Pharmacological treatment of type 2 diabetes in Saudi Arabia: A consensus statement from the Saudi Society of Endocrinology and Metabolism (SSEM).

BACKGROUND AND AIMS: The list of available treatment options for managing blood glucose in patients with type 2 diabetes (T2D) has grown over recent years making the task of choosing between traditional and newer glucose-lowering agents a difficult one for healthcare providers. METHODS: We summarize treatment algorithms developed by popular professional societies and propose a patient-centered and culture-driven recommendations for selecting diabetes medications for people with T2D in Saudi Arabia. RESULTS: Though most professional societies recognize patient's adherence to medications as an important factor in achieving glycemic targets, published algorithms schemes do not formally enlist adherence to medication as a deciding factor in the choice of glucose-lowering agents. Medication appeal to patients, an important determinant of medication adherence, is influenced by several factors including lifestyle, common beliefs, customs and traditions, health literacy, perception of health and disease, socioeconomic and cultural backgrounds, and religious commitments and obligations. In Saudi Arabia, poor adherence to therapy is a major obstacle to effective management of local people with T2D. CONCLUSIONS: The Saudi population has a unique socioeconomic and cultural background that widely respect adherence to religion and culture; and the applicability of international guidelines for the management of T2D to the Saudi population has been called into question. In this consensus statement, we propose patient-centered and culture-driven recommendations that integrate medication-adherence and medication-cost into overall selection of diabetes medications for people with T2D in Saudi Arabia.

Burden of disease and costs associated with type 2 diabetes in emerging and established markets: systematic review analyses.

Objectives: To estimate the clinical and economic burden of type 2 diabetes (T2D) in established (EST) and emerging markets (EMG).Methods: Three systematic literature reviews were conducted in MEDLINE and Embase to capture all relevant publications reporting 1) the epidemiology of T2D and complications in T2D and 2) the economic burden of T2D and associated complications.Results: In total, 294 studies were included in this analysis. Evidence indicates a high and increasing overall prevalence of T2D globally, ranging up to 23% in EMG markets and 14% in EST markets. Undiagnosed cases were higher in EMG versus EST markets (up to 67% vs 38%), potentially due to a lack of education and disease awareness in certain regions, that could lead to important clinical and economic consequences. Poor glycemic control was associated with the development of several complications (e.g. retinopathy, cardiovascular diseases and nephropathy) that increase the risk of morbidity and mortality. Direct costs were up to 9-fold higher in patients with vs without T2D-related complications.Conclusions: The burden of T2D, related complications and inherent costs are higher in emerging versus established market countries. This review explores potential strategies to reduce costs and enhance outcomes of T2D treatment in developing countries.

Physician-patient communication at prescription of an additional oral drug for type 2 diabetes and its links to patient outcomes - New findings from the global IntroDia® study.

AIMS: To investigate experiences of people with type 2 diabetes (T2DM) at the clinic visit when an additional oral antidiabetes drug (OAD) is prescribed, and how this affects their quality of life, self-management and key outcomes. METHODS: We surveyed adults with T2DM from a large multinational study of patient-physician communication during early T2DM treatment (IntroDia®). We examined their experiences when an additional OAD is prescribed ("add-on") after initial OAD monotherapy, focusing on 24 key conversational elements, overall patient-perceived communication quality (PPCQ), and associations with current patient-reported outcomes. The links between PPCQ and people's efforts to delay add-on therapy were also assessed. RESULTS: 4235 people with T2DM prescribed an additional OAD, or a combination of two, were analysed. Exploratory factor analyses of the conversational elements during add-on yielded three coherent, meaningful factors: Encouraging (Cronbach's α = 0.62), Collaborative (α = 0.81), and Discouraging (α = 0.81). PPCQ was positively associated with Encouraging (ß = +1.252, p < 0.001) and Collaborative (ß = +1.206, p < 0.001), but negatively associated with Discouraging (ß = -0.895, p < 0.001). Better PPCQ at add-on was associated with less diabetes distress, greater well-being and better self-care at the present time. Approximately 20% of people bargained (two-thirds successfully) with their physician to delay additional medication. Non-bargaining individuals reported significantly better mean PPCQ, diabetes distress, well-being and self-care than those who bargained. CONCLUSIONS: Encouraging and patient-inclusive conversations at add-on moments may improve patient well-being and self-care outcomes. People with T2DM who attempted to delay additional medication reported poorer PPCQ and outcomes.

