Monitoring
Glycemic monitoring
Self-monitoring of blood glucose levels is an integral part of treatment. Continuous glucose monitoring (CGM) is considered the standard for glucose monitoring for all patients with type 1 diabetes.[1][72] 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.[136] 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.[124][278] 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.[124] Although healthcare professionals should regularly access and review CGM data as part of clinical management, people with type 1 diabetes should be encouraged to review their own reports regularly and follow their progress over time, contacting their healthcare professional as needed for worsening or changing trends.[72]
Some people may not find CGM valuable; they may feel that they do not require it, or find it stressful because they dislike being "attached to a device", being constantly reminded of their diabetes or feeling exhausted by alarms (alarm fatigue). Cost considerations can also play a role.[72] In these situations, regular capillary blood glucose monitoring (BGM; previously known as self-monitoring of blood glucose) should instead be used. Frequent BGM measurements are important as an integrated part of diabetes management to guide insulin dosage, food intake, and prevention of hypoglycemia with exercise. Every person with type 1 diabetes should have the equipment to undertake BGM, regardless of whether they are using CGM.[1] Glycemic status should be evaluated by HbA1c and/or appropriate CGM criteria at least twice yearly.[1] More frequent evaluation (e.g., every 3 months) is recommended 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] It is important to note that HbA1c does not account for glycemic variability, and if this is suspected it should be correlated with 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]
Monitoring for macrovascular complications: adults
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 this can be safely attained (targets should be individualized as appropriate; less stringent targets may be appropriate for older adults).[1] Patients who are started on an ACE inhibitor, angiotensin-II receptor antagonist, aldosterone antagonist, or diuretic should have renal function and serum potassium levels checked within 1-2 weeks of initiation and then at least yearly.[1] In pregnancy, a blood pressure target of 110-135/85 mmHg is suggested.[1] For patients ages <40 years who are not on statins, 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]
Perform ankle-brachial index testing to screen for peripheral arterial disease in all asymptomatic diabetic patients ages 65 years and over, and in patients with microvascular disease, foot complications, or end-organ damage.[1] Screening should also be considered for those with diabetes duration of ≥10 years.[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]
Monitoring for macrovascular complications: children
Check blood pressure at diagnosis and every visit.[1] The target is blood pressure below the 90th percentile for age, sex, and height or, in adolescents ages ≥13 years, <130/80 mmHg.[1]
Check an initial lipid profile soon after diagnosis, preferably after glycemia has improved and age is ≥2 years. If initial LDL cholesterol is <100 mg/dL (<2.6 mmol/L), subsequent testing should be performed at 9-11 years of age.[1] If LDL cholesterol values are within the accepted risk level (<100 mg/dL [<2.6 mmol/L]), it is reasonable to repeat a lipid profile every 3 years.[1]
Monitoring for microvascular complications: adults
Initial screening for retinopathy by an ophthalmologist or optometrist is recommended within 5 years of initial diagnosis of diabetes, and every 1-2 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]
Perform yearly screening for increased urinary albumin excretion and estimated glomerular filtration rate in all patients who have had type 1 diabetes for 5 years or more.[1] 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]
Perform a comprehensive foot evaluation at least annually to identify risk factors, and evidence of sensory loss (or previous ulcers or amputations) should prompt foot inspection at every visit.[1] During the evaluation, patients should be asked about prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). The accompanying examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing or Ipswich touch test with at least one additional assessment: pinprick, temperature, or vibration), and vascular assessment, including pulses in the legs and feet.[1]
Screen all patients for peripheral neuropathy 5 years after the initial diagnosis of diabetes, and at least annually thereafter (increased to every visit if there is evidence of sensory loss, or prior ulceration or amputation).[1] Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function).[1]
Assess 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]
Screen for erectile dysfunction in men with diabetes, particularly in those with high cardiovascular risk, retinopathy, cardiovascular disease, chronic kidney disease, peripheral or autonomic neuropathy, longer duration of diabetes, depression, and hypogonadism, and in those who are not meeting glycemic goals.[1]
Screen women with type 1 diabetes for problems with libido, arousal, and orgasm, particularly those who experience depression and/or anxiety and those with recurrent urinary tract infections.[1] In postmenopausal women with diabetes or prediabetes, screen for symptoms and/or signs of genitourinary syndrome of menopause, including vaginal dryness and dyspareunia.[1]
