Management of Diabetes – GLUCOSE BAD mnemonic

Glycemic control

HbA1c 3 monthly or Bianually (if treatment goal acheived and glycemic control considered stable) – Target:

• Non-pregnant adult patients: <7%
• Minor cardiovascular disease, minor hypoglycemic episodes, short diagnosis time with diabetes, and long life expectancy: <6.5%
• Significant co-morbidities, progressive micro- and macrovascular complications, or short life expectancy: <8%

Self-monitoring of blood glucose – Target:

• Pre-prandial: 80-130 mg/dl
• Post-prandial: <180 mg/dl

Lipids

Annual or 2 yearly (if targets achieved) assessment of fasting lipid profiles with target:

• Triglyceride: <150 mg/dl
• HDL-c: >40 mg/dl (men) and >50 mg/dl (women)
• LDL-c: <100 mg/dl; <70 mg/dl (overt cardiovascular disease)

Statin therapy regardless of baseline lipid profile:

• Diabetes and overt CVD
• >40 years age without CVD but with atleast 1 risk factor for CVD (family history of CVD, smoking, albuminuria, hypertension, or dyslipidemia)

Urine microalbuminuria

Annual screening (albumin to creatinine ratio) for:

• Type 1 Diabetes diagnosed ≥ 5 years
• Type 2 Diabetes at the time of diagnosis

Albuminuria >30 mg/day: ACE Imhibitor or ARB recommended for Non-pregnant patients

Persistent microalbuminuria (30-300 mg/day) suggests:

• Type I DM: Pre-stages of nephropathy
• Type II DM: Nephropathy

Cigarettes

Advised to stop smoking or use of any tobacco products, and also to minimize second-hand smoke exposure.

Ophthalmology (Screening for eye disease and retinopathy)

• Type I DM: Within 5 years of diagnosis
• Type II DM: At the time of diagnosis

No evidence of retinopathy in 1 or more annual exam: Consider 2 yearly examination

Any evidence of retinopathy present: Atleast annualy

Retinopathy progressive or sight threatening: More frequently

Pregnant women with pre-existing diabetes:

• 1st examination: Prior to pregnancy and During 1st trimester
• Subsequent examination: Each trimester and upto 1 year postpartum as indicated by degree of retinopathy

Sexual dysfunction

HbA1c target <7% before becoming pregnant

Extremities

Annual comprehensive foot exam following 1st examination:

• Type I DM: At 5 years of diagnosis
• Type II DM: At the time of diagnosis

Examine:

1. