DR. Wedad Bardisi DM Saudi Guideline.pptx

Editor's Notes

• #3: In 2012, the International Diabetes Federation (IDF) estimated that 371 million people had diabetes . That number is projected to rise to 552 million (or 1 in 10 adults) by 2030. (IDF Diabetes Atlas) http://www.ncbi.nlm.nih.gov/pubmed/22079683 The IDF ranked Saudi Arabia the sixth of the Top Ten countries of the MENA.
• #4: The study of (Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (Riyadh cohort 2): a decade of an epidemic), 2011, found that, the overall crude prevalence of DMT2 was 23.1%. The age-adjusted prevalence of DMT2 was 31.6%. DMT2 prevalence was significantly higher in males, with an overall age-adjusted prevalence of 34.7%, than in females, who had an overall age-adjusted prevalence of 28.6. The overall crude prevalence of obesity was 31.1% . The age-adjusted prevalence of obesity was 40.0%. The prevalence of obesity was higher in females, with an overall prevalence of 36.5%, than in males (25.1% ). The age-adjusted prevalence of hypertension and CAD were 32.6% and 6.9% . Another study conducted in Jeddah, Armed Force hospital to find the Prevalence of diabetes mellitus in a Saudi community, 2011 found the prevalence of diabetes was 34.1% in males and 27.6% in females. The mean (SD) age for onset of diabetes in males and females was 57.5 and 53.4 (13.1) years, respectively. Females <50 years old had a higher prevalence than males in the corresponding age range—34.1% and 25.1%, respectively (P<.0001). The prevalence of diabetes decreased in patients older than 70 years. The prevalence of body mass index of ≥25 was 72.5%. Among patients with diabetes, the prevalence of body mass index of ≥25 was 85.7% . There was a higher prevalence of obesity (body mass index, ≥25) in females (87.7%) as compared to males (83.1%) Reference : Diabetes Impact in Saudi Health, Health minister,,Alruba,an et al - initial report 2008. Khalid A. Alqurashi, Khalid S. Aljabi, and Samia A. Bokhari
• #5: A study Economic costs of diabetes in Saudi Arabia (2013) found that People diagnosed with diabetes, on average, have medical healthcare expenditures that are ten times higher ($3,686 vs. $380) than what expenditures would be in the absence of diabetes. Over 96% of all medical healthcare expenditures attributed to diabetes are incurred by persons of Saudi nationality, with the remaining 4% incurred by persons of non-Saudi nationality. The population age 45-60 incurs 45% of diabetes-attributed costs, with the remaining population under age 15 incurs 3.8%, age 15-44 incurs 27.5%, and age 60 and above incurs 23.8%.(6) Among adults aged 20 to 49 years, those with diabetes were 2 times more likely to see a family physician and 2 to 3 times more likely to see a specialist . Also, people with diabetes were 3 times more likely to require hospital admission in the preceding year with longer lengths of stay . Therefore, the impact of diabetes is significant not only for individuals but also for their families and for society as a whole Reference : Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish Family Community Med. 2013 Jan-Apr; 20(1): 1–7.
• #6: These findings show that the Saudi population can be regarded as a moderate risk population for diabetes mellitus. The present management is unsatisfactory since those who are controlled (HbA1C <7%) are only 20% of diabetic patients. It is suggested that steps must be taken to improve awareness of the disease and to take measures to improve diabetes care Reference : Economic costs of diabetes in Saudi Arabia Abdulkarim K. Alhowaish Family Community Med. 2013 Jan-Apr; 20(1): 1–7.
