Monitoring

Optimal diabetes care requires a long-term relationship with the patient; regular monitoring and control of blood pressure (BP), HbA1c, and tobacco use; and supported lifestyle changes.

On diagnosis immediately refer the patient to the local eye screening service.[36] It is advised to repeat eye screening every year.[323]

On diagnosis, assess the patient’s risk of developing a diabetic foot problem; also do this at least annually (or more frequently depending on risk).[81]

  • Include assessment of ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 10-gram monofilament touch sensation.

  • All patients with insensate feet, foot deformities, or a history of foot ulcers or amputation should have their feet examined at every visit and are candidates for specialised footwear.[34]

  • When foot problems arise, patients should be referred to the foot protection service or a multi-disciplinary foot care service, as appropriate.[34][81]

On diagnosis, measure the patient’s urine albumin to creatinine ratio. Annual assessment of renal function including both a urinary albumin excretion test and a serum creatinine test with estimated glomerular filtration rate (eGFR) based on the CKD-EPI creatinine equation or equivalent is recommended.

Measure HbA1c levels at diagnosis and:[34][36] 

  • Every 3-6 months (tailored to individual needs), until the patient’s HbA1c is stable on unchanging therapy.

  • Every 6 months once the patient’s HbA1c level and blood glucose-lowering therapy are stable.

Most patients require diabetes assessments every 3-6 months, and some patients may benefit from more frequent visits, especially when motivated to improve their care.

Measure blood pressure at least once a year in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease.[82] 

  • Offer and reinforce preventive lifestyle advice.[82] The ESC recommends that home BP self-monitoring should be considered for patients on antihypertensive medicine to check that their BP is being adequately controlled.[80]

The ESC recommends additional cardiovascular monitoring:[80]

  • Systematic screening for symptoms or signs of heart failure at all clinical encounters. If heart failure is suspected, brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide (BNP/NT-proBNP) should be measured, with further work-up for heart failure as indicated.

  • Opportunistic screening for atrial fibrillation (AF) by pulse-taking or ECG (particularly when other risk factors for AF are present) because patients with diabetes exhibit a higher frequency of AF at a younger age. Systematic ECG screening for AF should be considered in patients aged 75 years or over (or those at high risk of stroke).

  • Screening for lower-extremity artery disease (with examination and/or ankle brachial index [ABI] measurement) regularly, considering further assessment with duplex ultrasound (first-line imaging) where necessary.

Ensure the patient receives ongoing individualised nutritional advice from a healthcare professional with specific expertise and competencies in nutrition.[36] The UK Medicines and Healthcare products Regulatory Agency recommends checking vitamin B12 serum levels in patients being treated with metformin who have symptoms suggestive of vitamin B12 deficiency, and to periodically monitor patients with risk factors for vitamin B12 deficiency.[324]

Aim to make a routine assessment of frailty whenever you review an older person with diabetes.[83][84][85]​ Use a validated tool (e.g., the electronic Frailty Index [eFI], the Rockwood frailty score, or Timed Up and Go) to confirm clinical suspicion of frailty.[84][85]​ Frail patients need a tailored approach to management; de-escalation of therapy is as important as intensification. Consult a specialist if you need guidance. 

Structured education programmes and use of diabetes educators is recommended, although traditional information-based diabetes patient education mandated by some professional organisations is only moderately effective in randomised studies.[80][325][326]​​ A multi-disciplinary team with access to nurses, educators, dietitians, clinical pharmacologists, psychologists, and other specialists as needed is recommended. Person-centred care is recommended to facilitate shared control and decision-making within the context of the patient’s priorities and goals.[80]​ Patient readiness to change is a strong predictor of improved care, and readiness to change may vary across the clinical domains of blood pressure, statin use, aspirin use, glucose, smoking, physical activity, and nutrition. Rapid assessment of readiness to change, and directing care to the domain with maximum potential to change, is advised.[327]​ Use of the principles of motivational interviewing to induce behavioural changes, and providing individual empowerment strategies to enhance self-efficacy and motivation should be considered.[80]

Self-management by regular blood glucose monitoring is not routinely recommended in patients with type 2 diabetes, because it does not significantly improve glycaemic control, health-related quality of life, or hypoglycaemia rates.[36]​​[Evidence C]​​ However, self-monitoring of blood glucose is recommended for those who (a) are on insulin; (b) have had prior hypoglycaemic episodes; (c) use oral medications that increase their risk of hypoglycaemia while driving or operating machinery; or (d) are pregnant, or planning to become pregnant.[36]

Due to disease progression, comorbidities, and non-adherence to lifestyle or medication, a substantial fraction of patients who achieve recommended goals for HbA1c, blood pressure, and lipid management relapse to uncontrolled states of one or more of these within 1 year. Relapse is usually asymptomatic; frequent monitoring of clinical parameters is desirable to anticipate or detect relapse early and adjust therapy.

Factors that may lead to loss of adequate glycaemic control include medication non-adherence, depression, musculoskeletal injury or worsening arthritis, competing illnesses perceived by the patient as more serious than diabetes, social stress at home or at work, substance abuse, occult infections, use of medications (such as corticosteroids, certain depression medications [paroxetine], mood stabilisers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing's disease.

Loss of control of blood pressure and lipids is also a common phenomenon. Close monitoring of patients with diabetes through frequent visits and lab work helps to maintain patients at treatment goals and proactively identify upward trends in blood pressure or HbA1c, and to reinforce the importance of statin adherence (if indicated) and non-smoking.

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