnancy care outlined below should be part of their routine diabetes care irrespective of the setting.
However, for women who cannot be managed in a primary/generalist care setting, referral to a specialist
preconception clinic should be made[R-GDG].

Care in a specialist pre-conception clinic should be provided jointly by the adult diabetes services and the
maternity service for women wishing to become pregnant[R-GDG].
The role of pre-conceptual care is as follows:
 Health education and counselling on the risk of diabetes in pregnancy.
 Review medical and obstetric history.
 Advise on glycaemic control to optimise HBA1C.
 Review medication.
 Screen for and manage complications.
 The complications of diabetes in pregnancy should be explained to the patients (see Table1).

NB: 3-6 months’ attendance for pre-pregnancy care is typically required to optimize glycemic control and
address all other issues. [R-GDG].

7.3.2.2 Complications of diabetes in pregnancy

MATERNAL COMPLICATIONS FETAL/NEONATAL COMPLICATIONS

Diabetes complications: Perinatal complications:
o Retinopathy (new /worsening). o Still birth/neonatal death.
o Nephropathy (new/worsening). o Congenital malformations.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 64 of 85

o Diabetic ketoacidosis (DKA). o Macrosomia.

o Hypoglycaemia (when using insulin). o Birth injury.
o Delayed fetal development
 Obstetric complications:  Neonatal complications:
o Pre-eclampsia. o Hypoglycaemia.
o Gestational hypertension. o Polycythaemia.
o Miscarriage (spontaneous abortion). o Hypocalcaemia.
o Preterm birth. o Hyperbilirubinaemia.
o Higher rate of caesarean section. o Cardiomyopathy.
o Higher rate of instrumental delivery. o Newborn Respiratory Distress
o Polyhydramnios. Syndrome.
o Shoulder dystocia.

 Longer term complications:

o Obesity.
o T2DM

7.3.2.3 Contraception advice

Discuss family planning [L1]:

 Avoidance of unplanned pregnancy should be an essential component of diabetes education from
adolescence for all women with diabetes.
 The need for preparation for pregnancy and pre-conceptual counselling should be emphasised
during each and every diabetes annual review appointment.
 Advise the use of contraception until HbA1c has been optimized and refer to Gynaecology for
contraceptive management.

7.3.2.4 Glycemic control and medication review

Emphasize the importance of glycemic control:

 Aim to keep HBA1C < 6.5%, if it can be achieved without problematic hypoglycaemia.[L2, RGA1].
o Good glycaemic control is necessary to reduce the risk of congenital abnormalities,
miscarriage, stillbirth and neonatal death.
o However, explain that risks can be reduced but not entirely eliminated.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 65 of 85

 If HBA1C is ≥10% the absolute risk of congenital malformation increases significantly and women
should therefore be advised not to become pregnant. The patient should be informed of the
associated risks should pregnancy occur (see table 1).

 Patients with T2DM should be managed with:

o Diet alone; or
o Diet plus metformin; or
o Metformin plus Insulin.
NB: Metformin was shown to be safe and efficacious during pregnancy whilst the safety profile of
other oral hypoglycaemic agents is not known and should stop prior to conception.

7.3.2.5 Insulin use in pregnancy:

Type of Insulin Approval in pregnancy

Rapid-acting insulin analogues - aspart and Approved in pregnancy and should be
lispro continued. They are more advantageous than
soluble human insulin during pregnancy in
reducing the risk of hypoglycaemia.
Insulin glulisine Not approved in pregnancy.
Intermediate-acting insulin (neutral protamine both approved in pregnancy
Hagedorn (NPH)) and basal insulin detemir
Insulin glargine Initiation during pregnancy is not recommended
currently. Patients, whose diabetes is well
controlled on insulin glargine, do not need to
discontinue it during pregnancy. L2, RGA1.
Continuous subcutaneous infusion of insulin May be considered for those otherwise unable
(insulin pump) to meet glycaemic targets. Patients should be
referred to insulin pump clinic. [R-GDG].

7.3.2.5 Medication should not to be used during pregnancy:

Medication should Not to be used during Alternative

pregnancy
Angiotensin converting enzyme (ACE) inhibitors and Labetalol, nifedipine and
angiotensin receptor blockers(ARBs) methyldopa [L2, RGA1].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 66 of 85

Statin should be discontinued before conception, or

as soon as pregnancy is confirmed

7.3.2.6 Monitoring Blood Glucose in The Pre-Conception Period

Advise the patient of the following:

 Newer reliable glucometers or recently-calibrated glucometers should be used and the patient’s
monitoring technique should be reviewed. [R-GDG].
 Women are encouraged to record their blood glucose (BG) measurements at a minimum of 3-4
times per day up to a maximum of 6-7 times per day.
 The ideal frequency of measurement will depend on the insulin regimen used and the frequency
of hypoglycaemia. At a minimum this should include: fasting measures and two hours after
meals.
 If nocturnal hypoglycaemia is suspected, patients should be advised to measure during the night
also.

