dm saudi guidelines by dr. wedad bardisi.pptx

The National Saudi Diabetic Guidelines for PHC

Quick Reference For The National Saudi Diabetic Guidelines

For Primary Health care

Dr Wedad BardisiABFM amp SBFM

Chief editor


Introduction

bull The Challenge of Diabetes

bull Diabetes mellitus is a serious condition with potentially devastating complications that affects all age groups worldwide

bull There is a huge increase in number of diabetics by 2030

bull Saudi Arabia the sixth of the Top Ten


Saudi Studies

bull The different national studies for the epidemiology of diabetes

mellitus type 2 found that the incidence increased annually

bull A study at (Riyadh- 2011) found that the overall crude

prevalence of DMT2 was 231

bull Another study at (Jeddah-2011) estimated the prevalence

diabetes was 341 in males and 276 in females


The Cost of diabetes

bull Diabetes and its complications increase costs and service pressures

on Ministry of Health

bull A study Economic costs of diabetes in Saudi Arabia (2013) found

that People diagnosed with diabetes on average have medical

healthcare expenditures that are ten times higher ($3686 vs $380)

than what expenditures would be in the absence of diabetes

bull The impact of diabetes is significant not only for individuals but also

for their families and for society as a whole


bull The Saudi population can be regarded as a moderate risk population for

diabetes mellitus

bull The present management is unsatisfactory since those who are controlled

(HbA1C lt7) are only 20 of diabetic patients

bull It is suggested that steps must be taken to improve awareness of the disease

and to take measures to improve diabetes care


Definition

Diabetes mellitus is a metabolic disorder characterized by the

presence of hyperglycemia due to defective insulin secretion

defective insulin action or both


Classification of DiabetesTable 1 Classification of diabetes

Type 1 diabetes is diabetes that is primarily a result of pancreatic beta cell destruction and is prone toketoacidosis This form includes cases due to an autoimmune process and those for which the etiologyof beta cell destruction is unknown

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

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

Other specific types

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


Diagnosis of diabetes1 HBA1Cge65

OR

2 FPG ge 126 mgdl (70 mmoll)

OR

2 Symptoms of hyperglycemia or hyperglycemic crisis and a casual (random) plasma glucose ge 200 mgdl (111 mmoll)

OR

3 2-hours plasma glucose ge 200 mgdl (111 mmoll) during an OGTT

In the absence of unequivocal hyperglycemia these criteria should be confirmed by repeated testing


Categories of increased risk for diabetes (prediabetes)

1- FPG 100 mgdL (56 mmolL) to 125 mgd (69 mmolL) (IFG)

OR

2- 2-h plasma glucose in the 75-gOGTT 140 mgdL (78 mmolL) to 199 mgdL (110 mmolL)(IGT)

OR

3- A1C 57ndash64

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


Risk factors for pre-diabetes and diabetes

bull Overweight (BMI ge25 kgm2) and have additional risk factors

bull Physical inactivity

bull Family history

bull High-risk raceethnicity

bull Women who delivered a baby weighing 9 lb or had GDM

bull Hypertension

bull HDL cholesterol level

bull polycystic ovary syndrome

bull A1C ge57 IGT or IFG

bull History of CVD


Screening for Type 2 Diabetes

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

should be performed every 3 years in individuals 40 years of age or

in individuals at high risk using a risk calculator

Diabetes will be diagnosed if A1C is ge65

Testing with a 2-hour plasma glucose (2hPG) in a 75 g oral glucose

tolerance test (OGTT) should be undertaken in individuals with an

FPG of 56-69 mmolL(100-125mhdl) andor an A1C of 57-64

in order to identify individuals with diabetes


PreventionDelay of Diabetes

bull Intensive and structured lifestyle modification that results in

loss of approximately 5 of initial body weight can reduce the

risk of progression from impaired glucose tolerance to type 2

diabetes by almost 60

bull Progression from prediabetes to type 2 diabetes can also be

reduced by pharmacologic therapy with metformin (30

reduction) acarbose ( 30 reduction)


Monitoring Glycemic Control

bull Glycated hemoglobin (A1C) is a valuable indicator of glycemic control

bull Self monitoring of blood glucose (SMBG) results and A1Cprovides the best to assess glycemic control

bull The frequency of SMBG should be determined individually


Table 2 Factors that can affect A1CFactor Increased A1C Decreased A1C Variable change in A1C

Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis

Use of erythropoietin iron or B12ReticulocytosisChronic liver diseaseAltered hemoglobin

Fetal hemoglobinHemoglobinopathiesMethemoglobinGenetic determinants

Altered glycation AlcoholismHemoglobinopathies

Chronic renal failureDecreased erythrocyte pH

Ingestion of aspirin vitamin C or vitamin E Increased erythrocyte pH

Erythrocyte destruction Increased erythrocyte lifespanSplenectomy

Decreased erythrocyte lifespanChronic renal failureHemoglobinopathiesSplenomegaly Rheumatoid arthritisAntiretroviralsRibavirinDapsone

Assays Hyperbilirubinemia Carbamylated hemoglobinAlcoholismLarge doses of aspirinChronic opiate use

Hypertriglyceridemia Hemoglobinopathies


Targets for Glycemic Control

bull A1C 70

bull FBS or Pre-prandial capillary plasma glucose

70ndash130mgdL (39ndash72mmolL)

bull Peak postprandial capillary plasma glucose

180 mgdL(100 mmolL)


Optimal glycemic control

bull Individual patient considerations

bull More or less stringent glycemic goals may be appropriate for

individual patients

bull Postprandial glucose may be targeted if A1C goals are not met

despite reaching pre-prandial glucose goals

bull Postprandial glucose measurements should be made 1ndash2 h after

the beginning of the meal generally peak levels in patients with

diabetes


Recommended Targets for Glycemic Control


Pharmacologic Management of Type 2 Diabetes

bull Lifestyle modification including nutritional therapy and

physical activity should continue to be emphasized while

pharmacotherapy is being used

bull Diabetic treatment must be dynamic


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

pharmacological agents considerations include efficacy cost

potential side effects effects on weight comorbidities

hypoglycemia risk and patient preferences

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

eventually indicated for many patients with type 2 diabetes


Treatment Recommendations

bull Metformin is the preferred initial pharmacological agent for type 2 diabetes

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

bull If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3ndash6 months add a second oral agent a GLP-1 receptor agonist or insulin


bull A long acting insulin analogue is added to oral antihyperglycemic agents

bull The addition of bedtime insulin to metformin therapy leads to less weight gain than insulin plus a sulfonylurea or twice daily NPH insulin

bull As type 2 diabetes progresses doses of basal insulin (intermediate acting or long acting analogues) will need increasing pre-prandial insulin (short acting or rapid acting analogues) may be required

bull A combination of oral antihyperglycemic agents and insulin often effectively controls glucose levels


bull DPP-4 inhibitors and GLP-1 receptor agonists have been shown to be effective

bull As type 2 diabetes progresses additional doses of basal insulin may also be required

bull Insulin regimens based on basal or bolus insulin appear to be equally effective and superior to biphasic insulin-based regimens


Insulin Therapy

bull When to initiate insulin therapy

bull Use a structured programme upon insulin initiation


Initiate Insulin Therapy from a choice of a number of insulin types and regimens

bull Begin with human NPH insulin injected at bed-time or twice daily according to need

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


bull Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ge 90)

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

bull Monitor persons on insulin frequently for any modifications


To lower post prandial blood glucose use either of these

a)- Alph-glucosidase inhibitor

b)- premixed insulin analogues

c)- meglitinides

d)- rapid-acting insulin analogues

Important

Counsel all diabetics about the recognition and prevention of

drug-induced hypoglycemia





Anti-platelet therapy for people with diabetes

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


Recommendations

bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged gt50 years female aged gt60 years) if blood pressure is below 14590 mmHg

bull Offer low-dose aspirin (75-162) mg daily to a person who is (male aged lt50 years female aged lt60 years) and has significant other cardiovascular risk factors if blood pressure is below 14590 mmHg

bull Clopidogrel (75mg) should be used instead of aspirin only in those with clear aspirin intolerance (except in the context of acute cardiovascular events and procedures)

bull Combination therapy with aspirin(75ndash162 mgday) and clopidogrel (75mgday) is reasonable for up to a year after an acute coronary syndrome


