Monitoring Diabetes

Monitoring diabetes
  • Reviews are done annually
    • May be done more frequently in some patients
  • Four key things need to be monitored regularly in diabetic patients (CCCC)
    • Glycaemic control
    • Complications
    • Competency – includes iatrogenic problems
    • Coping

Glycaemic control
  • Agree a target Hba1c with the patient. This can vary depending on the patient but typically the following levels are used:
    1. <6.5% / 48mmol is the ideal and used if:
      • Short duration of diabetes
      • Long life expectancy
      • Otherwise healthy
    2. <7.5% / 59mmolthis more relaxed threshold is used if:
      • Severe hypoglycaemia history
      • Limited life expectancy + comorbidities
      • On ≥2 medications (T2DM)
  • HbA1c is measured at diabetic reviews every 6 months – often by the GP
    • Every 3 months if there have been treatment changes
    • This is the main form of monitoring in known diabetics
  • Self-Monitoring Blood Glucose (SMBG) is only routinely used in  patients requiring tighter glucose control such as:
    1. Patients at risk of hypoglycaemia – i.e. those on suphonylureas/insulin or with T1DM
    2. Pregnancy – either diabetic women considering pregnancy or with gestational diabetes
    3. With acute illness
    4. With erratic lifestyles or those with high levels of phsyical activity

complications

See complications separately for more detail

This involves an MDT approach – ophthalmology, nephrology, podiatry – as well as the GP’s input

  • Record any events of acute complications – HONK, DKA, Hypoglycaemia
  • Assess cardiovascular disease
    • Peripheral pulses
    • Cardiac auscultation
    • Monitor risk factors for development
      • Weight and BMI – aim <25
      • BP – aim for <130/90 in most diabetics or <125/80 if there is proteinuria
      • Lipid profile –
        • Cholesterol <4
        • LDL <2
      • Smoking cessation assessment
  • Assess Retinopathy
    • Annual retinopathy review is required typically by ophthalmology.
      • Assess visiual acuity and fundoscopy in all patients
  • Assess Neuropathy
    • Annual podiatrist review for foot inspection and neurological exam of lower limb
      • Diabetic foot exam is part of this
  • Assess Nephropathy
    1. Urinalysis ACR and U&E measurements (done along with liver, lipids, and thyroid function)
  • Foot exam
    • Pulses
    • Neurology
    • Foot calluses, ulcers, and deformities

Competency
  • Essentially consider how well patients understand their condition and its management
    • Need to ensure that patients are injecting insulin properly and monitoring BM effectively
      • Check for lipohypertrophy
    • Also ensure that patients understand other medications, complications, etc

Coping

Consider how patients are coping in several areas

  • Psychosocial – e.g. depression
    • Eating disorders are also quite common (esp. in T1DM) and need to be addressed
  • Occupational therapy
  • Domicilliary