What is the proposed monitoring plan for Diabetes Mellitus (DM) management?

From the Guidelines

I strongly recommend implementing a comprehensive diabetes monitoring plan that includes daily blood glucose checks, quarterly HbA1c testing, and regular screening for complications, as outlined in the 2019 standards of medical care for type 2 diabetes in China 1. This approach is crucial for determining the degree of glucose metabolic disturbance, developing an effective hypoglycaemic plan, evaluating therapeutic effects, and guiding adjustments of hypoglycaemic regimens.

Key Components of the Monitoring Plan

• Daily blood glucose checks: 2-4 times daily (before meals and at bedtime) using a glucose meter, with target fasting levels of 80-130 mg/dL and post-meal levels below 180 mg/dL, as suggested by the 2004 diabetes management guidelines 1.
• Quarterly HbA1c testing: until targets are reached (generally <7% for most adults), then twice yearly if stable, as recommended by the 2016 American Diabetes Association standards of medical care in diabetes 1.
• Regular screening for complications: annual comprehensive foot exams, eye examinations, kidney function tests (eGFR and urine albumin-to-creatinine ratio), and lipid panels.
• Blood pressure monitoring: at each clinical visit, targeting <140/90 mmHg.
• Patient education and self-management: patients should maintain detailed logs of glucose readings, medication adherence, diet, physical activity, and any symptoms of hypo/hyperglycemia. The frequency of monitoring may need adjustment based on individual factors such as medication regimen, glycemic control stability, and presence of complications. Regular monitoring is essential because diabetes is progressive, and early intervention prevents long-term complications like neuropathy, retinopathy, nephropathy, and cardiovascular disease.

From the FDA Drug Label

Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia [see Warnings and Precautions (5. 3)] or hyperglycemia. Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring.

The proposed monitoring plan for diabetes management should include close medical supervision and increased frequency of blood glucose monitoring when making any changes to a patient's insulin regimen, such as switching from one type of insulin to another (e.g., from glargine to aspart) or changing the injection site.

• Key factors to consider when monitoring patients with diabetes include:
  • Changes in meal pattern or physical activity
  • Concomitant use of other medications that may affect blood glucose levels
  • Presence of renal or hepatic impairment, which may increase the risk of hypoglycemia
  • History of hypoglycemia or hyperglycemia
• Risk mitigation strategies for hypoglycemia include:
  • Patient and caregiver education on recognizing and managing hypoglycemia
  • Increased frequency of blood glucose monitoring, especially in patients at higher risk for hypoglycemia or with reduced symptomatic awareness of hypoglycemia 2, 3, 3

From the Research

Importance of Blood Glucose Monitoring in Diabetes Management

• Blood glucose monitoring is essential in diabetes care and management, as it helps individuals with diabetes to control their condition and prevent complications 4, 5.
• The measurement of blood glucose provides information on the effectiveness of blood glucose metabolism and guides interventions to achieve optimal glucose control within the body 5.
• Self-monitoring of blood glucose is a critical element in diabetes management, and healthcare providers should determine if and when patients are to perform glucose self-monitoring, set blood glucose targets, and help patients to interpret the results 6.

Frequency and Targets of Blood Glucose Monitoring

• The frequency of blood glucose monitoring and the identification of patterns and trends in blood glucose control are crucial in achieving maximum benefit for the patient and diabetes care team 4.
• Blood glucose targets and frequency of testing must be decided to meet each patient's needs, as diabetes is individual 7.
• Nurses have key roles in education and advocacy, and they can educate patients on what affects glucose levels, why they need to carry out self-monitoring of blood glucose, and how to interpret and act on the results 7.

Challenges and Opportunities in Diabetes Management

• Hemoglobin A1c, blood pressure, and LDL-cholesterol control are suboptimal among Hispanic/Latinos with diabetes living in the U.S., with only 8.4% meeting all three recommendations 8.
• There is a substantial opportunity to improve diabetes control in this population, and nurses can play a vital role in education, advocacy, and matching glucose monitoring meters to patients' needs 8, 7.
• Access to testing supplies is sometimes restricted, and nurses have an advocacy role in challenging inappropriate restrictions to ensure that patients have access to the necessary resources for effective diabetes management 7.