Guide de Bonnes Pratiques en Diabétologie

Objectives

The national guide seeks to harmonise diabetes care across Algeria, improve equitable access and quality, strengthen prevention and management at primary-care level, and reduce complications and mortality. It aligns diabetes action with Algeria’s 2015–2019 strategic plan addressing non-communicable disease risk factors.[1]It frames diabetes as a major public-health, social and economic concern, particularly because of chronic cardiovascular, renal, ocular, neurological and lower-limb complications.[2]

• Promote healthy diets, regular physical activity, normal body weight and tobacco cessation to prevent diabetes and its complications.[1]
• Standardise diagnosis, classification, treatment and follow-up for type 1, type 2, gestational and secondary diabetes, as well as acute and chronic complications and care in pregnancy, surgery, Ramadan and older age.[3][4][5]
• Achieve the best possible health and normal longevity without major impairment of quality of life, while avoiding symptomatic hypo- and hyperglycaemia and preventing or delaying long-term complications.[6][7]
• Individualise glycaemic and treatment objectives according to age, disease duration, comorbidities, vascular complications, hypoglycaemia risk, self-management capacity and psychosocial or socioeconomic circumstances.[8]
• Prioritise cardiovascular prevention and kidney protection through integrated control of glycaemia, blood pressure, lipids, smoking, weight and other risk factors.[9][10]
• Prevent disability from retinopathy, nephropathy, neuropathy, peripheral arterial disease and diabetic-foot lesions through early detection, metabolic and blood-pressure control, and specialist treatment where necessary.[11][12][13][14]
• Support safe care in specific circumstances, including pre-conception planning, pregnancy, childbirth, breastfeeding, gestational diabetes, surgery, fasting during Ramadan and frailty in older people.[15][16][17][18][19]

Implementation

The guide provides nationally standardised good-practice guidance for general practitioners, diabetes specialists and other relevant professionals across health-system levels.[20][21]Its development was led by the Directorate General for Prevention and Health Promotion through an expanded diabetes expert committee, with national experts, regional consultation seminars and civil-society representatives contributing.[20][3]Clinicians should use the guidance in accordance with locally available resources and avoid unnecessary patient travel.[21]

• Use recognised glucose, glycated haemoglobin and oral glucose-tolerance criteria to diagnose diabetes, and classify disease by type, cause and clinical context.[22][23][24]
• Deliver type 1 diabetes care through insulin therapy, therapeutic education, injection training, blood-glucose self-monitoring, dietary planning and physical activity, with basal-bolus treatment identified as the preferred regimen.[25][26][27]
• Base type 2 diabetes care on nutrition, physical activity and therapeutic education, use metformin first line unless contraindicated, and intensify treatment with additional medicines or insulin when individual glycaemic goals are not reached.[8][28][29]
• Use shared decision-making that reflects patients’ preferences, needs and values, while considering treatment cost, effectiveness, hypoglycaemia risk, weight effects, renal and hepatic function, age and adherence.[8][30][31]
• Provide scheduled clinical follow-up, including three-monthly consultations for weight, blood pressure, foot and neuropathy assessment, metabolic control, glycated haemoglobin, self-monitoring and adherence, with annual renal, lipid, retinal and cardiovascular assessments.[32]
• Manage acute events through prompt recognition and treatment of hypoglycaemia, diabetic ketoacidosis, hyperosmolar hyperglycaemic coma and lactic acidosis, with escalation to hospital or intensive care for severe presentations.[33][34][35][36]
• Integrate specialist assessment and referral for sight-threatening retinopathy, renal impairment, complex foot disease, peripheral arterial disease, coronary disease, pregnancy-related risks and severe metabolic complications.[11][37][38][14][16]
• Strengthen self-management through education on diet, medicines, glucose monitoring, hypoglycaemia, physical activity, smoking cessation, foot care and complication warning signs; involve families, carers and multidisciplinary teams where appropriate, especially during Ramadan and in older age.[39][40][41][19]

Monitoring & Evaluation

Monitoring is principally clinical and patient-level, supporting standardised diabetes care through self-monitoring, scheduled reviews, diagnostic testing and complication surveillance. The guide does not establish a consolidated national monitoring and evaluation framework, population-level indicator set, reporting timetable, audit process, surveillance architecture, targets or formal accountability arrangements.[21][42][43]