Physician experiences when discussing the need for additional oral medication with type 2 diabetes patients: Insights from the cross-national IntroDia® study.

AIMS: Physician-patient communication when discussing the need for additional oral medication for type 2 diabetes (add-on) may affect the self-care of people with this condition. We aimed to investigate physicians' recalled experiences of the add-on consultation. METHODS: We conducted a cross-sectional survey of physicians treating people with type 2 diabetes in 26 countries, as part of a large cross-national study of physician-patient communication during early treatment of type 2 diabetes (IntroDia®). The survey battery included novel questions about physician experiences at add-on and the Jefferson Scale of Physician Empathy. RESULTS: Of 9247 eligible physicians, 6753 responded (73.0% response rate). Most (82%) agreed that physician-patient discussions at add-on strongly influence patients' disease acceptance and treatment adherence. Half the physicians reported ≥1 challenge in most or all add-on conversations, with a significant inverse relationship between frequency of challenges and Jefferson Scale of Physician Empathy score (standardised ß coefficient: -0.313; p < 0.001). Physicians estimated that only around half their patients with type 2 diabetes follow their self-care advice. Exploratory factor analysis of physician beliefs about why their patients did not follow recommendations yielded two distinct dimensions: psychosocial barriers (e.g. depressed mood) and personal failings of the patient (e.g. not enough willpower) (r = 0.37, p < 0.001). CONCLUSIONS: Physicians' empathy and beliefs about their patients may play a significant role in their success with the add-on conversation and, consequently, promotion of patient engagement and self-care. Although the study was limited by its retrospective, cross-sectional nature, the findings from IntroDia® may inform efforts to improve diabetes care.

Competency of Prefilled Insulin Pen Usage Among Diabetes Patients in Saudi Arabia: A Cross-sectional Study.

BACKGROUND: Correct insulin injection practice is essential for better diabetic control. The aim of this study is to investigate the level of competency of prefilled insulin pen usage (injection technique and storage) among diabetes patients in Saudi Arabia. METHODS: A cross-sectional survey between March 2017 to July 2017 of randomly selected patients with diabetes attending Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia, who are actively using a prefilled insulin pen, were interviewed to complete a pre-structured questionnaire to assess the competency of using the insulin pen. The contents of the questionnaire addressed the 6 competency components according to manufacturer recommendation (priming, count time, storage, using new needles, a store with no needles, and discard date), background, clinical and metabolic data. Results of the questionnaire were analyzed to identify common pitfalls and were also contrasted with background clinical and metabolic data. RESULTS: 165 patients with diabetes (aged 14-70yrs) were interviewed for the study and all questioners completed properly. Only 14 (8.5%) patients were following all of the six competency components. Count time 52 (31.6%) was the least followed competency component of the six, whereas discard date and storage of insulin pen were the most followed with 165 (100%) and 159 (96.4%), consecutively. Education was the only significant variable related to the following more than 3 of the competency components, and logistic regression showed the college or higher educated patients to be three times more likely follow more than 3 of the competency components. CONCLUSION: The study concluded that majority of patients are either ignoring or unaware of the major components of correct use of prefilled insulin in Saudi Arabia.

Common Pathogens and Antibiotic Sensitivity Profiles of Infected Diabetic Foot Ulcers in Saudi Arabia.

We sought to define the type and antibiotic sensitivity response of pathogens isolated from diabetic foot ulcers based on ulcer location and Wagner classification. This retrospective analysis was done among 126 patients between 40 and 70 years of age at the Prince Sultan Military Medical City, Riyadh, Saudi Arabia, using the swab culture method for microbiological assessment. Data on demographic variables, ulcer sites (location), and depth of ulcer (Wagner classification) were also collected. A total of 134 pathogens were isolated from 126 patients. The most common gram-negative pathogen identified was Pseudomonas aeruginosa (15.6%), followed by Klebsiella spp (6.7%). The most common gram-positive pathogen was Staphylococcus aureus (35%), followed by Streptococcus (8.9%). The most widely accepted antibiotic to which the gram-negative bacteria were sensitive was gentamycin (20.1%), followed by ciprofloxacin (19%). The most routinely used antibiotic in the treatment of the gram-positive bacteria was erythromycin (16%), with trimethoprim-sulfamethoxazole (14.1%) being the next most effective. In conclusion, Pseudomonas aeruginosa, Klebsiella spp, Staphylococcus aureus, and Streptococcus were the most common causes of diabetic foot infections. However, the frequency of encountered pathogens and respective sensitivity to antibiotic therapy may be influenced by the location site and severity of the ulceration.