7.3.2.7 Nutritional Advice And Weight Management

Nutritional advice:
 It is good clinical practice to provide dietary advice before, during and after pregnancy. The diet
should be based on low glycaemic index foods and not excessive in fat.
 Women should be encouraged to achieve a normal body mass index (BMI) prior to pregnancy.
 Women with diabetes who are planning to become pregnant should be advised to take folic acid (5
mg/day) starting at least 3 months prior to conception and continuing until 12 weeks of gestation,
to reduce the risk of neural tube defect [L2].

7.3.2.7 Physical activity

Physical activity in non-diabetic patients:

 Preconception physical activity reduces the risk of GDM.

 Physical activity is also an important part of a healthy pregnancy, and once pregnant, regular
participation should be encouraged.

Physical activity in patients with diabetes mellitus:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 67 of 85

 At least 150 mins per week of moderate-intensity aerobic exercise (50-70% of maximum heart
rate) is recommended:
o Spread-out over at least 3 days per week.
o Ensure there are no more than two consecutive days without exercise.

 In patients with T2DM, if there are no contraindications, resistance training is recommended twice
per week.

 Patients with type 1 diabetes mellitus (T1DM), should be advised about:

o Safe pre-exercise BG levels (typically ≥100 mg/dL depending on the individual and type of
physical activity); and
o Appropriate adjustment of insulin and meals/snacks to reduce hypoglycaemia.
o Having a simple carbohydrate readily available before, during, and after exercise for
prevention or treatment of hypoglycaemia.

7.3.2.8 Screening for complications:

Nephropathy:

 There is strong association between pre-existing nephropathy and a poor pregnancy outcome.
 Worsening nephropathy and superimposed pre-eclampsia are amongst the most common causes
of pre-term delivery in women with diabetes.
 The following tests should be undertaken in all women:
o Albumin-creatinine ratio (ACR).
o Serum creatinine and eGFR.
 Patients with an abnormal ACR, confirmed on repeated testing. Because of biological variability in
urinary albumin excretion, two of three specimens of Urine ACR collected within a 3- to 6-month
period should be abnormal before considering a patient to have albuminuria [R-GDG].
 If the eGFR is <40 ml/min/m2 prior to conception, the woman may experience irreversible further
decline in renal function as a consequence of the pregnancy. Such patients should be referred to a
nephrologist for review. [R-GDG].
Retinopathy:

 Retinopathy can deteriorate significantly during pregnancy.

 Fundal examination is advised prior to conception, if not performed in the last 6 months.
 Patients with active retinopathy should be under the care of an ophthalmologist. [R-GDG].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 68 of 85

7.3.3- Screening for Diabetes in Pregnancy

Screening tests to detect pre-existing T2DM or GDM should be undertaken as follows [R-GDG]:

Table (1) Defines the groups of pregnant women who should be considered to be at low or high risk of
having undiagnosed T2DM in pregnancy, or for developing GDM.
Target population Time of Test
screening
At booking visit: FBS
Low risk women: At 24-28 weeks: If the above test is
All pregnant women without risk factors. normal:
Perform 75g OGTT
High risk women:
-Women with a history of GDM.

-Previous history of Impaired fasting glucose and/or At booking visit: FBS and HBA1C
Impaired glucose tolerance.

- History of unexplained still birth, IUFD or

unexplained neonatal death or birth of baby with
malformations associated with diabetes.

-History of macrosomic baby weighing ≥4kg.

-Pre-pregnancy results:
 HBA1C: 6.0% - 6.4%. If the above tests are
 FBS: 6.1 - 6.9 mmol/L (100-125mg/dl). 24-28 weeks: normal: Perform
75g OGTT
 OGTT at 2hrs: 7.8 - 11.0 mmol/L (140-
198mg/dl).

-Pre-pregnancy BMI of >25 kg/m2 (have a lower

threshold in South Asian women).

-Women with a history of PCOS

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 69 of 85

[Adapted from The International Federation of Gynecology and Obstetrics (FIGO) Initiative on
gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care [41]].

FBS: Fasting blood sugar (fasting for >8hours)

Figure (C-1): Screening and diagnosing GDM and T2DM in low-risk women [Adapted from The
International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A
pragmatic guide for diagnosis, management, and care. [41]].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 70 of 85

Fig C-2: Screening and diagnosis of GDM and T2DM in high-risk women [Adapted from [41]].
7.3.4 Referral Criteria to Specialist Care:

1- All patients with Type 1 and 2 diabetes Mellitus.

2- GDM target blood sugar is not met within 2 weeks of dietary management

7.3.5 Management of Gestational Diabetes Mellitus

7.3.5.1 Antenatal care

Antenatal care for women with GDM should be provided by a multidisciplinary team consisting of [R-GDG]:
 Family physician/obstetrician and endocrinologist if needed.
 Health counsellor/educator.
 Dietician.

Note:
 GDM is considered as high risk pregnancy and there should be a low threshold for referral to an
obstetrician.
 The frequency of antenatal visits is decided on individual basis, typically every 1-3 weeks after
diagnosis.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 71 of 85

 At each visit the following should be checked in particular, in addition to routine antenatal care:
o Blood pressure
o Urine dipstick primarily for proteinuria.
o Measure body weight.
o Review of SMBG.

