What Screening and Follow-Up Are Appropriate for Patients With Diabetes?

Q. What are the basic history elements of an office visit for a person with diabetes?

A. Any office visit of a patient with diabetes should include an assessment of lifestyle, diet, and behavioral changes. According to the American Diabetes Association (ADA),¹ an evaluation of the level of patients’ engagement should include their understanding of their diabetes, as well as review the symptoms and the details of self-management, including glucose self-monitoring. Each visit also should include attention to complications and comorbidities of diabetes, particularly the incidence and severity of hypoglycemia, such as addressing hypoglycemic events that may occur while the patient is driving an automobile.

The clinician should inquire about the results of the patient’s most recent dilated eye examination.² For persons with type 1 diabetes (T1D), this examination should be first performed within 5 years after onset. For those with type 2 diabetes (T2D), it should be done at the time of initial diagnosis, and for pregnant women it should be done either before onset or during the first trimester. Persons with T1D or T2D should be monitored at least annually unless there has been no evidence of retinopathy at 1 or more normal annual examinations; otherwise they should be monitored a minimum of every 2 years. Depending on the degree of retinopathy, pregnant women may need monitoring during each trimester and for 1 year following delivery.

The history should address existing complications and comorbidities, as well as address preventive strategies such as vaccinations and aspirin therapy. Clinicians should inquire about smoking history and counsel about cessation when needed. Patients should avoid electronic cigarettes.¹ At minimum, annual assessments of educational, nutrition, and psychosocial needs should be done.

A direct review of glucose test results provides the most accurate assessment of daily trends, particularly in relation to meals, activity, and work and sleep schedules. This may be achieved by reviewing patients’ glucose self-test result log sheets, an electronic download of blood glucose meter data, or a manual review of the meter’s memory. Persons with insulin pumps and/or continuous glucose monitors require more detailed evaluation. Persons on medications that increase the risk of hypoglycemia, such as insulin, sulfonylureas, and glinides, usually require multiple daily glucose tests, but the published guidelines note that multiple daily self-testing generally is not necessary when such agents are not being used.³

Q. What components of the physical examination should be performed at follow-up visits?

A. Monitoring blood pressure (BP) and treating hypertension are important in reducing the risk of cardiovascular events and the development of diabetic kidney disease.² A target systolic BP below 140 mm Hg and a diastolic BP below 90 mm Hg generally are recommended, but in older populations, there is an increased risk of adverse events if the diastolic BP is maintained below 70 mm Hg.

Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy should be considered, but combination therapy generally should be avoided. Of note, ACEI therapy and ARB therapy are not indicated for primary prevention of renal damage in the absence of hypertension, albuminuria, or renal impairment.²

Comprehensive foot examinations, including assessment for peripheral diabetic neuropathy, should be performed at least yearly.² Patients with any history of foot deformities, impaired sensation, impaired vascular flow, or a history of ulcers should have examinations at every office visit. Persons who smoke, have poor glycemic control, or have visual impairment also are at increased risk for ulcers and/or amputations and therefore require closer follow up.

Q. Which laboratory tests should be considered during follow-up visits?

A. The hemoglobin A_1c level is the foundation for monitoring glycemic control for most patients with diabetes.¹ Levels should be tested at least twice yearly for persons with stable glycemic control, but 4 times yearly for patients who are not meeting treatment goals.⁴

ADA guidelines⁵ state that lipid testing in persons with diabetes should be performed at the time of diagnosis and every 5 years thereafter if not on statin therapy, or periodically if taking medication. In contrast, the American Association of Clinical Endocrinologists/American College of Endocrinology guidelines⁶ recommend screening annually in all adults, reassessment 6 weeks after starting or adjusting therapy, and every 6 to 12 months thereafter. The American College of Cardiology/American Heart Association recommendations⁷ are to monitor fasting lipids 4 to 12 weeks after starting or changing doses and every 3 to 12 months once stable. The National Lipid Association⁸ also recommends monitoring every 4 to 12 months once lipid goals have been achieved.

Urinary albumin and the estimated glomerular filtration rate should be assessed at least yearly.² More frequent testing, in addition to assessing serum potassium levels, is indicated for persons on ACEI, ARB, or diuretic therapy.

Q. When should subspecialty evaluation be considered?

A. An endocrine specialist may be needed for persons at risk for hypoglycemia, with brittle T1D, or with uncontrolled diabetes, and those using special devices such as an insulin pump or a continuous glucose monitor. With a multitude of new medications and treatments, endocrinologists can help choose the best cost-effective strategies for individual patients and assist with monitoring of glycemic control. Expertise in lipid management also may be needed for persons with intolerance to statins, with inadequate response to statin therapy, or with very high triglyceride levels.

Renal consultation may be needed if there is uncertainty as to the etiology of renal disease, when there are difficult management concerns, and for persons with advanced renal disease.² Neurologists and/or pain management specialists may assist in helping persons with difficult complications of peripheral or autonomic neuropathy. Vascular, orthopedic, and/or podiatric specialists may be needed for persons with significant foot or lower extremity complications. Professional counseling may be indicated when patients have significant mood, psychosocial, or compliance concerns.

Kim A. Carmichael, MD, is an associate professor of medicine in the Department of Medicine, Division of Endocrinology, Metabolism and Lipid Research, at Washington University School of Medicine in St Louis, Missouri. He discloses that he is on the speakers bureaus for Merck and Janssen, which may be relevant to the content of this article.

References:

1. American Diabetes Association. 3. Foundations of care and comprehensive medical evaluation. Diabetes Care. 2016;39(suppl 1):S23-S35.
2. American Diabetes Association. 9. Microvascular complications and foot care. Diabetes Care. 2016;39(suppl 1):S72-S80.
3. Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. Choosing Wisely, an Initiative of the ABIM Foundation. http://www.choosingwisely.org/clinician-lists/endocrine-society-multiple-daily-self-glucose-monitoring-for-stable-type-2-diabetes. Released October 16, 2013. Accessed March 31, 2016.
4. American Diabetes Association. 5. Glycemic targets. Diabetes Care. 2016;39(suppl 1):S39-S46.
5. American Diabetes Association. 8. Cardiovascular disease and risk management. Diabetes Care. 2016;39(suppl 1):S60-S71.
6. Jellinger PS, Smith DA, Mehta AE, et al; AACE Task Force for Management of Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical Endocrinologists’ guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012;18(suppl 1):1-78.
7. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2016 executive summary. Endocr Pract. 2016;22(1): 84-113.
8. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1 – executive summary. J Clin Lipidol. 2014;8(5): 473-488.