• #7: Diabetes mellitus is a metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, defective insulin action or both References : National Saudi diabetic guidelines 2014 American diabetes standard of care 2013 http://care.diabetesjournals.org/content/36/Supplement_1/S11.full
• #8: Diabetes mellitus is classified to three main types and other specific types include a wide variety of relatively uncommon conditions, primarily specific genetically defined forms of diabetes or diabetes associated with other diseases or drug use like treatment of HIV or after organ transplantation. Reference : American diabetes standard of care 2013
• #9: HBA1C≥6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay. OR FPG ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. OR . Symptoms of hyperglycemia or hyperglycemic crisis, and a casual (random) plasma glucose ≥ 200 mg/dl (11.1 mmol/l). Casual (random) is defined as any time of day without regard to time since last meal. The classic symptoms of hyperglycemia include polyuria, polydipsia, and unexplained weight loss. OR 2-h plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. *In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeated testing. HbA1c >6.5% Reference : American diabetes standard of care 2013
• #10: Reference : American diabetes standard of care 2013
• #11: These are conditions that place a symptomatic individuals, at risk of developing diabetes and its complications and they would benefit from CV risk factor modification. Reference : American diabetes standard of care 2013
• #12: The clinical spectrum of diabetes ranges from a low-risk to a higher-risk individual or to the symptomatic patient who needs immediate treatment. Screening for diabetes implies testing for diabetes in individuals without symptoms who are unaware of their condition. Screening for diabetes will also detect individuals at increased risk for diabetes (prediabetes) or individuals with less severe states of dysglycemia who may still be at risk for type 2 diabetes. Screening strategies vary according to the type of diabetes and evidence of effective interventions to prevent progression of prediabetes to diabetes and/or reduce the risk of complications associated with diabetes.  The growing importance of diabetes screening is undeniable ,to screen for diabetes and prediabetes, the same tests would be used as for diagnosis of both medical conditions.  To be effective, population-based screening would have to involve wide coverage and would have the goal of early identification and subsequent intervention to reduce morbidity and mortality. References : National Saudi diabetic guidelines first update.2014  Canadian Clinical Practice guidelines 2013 Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1
• #13: Preventing type 2 diabetes would result in significant public health benefits, including lower rates of cardiovascular diseases (CVD), renal failure, blindness and premature mortality. Primary approaches to preventing diabetes in a population include the following: 1) programs targeting high-risk individuals in the community (such as those with impaired glucose tolerance [IGT] or obesity) 2) programs targeting high-risk subgroups of the population, such as high-risk ethnic Groups. and 3) programs for the general population, such as those designed to promote physical activity and healthy eating in adults or children References : National Saudi diabetic guidelines first update.2014 Canadian Clinical Practice guidelines 2013  
• #14: GLYCATED HEMOGLOBIN TESTING Currently,A1C is the preferred standard for assessing glycemic control. A1C is a reliable estimate of mean plasma glucose (PG) levels and a valuable indicator of treatment effectiveness , over the previous 3 to 4 months for most individuals .and should be measured every 3 months when glycemic targets are not being met and when diabetes therapy is being adjusted. Testing at 6-month intervals may be considered in situations when glycemic targets are consistently achieved . In uncommon circumstances where the rate of red blood cell turnover is significantly shortened or extended (certain anaemias), or the structure of hemoglobin is altered ( haemoglobinpathies),A1C may not accurately reflect glycemic status.  References : National Saudi diabetic guidelines first update.2014  Canadian Clinical Practice guidelines 2013
• #15: Reference : Canadian Clinical Practice guidelines 2013 Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1 There some factors which can affect the accuracy of A1C, and the readings are considered false and cannot taken in consideration.  
• #16: Goals should be individualized based on: duration of diabetes age/life expectancy comorbid conditions known CVD or advanced microvascular complications hypoglycemia unawareness Reference: American Diabetes Association2013 Standards of Medical Care in Diabetes 
• #17: Optimal glycemic control is fundamental to the management of diabetes. Both fasting and postprandial plasma glucose levels correlate with the risk of complications and contribute to the measured glycated hemoglobin value. When setting treatment goals and strategies, consideration must be given to individual risk factors such as age, prognosis, presence of diabetes complications or comorbidities, and their risk for and ability to perceive hypoglycemia Reference: American Diabetes Association2013 Standards of Medical Care in Diabetes 
• #18: References : Canadian Clinical Practice guidelines 2013 Canadian journal of diabetes; April 2013 - Volume 37 - Supplement 1
• #19: American Diabetes Association2013 , Standards of Medical Care in Diabetes CG66 in NICE clinical guideline 87 ,September 2010 European Medicines National Saudi diabetic guidelines 2014. Lifestyle modification, including nutritional therapy and physical activity, should continue to be emphasized while pharmacotherapy is being used. As type 2 diabetes is characterized by insulin resistance and ongoing decline in beta cell function, glucose levels will likely worsen over time and treatment must be dynamic. 