7.3.5.2 Education

All patients should receive education (supported by an information leaflet) that explains the following
[R-GDG]:

 Health education and counselling on the risks to both mother and baby, associated with GDM in
pregnancy.
 The symptoms of hypoglycaemia.
 The role of diet, weight gain during pregnancy and exercise.
 The importance of good maternal glycaemic control to avoid complications.
 The possibility of transient morbidity in the baby during the neonatal period, which may require
admission to the neonatal unit.
 The risk of the baby developing obesity and/or diabetes in later life.
 In the absence of contraindications, exercise of 15-30 minutes per day should be encouraged.

Change in lifestyle is essential in the management of women with GDM, and in some cases may be
the only treatment required [L1].

7.3.5.3 Weight management

Women should adhere to the following acceptable weight gain limits during pregnancy in order to
minimize the risk of complications, but active weight loss should not be attempted [R-GDG].

Table 2: Acceptable weight gain for women with GDM by pre-pregnancy BMI and gestational age [R-
GDG].
Weight category Pre-pregnancy BMI Acceptable weight gain by gestation
<20 weeks ≥20 weeks
Underweight <18.5 4.0 - 6.0kg 8.0 - 12.0kg
Normal 18.5 - 24.9 4.0 - 5.5kg 7.5 - 10.5kg

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 72 of 85

Overweight 25.0 - 29.9 2.0 - 3.0kg 5.0 - 8.0kg

Obesity Class I 30.0 - 34.9 0kg 5.0 - 9.0kg
Obesity Class II & ≥35 0kg 0 - 5.0kg
III

Caloric intake:
 Is the best predictor of weight gain during pregnancy.
 Calculate the appropriate caloric intake dependent on the individual patient:
o Based on current pregnant BMI.
 Should increase in the second and third trimesters [L3, RGA2]:
 Additional calorie consumption in obese pregnant women may not be necessary:
o Obese women may reduce their calorie intake during pregnancy by 30% compared to
their pre-pregnancy intake [L1, RGA2], with a minimum intake of 1600-1800 kcal/day.

7.3.5.4 Dietary advice:

Dietary advice:
 Offer advice surrounding diet and exercise at the time of GDM diagnosis [L1, RGA1].
 Advise the patient to eat a healthy diet during pregnancy [L1, RGA1].
 Emphasise the benefit of foods with a low glycaemic index [L1, RGA1].
 All patients with GDM should be referred to a dietitian for medical nutrition therapy [L2].
 Women with GDM should adhere to the healthy eating recommendations for all pregnant women
[L2].
 Eat small, frequent meals with protein to reduce the risk of postprandial hyperglycaemia and pre-
prandial starvation ketosis [L2].
 Advice should be tailored to each patient’s individual needs, culture, and preferences [L2].

Carbohydrate intake:
 It is recommended that women with GDM, limit carbohydrate intake to 35% - 45% of total calorie
intake.
 Patients should consider meeting carbohydrate requirements using the following foods:
o Vegetables.
o Legumes.
o Whole grains.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 73 of 85

o Complex carbohydrates.
 Discourage the consumption of simple carbohydrates.

Protein:
 Women who are pregnant should consume around 1.1 g/kg of protein per day in the second and
third trimesters [L3, RGA2].
 This is higher than for non-pregnant women (0.8 g/kg/day).
 Patients should consider meeting protein requirements from animal, fish, or plant origins.

Fat:
 Less than 10% of calories should be from saturated fats.
 Trans-fatty acids should be avoided.
 The diet should contain 13 g/day of omega-6, and 1.4 g/day of omega-3.
 Women should be encouraged to eat 12 ounces of fish per week.

7.3.5.5 Home glucose monitoring and glycemic targets

HOME GLUCOSE MONITORING GLYCAEMIC TARGETS

Every patient should have a glucometer at home. Should be individualised taking into account the
risk of hypoglycaemia.
Patients on diet management alone, metformin Patients on Insulin should keep their
therapy or single dose of basal insulin, should be capillary BG >4 mmol/l (72 mg/dl) [L3].
advised to monitor 4 times per day, including:
o Fasting; and 1 hour or 2 hours post-meals.

Patient on multi-dose injections of insulin should If achievable without causing problematic

be advised to monitor up to 6-7 times per day to hypoglycaemia [L1, RGA2]:
include: o FBS should be ≤5.3 mmol/L (≤95 mg/dL).
o Fasting. o 1 hour after meals ≤7.8 mmol/L
o Pre-meals. (140mg/dL).
o 1 hour or 2 hours post-meals; and o 2 hours after meals should be ≤6.7 mmol/L
o Before bed-time. (≤120 mg/dL).

Regular monitoring of HBA1C is not

recommended after measurement at initial
diagnosis [L2].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 74 of 85

7.3.5.6 Pharmacological therapy for GDM

7.3.5.6.1 Management of blood glucose:

 Diet and physical activity should be the first step in management.
 If patients fail to achieve the glycaemic targets outlined within 2 weeks, then medication should be
commenced.

