Standard follow-up program
Blood glucose monitoring
Glycosylated hemoglobin (HbA1c): HbA1c is the most important assessment indicator for long-term glycemic control (normal value 4-6%) and one of the important bases to guide the adjustment of clinical treatment plan. It is tested at least once every three months at the beginning of treatment, and can be checked every six months once the treatment goal is reached. In patients with abnormal hemoglobin disorders, HbA1c test results are unreliable and should be based on fasting and/or postprandial venous plasma glucose. If a laboratory is not available, fingertip capillary glucose determination can be applied, provided that it is calibrated periodically; such a center should regularly refer patients to a center that has the means to check or establish contact with a higher central laboratory to forward specimens. HbAlc determination should be performed by methods traceable to those once used by the DCCT.
Self-monitoring of blood glucose
Self-monitoring of blood glucose is an important measure to guide blood glucose control to the standard and to reduce the risk of hypoglycemia. Fingertip capillary blood glucose testing is the most ideal method, but if conditions prevent blood glucose checking, urine glucose testing including quantitative urine glucose testing is also acceptable.
Self-monitoring of blood glucose is applicable to all diabetic patients, but for patients on insulin injections and during pregnancy, self-monitoring of blood glucose is necessary for these patients in order to achieve strict control of blood glucose while reducing the occurrence of hypoglycemia. For those patients not on insulin therapy there is some evidence that self-monitoring is beneficial in improving glycemic control, but there is also unsupportive evidence.
The frequency of self-monitoring depends on the goals and modalities of treatment.
▪ Patients with poor glycemic control or those who are critically ill should be monitored 4-7 times a day until their condition is stable and their blood glucose is under control. When the condition is stable or the goal of blood glucose control has been reached, monitoring can be done 1-2 days a week.
▪ Those using insulin therapy should monitor blood glucose at least 5 times a day at the beginning of treatment, and 2-4 times a day after reaching the treatment goal; patients using oral medication and lifestyle interventions should monitor blood glucose 2-4 times a week after reaching the goal.
Blood glucose monitoring time
▪ Pre-meal blood glucose testing, fasting blood glucose level is the first concern when the blood glucose level is very high, and those who are at risk of hypoglycemia (elderly people, those with better glycemic control) should also measure pre-meal blood glucose.
▪ Postprandial 2 hours blood glucose monitoring is suitable for those whose fasting blood glucose has been well controlled but still cannot reach the treatment target.
▪ Bedtime glucose monitoring is suitable for patients who inject insulin, especially those who inject medium- and long-acting insulin.
Nocturnal blood glucose monitoring is suitable for patients whose insulin therapy is close to the therapeutic target but whose fasting blood glucose is still high.
Blood glucose should be monitored promptly when symptoms of hypoglycemia appear.
▪ Blood glucose should be monitored before and after strenuous exercise.
Blood glucose monitoring program
Patients using basal insulin should monitor fasting blood glucose three days a week before reaching the blood glucose standard, and then follow up once every two weeks, with an additional 5-point blood glucose profile measured the day before the follow up; after reaching the blood glucose standard, blood glucose should be monitored three times a week, i.e., fasting, after breakfast and after dinner, and then follow up once a month, with an additional 5-point blood glucose profile measured the day before the follow up.
For those who use premixed insulin, they should monitor fasting blood glucose 3 days a week and blood glucose before dinner 3 times a week before reaching the blood glucose standard, and then they should follow up once every two weeks, and take 5 points of blood glucose spectrum on the day before the follow-up.
▪ Intensive blood glucose monitoring program for those not on insulin therapy: 5 to 7 points of blood glucose monitoring per day, 3 days per week, mainly during medication adjustment.
▪ Low-intensity blood glucose monitoring program for those not using insulin therapy: blood glucose monitoring before and after one meal every day for three days a week or before breakfast and bedtime for three days a week, so as to grasp the trend of blood glucose control and understand the effect of meals on blood glucose, and focus on monitoring premeal blood glucose if asymptomatic hypoglycemia is suspected.
Guidance and quality control of blood glucose monitoring
Before starting self-monitoring, the physician or nurse should instruct the diabetic patient on monitoring techniques and monitoring methods, including how to measure blood glucose, when to monitor, how often to monitor and how to record the monitoring results. The physician or diabetes management team should check the patient’s self-monitoring technique and calibrate the glucose meter 1-2 times a year, especially if the self-monitoring results are inconsistent with glycated hemoglobin or clinical conditions.
Self-monitoring of urine glucose
Although self-monitoring of blood glucose is the most ideal means of blood glucose monitoring, sometimes urine glucose measurement can be used for self-monitoring when conditions prevent blood glucose from being made. The goal of urine glucose control is negative urine glucose at any time, but urine glucose monitoring is not helpful in detecting hypoglycemia; in some special cases, such as when the renal glucose threshold is increased (e.g., in the elderly) or decreased (pregnancy), urine glucose monitoring is not meaningful.