• #20: A patient-centered approach should be used to guide choice of pharmacological agents; considerations include efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia risk, and patient preferences (E) Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #21: Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes (A) In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset (E) The ADA and EASD have recently partnered on guidance for individualization of use of medication classes and combinations in patients with type 2 diabetes2 This 2012 position statement is less prescriptive than prior algorithms and discusses advantages and disadvantages of the available medication classes and considerations for their use A patient-centered approach is stressed, taking into account patient preferences, cost and potential side effects of each class, effects on body weight, and hypoglycemia risk If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3–6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin (A) Reference: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #22: When insulin is added to oral antihyperglycemic agents, a single injection of intermediate-acting(NPH) or an extended longacting insulin analogue(insulin glargine or insulin detemir) may be added. This approach may result in better glycemic control with a smaller dose of insulin and may induce less weight gain and less hypoglycemia than that when oral agents are stopped and insulin is used alone . The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin . As type 2 diabetes progresses, doses of basal insulin (intermediate acting or long acting analogues) will need increasing pre-prandial insulin (short acting or rapid acting analogues) may be required. A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels. References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #23: DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective at further lowering glucose levels when combined with insulin therapy. As type 2 diabetes progresses, insulin requirements will likely increase, additional doses of basal insulin (intermediate-acting or long-acting analogues) may need to be added and bolus insulin (short-acting or rapid-acting analogues) may also be required. Insulin regimens based on basal or bolus insulin appear to be equally effective and superior with respect to glycemic lowering compared to biphasic insulin-based regimens References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #24: When other measures no longer achieve or maintain adequate blood glucose control over 3-6 months ,discuss the benefits and risks of insulin therapy. When starting insulin therapy, use a structured programme employing active insulin dose titration that include: Structured education. Frequent self monitoring. Dietary understanding. Management of hypoglycemia. Management of acute changes in plasma glucose control. Support from an appropriately and experienced health care professional References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #25: Begin with human NPH insulin injected at bed-time or twice daily according to need. Consider, as an alternative, using a long-acting insulin analogue (insulin detemir, insulin glargine) if: the person needs assistance from a carer or healthcare professional to inject insulin, and use of a long-acting insulin analogue (insulin detemir, insulin glargine) would reduce the frequency of injections from twice to once daily, or the person's lifestyle is restricted by recurrent symptomatic hypoglycemic episodes, or the person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs, or the person cannot use the device to inject NPH insulin. References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #26: Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ≥ 9.0%). A once-daily regimen may be an option. Consider pre-mixed preparations that include short-acting insulin analogues, rather than pre-mixed preparations that include short-acting human insulin preparations, if: a person prefers injecting insulin immediately before a meal, or hypoglycemia is a problem, or blood glucose levels rise markedly after meals Monitor a person on a basal insulin regimen (NPH insulin or a long-acting insulin analogue [insulin detemir, insulin glargine]) for the need for short-acting insulin before meals (or a pre-mixed insulin preparation). Monitor a person who is using pre-mixed insulin once or twice daily for the need for a further injection of short-acting insulin before meals or for a change to a regimen of mealtime plus basal insulin, based on NPH insulin or long acting insulin analogues (insulin detemir, insulin glargine), if blood glucose control remains inadequate References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #27: The following antihyperglycemic agents (listed in alphabetical order), should be considered to lower postprandial blood glucose levels: a)- Alph-glucosidase inhibitor b)- premixed insulin analogues (i.e. biphasic insulin aspart and insulin lispro/protamine) instead of regular /NPH premixtures . c)- meglitinides (repaglinide, nateglinide) instead of sulfonylureas d)- rapid-acting insulin analogues (aspart, gluslisine, lispro) instead of short-acting insulin (i.e. regular insulin). All individuals with type 2 diabetes currently using or starting therapy with insulin or insulin secretagogues should be counseled about the recognition and prevention of drug-induced hypoglycemia References: National Saudi diabetic guidelines 2014. American Diabetes Association2013 , Standards of Medical Care in Diabetes  CG66 in NICE clinical guideline 87 ,September 2010 European Medicines
• #28: Reference: National Saudi diabetic guidelines 2014.
• #29: Reference: National Saudi diabetic guidelines 2014.
• #30: Reference: National Saudi diabetic guidelines 2014.