• Monitor type 1 diabetes through self-measured blood glucose before meals and at bedtime to identify insulin doses requiring adjustment, and assess fasting, post-prandial and bedtime glucose alongside glycated haemoglobin against stated targets.[26][6]
• Review type 2 diabetes every three months, including weight, blood pressure, foot and neuropathy assessment, metabolic control, glycated haemoglobin, self-monitoring results and treatment adherence.[32]
• Undertake annual or more frequent assessment of albuminuria or proteinuria, renal function, lipid profile, retinal status, electrocardiography, body mass index, blood pressure and macrovascular complications, with further tests guided by progression and complications.[32][7]
• Assess glycaemic-target attainment after treatment changes and intensify therapy after three months where targets are not met.[28]
• Monitor insulin initiation and adjustment against fasting glucose, assess hypoglycaemia, and evaluate persistent inadequate glycaemic control before moving to more intensive insulin regimens.[29][44]
• Recheck glucose 15 minutes after treating mild hypoglycaemia and repeat treatment where hypoglycaemia persists.[33]
• Monitor acute metabolic emergencies with clinical observations and laboratory tests. Ketoacidosis monitoring includes hydration, ventilation, vital signs, glucose, ketones, blood gases, pH, electrolytes, renal tests and electrocardiography; deep coma warrants referral to medical intensive care.[34][45]Hyperosmolar coma monitoring includes hydration, urine output, glucose, neurological status and renal function, while lactic acidosis assessment includes lactate, pH, bicarbonate and anion gap.[35][36]
• Conduct eye surveillance at diagnosis and annually where no lesions or only early retinopathy are present, with immediate assessment for declining visual acuity. Screen renal disease in type 1 diabetes from five years after onset and in type 2 diabetes from diagnosis, using blood pressure, albuminuria and renal-function measures once or twice yearly.[11][46]
• Monitor potassium and creatinine when starting angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, recognising a creatinine rise exceeding 30% of baseline as excessive.[37]Reassess blood pressure after four weeks following antihypertensive treatment initiation or adjustment, and measure potassium and creatinine after 7 to 10 days.[47]
• Assess cardiovascular risk through regular clinical review, blood pressure, lipid measures, renal tests, electrocardiography and indicated vascular investigations. Annual electrocardiography is specified for type 2 diabetes, with carotid ultrasound every three years.[38][48]Screen lower-limb peripheral arterial disease annually using history, pulse examination and ankle-brachial pressure index, and repeat colour Doppler ultrasound every three years or sooner if deterioration is rapid.[49]
• Monitor pregnancy-related diabetes closely: before conception, measure glycated haemoglobin every six to eight weeks; during pregnancy, monitor glucose five to seven times daily and repeat glycated haemoglobin every six to eight weeks.[15][16]For gestational diabetes, undertake post-partum fasting and post-prandial glucose checks and an oral glucose tolerance test 12 weeks after delivery.[17]
• Monitor blood pressure through clinic, home or ambulatory measurement, including assessment for orthostatic hypotension and target-organ damage.[50][51]Follow cardiovascular-risk management every three or six months according to risk, including treatment adherence, tolerance, urine testing, renal function, glucose, lipids and electrocardiography.[52]
• Use condition-specific safety monitoring, including liver enzymes before lipid-lowering therapy, eight weeks after starting or escalating treatment, and annually thereafter; assess creatine phosphokinase when myalgia or relevant risk factors occur.[53]During Ramadan, assess readiness before fasting through clinical review, glycated haemoglobin, self-monitoring and lipid testing, and interrupt fasting at specified low or high glucose thresholds.[18][41]

Costing & Financing

Diabetes is characterised as a substantial social and economic burden, but the guide provides no programme costing, budget allocation, financing source, resource-mobilisation plan, procurement budget, funding-gap assessment or quantitative economic assumptions.[1][47][54][55]Financial considerations appear only as qualitative factors in clinical treatment selection rather than as an implementation financing framework.[31]

• Consider medicine cost alongside glycated-haemoglobin effectiveness, hypoglycaemia risk and effects on body weight when selecting glucose-lowering treatment.[31]
• Recognise that echocardiography may not be used systematically because of cost, despite detecting left-ventricular hypertrophy more effectively than electrocardiography.[56]
• Note that beta-blockers are described qualitatively as inexpensive, without a price, currency, procurement mechanism or budget implication.[54]
• Interpret reported reductions in insulin requirements from combined insulin and metformin treatment as clinical-effect information, not as a monetary saving or budget estimate.[29]