Identification of Individuals at High Risk of Coronary Events

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

CAD events if 45 years and male or 50 years and female

bull For the younger person (male lt45 years or female lt50 years) with diabetes

the risk of developing CAD may be assessed from the evaluation of risk

factors for CAD (both classical and diabetes related)

bull When assessing the need for pharmacologic measures to reduce risk in the

younger person with diabetes it is important to consider his or her high

lifetime risk of developing CAD


Treatment of Hypertension

bull In the prevention of diabetes-related complications vascular protection is the

first priority followed by control of hypertension in those whose blood

pressure (BP) levels remain above target then nephroprotection for those with

proteinuria

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

a target BP of lt14080 mm Hg to reduce the risk of both micro- and

macrovascular complications

bull Patients with diabetes should be treated to a diastolic blood pressure lt80

mmHg

bull Most people with diabetes will require more than one BP lowering medications

to achieve BP targets

bull


JNC (American) classification OF Blood Pressure

Category Systolic Diastolic

Optimal lt120 And lt80Normal lt130 And or lt85

Prehypertension 130-139 And or 85-89Stage 1 (mild hypertension)

140-159 And or 90-99

Stage 2 (moderate to severe

hypertension)

ge160 And or ge100


Screening And Diagnosis

bull Blood pressure should be measured at every routine visit

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


Goals

bull The goal is 140 for systolic and 80 for diastolic

bull Some cases the systolic is recommended to be 130 for systolic

and 80 for diastolic


Treatment

bull Life style therapy low sodium high potassium DASH diet

Exercise

bull ACE inhibitors or ARBS

bull If ACE inhibitors ARBs or diuretics are used monitor serum

creatinineestimated glomerular filtration rate (eGFR) and

serum potassium levels

bull Alpha-blockers are not recommended


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

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

bull

bull If BP remains ge 14080 mm Hg additional antihypertensive drugs should be used to obtain target BP

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


Dyslipidemia in Diabetes

bull The primary treatment goal for people with diabetes is LDL-C mmolL(100mgdl)HDL-c (ge50 mgdl)TG le 150 mgdl)

bull Achievement of the primary goal may require intensification of lifestyle changes andor statin therapy


Nephropathy

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

bull

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

bull A diagnosis of CKD should be made in patients with a random urine ACR gt20 mgmmol andor an eGFRlt60 mLmin on at least 2 of 3 samples over a 3-month period


bull Suspect renal disease when the albumin creatinine ratio (ACR) is raised and any of the following apply

No retinopathy

High BP or resistant to treatment

had a documented normal ACR and develops heavy proteinuria (ACR gt100 mgmmol)

Haematuria is present

Glomerular filtration rate has worsened rapidly

The person is systemically ill


bull Adults with diabetes and persistent albuminuria (ACR gt2 0

mgmmol in males and females) should receive an ACE

inhibitor or an ARB to delay progression of CKD even in the

absence of hypertension

bull For a person with an abnormal albumin creatinine ratio

maintain blood pressure below 13080mmHg


Retinopathy

bull Screening is important for early detection of treatable disease

bull Screening intervals for diabetic retinopathy vary according to

the individualrsquos age and type of diabetes

bull Tight glycemic BP and lipid control reduces the onset and

progression of sight-threatening diabetic retinopathy

bull Laser therapy reduces the risk of significant visual loss


Neuropathy

bull Screening for distal symmetric polyneuropathy (DPN) starting

at diagnosis of type 2 diabetes and 5 years after the diagnosis

of type 1 diabetes and at least annually thereafter

bull Tests are monofilament vibration with 128 tuning fork and

reflexes

bull Management of neuropathy include a trial of duloxetine

gabapentin or pregabalin


Erectile Dysfunction

bull Erectile dysfunction (ED) affects approximately 34 to 45 ofmen with diabetes

bull All adult men with diabetes should be regularly screened for EDwith a sexual function history

bull The current mainstays of therapy are phosphor diesterase type5 inhibitors


RecommendationsMedical Nutrition Therapy (MNT)

bull Individuals who have prediabetes or diabetes should receive

individualized MNT as needed to achieve treatment goals

preferably provided by a diabetic dietitian


Foot care

bull For all patients with diabetes perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations

ndash Inspection

ndash Assessment of foot pulses

ndash Test for loss of protective sensation 10-g monofilament plus testing any one of

bull Vibration using 128-Hz tuning fork

bull Pinprick sensation

bull Ankle reflexes

bull Vibration perception threshold


Upper panel

bull To perform the 10-g monofilament test place the device perpendicular to the skin with pressure applied until the monofilament buckles

bull Hold in place for 1 second and then release

Lower panel

bull The monofilament test should be performed at the highlighted sites while the patientrsquos eyes are closed