• #31: The first priority in the prevention of macrovascular complications should be reduction of cardiovascular (CV) risk through a comprehensive, multifaceted approach, integrating both lifestyle and pharmacologic measures. Low-dose acetylsalicylic acid therapy may be considered in people with stable CVD. The decision to prescribe antiplatelet therapy for primary prevention of CV events, however, should be based on individual clinical judgment References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013  
• #32: Offer low-dose aspirin, (75-162) mg daily, to a person who is (male aged <50 years /female aged <60 years) and has significant other cardiovascular risk factors (features of the metabolic syndrome, strong early family history of cardiovascular disease, smoking, hypertension, extant cardiovascular disease, micro albuminuria) if blood pressure is below 145/90 mmHg Clopidogrel (75mg) should be used instead of aspirin only in those with clear aspirin intolerance. (except in the context of acute cardiovascular events and procedures). *Combination therapy with aspirin(75–162 mg/day) and clopidogrel (75mg/day) is reasonable for up to a year after an acute coronary syndrome. (B)  References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013
• #33: Goals of the screening are to improve life expectancy and quality of life by preventing MI and heart failure through the early detection of coronary artery disease (CAD). The majority (65 to 80%) of people with diabetes will die from heart disease . Compared to people without diabetes, people with diabetes (especially women) are at higher risk of developing heart disease, and at an earlier age. A high proportion of deaths occur in patients with no prior signs or symptoms of cardiovascular disease (CVD). Furthermore, people with diabetes have a high prevalence of silent myocardial ischemia, and almost one-third of myocardial infarctions (MIs) occur without recognized or typical symptoms (silent MIs) .  References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013
• #34: Goals of the screening are to improve life expectancy and quality of life by preventing MI and heart failure through the early detection of coronary artery disease (CAD). The majority (65 to 80%) of people with diabetes will die from heart disease . Compared to people without diabetes, people with diabetes (especially women) are at higher risk of developing heart disease, and at an earlier age. A high proportion of deaths occur in patients with no prior signs or symptoms of cardiovascular disease (CVD). Furthermore, people with diabetes have a high prevalence of silent myocardial ischemia, and almost one-third of myocardial infarctions (MIs) occur without recognized or typical symptoms (silent MIs) . References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013
• #35: Reference: JNC 7
• #36: References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013
• #37: People with diabetes with hypertension should be treated to a systolic blood pressure goal of 140 mmHg. Lower systolic targets, such as ,130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden. Patients with diabetes should be treated to a diastolic blood pressure,80 mmHg References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #38: Life style therapy: low sodium , high potassium, DASH diet and Exercise. ACE inhibitors, or ARBS. Multiple-drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets. If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored Alpha-blockers are not recommended as first-line agents for the treatment of hypertension in persons with diabetes References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #39: A calcium channel blocker should be the first-line blood pressure-lowering therapy for a woman for whom, after an informed discussion, it is agreed there is a possibility of her becoming pregnant (ACE and ARB are absolute contraindication in pregnancy) For people with diabetes and albuminuria (persistent albumin to creatinine ratio [ACR] ≥ 2. 0 mg/mmol in men and women), an ACE inhibitor or an ARB is recommended as initial therapy. If BP remains ≥ 140/80 mm Hg despite lifestyle interventions and the use of an ACE inhibitor or ARB, additional antihypertensive drugs should be used to obtain target BP. For persons with diabetes and a normal urinary albumin excretion rate, with no chronic kidney disease and with isolated systolic hypertension, a long-acting DHP CCB is an alternative initial choice to an ACE inhibitor, an ARB. or a thiazide-like diuretic References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #40: The beneficial effects of lowering low-density lipoprotein cholesterol (LDL-C) with statin therapy apply equally well to people with diabetes as to those without the disease  The primary treatment goal for people with diabetes is LDL-C mmol/L(100mg/dl)HDL-c (≥50 mg/dl),TG ≤ 150 mg/dl) which is generally achievable with statin monotherapy  Achievement of the primary goal may require intensification of lifestyle changes and/or statin therapy and, on occasion, the addition of other lipid-lowering medications References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #41: In adults, screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and yearly thereafter, and 5 years after diagnosis in adults with type 1 diabetes and repeated yearly thereafter. A diagnosis of CKD should be made in patients with a random urine ACR >2.0 mg/mmol and/or an eGFR<60 mL/min on at least 2 of 3 samples over a 3-month period. Screening should be delayed when causes of transient albuminuria or low eGFR are present References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #42: Suspect renal disease, other than diabetic nephropathy and consider further investigation or referral when the albumin: creatinine ratio (ACR) is raised and any of the following apply: there is no significant or progressive retinopathy blood pressure is particularly high or resistant to treatment had a documented normal ACR and develops heavy proteinuria (ACR >100 mg/mmol) significant hematuria is present the glomerular filtration rate has worsened rapidly the person is systemically ill. References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #43: - People with diabetes on an ACE inhibitor or an ARB should have their serum creatinine and potassium levels checked within 1 to 2 weeks of initiation or titration of therapy. .  Potassium and serum creatinine levels should be checked in people with diabetes receiving an ACE inhibitor or ARB during times of acute illness. .  