Physician-patient communication at diagnosis of type 2 diabetes and its links to patient outcomes: New results from the global IntroDia® study.

AIMS: To investigate patient experiences during the diagnosis of type 2 diabetes mellitus (T2DM), focusing on how physician-patient communication at diagnosis influences patients' psychosocial stress and subsequent self-management and outcomes. METHODS: We surveyed adults with T2DM in 26 countries in a large cross-national study of physician-patient communication during early T2DM treatment (IntroDia®). The self-report questionnaire assessed retrospectively patient experiences during diagnosis conversations (focusing on 43 possible conversational elements, and communication quality) and potential effects on patient-reported outcomes. RESULTS: Data from 3628 people with T2DM who had been prescribed oral treatment at diagnosis were analysed. Exploratory factor analyses of the conversational elements yielded four coherent, meaningful factors: Encouraging (Cronbach's α=0.86); Collaborative (α=0.88); Recommending Other Resources (α=0.75); and Discouraging (α=0.72). Patient-perceived communication quality (PPCQ) at diagnosis was positively associated with Encouraging (ß=+1.764, p<0.001) and Collaborative (ß=+0.347, p<0.001), negatively associated with Discouraging (ß=-1.181, p<0.001) and not associated with Recommending Other Resources (ß=+0.087, p=0.096), using a stable path model. PPCQ was associated with less current diabetes distress, greater current well-being and better current self-care. Conversation elements comprising factors associated with better PPCQ (Encouraging and Collaborative) were recalled more frequently by patients than elements associated with poor PPCQ (Discouraging). CONCLUSIONS: Better physician-patient communication at T2DM diagnosis may contribute to subsequent greater patient well-being and self-care, and may be enhanced by greater physician use of Collaborative and Encouraging conversation elements.

Empa's New Clothes: The Untold Story of the Empa-Reg Outcome Trial.

It is no secret that the diabetes community has been yearning for good news for quite some time. One outstanding issue undermining effective diabetes management has been the lack of demonstrable effects of glycemic interventions on cardiovascular (CV) outcome in people with type 2 diabetes. This, however, seems to have changed recently after the publication of the Empa-Reg Outcome Trial. The study reported an impressive reduction in CV deaths that was observed within weeks of treatment with the diabetes agent, Empagliflozin. The results exceeded all expectations and was quickly embraced by a wide and receptive diabetes audience. Fans and admirers of the study have since set out to accommodate the new findings to reshape our diabetes practice guidelines. However, before everything becomes cast in stone, I believe there's another side to the story of the Empa-Reg Outcome trial that the diabetes community needs to hear. Here, I debate the merits of the study and present the case as to why I think we might be led down the garden path by accepting this study at mere face value.

Double diabetes in Saudi Arabia: A new entity or an underestimated condition.

AIM: To determine the clinical and biological characteristics of double diabetes (DD) among young people in Saudi Arabia. METHODS: This was a retrospective descriptive chart review study including 312 young newly diagnosed diabetic patients (aged 12-20 years), whom were admitted over a five year period (January 2009 to December 2013). Family history of diabetes mellitus (DM) (first degree), physical body mass index (BMI), acanthosis nigricans, history of auto-immune disease and laboratory information for glycosylated hemoglobin, basal C peptide level and diabetes autoantibody response (anti-GAD, anti-IA2 and anti-ICA) were collected from medical report. A mean follow-up of 3 years for these patients was performed. RESULTS: Patients were categorized into 4 groups, based on the autoantibody response (Ab+ or Ab-) and C-peptide secretion (ß+ for fasting level 0.4-2.1 ng/mL and ß- if < 0.4 ng/mL). Group1 (type 1a): Ab+ ß- (21%), group 2 (type 1b): Ab- ß- (9%), group 3 (DD): Ab+ ß+ (31%) and group 4 (classic type 2 DM): Ab- ß+ (39%). The mean age of the DD patients in our study was 15.1 ± 6.4 years. A total of 41% of the study population presented with diabetic ketoacidosis and 61% of the study population presented with positive family history of DM. The mean BMI was 26.8 kg/m2 with 64% of overweight or obese patients. Ninety two percent of the patients were started on insulin at the time of diagnosis. During a mean follow-up of 3 years, only 32% of the patients with DD required insulin and 78% were on metformin alone or with insulin. CONCLUSION: Our findings enable us to arrive at the conclusion that almost one-third of the young Saudi diabetic patients reveal atypical forms of DM (double diabetes) expressing features resulting from both T1D and T2D.