7.3.5.6.2 Medication used in GDM:

A- Metformin:
 Should be offered:
o To patients with GDM if BG targets are not being achieved using diet and exercise within
1-2 weeks [L1, RGA2].
 May be preferred to insulin for maternal health if it controls BG sufficiently.
 Patients should be advised that [L2]:
o Metformin cross the placenta.
o No adverse effects on the fetus have been demonstrated, however long-term studies are
needed.
 Insulin should be started if glycaemic control could not be achieved with Metformin; when
Metformin is contraindicated or not acceptable to patients.

B- Insulin
Offer insulin treatment [L1, RGA2]:
 In addition to metformin and diet and lifestyle changes if BG targets are not achieved.
 Refer to Table 3 for further detail on the types of insulin that may be used in pregnancy.

7.3.6 Management of Type 1 And Type 2 Diabetes Mellitus in Pregnancy

7.3.6.1 Nutrition and diet

Pregnant women with diabetes mellitus should follow the same nutritional vitamin and mineral advice
as for women without diabetes in pregnancy

7.3.6.2 Home glucose monitoring and glycaemia targets

A- Home glucose monitoring:

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 75 of 85

 Every patient should have a glucometer at home.

 Patients on diet management alone, metformin therapy or single dose of basal insulin, should be
advised to monitor 4 times per day, including:
o Fasting; and
o 1 hour or 2 hours post-meals.
 Patient on multi-dose injections of insulin should be advised to monitor up to 6-7 times per day to
include:
o Fasting.
o Pre-meals.
o 1 hour or 2 hours post-meals; and
o Before bed-time.

B- Glycemic targets:
 Should be individualised taking into account the risk of hypoglycaemia.
 Patients on Insulin should keep their capillary BG >4 mmol/l (72 mg/dl).
 If achievable without causing problematic hypoglycaemia [L1, RGA2]:
o FBS should be ≤5.3 mmol/L (≤95 mg/dL).
o 1 hour after meals ≤7.8 mmol/L (140mg/dL).
o 2 hours after meals should be ≤6.7 mmol/L (≤120 mg/dL).
o Patients on insulin should keep their capillary BG >4 mmol/l (72 mg/dl).

C- HBA1C monitoring:
 HBA1C should be measured in the first clinic review.
 Due to increases in red blood cell turnover associated with pregnancy, HBA1C levels fall during
pregnancy. HBA1C should be used as a secondary measure and should not replace SMBG.
 HBA1C should be measured at least once in each trimester or more frequently e.g. monthly.
 The frequency of monitoring should be judged by the treating physician [R-GDG].
 HBA1C target is ≤6.5%.

D- Continuous Glucose Monitoring System (CGMS):

 CGMS should be considered for pregnant women on insulin therapy [L1]:
o Who have problematic hypoglycaemia.
o Who have unstable BG levels.
o If self-monitoring of BG has failed to assess glycaemic control; or
o To gain more information about variability in BG.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 76 of 85

7.3.6.3 Hypoglycemia:
 All patients should be advised about the risks of hypoglycaemia, and impaired awareness.
 Patients and one family member, ideally the husband, should be educated regarding treatment of
hypoglycaemia.
 Women with insulin-treated diabetes should always have available fast-acting form of glucose with
them [L2].
 Provide glucagon to pregnant women with T1DM for use if needed [L2].
o A family member, should be educated when and how to use glucagon.

7.3.6.4 Pharmacological Management

 A multi-dose injection (MDI) regime is recommended for the majority of patients.
 Patients with T2DM taking Metformin can be continued on their treatment as usual [L2].
 Patients should be empowered and taught how to adjust their own insulin doses.
 Frequent telephone contact with the diabetes educators is encouraged for those who need support
with dose adjustment.
 The fall in insulin requirement in pregnancy could indicate placental insufficiency. Closer
monitoring of the mother and the fetus is recommended.

7.3.6.5 Management of Complications

Complication Management
Vomiting Patient with diabetes in pregnancy are prone to ketosis in the presence of
recurrent vomiting. They should be instructed on how to cope with it and, in
cases of severe vomiting, they should be hospitalized.

Bolus doses on insulin can be given 15-20 minutes after food to avoid
hypoglycemia in cases of recurrent vomiting [R-GDG]
Nephropathy Pre-existing nephropathy is associated with a poor pregnancy outcome [22, 23].
The incidence of worsening chronic hypertension or pregnancy-induced
hypertension/pre-eclampsia is high (40-70%) in women with both incipient and
overt nephropathy.

All patients should undergo the following:

 Screening for albumin excretion at booking and/or in the first or second
trimester.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 77 of 85

o NB: Proteinuria increases transiently during pregnancy, returning to pre-

pregnancy levels within 3 months of delivery.

Women with nephropathy [R-GDG]:

 Monitor using a morning urine sample for ACR.
 For high-grade proteinuria (particularly if the patient is suspected of having
nephrotic syndrome):
o A 24-hour urine collection for proteinuria may be requested.

