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      Patient Preference and Adherence (submit here)

      This international, peer-reviewed Open Access journal by Dove Medical Press focuses on the growing importance of patient preference and adherence throughout the therapeutic process. Sign up for email alerts here.

      34,896 Monthly downloads/views I 2.314 Impact Factor I 3.8 CiteScore I 1.14 Source Normalized Impact per Paper (SNIP) I 0.629 Scimago Journal & Country Rank (SJR)

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      Illness Perceptions, HbA1c, And Adherence In Type 2 Diabetes In Saudi Arabia

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          Abstract

          Purpose

          Little is known about predictors of adherence to diabetes medication in Saudi Arabia. This study aimed to investigate whether illness perceptions, beliefs about medicine, and God locus of health control beliefs were associated with adherence to medication and glycaemic control (HbA1c) in Saudi patients with type 2 diabetes (T2D).

          Patients and methods

          A convenience sample of 115 adults with T2D were recruited from a diabetes outpatient clinic. Validated self-reported measures of adherence to medication, illness perceptions, beliefs about medicine, and God locus of health control were administered. Patients’ most recent HbA1c levels were extracted from medical records. Multivariable logistic and linear regressions were used to examine the association between illness perceptions, beliefs about medicine and adherence to medication and HbA1c.

          Results

          More than two thirds of patients (69%) reported poor adherence to medication. All illness perceptions domains, beliefs about medicine, and God locus of health control beliefs were associated with adherence. Multivariable logistic regression revealed that older age (OR= 3.76, p= 0.023), worse consequences perceptions (OR= 0.21, p= 0.011), worse illness identity (OR= 0.23, p= 0.010), and greater illness coherence (OR= 3.24, p= 0.022) were independent predictors of adherence. Two thirds of patients (67%) had suboptimal HbA1c; and perceptions of a cyclical timeline and lower insulin effectiveness were associated with higher HbA1c. In multiple linear regression, perceptions of a cyclical timeline (β= 0.19, p= 0.040) were an independent significant predictor of HbA1c.

          Conclusion

          In Saudi Arabia, patients’ perceptions of T2D, beliefs about medicine, and God locus of control beliefs are associated with adherence. These results inform the development of interventions based on the Common-Sense Model (CSM) to encourage improved adherence and glycaemic control among Saudi patients with T2D. Further research with larger and more diverse samples is warranted to expand the generalizability of these findings.

          Most cited references37

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          Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors

          At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.
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            Determinants of patient adherence: a review of systematic reviews

            Purpose: A number of potential determinants of medication non-adherence have been described so far. However, the heterogenic quality of existing publications poses the need for the use of a rigorous methodology in building a list of such determinants. The purpose of this study was a systematic review of current research on determinants of patient adherence on the basis of a recently agreed European consensus taxonomy and terminology. Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library, IPA, and PsycINFO were systematically searched for systematic reviews published between 2000/01/01 and 2009/12/31 that provided determinants on non-adherence to medication. The searches were limited to reviews having adherence to medication prescribed by health professionals for outpatient as a major topic. Results: Fifty-one reviews were included in this review, covering 19 different disease categories. In these reviews, exclusively assessing non-adherence to chronic therapies, 771 individual factor items were identified, of which most were determinants of implementation, and only 47—determinants of persistence with medication. Factors with an unambiguous effect on adherence were further grouped into 8 clusters of socio-economic-related factors, 6 of healthcare team- and system-related factors, 6 of condition-related factors, 6 of therapy-related factors, and 14 of patient-related factors. The lack of standardized definitions and use of poor measurement methods resulted in many inconsistencies. Conclusions: This study provides clear evidence that medication non-adherence is affected by multiple determinants. Therefore, the prediction of non-adherence of individual patients is difficult, and suitable measurement and multifaceted interventions may be the most effective answer toward unsatisfactory adherence. The limited number of publications assessing determinants of persistence with medication, and lack of those providing determinants of adherence to short-term treatment identify areas for future research.
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              Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers

              (2019)
              The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care. The ADA’s Professional Practice Committee, which includes physicians, diabetes educators, registered dietitians (RDs), and public health experts, develops the Standards. The Standards include the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes. ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation. A—Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered B—Supportive evidence from well-conducted cohort studies C—Supportive evidence from poorly controlled or uncontrolled studies E—Expert consensus or clinical experience This is an abridged version of the 2019 Standards containing the evidence-based recommendations most pertinent to primary care. The tables and figures have been renumbered from the original document to match this version. The complete 2019 Standards of Care document, including all supporting references, is available at professional.diabetes.org/standards. 1. IMPROVING CARE AND PROMOTING HEALTH IN POPULATIONS Diabetes and Population Health Recommendations Ensure treatment decisions are timely, rely on evidence-based guidelines, and are made collaboratively with patients based on individual preferences, prognoses, and comorbidities. B Align approaches to diabetes management with the Chronic Care Model, emphasizing productive interactions between a prepared proactive care team and an informed activated patient. A Care systems should facilitate team-based care, patient registries, decision support tools, and community involvement to meet patient needs. B Population health is defined as “the health outcomes of a group of individuals, including the distribution of health outcomes within the group”; these outcomes can be measured in terms of health outcomes (mortality, morbidity, health, and functional status), disease burden (incidence and prevalence), and behavioral and metabolic factors (exercise, diet, A1C, etc.). Clinical practice recommendations for health care providers are tools that can ultimately improve health across populations; however, for optimal outcomes, diabetes care must also be individualized for each patient. Thus, efforts to improve population health will require a combination of system-level and patient-level approaches. The proportion of patients with diabetes who achieve recommended A1C, blood pressure, and LDL cholesterol levels has increased in recent years. Nevertheless, a 2013 report found that 33–49% of patients still did not meet general targets for glycemic, blood pressure, or cholesterol control, and only 14% met targets for all three measures while also avoiding smoking. Diabetes poses a significant financial burden to individuals and society. After adjusting for inflation, economic costs of diabetes increased by 26% from 2012 to 2017. This is attributed to the increased prevalence of diabetes and the increased cost per person with diabetes. The Chronic Care Model (CCM) is an effective framework for improving the quality of diabetes care and includes six core elements: Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach) Self-management support Decision support (basing care on evidence-based, effective care guidelines) Clinical information systems (using registries that can provide patient-specific and population-based support to the care team) Community resources and policies (identifying or developing resources to support healthy lifestyles) Health systems (to create a quality-oriented culture) Redefining the roles of the health care delivery team and empowering patient self-management are fundamental to the successful implementation of the CCM. Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients’ self-management. Tailoring Treatment for Social Context Recommendations Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. A Refer patients to local community resources when available. B Provide patients with self-management support from lay health coaches, navigators, or community health workers when available. A Health inequities related to diabetes and its complications are well documented and are heavily influenced by social determinants of health. Social determinants of health are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. Food insecurity (FI) is the unreliable availability of nutritious food and the inability to consistently obtain food without resorting to socially unacceptable practices. FI affects more than 14% of the U.S. population, with higher rates in some racial/ethnic minority groups, in low-income households, and in homes headed by a single mother. FI is associated with increased risk for type 2 diabetes, suboptimal glycemic control, psychosocial conditions, and low treatment adherence. Community health workers (CHWs), peer supporters, and lay leaders may assist in the delivery of diabetes self-management education and support (DSMES) services, particularly in underserved communities. CHWs can be part of a cost-effective, evidence-based strategy to improve the management of diabetes and cardiovascular risk factors in underserved communities and health care systems. 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Diabetes can be classified into the following general categories: Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance) Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation) Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation) Diagnostic Tests for Diabetes Recommendations Testing for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes (Table 1). B For all people, testing should begin at age 45 years. B If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. C In patients with prediabetes and type 2 diabetes, identify and, if appropriate, treat other cardiovascular disease risk factors. B Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents who are overweight (BMI ≥85th percentile) or obese (BMI ≥95th percentile) and who have additional risk factors for diabetes. See Table 2 for evidence grading of risk factors. TABLE 1. Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults 1. Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the following risk factors:  • First-degree relative with diabetes  • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)  • History of CVD  • Hypertension (≥140/90 mmHg or on therapy for hypertension)  • HDL cholesterol level 250 mg/dL (2.82 mmol/L)  • Women with polycystic ovary syndrome  • Physical inactivity  • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) 2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly. 3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. 4. For all other patients, testing should begin at age 45 years. 