Monitoring for microvascular complications: children
Microvascular complication screening in children is generally not recommended until they reach puberty or age 10 years (whichever comes first), as there is low risk of occurrence before this.[1]
An initial dilated and comprehensive eye exam is recommended once a child has had type 1 diabetes for 3-5 years, provided they are ages ≥11 years or puberty has started, whichever is earlier. The exam should then be repeated every 2 years.[1] Less frequent exams, every 4 years, may be acceptable on the advice of an eye care professional and based on risk factor assessment, including a history of HbA1c <8% (<64 mmol/mol).[1]
Commence annual comprehensive foot exams, along with assessment of symptoms of neuropathic pain, at the start of puberty or at age ≥10 years, whichever is earlier, once the child has had type 1 diabetes for 5 years.[1]
Initiate annual screening for albuminuria with a random (morning sample preferred to avoid effects of exercise) spot urine sample for albumin-to-creatinine ratio at puberty or at age >10 years, whichever is earlier, once the youth has had diabetes for 5 years.[1]
Assessment for other complications
Yearly dental exams are indicated in patients with and without teeth, to control periodontal disease, which both contributes to and exacerbates hyperglycemia.[1]
Regular monitoring of height, weight, growth, and physical development is important for children and adolescents with type 1 diabetes, who have been shown to have impaired linear growth compared with healthy peers.[48][279]
In adults, thyroid disease should be screened for at diagnosis once the patient is clinically stable, and thereafter at repeated intervals if clinically indicated.[1] In children, thyroid-stimulating hormone (TSH) concentration should be checked after diagnosis once the patient is clinically stable and blood glucose is within the target range (this is because thyroid function tests may be misleading [euthyroid sick syndrome] if performed at the time of diagnosis owing to the effect of previous hyperglycemia, ketosis or ketoacidosis, weight loss, etc.).[1] If normal, TSH should be rechecked every 1-2 years, or sooner if the child has positive thyroid antibodies or develops symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability.[1] The American Diabetes Association (ADA) also suggests testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. At the time of diagnosis, approximately 25% of children with type 1 diabetes have thyroid autoantibodies, the presence of which is predictive of thyroid dysfunction - most commonly hypothyroidism.[1]
In children and adolescents, screen for celiac disease shortly after diagnosis (and then again within 2 years and after 5 years). In adults, the decision to screen is prompted by clinical suspicion.[1][48]
Screen for other associated autoimmune diseases, such as primary adrenal insufficiency and pernicious anemia, when there is increased suspicion.[1][48] For example, consider checking vitamin B12 levels in patients with peripheral neuropathy or unexplained anemia.[1]
Perform psychosocial screening (e.g., for stress, quality of life, resources), and specifically screening for depressive symptoms and diabetes distress, at diagnosis and then at least annually.[1] Consider screening at similar intervals for anxiety symptoms and diabetes-related fears or worries in addition.[1] Consider more frequent screening 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] Physicians can help prompt these conversations with informal verbal inquiries; for example, by asking whether the patient has experienced any persistent changes in mood, or if there are any new or different barriers to their diabetes treatment.[1] Consider screening for disordered eating behaviors when signs and symptoms (e.g., unexplained weight loss, hyperglycemia, and diabetic ketoacidosis) and/or behavioral and emotional indicators (e.g., secrecy around eating and excessive concern about weight) are present using available screening tools.[1]
In children and adolescents, screen for psychosocial concerns, family factors, and behavioral health concerns that could impact diabetes management at diagnosis and during routine follow-up care using age-appropriate standardized and validated tools.[1] The ADA recommends that screening for diabetes distress (which should also extend to family members/caregivers) should start at ages 7 or 8 years and use validated tools.[1] The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends screening for symptoms of depression, diabetes distress, and disordered eating in children ages ≥12 years using validated tools at the initial visit, at periodic intervals (at least once a year), and when there is a change in disease, treatment, or life circumstance.[48]
Perform an assessment of disability at the initial visit and for decline in function at each subsequent visit.[1] If a disability is impacting functional ability or capacity to manage their diabetes, a referral should be made to an appropriate healthcare professional specializing in disability (e.g., physical medicine and rehabilitation specialist, physical therapist, occupational therapist, or speech language pathologist).[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]
The ADA 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]
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