Monitoring
Patients with diabetes benefit from monitoring at least every 3 months if their diabetes is not well controlled and every 6 to 12 months otherwise.[30] Blood pressure and activity level should be monitored at each visit and healthy lifestyle modifications encouraged.[30]
Measurement of weight and height (to calculate body mass index [BMI]), and other anthropometric measurements of body fat distribution (e.g., waist circumference, waist-to-hip circumference ratio, or waist-to-height ratio) if BMI is indeterminate, should be performed at least annually in people with type 2 diabetes to aid the diagnosis of obesity.[30] More frequent assessment (at least every 3 months) should be undertaken to monitor response to treatment during active weight management.[30]
People with diabetes and obesity who have lost significant weight, especially those who have undergone metabolic surgery and those treated with weight management pharmacological therapy, should be routinely screened for malnutrition.[30]
For individuals who have undergone metabolic surgery, routine screening for psychosocial or behavioural health changes is recommended, with referral to a qualified behavioural health professional as needed.[30] Additionally, these individuals should be monitored for insufficient weight loss or weight regain at least every 6-12 months. If such issues arise, potential predisposing factors should be assessed, and additional weight loss interventions, such as weight management pharmacotherapy, should be considered if appropriate.[30]
Joint American Heart Association and American College of Cardiology guidelines recommend that all patients with signs or symptoms suggestive of peripheral arterial disease (PAD) (e.g., calf claudication; decreased or absent pedal pulses; non-healing wounds) should have an ankle-brachial index (ABI) measured, with or without ankle pulse volume recordings and/or Doppler waveforms.[29] ABI testing is also considered reasonable in asymptomatic patients with diabetes and any of the following characteristics: aged ≥50 years; aged <50 years with diabetes and one additional risk factor for atherosclerosis; known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, or mesenteric artery stenosis, or abdominal aortic aneurysm).[29] The American Diabetes Association (ADA) recommends screening for PAD using ABI in asymptomatic patients with diabetes who are aged ≥65 years, as well as in people with microvascular disease in any location, or foot complications, or any end-organ damage from diabetes, if a PAD diagnosis would change management.[30] It should also be considered in individuals with diabetes duration ≥10 years and high CV risk.[30] See Diabetes-related foot disease.
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.[30]
Serum creatinine, estimated glomerular filtration rate (eGFR), and potassium levels require monitoring within 7-14 days of starting an ACE inhibitor, angiotensin-II receptor antagonist, aldosterone antagonist, or diuretic, and again 7-14 days after any dose adjustment.[30] Regular checks should then be performed at subsequent routine appointments.[30]
Screening for heart failure in patients with diabetes is important for starting therapy early and optimising prognosis. The ADA recommends annual screening of asymptomatic adults with diabetes for heart failure with measurement of B-type natriuretic peptide (BNP)/N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.[30] If abnormal natriuretic peptide levels are detected, echocardiography is recommended.
Opportunistic screening for atrial fibrillation is recommended by the European Society of Cardiology in all patients with diabetes aged under 65 years, while systematic screening should be considered for those aged 75 years and over or at high stroke risk.[7]
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