Optimal diabetes care requires a long-term relationship with the patient, appropriate use of consultants when needed, and regular monitoring and control of blood pressure, HbA1c, tobacco use, and statin/aspirin use. Most patients require diabetes assessments every 3 to 4 months, and some patients may benefit from more frequent (monthly) visits, especially when motivated to improve their care. Use of diabetes educators is recommended, although traditional information-based diabetes patient education mandated by some professional organizations is only moderately effective in randomized studies. A multidisciplinary team with access to nurses, educators, dietitians, clinical pharmacists, psychologists, and other specialists as needed is recommended. Patient readiness to change is a strong predictor of improved care, and readiness to change 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.
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.[Evidence C] However, self-monitoring of blood glucose is recommended for those who (a) are on insulin; (b) have had prior hypoglycemic episodes; (c) drive or operate machinery and use oral medications that increase his or her risk of hypoglycemia; or (d) are pregnant, or planning to become pregnant. Continuous glucose monitoring 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. The data form an ambulatory glucose profile showing time in range and times of hypoglycemia, which can be used for personalized therapy decisions.
In addition to care required to achieve recommended levels of blood pressure, statin use, aspirin use, tobacco non-use, and glucose control, the following periodic monitoring for complications is advised:
Dilated eye exam every 1 to 2 years
Annual assessment of renal function including 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 or equivalent
Annually or more frequent foot exams including assessment of ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 10-gram monofilament touch sensation. All patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit and are candidates for specialized footwear.
Due to disease progression, comorbidities, and nonadherence to lifestyle or medication, 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 medication nonadherence, 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 medications (such as corticosteroids, certain depression medications [paroxetine], mood stabilizers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing disease.
Loss of control of blood pressure and lipids is also a common phenomenon. Close monitoring of patients with diabetes through frequent visits and lab work helps to maintain patients at treatment goals and proactively identify upward trends in blood pressure or HbA1c, and to reinforce the importance of statin adherence and nonsmoking.
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