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

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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% / 59mmol – this 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

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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

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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

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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