5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. IFG, impaired fasting glucose; IGT, impaired glucose tolerance. TABLE 2. Risk-Based Screening for Type 2 Diabetes or Prediabetes in Asymptomatic Children and Adolescents in a Clinical Setting Testing should be considered in youth* who are overweight (≥85% percentile) or obese (≥95 percentile) A and who have one or more additional risk factors based on the strength of their association with diabetes: • Maternal history of diabetes or GDM during the child’s gestation A • Family history of type 2 diabetes in first- or second-degree relative A • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) B * After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing, is recommended. Diabetes and prediabetes may be screened based on plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value during a 75-g oral glucose tolerance test (OGTT), or A1C criteria (Table 3). TABLE 3. Criteria for the Screening and Diagnosis of Diabetes Prediabetes Diabetes A1C 5.7–6.4%* ≥6.5%† FPG 100–125 mg/dL (5.6–6.9 mmol/L)* ≥126 mg/dL (7.0 mmol/L)† OGTT 140–199 mg/dL (7.8–11.0 mmol/L)* ≥200 mg/dL (11.1 mmol/L)† RPG ≥200 mg/dL (11.1 mmol/L)‡ * For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range. † In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate samples. ‡ Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis. RPG, random plasma glucose. There is incomplete concordance between A1C, FPG, and 2-h PG, and the 2-h PG value diagnoses more people with prediabetes and diabetes than the FPG or A1C cut points. Marked discrepancies between measured A1C and plasma glucose levels should prompt consideration that the A1C assay may not be reliable for that individual, since a relatively small percentage of patients have conditions such as sickle cell trait or hemoglobinopathies that skew A1C results. See “6. Glycemic Targets” in the complete 2019 Standards of Care for conditions causing discrepancies. Unless there is a clear clinical diagnosis based on overt signs of hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples. If using two separate test samples, it is recommended that the second test, which may either be a repeat of the initial test or a different test, be performed without delay. If patients have test results near the margins of the diagnostic threshold, the health care professional should follow the patient closely and repeat the test in 3–6 months. 3. PREVENTION OR DELAY OF TYPE 2 DIABETES Recommendation At least annual monitoring for the development of type 2 diabetes in those with prediabetes is suggested. E “Prediabetes” is the term used for individuals whose glucose levels do not meet the criteria for diabetes but are too high to be considered normal. (See Table 3.) Prediabetes should not be viewed as a clinical entity in its own right but rather as an increased risk for diabetes and cardiovascular disease (CVD). Screening for prediabetes and type 2 diabetes risk through an informal assessment of risk factors or with an assessment tool such as the ADA risk test is recommended to guide providers on whether to perform a diagnostic test for prediabetes (Table 3) and previously undiagnosed type 2 diabetes. Lifestyle Interventions Recommendations Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing type 2 diabetes and should be considered. B Several major randomized controlled trials, including the Diabetes Prevention Program (DPP), have demonstrated that an intensive lifestyle intervention can reduce the incidence of type 2 diabetes. In the DPP, diabetes incidence was reduced by 58% over 3 years. Follow-up in the Diabetes Prevention Program Outcomes Study has shown sustained reduction in the rate of conversion to type 2 diabetes of 34% at 10 years and 27% at 15 years. The DPP’s 7% weight loss goal was selected because it was feasible to achieve and maintain and likely to lessen the risk of developing diabetes. Nutrition Structured behavioral weight loss therapy, including a reduced calorie meal plan and physical activity, is of paramount importance for those at high risk for developing type 2 diabetes who have overweight or obesity. Based on intervention trials, the eating patterns that may be helpful for those with prediabetes include a Mediterranean eating plan and a low-calorie, low-fat eating plan. Additional research is needed regarding whether a low-carbohydrate eating plan is beneficial for persons with prediabetes. In addition, evidence suggests that the overall quality of food consumed (as measured by the Alternative Healthy Eating Index), with an emphasis on whole grains, legumes, nuts, fruits, and vegetables and minimal refined and processed foods, is also important. Whereas overall healthy low-calorie eating patterns should be encouraged, there is also some evidence that particular dietary components impact diabetes risk in observational studies. Higher intakes of nuts, berries, yogurt, coffee, and tea are associated with reduced diabetes risk. Conversely, red meats and sugar-sweetened beverages are associated with an increased risk of type 2 diabetes. Cost-Effectiveness A cost-effectiveness model suggested that the lifestyle intervention used in the DPP was cost-effective. The use of CHWs to support DPP efforts has been shown to be effective with cost savings. The Centers for Medicare & Medicaid Services has expanded Medicare reimbursement coverage for the Centers for Disease Control and Prevention (CDC)-coordinated National DPP lifestyle intervention to CDC-recognized organizations that become Medicare suppliers for this service. Pharmacologic Interventions Recommendation Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged 5% weight loss should be prescribed for patients with type 2 diabetes who are overweight or obese and ready to achieve weight loss. A Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A Diets should be individualized, as those that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. A For patients who achieve short-term weight-loss goals, long-term (≥1 year) comprehensive weight maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently) and/or other self-monitoring strategies, such as tracking intake, steps, etc.; continued consumption of a reduced-calorie diet; and participation in high levels of physical activity (200–300 min/week). A To achieve weight loss of >5%, short-term (3-month) interventions that use very low-calorie diets (≤800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. B Pharmacotherapy Recommendations When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. E Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits must be weighed against the potential risks of the medications. A If a patient’s response to weight-loss medications is 10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. E Consider