Consider referral to a nephrologist if [R-GDG]:

 Serum creatinine is abnormal (≥ 120 umol/l); or
 The urinary ACR is > 30 mg/mmol; or
Total protein excretion exceeds 2g/day.
Retinopathy Pregnancy is a risk factor for the development and progression of diabetic
retinopathy. This may progress into sight threatening disease and can cause
devastating visual impairment.

Retinal assessment by an ophthalmologist:

 Conduct in all women with pre-existing diabetes:
o Conduct retinal assessment in the first trimester and at 28 weeks.
 Conduct in women with diabetes first diagnosed during pregnancy.
o Conduct retinal assessment as soon as possible.
 If retinopathy is noted, then close follow-up throughout pregnancy and for 1
year postpartum, is required.

NB: Diabetic retinopathy should not delay rapid optimization of glycemic control
and should not be considered a contraindication to vaginal delivery [R-GDG].
DKA and HHS Women should be educated about DKA and HHS and its prevention through
SMBG, appropriate diet, suitable pharmacological therapy and sick-day
management. Euglycemic ketoacidosis is also well recognized in pregnancy.

Consider the following:

 Investigation for DKA or HHS, is indicated in women who present with
nausea, vomiting, abdominal pain and hyperglycaemia.
 If diagnosed, admit the patient to a high dependency unit in accordance with
hospital guidelines and include continuous fetal monitoring after 24 weeks

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 78 of 85

gestation.
Immediate delivery may not be necessary as fetal heart rate abnormalities may
resolve with the correction of the metabolic state.
Thyroid All women with T1DM should be screened for thyroid dysfunction with thyroid
dysfunction stimulating hormone (TSH) levels and thyroid peroxidase antibodies during the
first trimester of pregnancy [L1, RGA1].

7.3.7 Special Considerations

7.3.7.1 Ramadan:
 All patients on insulin therapy should be advised not to fast.
 Patients on diet alone or Metformin should be made aware about the risk of ketosis and
dehydration during pregnancy and discouraged from fasting [R-GDG].

7.3.7.2 Driving [R-GDG]

 There are currently no regulations for diabetes and driving in the state of Qatar.
 Patients on insulin treatment during pregnancy are typically on a very intensive regimen which
renders them at higher risk for recurrent hypoglycaemia and hypoglycaemia unawareness.
 Patients who had one or more episode of severe hypoglycaemia and/or, are suffering with hypo
unawareness should be advised not to drive during pregnancy.
 Safe driving advice:
o Check capillary BG prior to starting a journey, do not drive till BG are >5.0 mmol/l.
o Avoid long journeys or take frequent breaks.
o Always keep hypo treatment handy in the car.
o If you felt hypo; stop the car; take the switch off the ignition; correct the hypo and do not
start driving till 45 minutes after normalising the BG.

7.3.8 Post-Natal Care:

POST-NATAL CARE DESCRIPTION

Breast Feeding
Breastfeeding should be actively  There is an increased risk of hypoglycaemia while
encouraged in women with pre- breastfeeding.
existing diabetes, not only for the  Mothers may require less insulin due to the calories

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 79 of 85

Breast Feeding
proven benefits offered to the expended with breastfeeding and may require a
general population but also for the carbohydrate-containing snack before or during breast
protective effects against type 2 feeding.
diabetes in the off spring in later  Diabetes medications which were discontinued for safety
life. reasons in the pre-conceptual or antenatal period should
Women should be advised: continue to be avoided during lactation.
 Women should be advised to maintain frequent contact
with the diabetes service during the postpartum period to
allow for glycemic assessment and insulin dose
adjustment.
 Metformin, glibenclamide and insulin are all considered
compatible with breast feeding.
 Women who intend to formula-feed their infant may
recommence diabetes therapy as per their pre-pregnancy
management.
Post-natal health education and promotion
Women with GDM:  Has increased risk of developing T2 DMD in future and
should be advised for postnatal screening for diabetes
mellitus.
Women with preexisting diabetes  Management should be reviewed at WH NDC in 6
weeks’ time then refer to HGH NDC for future follow up.

8.0 REFERENCES

1. National Clinical Guideline: The diagnosis and management of type 2 diabetes in adults and the
elderly. Ministry of Public Health. 2017
2. Standards of Medical Care in Diabetes. Diabetes Care Volume 40, Supplement 1, January 2017
3. Cefalu WT, Bakris G, Blonde L et al. American Diabetes Association: Standards of medical care
in diabetes - 2016. Diabetes Care 2016; 39: s1-s112.
4. American Diabetes Association (ADA). Diagnosis and classification of diabetes mellitus.
Diabetes Care 2014. 37:S81-S90.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 80 of 85

5. Sacks DB, Arnold M, Bakris GL et al. Guidelines and recommendations for laboratory analysis
in the diagnosis and management of diabetes mellitus. Diabetes Care 2011; 34: 1419-23.
6. Handelsman Y, Bloomgarden ZT, Grunberger G et al. American Association of Clinical
Endocrinologists (AACE) and American College of Endocrinology (ACE) - clinical practice
guidelines for developing a diabetes mellitus comprehensive plan - 2015. Endocrine Practice
2015; 21: 1-86.
7. Mechanick JI, Youdim A, Jones DB et al. Clinical practice guidelines for the perioperative
nutritional, metabolic and nonsurgical support of the bariatric surgery patient - 2013 update.
Endocrine Practice 2013; 19: e1-336.
8. International Diabetes Federation (IDF). IDF Diabetes Altas. Seventh edition. Brussels, Belgium:
IDF; 2015.
9. Supreme Council of Health. Qatar Stepwise Report 2012. Doha: SCH, 2013.
10. National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults:
management. NICE NG28. London: NICE; 2016.
11. Davies MJ, Heller S, Skinner TC, Campbell MJ et al. Effectiveness of the diabetes education
and self management for ongoing and newly diagnosed (DESMOND) programme for people
with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ. 2008;
336(7642):491-5.
12. Garber AJ, Abrahamson MJ, Barzilay JI et al. Consensus statement by the American
Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE)
on the comprehensive type 2 diabetes management algorithm - 2016 executive summary.
Endocrine Practice 2016; 22: 84-113.
13. National Institute for Health and Care Excellence (NICE). Type 2 diabetes: prevention in people
at high risk. NICE PH38. Manchester: NICE; 2012.
14. Al-Bibi K, The state of Qatar. National physical activity guidelines. 1st edn. Doha, Qatar:
Orthopaedic & Sports Medicine Hospital; 2014.
15. Seaquist ER, Anderson J, Childs B et al. Hypoglycemia and diabetes: A report of a workgroup
of the American Diabetes Association and The Endocrine Society. Diabetes Care 2013; 36:
1384-95.
16. Ministry of Public Health. National immunization guidelines for vaccine providers. 2016.
17. Supreme Council of Health. Pneumococcal vaccination in children and teens. 2015.
18. Inzucchi SE, Bergenstal RM, Buse JB et al. Management of hyperglycemia in type 2 diabetes,
2015: A patient centered approach. Diabetes Care 2015; 38: 140-9.
19. Qatar National Formulary. Ministry of Public Health; 2016. Available at: http://crlonline.com/en/
[Accessed 18th December 2016].

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 81 of 85

20. International Diabetes Federation and the DAR International Alliance. Diabetes and Ramadan:
Practical Guidelines. Brussels, Belgium: International Diabetes Federation, 2016. Available at:
www.idf.org/guidelines/diabetes-in-ramadan [Accessed 18th December 2016].
21. Qatar Diabetes Association (QDA). Ramadan Advices. Doha, State of Qatar: QDA; 2016.
22. National Clinical Guideline Centre (NCGC). Hypertension: The clinical management of primary
hypertension in adults. Clinical Guideline 127. London: NCGC; 2011.
23. National Institute for Health and Care Excellence Internal Clinical Guidelines Team. Type 2
diabetes in adults: management. Clinical Guideline NG28. London: NICE; 2015.
24. Stone NJ, Robinson JG, Lichtenstein AH et al. 2013 American College of Cardiology/American
Heart Association guideline on the treatment of blood cholesterol to reduce atherosclerotic
cardiovascular risk in adults: a report of the ACC/AHA Task Force on Practice Guidelines.
Circulation 2014; 129 Suppl 2:1-45.
25. National Institute for Health and Care Excellence (NICE). Ezetimibe for the treatment of primary
heterozygous-familial and non-familial hypercholesterolaemia. Technology appraisal 385.
London: NICE; 2016.
26. Catapano AL, Graham, I, De Backer G, Wickland O et al. ESC/EAS Guidelines for the
management of dyslipidaemias. Euro Heart J. 2016. 37:2999–3058.
27. Scottish Intercollegiate Guidelines Network (SIGN). Antithrombotics: indications and
management. SIGN 129. Edinburgh: SIGN; 2013.
28. Munshi MN, Florez H, Huang ES et al. Management of diabetes in long-term care and skilled
nursing facilities: A position statement of the American Diabetes Association. Diabetes Care
2016; 39: 308-18.
29. Kirkman MS, Jones Briscoe V, Clark N et al. Diabetes in older adults. Diabetes Care 2012; 35:
2650-64.
30. Chiang JL, Kirkman MS, Laffel LM et al. Type 1 diabetes through the life span: a position
statement of the American Diabetes Association. Diabetes Care 2014; 37: 2034-54.
31. Habibzadeh F. Type 1 diabetes in the Middle East. The Lancet 2014; 383: 1.
32. National Clinical Guideline Centre (NCGC). Type 1 diabetes in adults: diagnosis and
management. London: NCGC; 2016.
33. Qatar Diabetes Association (QDA). Haji & diabetes. Doha, State of Qatar: QDA; 2016.
34. National Collaborating Centre for Women's and Children's Health (NCC-WCH). Diabetes (type 1
and type 2) in children and young people: diagnosis and management. London: NCC-WCH;
2015.
35. National Institute for Health and Care Excellence (NICE). Diabetes in children and young
people. Quality Standard 125. London: NICE; 2016.
36. The Look AHEAD Research Group. The Look AHEAD Study: A Description of the Lifestyle
Intervention and the Evidence Supporting It. Obesity (Silver Spring) 2006; 14:737-52.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 82 of 85

37. National Institute for Health and Care Excellence (NICE). Continuous subcutaneous insulin
infusion for the treatment of diabetes mellitus. Technology Appraisal Guidance 151 London:
NICE; 2008.
38. Wolfsdorfa JI, Allgrove J, Craig ME et al. ISPAD Clinical Practice Consensus Guidelines 2014
Compendium. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes
2014; 15: 154-79.
39. Pignone M, Alberts MJ, Colwell JA et al. Aspirin for primary prevention of cardiovascular events
in people with diabetes: a position statement of the American Diabetes Association, a scientific
statement of the American Heart Association, and an expert consensus document of the
American College of Cardiology Foundation. Diabetes Care 2010; 33: 1395-402.
40. Kidney Disease: Improving Global Outcomes Guidelines. 2012 Clinical Practice Guideline for
the evaluation and management of chronic kidney disease. Kidney International Supplements
2013; 3: 1-150.
41. Hod M, Kapur A, Sacks DA, Hadar E et al. The International Federation of Gynecology and
Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis,
management, and care. International Journal of Gynecology and Obstetrics 2015. 131(S3):
S173–S211.
42. Bener A, Saleh N, Al-Hamaq A. Prevalence of gestational diabetes and associated maternal
and neonatal complications in a fast-developing community: global comparisons. Int J Womens
Health 2011; 3: 376-3.
43. NCD Alliance. Non-communicable diseases: a priority for women's health and development.
Geneva, Switzerland: NCD Alliance; 2011.
44. Diabetes Voice. Global perspectives on diabetes. International Diabetes Federation 2009. 54: 2-
44.
45. National Collaborating Centre for Women's and Children's Health (NCC-WCH). Diabetes in
pregnancy: management from preconception to the postnatal period. London: NCC-WCH; 2015.
46. National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy. NICE QS109.
London: NICE; 2016.
47. Morin-Papunen, L. et al. Metformin improves pregnancy and live-birth rates in women with
polycystic ovary syndrome (PCOS): a multicenter, double-blind, placebo-controlled randomized
trial. J. Clin. Endocrinol. Metab. 2012. 97:1492–500.
48. Nawaz, F. H. & Rizvi, J. Continuation of metformin reduces early pregnancy loss in obese
Pakistani women with polycystic ovarian syndrome. Gynecol. Obstet. Invest. 2010. 69:184–9.
49. Hickman, M. A., McBride, R., Boggess, K. A. & Strauss, R. Metformin Compared with Insulin in
the Treatment of Pregnant Women with Overt Diabetes: A Randomized Controlled Trial. Am. J.
Perinatol. 2012.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 83 of 85

50. Pollex, E., Moretti, M. E., Koren, G. & Feig, D. S. Safety of insulin glargine use in pregnancy: a
systematic review and meta-analysis. Ann. Pharmacother. 2011. 45;9–16.
51. Bruttomesso, D. et al. Type 1 diabetes control and pregnancy outcomes in women treated with
continuous subcutaneous insulin infusion (CSII) or with insulin glargine and multiple daily
injections of rapid-acting insulin analogues (glargine-MDI). Diabetes Metab. 2011. 37;426–31.
52. Pantalone, K. M., Faiman, C. & Olansky, L. Insulin glargine use during pregnancy. Endocr.
Pract. 2011. 17;448–55.
53. Callesen, N. F. et al. Treatment with the long-acting insulin analogues detemir or glargine during
pregnancy in women with type 1 diabetes: comparison of glycaemic control and pregnancy
outcome. J. Matern. Fetal. Neonatal Med. 2013. 26;588–92.
54. Blumer, I. et al. Diabetes and pregnancy: an endocrine society clinical practice guideline. J. Clin.
Endocrinol. Metab. 2013. 98;4227–49.
55. National Institute for Health and Care Excellence (NICE). Hypertension in Pregnancy. NICE
CG107. London: NICE; 2011.
56. Owens LA, O'Sullivan EP, Kirwan B, Avalos G et al. ATLANTIC DIP: the impact of obesity on
pregnancy outcome in glucose-tolerant women. Diabetes Care. 2010. 33(3):577-9.
57. Gonzalez-Campoy MJ, St Jeor ST, Castorino K et al. Clinical practice guidelines for healthy
eating for the prevention and treatment of metabolic and endocrine diseases in adults.
Endocrine Practice 2013; 19: 1-82.
58. Landon, M. B. Diabetic nephropathy and pregnancy. Clin. Obstet. Gynecol. 2007. 50: 998-1006.
59. Young EC, Pires MLE, Marques LPJ, de Oliveira JEP et al. Effects of pregnancy on the onset
and progression of diabetic nephropathy and of diabetic nephropathy on pregnancy outcomes.
Diabetes Metab Syndr 2011. 5:137–142.
60. Axer-Siegel, R. et al. Diabetic retinopathy during pregnancy. Ophthalmology 1996. 103:1815–9.
61. Metzger BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth
International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 2007. 30
(Suppl.2):S251–S260.
62. American Diabetes Association. Diabetes in Pregnancy. Diabetes Care 2015. 38(Suppl. 1):S77–
S79.
63. Rouhani, M. H., Azadbakht, L. Is Ramadan fasting related to health outcomes? A review on the
related evidence. J. Res. Med. Sci. 2014. 19:987–92.
64. Committee on Practice Bulletins–Obstetrics. Practice Bulletin No. 137: gestational diabetes
mellitus. Obstet. Gynecol. 2013. 122:406–416.
65. National Clinical Guideline: The diagnosis and management of diabetes mellitus in pregnancy,
Ministry of Public Health- Qatar, December 2016.

