Glycosylated hemoglobin (HbA1c) should be checked twice yearly in patients who are meeting treatment goal of <7.5% for patients aged under 18 years with type 1 diabetes and <7% for adult patients. It is recommended to check HbA1c every 3 months in patients whose therapy is being modified or who are not meeting the goal. In very old or very young patients and in those with a history of severe hypoglycemia or limited lifespan, the HbA1c goal can be less stringent.
Check blood pressure at each visit and treat to a goal of <140/90 mmHg. In older adults, treating to <130/70 mmHg is not recommended.
For patients who are not on statins, it is recommended to check a screening lipid profile (total cholesterol, low-density lipoprotein [LDL] cholesterol, high-density lipoprotein [HDL] cholesterol, and triglycerides) in adults with diabetes at the time of first diagnosis, at initial medical evaluation, and then every 5 years thereafter if aged under 40 years (annually may be indicated in some cases). Lifestyle modification should be recommended to all patients with diabetes to improve lipid profile. For patients with atherosclerotic cardiovascular disease, a high-intensity statin should be added to lifestyle therapy. For patients aged 40-75 years without additional atherosclerotic cardiovascular disease risk factors, the American Diabetes Association (ADA) recommends adding a moderate-intensity statin. For patients aged 40-75 years with additional atherosclerotic cardiovascular disease risk factors, the ADA recommends adding a high-intensity statin. Once a patient is taking a statin, LDL cholesterol levels should be assessed 4-12 weeks after initiation of statin therapy, after any change in dose, and on an individual basis (e.g., to monitor adherence and efficacy). If a patient is adherent to statin therapy but not responding, clinical judgment is recommended to determine the need for and timing of lipid panels.
In the US, initial screening for retinopathy by an ophthalmologist is recommended within 5 years of initial diagnosis of diabetes, and every 2 years after that if no evidence of retinopathy. In the presence of abnormal findings, more frequent follow-up may be indicated (e.g., annually). Recommendations differ in other countries; for example, in the UK, screening for retinopathy is offered at the time of diagnosis and annually to all patients over the age of 12 years. Local guidance should be consulted.
Yearly screening for increased urinary albumin excretion and serum creatinine to estimate glomerular filtration rate should be done in all patients who have had type 1 diabetes for 5 years or more.
Screen yearly for distal symmetric polyneuropathy using pinprick sensation, temperature and vibration perception (with 128 Hz tuning fork), and 10 g monofilament pressure sensation at the distal plantar aspect of both great toes and ankle reflexes.
Symptoms of autonomic neuropathy can be assessed through history (exercise intolerance, constipation, diarrhea, gastroparesis, bladder or sexual dysfunction, hypoglycemic autonomic failure), and physical exam (resting tachycardia, orthostatic hypotension).
Yearly dental exams are indicated in patients with and without teeth, to control periodontal disease, which both contributes to and exacerbates hyperglycemia.
Vaccines should be provided in accordance with age-specific guidelines for the general population, including those for influenza and pneumococcal pneumonia. Hepatitis B vaccine should be provided for unvaccinated adults with diabetes aged 19-59 years, and should be considered for unvaccinated adults with diabetes aged ≥60 years.
Patients with autoimmune diabetes are more likely to have thyroid disease, celiac disease, and depression. Physicians should have a low threshold for screening for these conditions.
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