initiating dual therapy in patients with newly diagnosed type 2 diabetes who have A1C ≥1.5% (12.5 mmol/mol) above their glycemic target. E A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include comorbidities (ASCVD, heart failure, CKD), hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences. E Among patients with type 2 diabetes who have established ASCVD, sodium–glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists with demonstrated CVD benefit (Table 5) are recommended as part of the antihyperglycemic regimen. A Among patients with ASCVD at high risk of heart failure or in whom heart failure coexists, SGLT2 inhibitors are preferred. C For patients with type 2 diabetes and CKD, consider use of an SGLT2 inhibitor or GLP-1 receptor agonist shown to reduce risk of DKD progression, cardiovascular events, or both. C In most patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are preferred to insulin. B Intensification of treatment for patients with type 2 diabetes not meeting treatment goals should not be delayed. B The medication regimen should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate new patient factors (Table 5). E TABLE 5. Drug-Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults With Type 2 Diabetes *For agent-specific dosing recommendations, please refer to the manufacturers’ prescribing information. †FDA approved for CVD benefit. CHF, congestive heart failure; CV, cardiovascular; DPP-4, dipeptidyl peptidase 4; DKA, diabetic ketoacidosis; GLP-1 RAs, GLP-1 receptor agonists; NASH, nonalcoholic steatohepatitis; SQ, subcutaneous; T2DM, type 2 diabetes. Table 5 highlights considerations for a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose. Figures 3 and 4 outline monotherapy and combination therapy, including initiating and intensifying injectable therapies, emphasizing drugs commonly used in the United States and/or Europe. FIGURE 3. Glucose-lowering medication in type 2 diabetes: overall approach. For appropriate context, see Figure 1. CV, cardiovascular; CVOTs, cardiovascular outcomes trials; DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 RA, GLP-1 receptor agonist; HbA1c, glycated hemoglobin; HF, heart failure; SGLT2i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701. FIGURE 4. Intensifying to injectable therapies. FRC, fixed-ratio combination; GLP-1 RA, GLP-1 receptor agonist; Hba1c, glycated hemoglobin; iDegLira, insulin degludec/liraglutide; iGlarLixi; insulin glargine/lixsenatide; max, maximum; PPG, postprandial glucose. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701. 10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT ASCVD—defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease (PAD) presumed to be of atherosclerotic origin—is the leading cause of morbidity and mortality for individuals with diabetes. Heart failure is another major cause of morbidity and mortality from CVD. For prevention and management of both ASCVD and heart failure, cardiovascular risk factors should be systematically assessed at least annually in all patients with diabetes. These risk factors include obesity/overweight, hypertension, dyslipidemia, smoking, a family history of premature coronary disease, CKD, and the presence of albuminuria. The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is generally a useful tool to estimate 10-year ASCVD risk. Hypertension/Blood Pressure Control Recommendations Screening and Diagnosis Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. B All hypertensive patients with diabetes should monitor their blood pressure at home. B Treatment Goals For patients with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. C For individuals with diabetes and hypertension at higher cardiovascular risk (existing ASCVD or 10-year ASCVD risk >15%), a blood pressure target of 120/80 mmHg, lifestyle intervention consists of weight loss if overweight or obese, a DASH-style dietary pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. B Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals. A Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes. A Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes (ACE inhibitors, angiotensin receptor blockers [ARBs], thiazide-like diuretics, or dihydropyridine calcium channel blockers). A Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors with ARBs and combinations of ACE inhibitors or ARBs with direct renin inhibitors should not be used. A An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored at least annually. B Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy. B Lipid Management Recommendations Lifestyle Intervention Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean eating plan or DASH dietary pattern; the reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes. A Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol ( 20%, high-intensity statin therapy should be added to lifestyle therapy. A For patients with diabetes aged 75 years B without ASCVD, use moderate-intensity statin in addition to lifestyle therapy. In patients with diabetes who have multiple ASCVD risk factors, it is reasonable to consider high-intensity statin therapy. C For patients who do not tolerate the intended intensity, the maximally tolerated statin dose should be used. E For patients with diabetes and ASCVD, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). A Ezetimibe may be preferred due to lower cost. Treatment of Other Lipoprotein Fractions or Targets For patients with fasting triglyceride levels ≥500 mg/dL (5.7 mmol/L), evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. C In adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. C Other Combination Therapy Combination therapy (statin/fibrate) has not been shown to improve ASCVD outcomes and is generally not recommended. A Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended. A Antiplatelet Agents Recommendations Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD. A For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome A and may have benefits beyond this period. B Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding. C Cardiovascular Disease Recommendations Screening In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated. A Consider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease; or electrocardiogram abnormalities (e.g., Q waves). E Treatment In patients with known ASCVD, consider ACE inhibitor or ARB therapy to reduce the risk of cardiovascular events. B In patients with prior myocardial infarction, β-blockers should be continued for at least 2 years after the event. B In patients with type 2 diabetes with stable congestive heart failure, metformin may be used if eGFR remains >30 mL/min but should be avoided in unstable or hospitalized patients with congestive heart failure. B Among patients with type 2 diabetes who have established ASCVD, SGLT2 inhibitors or GLP-1 receptor agonists with demonstrated cardiovascular disease benefit (Table 5) are recommended as part of the antihyperglycemic regimen. A Among patients with ASCVD at high risk of heart failure or in whom heart failure coexists, SGLT2 inhibitors are preferred. C See Figure 3 for additional recommendations on antihyperglycemic treatment in adults with type 2 diabetes. 