Foot care

bull Provide general foot self-care education

bull Use multidisciplinary approach

ndash Individuals with foot ulcers high-risk feet especially prior ulcer or

amputation

bull Refer patients to foot care specialists for ongoing preventive care

life-long surveillance

ndash Smokers

ndash Loss of protective sensation or structural abnormalities

ndash History of prior lower-extremity complications


bull Initial screening for peripheral arterial disease (PAD)

ndash Include a history for claudication assessment of pedal pulses

ndash Consider obtaining an ankle-brachial index (ABI) many patients with PAD

are asymptomatic

bull Refer patients with significant claudication or a positive ABI for

further vascular assessment

ndash Consider exercise medications surgical options


In Summary

bull Diabetes mellitus is a chronic illness that requires continuing

medical care and ongoing patient self-management education

and support to prevent acute complications and to reduce the

risk of long-term complications

bull Diabetes care is complex and requires multifactorial risk

reduction strategies beyond glycemic control


References

1- the Saudi national diabetic guideline for primary care 2014

2-Diabetes mellitus in Saudi Arabia

Al-Nozha MM Al-Maatouq MA Al-Mazrou YY Al-Harthi SS Arafah MR Khalil MZ Khan NB Al-Khadra A Al-

Marzouki K Nouh MS Abdullah M Attas O Al-Shahid MS Al-Mobeireek A 2004

3- Diabetes Impact in Saudi Health Health ministerAlrubaan et al - initial report 2008

4- Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region Saudi Arabia

(riyadh cohort 2) a decade of an epidemic Nasser M Al-Daghri12 Omar S Al-Attas12 Majed S Alokail12 Khalid

M Alkharfy123 Mansour Yousef4 Shaun Louie Sabico1 and George P Chrousos Al-Daghri et al licensee BioMed

Central Ltd 2011

5- Prevalence of diabetes mellitus in a Saudi community 2011

Khalid A Alqurashi Khalid S Aljabri and Samia A Bokhari

6-IDF Diabetes Atlas Global estimates of the prevalence of diabetes for 2011 and 2030 Received 19 October 2011

accepted 20 October 2011 published online 14 November 2011


References

7-Economic costs of diabetes in Saudi Arabia Abdulkarim K Alhowaish

Family Community Med 2013 Jan-Apr 20(1) 1ndash7

8- Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1

9--Canadian Clinical Practice guidelines 2013

Canadian journal of diabetes April 2013 - Volume 37 - Supplement 1

10-American Diabetes Association2013

Standards of Medical Care in Diabetes

11- CG66 in NICE clinical guideline 87

September 2010 European Medicines


Introduction

bull The Challenge of Diabetes

bull Diabetes mellitus is a serious condition with potentially devastating complications that affects all age groups worldwide

bull There is a huge increase in number of diabetics by 2030

bull Saudi Arabia the sixth of the Top Ten


Saudi Studies



















diabetes mellitus






Definition













OR


OR


OR






OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Saudi Studies



















diabetes mellitus






Definition













OR


OR


OR






OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References






















diabetes mellitus






Definition













OR


OR


OR






OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Definition













OR


OR


OR






OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References



















OR


OR


OR






OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References













OR


OR

3- A1C 57ndash64






bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References














bull Family history



bull Hypertension




bull History of CVD







































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References
















































bull A1C 70




180 mgdL(100 mmolL)





individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References














individual patients





diabetes































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References








































Insulin Therapy















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References






















c)- meglitinides


Important










Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References

















Recommendations




















proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References

























proteinuria





mmHg



bull






140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References















140-159 And or 90-99


hypertension)

ge160 And or ge100






Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References















Goals





Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Treatment


Exercise









bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References













bull








Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References















Nephropathy


bull





No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References












No retinopathy














Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References


















Retinopathy








Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Neuropathy





reflexes














Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References





















Foot care


ndash Inspection





bull Ankle reflexes



Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Upper panel



Lower panel



Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References











Foot care




amputation



ndash Smokers







are asymptomatic





In Summary








References









Central Ltd 2011






References














are asymptomatic





In Summary








References









Central Ltd 2011






References











In Summary








References









Central Ltd 2011






References











References









Central Ltd 2011






References











References










dm saudi guidelines by dr. wedad bardisi.pptx

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