Factors Associated with Health-Related Quality of Life among Saudi Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Survey.

BACKGROUND: Diabetes mellitus (DM) is associated with high mortality, morbidity, poor general health, and loss of health-related quality of life (HRQOL). The objective of the study was to assess the factors associated with HRQOL among patients with type 2 diabetes mellitus (T2DM). METHODS: This was a cross sectional study conducted among 283 T2DM patients during June 2011 and September 2012 at a major tertiary hospital in Riyadh, Saudi Arabia. The respondents were purposively and conveniently selected according to their availability during their routine visit to the outpatient clinics and they were interviewed using the Arabic version of the Short-Form 36-item survey (SF-36) to assess the HRQOL. RESULTS: The mean age of the participants was 56.4±13.2 years. Around 63% (178) were males and 37% (105) were females. Glycosylated hemoglobin level was found to be significantly higher among female and HRQOL was higher among male. Respondents who were more than 50 years old had poor HRQOL than less than 50 years age group. Poor economic status, reported diabetic complications and longer duration of diabetes were significantly associated with poor HRQOL. The respondents treated with combination of therapies (oral medication plus insulin) indicated better HRQOL than patients with insulin therapy alone. Multivariate analysis indicated that gender, economic status (except subscale energy), and complications of DM (except subscale energy) as independent risk factor for HRQOL. CONCLUSION: Gender, economic status, and complication of DM were independent risk factors for majority of the subscales of HRQOL.

6(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG) applications and beyond, April 25-27, 2013, Riga, Latvia.

International experts in the fields of diabetes, diabetes technology, endocrinology, and pediatrics gathered for the 6(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG) Applications and beyond. The aim of this meeting was to continue setting up a global network of experts in this field and provide an international platform for exchange of ideas to improve life for people with diabetes. The 2013 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures. All these discussions were intended to help identify gaps and areas where further scientific work and clinical studies are warranted.

Impact of an education program on patient anxiety, depression, glycemic control, and adherence to self-care and medication in Type 2 diabetes.

BACKGROUND: Diabetes mellitus (DM) requires continuous medical care, patients' self-management, education, and adherence to prescribed medication to reduce the risk of long-term complications. The aim of this study was to assess the benefits of an education program on diabetes, patient self-management, adherence to medication, anxiety, depression and glycemic control in type 2 diabetics in Saudi Arabia. MATERIALS AND METHODS: This was a prospective study, conducted among 104 diabetic patients at a major tertiary hospital in Riyadh, Saudi Arabia, between May 2011 and October 2012. Education materials given to diabetic patients included pamphlets/handouts written in Arabic, the national language. Special videotapes about DM were made and distributed to all participants. In addition, specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged. Patients were interviewed using a structured interview schedule both during the baseline, and after 6 months of the program. The interview schedule included, socio-demographics, clinical characteristics, diabetes self-management, adherence to medication, anxiety, and depression. Glycemic control was considered poor, if hemoglobin A1c (HbA1c) was ≥ 7%. RESULTS: The mean age of the study population was 57.3 ± 14.4 years. Seventy one were males (68.3%) and 33 (31.7%) were females. After six months of the diabetes education program, there were significant improvements in patients' dietary plan (P = 0.0001), physical exercise (P = 0.0001), self-monitoring of blood glucose (SMBG) (P = 0.0001), HbA1c (P = 0.04), adherence to medication (P = 0.007), and depression (P = 0.03). CONCLUSIONS: Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan, physical exercise, SMBG, adherence to medication, HbA1c and depression.