Monitoring

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Diabetes Mellitus Type 2Published by: Domus Medica | SSMGLast published: 2017Diabète sucré de type 2Published by: SSMG | Domus MedicaLast published: 2017

Optimal diabetes care requires a long-term relationship with the patient, appropriate use of attending physicians when needed, and regular monitoring and control of blood pressure, hemoglobin A1c (HbA1c), tobacco use, and statin/aspirin use. Most patients require diabetes assessments every 3-4 months, and some patients may benefit from more frequent (monthly) visits, especially when motivated to improve their care.

Use of diabetes care and education specialists is recommended, although traditional information-based diabetes patient education mandated by some professional organizations has been shown to be only moderately effective in randomized studies.[428][429] A multidisciplinary team with access to nurses, educators, dietitians, clinical pharmacists, psychologists, and other specialists as needed is recommended. 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.[430]

The American Diabetes Association recommends measurement of glycemic status by HbA1c and/or appropriate continuous glucose monitoring (CGM) metrics at least twice a year. More frequent assessment (e.g., every 3 months) is recommended for individuals not meeting treatment goals, those whose therapy has recently changed, and those with frequent or severe hypoglycemia or hyperglycemia, changing health status, or growth and development in youth.[2] The use of point-of-care HbA1c testing may provide an opportunity for more timely treatment changes during encounters between individuals with diabetes and healthcare professionals.[2]

Fructosamine and glycated albumin are alternative measures of glycemia that are approved for clinical use for monitoring glycemic status. Fructosamine reflects total glycated serum proteins (mostly albumin). Glycated albumin assays reflect the proportion of total albumin that is glycated. Due to the turnover rate of serum protein, fructosamine and glycated albumin reflect glycemia over the past 2-4 weeks, a shorter-term time frame than that of HbA1c. However, there have been few clinical trials, and the evidence base supporting the use of these biomarkers to monitor glycemic status is much weaker than that for HbA1c. They may be useful in people with diabetes who have conditions where the interpretation of HbA1c may be problematic or when HbA1c cannot be measured (e.g., homozygous hemoglobin variants).[2]

Self-management by regular blood glucose monitoring is not routinely recommended in patients with type 2 diabetes, because it does not significantly improve glycemic control, health-related quality of life, or hypoglycemia rates.[431][432][Evidence C]​​ However, it is recommended for those who (a) are on insulin; (b) have had prior hypoglycemic episodes; (c) drive or operate machinery and use oral medications that increase his or her risk of hypoglycemia; or (d) are pregnant, or planning to become pregnant.[432] Blood glucose monitoring may be complicated by cognitive or physical impairments, especially if the patient lacks a support system, and this should be considered when deciding on the method of, and approach to, monitoring.[25]

CGM may be helpful in people with type 2 diabetes (particularly those on insulin therapy) to create a more complete picture of patients' actual glucose status throughout the day and night.[2][433][434] It involves a small, disposable device with a subcutaneous sensor constantly attached to the skin, which measures glucose levels in interstitial fluid, and sends the readings to a display device or smart device.[435] CGM devices may provide real-time data or intermittently scanned data (commonly referred to as "flash" glucose monitoring). Data from ambulatory glucose profiles show time in range and times of hypoglycemia, which can help support personalized therapy decisions.[103][436] CGM devices can also display trend arrows that help patients to anticipate a significant fall or rise in glucose and take timely steps to rectify this.[103]

The American Association of Clinical Endocrinology strongly recommends CGM for all persons with diabetes treated with intensive insulin therapy, defined as three or more injections of insulin per day or the use of an insulin pump.[437] Real-time CGM is also recommended by the Endocrine Society for those taking insulin or sulfonylureas who have significant risk for hypoglycemia.[103] In patients with type 2 diabetes treated with insulin, real-time CGM results in better glycemic control and lower rates of hypoglycemia and emergency department visits or hospitalization for hypoglycemia.[103][438][439] Real-time CGM has also resulted in improvement in glycemic parameters in both users of multiple daily dose insulin and those on basal insulin regimens, compared with blood glucose testing, in randomized controlled trials.[440][441][442] Intermittently scanned CGM technology has been shown to decrease hypoglycemia, compared with blood glucose testing, in individuals with type 2 diabetes on multiple daily dose insulin.[443] All patients using CGM should be appropriately educated in the use of their device, know what to do if the device stops working, and be advised that they will still require finger-prick blood glucose sampling sometimes to verify readings.[103] It should also be noted that CGM is not Food and Drug Administration (FDA)-approved for inpatient use at present, but does have enforcement discretion (i.e., for patients who are at high risk of hypoglycemia).[103]

In addition to care required to achieve recommended levels of blood pressure, statin use, antiplatelet use, tobacco non-use, and glucose control, the following periodic monitoring for complications is advised:[2]

  • Dilated and comprehensive eye exam every year after the initial exam at diagnosis.

  • Assessment at least annually of renal function including both a urinary albumin excretion test and a serum creatinine test with estimated glomerular filtration rate (eGFR) based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation (2021) or equivalent. [ CKD-EPI equations for glomerular filtration rate (GFR) Opens in new window ] ​​​ In people with diabetes and hypertension, if GFR is <60 mL/minute/1.73 m² and/or albuminuria is >30 mg/g creatinine in a spot urine sample, the urinary albumin to creatinine ratio should be repeated every 6 months to assess for change.[98] Serum creatinine/eGFR and potassium should be checked within 7-14 days of initiation of treatment with an ACE inhibitor, angiotensin-II receptor antagonist, aldosterone antagonist, or diuretic, as well as following uptitration of dose and then at least annually.[2]

  • An annual assessment of liver function tests; liver function tests may also need to be checked after initiation or dose changes of medications that affect laboratory values.

  • Annually or more frequent foot exams including assessment of ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 10-g monofilament touch sensation. All patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit and are candidates for specialized footwear.

  • In asymptomatic individuals, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as risk factors for atherosclerotic cardiovascular disease (ASCVD) are treated.[2] However, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone B-type natriuretic peptide (NT-proBNP) on at least a yearly basis should be considered to screen asymptomatic adults with diabetes for heart failure (HF).[2][388] This is because adults with diabetes are at increased risk for the development of asymptomatic cardiac structural or functional abnormalities (stage B HF) or symptomatic (stage C) HF.[2] If abnormal natriuretic peptide levels are detected, echocardiography is recommended. Identification, risk stratification, and early treatment of risk factors in people with diabetes and asymptomatic stages of HF reduce the risk for progression to symptomatic disease.[2]

Due to disease progression, comorbidities, and nonadherence 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 glycemic control include medication nonadherence, 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 (e.g., corticosteroids, certain depression medications, mood stabilizers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing 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 and nonsmoking. In patients on lipid-lowering therapy, a lipid profile should be checked: at initiation of statins or other lipid-lowering therapy; 4-12 weeks after initiation or a change in dose; and annually thereafter.[2]

Due to the increased risk of dementia in patients with diabetes, physicians should closely monitor cognitive function; consider screening for cognitive impairment in older adults with diabetes ages ≥65 years.[2][424][425][444]

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