Ayla M. Tourkmani

Adherence to the American Diabetes Association standards of care among patients with type 2 diabetes in primary care in Saudi Arabia

Objectives: To assess adherence to 11 American Diabetes Association (ADA) standards of diabetic care. Methods: We conducted this one-year historical prospective study between October 2010 and September 2011 on 450 adult type 2 diabetes patients in a primary care center in Saudi Arabia. We used the definitions of the 2010 ADA standards of diabetic care processes and targets. Results: Four-hundred and fifty medical files were valid. The adherence to ADA process standards of measurement of glycated hemoglobin (HbA1c) was 68.7%, 92.9% for blood pressure, and 80.2% for serum lipids. Screening was lowest for nephropathy (35.6%), and highest for diabetic foot (72%). Adherence to medications ranged between 82.2% for antiplatelets, and 92.4% for dyslipidemia. For outcome standards, 24.2% of the patients had an HbA1c <7%, and 32.2% had controlled blood pressure (<130/80 mm Hg); and 58.5% achieved targeted low-density lipoproteins (LDL). Only 7.2% had glycemic control in addition to controlled blood pressure and targeted LDL level. An increasing trend of patients achieving glycemic control (<7%) was shown throughout follow-up (p=0.003). Conclusions: We found suboptimal adherence with many ADA standards of diabetic care among patients with type 2 diabetes treated at a primary care center in Saudi Arabia. The achievement of outcome standards, either singly or combined, is lower than the adherence rates. However, the figures show improvement in adherence during the follow-up period.

Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes

Background Fasting during the month of Ramadan could lead to acute complications and increased hypoglycemic risk of patients with type 2 diabetes. Therefore, diabetes is one of the diseases that need careful observation and special considerations during Ramadan including patients’ education and counseling. Objectives To evaluate the impact of Ramadan focused education program on acute complications and biomedical parameters. Methods A prospective nonrandomized interventional controlled design was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n=140) received focused individualized diabetic education sessions and antidiabetic medications adjustment before and after Ramadan, while the control group (n=122) received standard diabetic care. A validated hypoglycemia questionnaire was used in both groups to assess the change of the risk. Patients were advised to adjust the dosage and timing of antidiabetic agents according to the recommendations for management of diabetes during Ramadan. Primary outcomes were postintervention change of hypoglycemia score and HbA1c over 6-month follow-up. Data were presented as mean ± standard deviation. HbA1c was expressed in percentage. Results The hypoglycemic scores before, during, and after Ramadan were 14.21±8.50, 6.36±6.17, and 5.44±5.55 in the intervention group, respectively (P<0.001) and 14.01±5.10, 13.46±5.30, and 9.27±4.65 in the control group, respectively (P<0.001). HbA1c levels were 9.79±1.89, 8.26±1.54, and 8.52±1.61 before, during, and after Ramadan in the intervention group, respectively (P<0.001), and 10.04±1.47, 9.54±1.38, and 9.59±1.79 in the control group, respectively (P<0.001). Post-Ramadan reductions of HbA1c and hypoglycemic scores were significantly higher in the intervention group (−13.0% vs −4.5%, P=0.004 for HbA1c and −61.7% vs −33.8%, P<0.001 for hypoglycemic score). Low-density lipoprotein cholesterol improved in the intervention group from 2.41±0.91 mmol/L before Ramadan to 2.28±0.68 mmol/L after Ramadan (P<0.001). No statistically significant effects were observed on blood pressure or body weight in the intervention group. Also, no change was observed in the control group. Conclusion Ramadan educational program had a positive impact with reduction of hypoglycemic risk, HbA1c, and low-density lipoprotein cholesterol. Therefore, it could be recommended for patients with increased risk of hypoglycemia during Ramadan fasting.

Potentially inappropriate medications prescribed for elderly patients through family physicians

The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug–drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.

Microvascular and macrovascular complications of type 2 diabetic mellitus in Central, Kingdom of Saudi Arabia.

Objectives To determine the prevalence of macrovascular and microvascular complications of type 2 diabetes mellitus and its associated determinants. Methods We evaluated the online medical records of patients with type 2 diabetes mellitus who have been seen in chronic disease unit between April and June 2014. Seven hundred and forty-eight participants satisfied the inclusion criteria. Of these, 317 (42.4%) were males with a mean age of 57.9 years, 681 (64.3%) were obese with body mass index (BMI) of greater than 30, while only 9.6% had normal BMI (<25). Results Only 158 (21.1%) had controlled hemoglobin A1c level. Retinopathy prevalence was 14.8% and neuropathy was 5.6%. Macrovascular complications accounted for 12.1%. Patients’ age and duration of diabetes were main predictors of developing complications. Patients with more than 20 years history of diabetes have 30% more odds of developing the complications when compared to patients with less than 10 years of diabetes history. Each increment in age by one year increases the odds of developing microvascular complications by 4% and macro vascular complication by 2%. Conclusion Our results showed diabetic patients with poor glycemic control, and longer duration of diabetic history had higher prevalence of both macrovascular and microvascular.

Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia

AIMS To examine the impact of Ramadan Focused Education Program (RFEP) on medications adjustment in type 2 diabetes patients in Ramadan. METHODS This is a controlled, intervention based study. It was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n = 140) received RFEP on medications doses & timing adjustment before and after Ramadan, while the control group (n = 122) received standard care. RESULTS The dose of insulin glargine was reduced from 42.51 ± 22.16 at the baseline to 40.11 ± 18.51-units during Ramadan (p = 0.002) in the intervention group while it remained the same in the control group before Ramadan and during Ramadan (38.51 ± 18.63 and 38.14 ± 18.46, P = 0.428, respectively). The hypoglycemia score was 14.2 ± (8.5) pre-Ramadan in the intervention and reduced to 6.36 ± 6.17 during Ramadan (p < 0.001) while in the control group, no significant changes were noted before and during Ramadan (14.01 ± 5.10 versus 13.46 ± 5.30). CONCLUSIONS Ramadan Focused Education Program done at a primary healthcare setting had a positive impact on medication adjustment for dose and timing during fasting in Ramadan in diabetic patients, and it can be a useful tool to achieve better outcomes; less hypoglycemia and safe fasting among T2D patients during Ramadan.

The association of metformin use with vitamin B12 deficiency and peripheral neuropathy in Saudi individuals with type 2 diabetes mellitus

Aims To compare the prevalence of vitamin B12 deficiency and peripheral neuropathy between two groups of type 2 diabetes mellitus (T2DM) patients treated with or without metformin, and to determine factors associated with vitamin B12 deficiency therapy and dietary intake of vitamin B12. Methods In this retrospective study, we recruited 412 individuals with T2DM: 319 taking metformin, and 93 non-metformin users. Demographics, dietary assessment for vitamin B12 intakes, and medical history were collected. Participants were assessed for peripheral neuropathy. Blood specimens were collected and checked for serum vitamin B12 levels. The differences between the two groups were analyzed using an independent t-test for continuous data, and the Chi-squared or Fishers exact test was used for categorical data. The relationship of vitamin B12 deficiency with demographics and clinical characteristics was modeled using logistic regression. Results The prevalence of B12 deficiency was 7.8% overall, but 9.4% and 2.2% in metformin users and non-metformin users, respectively. The odds ratio for serum vitamin B12 deficiency in metformin users was 4.72 (95% CI, 1.11–20.15, P = 0.036). There were no significant differences in a test of peripheral neuropathy between the metformin users and non-metformin users (P > 0.05). Low levels of vitamin B12 occurred when metformin was taken at a dose of more than 2,000 mg/day (AOR, 21.67; 95% CI, 2.87–163.47) or for more than 4 years (AOR, 6.35; 95% CI, 1.47–24.47). Conclusion Individuals with T2DM treated with metformin, particularly those who use metformin at large dosages (> 2,000 mg/day) and for a longer duration (> 4 years), should be regularly screened for vitamin B12 deficiency and metformin is associated with B12 deficiency, but this is not associated with peripheral neuropathy.

Hypoglycemia in Type 2 Diabetes Mellitus patients: A review article

Hypoglycemia is an essential issue for diabetic patients and considered a limiting factor in the glycemic management. Heterogeneity of the diseases in Type 2 Diabetes Mellitus can affect the frequency of hypoglycemia, especially when the patient has cardiovascular diseases. There are several factors that lead to hypoglycemia including sulfonylurea therapy, insulin therapy, delaying or missing a meal, physical exercise, or alcohol consumption. Long-term studies reported that repeated hypoglycemia could increase the risk of cardiovascular diseases. During Ramadan fasting, diabetic patients have high incidence of hypoglycemia. Therefore, focused education about hypoglycemia in routine life of diabetic patients and during fasting in Ramadan is important to reduce the complications.

Clinical audit for the adherence to safety monitoring for pioglitazone use in patients with type 2 diabetes in the Al-Wazarat primary care center, Saudi Arabia

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