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 84 of 85

Indicators:

1. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and had Hemoglobin
A1c (HbA1c) test done at least once every 6 months
2. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were referred to
the Podiatry Screening Clinic at least once annually
3. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were seen at the
Podiatry Screening Clinic at least once annually
4. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were referred to
the Retina Screening Clinic at least once annually
5. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were seen at the
Retina Screening Clinic at least once annually
6. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were referred to
the Diabetes Educator at least once annually
7. Percentage of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and were seen by
the Diabetes Educator at least once annually
8. Percentage of Diabetes Mellitus patients seen in NDC clinics and had Hemoglobin A1c (HbA1c)
test done at least once every 6 months
9. Percentage of Diabetes Mellitus patients seen in NDC clinics and were referred to the Podiatry
Screening Clinic at least once annually
10. Percentage of Diabetes Mellitus patients seen in NDC clinics and were seen at the Podiatry
Screening Clinic at least once annually
11. Percentage of Diabetes Mellitus patients seen in NDC clinics and were referred to the Retina
Screening Clinic at least once annually
12. Percentage of Diabetes Mellitus patients seen in NDC clinics and were seen at the Retina
Screening Clinic at least once annually
13. Percentage of Diabetes Mellitus patients seen in NDC clinics and were referred to the Diabetes
Educator at least once annually
14. Percentage of Diabetes Mellitus patients seen in NDC clinics and were seen by the Diabetes
Educator at least once annually
15. Percentage of pregnant patients with pre-existing Diabetes Mellitus seen in WWRC-NDC clinics
and had Hemoglobin A1c (HbA1c) test done at least once every trimester during the current
pregnancy
16. Percentage of pregnant patients with pre-existing Diabetes Mellitus seen in WWRC-NDC clinics
and were referred for retinal screening at least once during the current pregnancy
17. Percentage of pregnant patients with pre-existing Diabetes Mellitus seen in WWRC-NDC clinics
and were seen by the Diabetes Educator at least once during the current pregnancy

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee

APPENDIX B-1
CLINICAL PRACTICE GUIDELINES

National Diabetes Center Outpatient Management ORIGINAL DATE:

TITLE:
Guidelines January 2019
IDENTIFICATION CG 10032 LAST REVISION DATE:
NUMBER: Jan 2019
HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
Jan 2022

Sheet No. 85 of 85

18. Percentage of pregnant patients with pre-existing Diabetes Mellitus seen in WWRC-NDC clinics
and had fetal ultrasound examination at least once during the 3rd trimester of the current
pregnancy
19. Number of Diabetes Mellitus patients seen in NDC Insulin Pump clinics and had Diabetic
Ketoacidosis (DKA) for the past 12 months
20. Percentage of Diabetes Mellitus patients seen in NDC clinics with <2.6 mmol/L Low Density
Lipoprotein (LDL) level on the latest result for the past 12 months.
21. Percentage of pregnant patients with pre-existing DM seen at WWRC-NDC clinics with
macrosomic fetus at term

Authors:

Diabetes/ Endocrine CPG committee

Dr. Mahmoud Zirie. Head and Sr. Consultant Diabetes and Endocrine
Dr. Sara Mohammed Darwish. Sr. Consultant Diabetes and Endocrine
Dr. Mohammed Bashir. Consultant Diabetes and Endocrine
Ms. Manal Musallam Othman. Head of Diabetes Education
Mr. Zohair Ali Al Arabi. Clinical Dietitian Supervisor

Reviewers:

Dr. Mahmoud Zirie. Head and Sr. Consultant Diabetes and Endocrine
Dr. Mohammed Bashir. Consultant Diabetes and Endocrine
Dr. Zeinab Dabbous, Consultant Diabetes and Endocrine
Ms. Manal Musallam Othman. Head of Diabetes Education
Mr. Zohair Ali Al Arabi. Clinical Dietitian Supervisor
Ms. Enas Abdelgadir Abdoun Pharmacist, NDC
Mr Ayman Tayseer Ghanem, Assistant Executive Director of Nursing

Governance, Leadership & Direction Corporate Clinical Practice Guidelines Committee