What is the recommended follow-up and management plan for a patient with diabetes?

Follow-Up Care for Diabetic Patients

Diabetic patients require structured follow-up visits every 3-6 months based on glycemic control and treatment complexity, with mandatory annual comprehensive evaluations for all patients to prevent morbidity and mortality from complications. 1

Visit Frequency and Timing

• Schedule follow-up appointments every 3-6 months for patients with stable glycemic control, with at least annual visits mandatory for all diabetic patients 1
• Increase visit frequency to every 1-2 weeks to 3 months for patients with poor glycemic control (A1C not at target), recent medication changes, or active complications 1
• Post-hospitalization follow-up within 1 month of discharge is required for patients who experienced hyperglycemia or hypoglycemia during hospitalization, with earlier appointments (1-2 weeks) preferred if glycemic medications were changed or glucose control was suboptimal at discharge 1

Components of Every 3-6 Month Visit

At each routine follow-up visit, the following assessments must be performed:

• Measure height, weight, and calculate BMI to track weight trends and obesity management 1
• Check blood pressure at every visit as part of cardiovascular risk assessment 1
• Perform A1C testing if results are not available within the past 3 months 1
• Review self-management behaviors, including nutrition adherence, medication compliance, and physical activity patterns 1
• Assess hypoglycemia and hyperglycemia episodes, including frequency, severity, and precipitating factors 1
• Screen for depression, anxiety, and disordered eating at every visit, as these conditions are highly prevalent (18-45%) and bidirectionally related to diabetes control 2, 1

Annual Comprehensive Evaluation

Laboratory Testing (Annual)

The following laboratory tests should be performed at least annually:

• Lipid profile (total cholesterol, LDL, HDL, and triglycerides) 1
• Spot urinary albumin-to-creatinine ratio to screen for diabetic kidney disease 1
• Serum creatinine and estimated glomerular filtration rate (eGFR) for kidney function assessment 1
• Liver function tests to monitor for hepatotoxicity, especially in patients on certain medications 1
• Thyroid-stimulating hormone (TSH) in patients with type 1 diabetes due to increased autoimmune thyroid disease risk 1
• Vitamin B12 levels in patients taking metformin, as long-term use can cause deficiency 1
• Serum potassium in patients on ACE inhibitors, ARBs, or diuretics 1

Physical Examination (Annual)

• Comprehensive foot examination including visual inspection for skin integrity, callous formation, deformities, or ulcers 1
• Peripheral arterial disease screening by checking pedal pulses, with referral for ankle-brachial index if pulses are diminished 1
• Neurologic assessment including temperature sensation, vibration or pinprick sensation, and 10-g monofilament examination 1
• Skin examination for acanthosis nigricans, insulin injection sites, and lipodystrophy 1
• Thyroid palpation to detect goiter or nodules 1

Ophthalmologic Follow-Up

• Type 1 diabetes patients require initial dilated comprehensive eye examination within 3-5 years after diabetes onset, while type 2 diabetes patients require examination shortly after diagnosis 1
• Annual eye examinations are required for both type 1 and type 2 diabetes patients thereafter 1
• More frequent examinations are necessary if retinopathy is progressing 1
• Immediate referral to an ophthalmologist for patients with severe nonproliferative diabetic retinopathy, any proliferative diabetic retinopathy, or macular edema 1

Glycemic Monitoring Strategy

• Monitor A1C every 3 months until glycemic targets are achieved, then at least twice yearly once stable 1
• Target A1C <7% for most adults, with more stringent targets (<6.5%) for selected individuals without significant hypoglycemia risk 1
• Individualize blood glucose monitoring frequency based on pharmacologic treatment, with patients on insulin requiring more frequent monitoring 1

Vaccination and Preventive Care

• Annual influenza vaccine for all diabetic patients ≥6 months of age 2
• Pneumococcal polysaccharide vaccine 23 (PPSV23) for all diabetic patients ≥2 years of age 2
• Pneumococcal conjugate vaccine 13 (PCV13) for adults ≥65 years, followed by PPSV23 6-12 months later if not previously vaccinated 2
• Hepatitis B vaccination for unvaccinated adults with diabetes aged 19-59 years, with consideration for those ≥60 years 2
• All age-appropriate vaccinations according to CDC schedules, including COVID-19 vaccines 1

Psychosocial and Lifestyle Assessment

• Assess diabetes self-management behaviors at each visit, including problem-solving skills for all aspects of diabetes management 1
• Screen for depression, anxiety, disordered eating, and cognitive impairment, particularly when self-management is poor 1
• Evaluate social determinants of health that may impact diabetes care access and adherence 1
• Assess sleep patterns and duration, as poor sleep quality and abnormal sleep duration are associated with higher A1C in type 2 diabetes 1

Diabetes Self-Management Education and Support

• Provide ongoing diabetes self-management education and support (DSMES) throughout the course of care, not just at diagnosis 1
• Include smoking cessation counseling as a routine component of diabetes care for all tobacco users 2
• Ensure education is provided by qualified diabetes educators and includes problem-solving skills for medication management, nutrition, physical activity, and glucose monitoring 1

Team-Based Care Coordination

• Coordinate care through a multidisciplinary team including physicians, nurses, dietitians, pharmacists, and mental health professionals with diabetes expertise 3
• Ensure structured discharge communication after hospitalizations, with medication reconciliation, transmission of discharge summaries to primary care clinicians, and scheduling of follow-up appointments prior to discharge 2

Common Pitfalls to Avoid

• Do not delay intensification of therapy when A1C remains above target for 3 months despite maximum tolerated doses of current medications—this "clinical inertia" is a major barrier to optimal diabetes control 4
• Do not overlook psychosocial screening, as diabetes-related distress affects 18-45% of patients and significantly impacts self-management 2
• Do not forget to assess for autonomic neuropathy before recommending vigorous exercise, as it increases risk of exercise-induced injury and silent myocardial ischemia 2
• Do not postpone exercise based solely on hyperglycemia if the patient feels well and ketones are negative 2