11. MICROVASCULAR COMPLICATIONS AND FOOT CARE Chronic Kidney Disease Recommendations Screening At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and eGFR in patients with type 1 diabetes with duration of ≥5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. B Treatment Optimize glucose control to reduce the risk or slow the progression of CKD. A For patients with type 2 diabetes and CKD, consider use of an SGLT2 inhibitor or a GLP-1 receptor agonist shown to reduce risk of CKD progression, cardiovascular events, or both (Table 5). C Optimize blood pressure control to reduce the risk or slow the progression of CKD. A For people with nondialysis-dependent CKD, dietary protein intake should be approximately 0.8 g/kg body weight per day (the recommended daily allowance). For patients on dialysis, higher levels of dietary protein intake should be considered. B In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an ARB is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) B and is strongly recommended for those with urinary albumin-to-creatinine ratio ≥300 mg/g creatinine and/or eGFR 50%) than for basal insulin ( 140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months. B Considerations on Admission Initial orders should state the type of diabetes. For best practice, hospitals should establish protocols for structured patient care and structured order sets, which include computerized physician order entry. Recommendation Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. E Glycemic Targets in Hospitalized Patients Recommendations Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and non-critically ill patients. A More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients, if this can be achieved without significant hypoglycemia. C Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL (7.8 mmol/L). An admission A1C value ≥6.5% (48 mmol/mol) suggests that diabetes preceded hospitalization. Hypoglycemia in the hospital is classified the same as in any setting. (See Sec. 6 “Glycemic Targets” above.) Bedside Blood Glucose Monitoring In the patient who is eating meals, glucose monitoring should be performed before meals. In the patient who is not eating, glucose monitoring is advised every 4–6 h. Testing every 30 min to every 2 h is required for intravenous insulin infusion. Several inpatient studies have shown that CGM use did not improve glucose control but detected a greater number of hypoglycemic events than point-of-care (POC) glucose testing. However, a recent review has recommended against using CGM in adults in a hospital setting until more safety and efficacy data become available. Antihyperglycemic Agents in Hospitalized Patients Recommendations Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for non-critically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A In most instances in the hospital setting, insulin is the preferred treatment for glycemic control. Insulin Therapy In the critical care setting, continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets. Outside of critical care units, scheduled insulin regimens as described above are recommended. If the patient is eating, insulin injections should align with meals. In such instances, POC glucose testing should be performed immediately before meals. Patients with type 1 diabetes should have basal-bolus insulin plus nutritional insulin if they are eating. A transition protocol from insulin infusion to subcutaneous insulin is recommended. Noninsulin Therapies The safety and efficacy of noninsulin antihyperglycemic therapies in the hospital setting is an area of active research. See “15. Diabetes Care in the Hospital” in the complete 2019 Standards of Care for a comprehensive review of the inpatient use of these medications. Hypoglycemia Recommendations A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C Patients with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality, it may be a marker of underlying disease rather than the cause of increased mortality. However, until it is proven not to be causal, it is prudent to avoid hypoglycemia. Studies of “bundled” preventive therapies including proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic management showed that hypoglycemic episodes in the hospital could be prevented. MNT in the Hospital The goals of MNT in the hospital are to provide adequate calories to meet metabolic demands, optimize glycemic control, and address personal food preferences. The ADA does not endorse any single meal plan. An RD can serve as an inpatient team member. Self-Management in the Hospital Diabetes self-management in the hospital may be appropriate for select youth and adult patients. Sufficient cognitive and physical skills, adequate oral intake, proficiency in carbohydrate estimation, and knowledge of sick-day management are some of the requirements. Self-administered insulin with a multiple daily injection regimen or insulin pump therapy may be considered. A protocol should exist for these situations. Standards for Special Situations See “15. Diabetes Care in the Hospital” in the complete 2019 Standards of Care for guidance on enteral/parenteral feedings, diabetic ketoacidosis and hyperosmolar hyperglycemic state, perioperative care, and glucocorticoid therapy. Transition From the Acute Care Setting Recommendation There should be a structured discharge plan tailored to the individual patient with diabetes. B Transition from the acute care setting is a risky time for all patients A structured discharge plan tailored to the individual patient may reduce length of hospital stay and readmission rates and increase patient satisfaction. A structured discharge plan should be tailored to each patient and should include medication re-conciliation and structured discharge communication. Discharge planning should begin at admission and be updated as patient needs change. An outpatient follow-up visit 1 month after discharge is recommended. 16. DIABETES ADVOCACY For a list of ADA advocacy position statements, including “Diabetes and Driving” and “Diabetes and Employment,” see “16. Diabetes Advocacy” in the complete Standards of Care.
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                Author and article information

