Monitoring

Your Organizational Guidance

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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.

​Access to a multidisciplinary team with nurses, educators, dietitians, clinical pharmacists, psychologists, and other specialists as needed is recommended. Patient readiness to change is a strong predictor of improved care; this 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.[472]

The American Diabetes Association (ADA) 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.[473][474][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 drugs that increase his or her risk of hypoglycemia; or (d) are pregnant, or planning to become pregnant.[474] 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.[35]

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][475][476]​ 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.[477] 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.[133][478]​ 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.[133]

The ADA recommends CGM for all patients on any type of insulin therapy.[2] It also advises that CGM can be considered for patients treated with glucose-lowering drugs other than insulin.[2]​​ 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.[479] Real-time CGM is also recommended by the Endocrine Society for those taking insulin or sulfonylureas who have significant risk for hypoglycemia.[133] 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.[133][480][481]​​ 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.[482][483][484]​​ Compared with blood glucose testing, intermittently scanned CGM technology has been shown to decrease hypoglycemia in individuals with type 2 diabetes on multiple daily dose insulin.[485] 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.[133] 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).[133]

In addition to regular monitoring of glycemic status, the following components should form part of the comprehensive medical evaluation at follow-up visits:

  • Check height, weight, and body mass index (BMI) at each visit, and at least every 3 months during active weight management treatment.[2] ​Screen for malnutrition in patients with obesity who have lost significant weight.[2]

  • Ask people with diabetes routinely about the use of cigarettes or other tobacco products. After identification of use, recommend and refer for combination treatment consisting of both tobacco/smoking cessation counseling and pharmacologic therapy.[2]

  • Check blood pressure at each routine clinical visit, or at least every 6 months.[2] ​Hypertension is defined as a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥80 mmHg based on an average of two or more measurements obtained on two or more occasions. In individuals with cardiovascular disease and blood pressure ≥180/110 mmHg, it is reasonable to diagnose hypertension at a single visit.[2] ​A blood pressure treatment goal of <130/80 mmHg is recommended for most nonpregnant adults if it can be safely attained. However, the ADA emphasizes that targets should be individualized as appropriate; for example, less stringent targets may be appropriate for older adults.[2] ​In pregnancy, a blood pressure target of 110-135/85 mmHg is suggested.[2]​ All patients with hypertension and diabetes should be advised to monitor their blood pressure at home after appropriate education.[2]

  • 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 annually thereafter (or more frequently if indicated).[2]​ In people age <40 years without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent (e.g., every 5 years).[2] ​Initial testing may be done with a nonfasting lipid level, with confirmatory testing with a fasting lipid panel. If a patient starts taking a statin, LDL cholesterol levels should be assessed 4-12 weeks after initiation of statin therapy, after any change in dose, and annually.[2]

  • Refer for dilated and comprehensive eye exam by an ophthalmologist or optometrist at the time of diabetes diagnosis and annually thereafter.[2] ​If there is no evidence of retinopathy from one or more annual eye exams and glycemic indicators are within the goal range, screening every 1-2 years may be considered.[2]​ If any level of diabetic retinopathy is present, subsequent dilated retinal exams should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then exams by an ophthalmologist will be required more frequently.[2]

  • Assess renal function at least annually, with 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.[2] [ 2021 race-free 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, repeat the urinary albumin to creatinine ratio every 6 months to assess for change.[127] Check serum creatinine/eGFR and potassium 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 drugs that affect laboratory values.[2]

  • Annual complete blood count with platelets to check for anemia.[2] ​In individuals with diabetes, anemia occurs often (but not exclusively) in association with chronic kidney disease. In addition, metformin can be associated with vitamin B12 deficiency and, rarely, with anemia.

  • Annual monitoring of serum vitamin B12 levels for patients who have been taking metformin for >4 years.[2]

  • Annual foot exams including visual inspection (e.g., skin integrity, callous formation, foot deformity peripheral vascular disease, or ulcers, and toenails), assessment of ankle reflexes, dorsalis pedis pulse, vibratory, temperature, or pinprick sensation, and 10-g monofilament touch sensation.[2]​ All patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit and may be candidates for specialized footwear.[2]

  • In asymptomatic individuals with diabetes and age ≥65 years, diabetes duration ≥10 years, any microvascular disease, or diabetes-related end-organ damage or foot complications, ankle-brachial index (ABI) testing should be performed to check for peripheral arterial disease.[2]

  • Dental checks at least annually.[2]

  • 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][414]​ 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]

  • Assess fracture risk as part of routine care of people with type 2 diabetes.[2]​ Bone mineral density should be monitored by dual-energy x-ray absorptiometry (DEXA) scan in all older adults (age ≥65 years) and in younger individuals (age >50 years) with bone or diabetes-related risk factors, such as insulin use or diabetes duration >10 years.[2]​ Reassessment is recommended every 2-3 years, depending on the screening evaluation and the presence of additional risk factors.[2]

  • Due to the increased risk of dementia in patients with diabetes, consider screening for cognitive impairment in older adults with diabetes age ≥65 years.[2][452][453][486]

  • Ask men about sexual dysfunction, in particular erectile dysfunction, which is more likely in those with CVD or at high risk of CVD, retinopathy, chronic kidney disease, peripheral or autonomic neuropathy, longer duration of diabetes, depression, or hypogonadism, and in those who are not meeting glycemic goals.​​​​[2] ​If symptoms and/or signs of hypogonadism are detected (e.g., low libido, erectile dysfunction, and depression), check a morning serum total testosterone level.

  • Screen women for sexual dysfunction, such as low libido and difficulties with arousal or orgasm. These issues are more likely to affect those with depression, anxiety, or recurrent urinary tract infections.[2] Ask postmenopausal women about symptoms and/or signs of genitourinary syndrome of menopause, including vaginal dryness and dyspareunia.​[2]

  • Assess for disability at the initial visit and for decline in function at each subsequent visit. If a disability is impacting functional ability or capacity to manage their diabetes, refer the patient to an appropriate health care professional specializing in disability (e.g., physical medicine and rehabilitation specialist, physical therapist, occupational therapist, or speech-language pathologist).[2]

  • Screen patients for psychologic problems (including diabetes distress, depression, anxiety, fear of hypoglycemia, and disordered eating) at least annually and repeat screening when treatment goals are not met, at transitional times, and/or in the presence of diabetes complications.[2]​ Screening for diabetes distress should also be extended to family members and caregivers.[2]​ Consider referral to a qualified behavioral health professional, ideally one with experience in diabetes, for further assessment and treatment if indicated.[2]

  • Screen for adverse social determinants of health (including food insecurity, housing insecurity, financial barriers, health insurance and health care access, environmental and neighborhood factors, and social community support) during clinical encounters and refer patients to appropriate clinical and community resources to address these needs.[2]

Due to disease progression, comorbidities, and nonadherence to lifestyle or drug treatment, 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 nonadherence to treatment, 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 drugs (e.g., corticosteroids, certain antidepressants, mood stabilizers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing disease.

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