Level A  Level B The use of Thiazide-like diuretics should be considered in individuals with CKD and diabetes for control of sodium and water retention, hypertension or hyperkalemia . Alternatively, furosemide can be substituted for or added to Thiazide-like diuretics for individuals who fail monotherapy with Thiazide-like diuretics or who have severe sodium and water retention or hyperkalemia. Level C Consideration should be given to stopping ACE inhibitor, ARB and/or diuretic therapy during times of acute illness (E. g. febrile illness, diarrhea), especially when intravascular volume contraction is present or suspected. Women should avoid becoming pregnant when receiving ACE inhibitor or ARB therapy, as the use of medications that has been associated with adverse fetal outcomes.  Level C Adults with diabetes and CKD should be given a “sick day” medication list that outlines which medications should be held during times of acute illness . Level C Combination of agents that block the renin-angiotensin-aldosterone system (ACE inhibitor, ARB, DRI) should not be routinely used in the management of diabetes and CKD . Level A A referral to a nephrologist or internist with an expertise in diabetic nephropathy should be considered if there is a chronic, progressive loss of kidney function, if the eGFR is <30 mL/minute. If the ACR is persistently >60 mg/mmol. Or if the individual is unable to achieve BP targets or remain on renal-protective therapies due to adverse effects, such as hyperkalemia or A >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or RRBs. Level A  References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes    
• #44: References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #45: All patients should be screened for distal symmetric polyneuropathy (DPN) starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter, using simple clinical tests; Monofilament , vibration with 128 tuning fork, and reflexes. Management of neuropathy include a trial of duloxetine, gabapentin, or pregabalin References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #46: Erectile dysfunction (ED) affects approximately 34 to 45% of men with diabetes, has been demonstrated to negatively impact quality of life among those affected across all age strata, and may be the earliest sign of cardiovascular disease. All adult men with diabetes should be regularly screened for ED with a sexual function history. The current mainstays of therapy are phosphor diesterase type 5 inhibitors. They have been reported to have a major impact on erectile function and quality of life, and should be offered as first-line therapy to men with diabetes wishing treatment for ED References: National Saudi diabetic guidelines 2014 Canadian Clinical Practice guidelines 2013 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #47: The general recommendations for medical nutrition therapy (MNT)1 are included on this slide Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (A) Because it can result in cost savings and improved outcomes (B), MNT should be covered by insurance and other payers (E) Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists; the best mix of carbohydrates, protein, and fat appears to vary depending on individual circumstances MNT is an integral component of diabetes prevention, management, and self-management education In addition to its role in preventing and controlling diabetes, ADA recognizes the importance of nutrition as an essential component of an overall healthy lifestyle A full review of the evidence regarding nutrition in preventing and controlling diabetes and its complications and additional nutrition-related recommendations can be found in the ADA position statement “Nutrition Recommendations and Interventions for Diabetes,”2 which is being updated as of 2013 References: National Saudi diabetic guidelines 2014 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #48: Recommendations for foot care in patients with diabetes are summarized in four slides For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (LOPS) (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold) (B) Amputation and foot ulceration, consequences of diabetic neuropathy and/or peripheral artery disease (PAD), are common and major causes of morbidity and disability in people with diabetes; early recognition and management of risk factors can prevent or delay adverse outcomes Risk of ulcers or amputations is increased in people who have the following risk factors: Previous amputation Past foot ulcer history Peripheral neuropathy Foot deformity Peripheral vascular disease Visual impairment Diabetic nephropathy (especially patients on dialysis) Poor glycemic control Cigarette smoking
• #49: Recommendations for foot care in patients with diabetes are summarized in four slides This slide illustrates how to perform the 10-g monofilament test2 References: National Saudi diabetic guidelines 2014 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #50: Recommendations for foot care in patients with diabetes are summarized in four slides Provide general foot self-care education to all patients with diabetes (B) A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation (B) Refer patients who smoke, have LOPS and structural abnormalities, or have history of prior lower-extremity complications to foot care specialists for ongoing preventive care and life-long surveillance (C) References: National Saudi diabetic guidelines 2014 American Diabetes Association2013 ,Standards of Medical Care in Diabetes
• #51: Recommendations for foot care in patients with diabetes are summarized in four slides Initial screening for peripheral arterial disease (PAD) should include a history for claudication and an assessment of the pedal pulses; consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic (C) Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options (C) Initial screening for PAD should include a history for claudication and an assessment of the pedal pulses A diagnostic ABI should be performed in any patient with symptoms of PAD Due to the high estimated prevalence of PAD in patients with diabetes and the fact that many patients with PAD are asymptomatic, an ADA consensus statement on PAD (386) suggested that a screening ABI be performed in patients over 50 years of age and be considered in patients under 50 years of age who have other PAD risk factors (e.g., smoking, hypertension, hyperlipidemia, or duration of diabetes >10 years) Refer patients with significant symptoms or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options References: National Saudi diabetic guidelines 2014 American Diabetes Association2013 ,Standards of Medical Care in Diabetes