                Journal
                Patient Prefer Adherence
                Patient Prefer Adherence
                PPA
                ppa
                Patient preference and adherence
                Dove
                1177-889X
                25 October 2019
                2019
                : 13
                : 1839-1850
                Affiliations
                [1 ]Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland , Auckland, New Zealand
                [2 ]Diabetes and Endocrine Centre, Department of Internal Medicine, King Khaled Hospital, Ministry of Health , Najran, Saudi Arabia
                Author notes
                Correspondence: Elizabeth Broadbent Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland , Auckland Hospital- Building 599, 2 Park Road, Grafton, Auckland1023, New ZealandTel +64 9 3737599Fax +64 9 3737013 Email e.broadbent@auckland.ac.nz
                Author information
                http://orcid.org/0000-0001-9278-1841
                http://orcid.org/0000-0003-3626-9100
                Article
                228670
                10.2147/PPA.S228670
                6818533
                31749610
                18aee865-c6b2-4bbb-a6a4-a98d8691f088
                © 2019 Alyami et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 31 August 2019
                : 11 October 2019
                Page count
                Tables: 4, References: 61, Pages: 12
                Categories
                Original Research

                Medicine
                type 2 diabetes,adherence,glycaemic control,illness perceptions,saudi arabia
                Medicine
                type 2 diabetes, adherence, glycaemic control, illness perceptions, saudi arabia

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