Monitoring
Self-monitoring of blood glucose levels is an integral part of treatment for everyone with type 1 diabetes.
Glycemic status should be evaluated by HbA1c and/or appropriate continuous glucose monitoring (CGM) criteria at least twice yearly.[1] The American Diabetes Association (ADA) recommends more frequent evaluation of glycemic status (e.g., every 3 months) for patients whose therapy is being modified or who are not meeting their treatment goals, or if there is frequent or severe hypo- or hyperglycemia or changing health status, and during growth and development in youth.[1] The ADA recommends a target HbA1c goal of <7% (<53 mmol/mol without significant hypoglycemia) for many nonpregnant adults, adolescents, and children.[1] Less stringent goals may be appropriate for very young children; older adults; people with a history of severe or frequent hypoglycemia; and those with limited life expectancies, advanced microvascular or macrovascular complications, or comorbid conditions.[1] It is important to note that HbA1c does not account for glycemic variability, and if this is suspected it should be correlated with blood glucose monitoring (BGM) or CGM results.[1] Insulin regimens should be regularly reassessed in the context of the person’s individualized glycemic goals, and deintensification considered where burdens/harms of treatment outweigh the benefits.[1]
Check blood pressure at each visit (including orthostatic blood pressure at initial visit, then as indicated) and treat to a goal of <130/80 mmHg in nonpregnant adults if it can be safely attained (targets should be individualized as appropriate: for example, in most older adults, and are different for children).[1] In pregnancy, a blood pressure target of 110-135/85 mmHg is suggested.[1] Adults started on an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, mineralocorticoid receptor antagonist, or diuretic should have renal function and serum potassium levels checked within 1 to 2 weeks of initiation and then at least yearly.[1]
For adult patients ages <40 years who are not on statins, it is recommended to check a screening lipid profile (total cholesterol, low-density lipoprotein [LDL] cholesterol, high-density lipoprotein [HDL] cholesterol, and triglycerides) at the time of first diagnosis, at initial medical evaluation, and then every 5 years thereafter (more frequent evaluation may be indicated in some cases).[1]
Initial screening for retinopathy by an ophthalmologist or optometrist is recommended within 5 years of initial diagnosis of diabetes, and every 1 to 2 years thereafter if there is no evidence of retinopathy (and glycemic goals are met).[1] In the presence of abnormal findings (and in the presence of risk factors such as uncontrolled hyperglycemia), more frequent follow-up is indicated as appropriate (e.g., at least annually).[1]
Yearly screening for increased urinary albumin excretion and estimated glomerular filtration rate should be done in all patients who have had type 1 diabetes for 5 years or more. In those with chronic kidney disease (CKD), monitoring may be done up to four times per year (as appropriate for the stage of kidney disease).[1]
All patients should be screened for peripheral neuropathy 5 years after the initial diagnosis of diabetes, and at least annually thereafter.[1] The ADA recommends annual comprehensive foot assessment (including 10 g monofilament testing) for everyone with diabetes (increased to every visit if there is evidence of sensory loss, or prior ulceration or amputation).[1]
Symptoms of autonomic neuropathy can be assessed through history (syncope, dizziness, or weakness on standing, exercise intolerance, changes in sweating, constipation, diarrhea, gastroparesis, bladder or sexual dysfunction, hypoglycemic autonomic failure), and physical exam (resting tachycardia, orthostatic hypotension, peripheral dryness/cracking of skin) 5 years after initial diagnosis of diabetes, and at least annually thereafter (more frequent screening may be indicated with onset of other microvascular complications).[1]
Microvascular complication screening in children is generally not recommended by the ADA until they reach puberty or age 10 to 11 years (whichever comes first), as there is low risk of occurrence before this.[1] The ADA also recommends that screening for diabetes complications in older adults should be individualized, paying attention to those that would impair function or quality of life.[1]
Due to the increased risk for heart failure in adults with diabetes (which may be asymptomatic), screening using B-type natriuretic peptide (BNP) or N-terminal pro-BNP should be considered.[1] If abnormal levels are detected in an asymptomatic individual, echocardiography is recommended to identify people who may benefit from treatment.[1]
Screening for PAD (with ankle-brachial index testing) is recommended by the ADA to guide treatment for cardiovascular disease prevention and limb preservation in asymptomatic patients who are ages 50 years or over, or who have any microvascular disease, foot complications, or any end organ damage from diabetes.[1] Screening should also be considered for those with diabetes duration of ≥10 years.[1]
Yearly dental exams are indicated in patients with and without teeth, to control periodontal disease, which both contributes to and exacerbates hyperglycemia.
Regular monitoring of height, weight, growth, and physical development is important for children and adolescents.[56]
Thyroid disease should be screened for at diagnosis once the patient is clinically stable, and then on a regular basis.[1] In children and adolescents, celiac disease should also be screened for shortly after diagnosis (and then again within 2 years and after 5 years), whereas in adults clinical suspicion should prompt screening.[1][56] Other associated autoimmune diseases such as primary adrenal insufficiency and pernicious anemia (among others) should also be screened for when there is increased suspicion.[1][56]
The ADA recommends psychosocial screening (e.g., for stress, quality of life, resources), and specifically screening for depressive symptoms and diabetes distress, at least annually in all patients with diabetes (and consideration of the same for anxiety symptoms and diabetes-related fears or worries).[1] Consider screening for diabetes distress starting at ages 7 or 8 years (screening for diabetes distress should also extend to family members/caregivers).[1] More frequent screening should be considered in those with a history of depression, with change in medical status (e.g., goals not met, presence of diabetes complications) or social situation, or during service transition (e.g., pediatric to adult services).[1]
At each visit, people should be screened for disability, with referral made as appropriate (e.g., to occupational therapy), as this may affect diabetes self-management.[1] Older adults in particular may require increased support, and should be screened for geriatric syndromes (e.g., cognitive impairment, depression, urinary incontinence, falls, persistent pain, and frailty), and for polypharmacy, which can negatively impact on self-management and quality of life.[1] Screening at least annually for cognitive impairment is recommended by the ADA for those ages 65 years and over.[1]
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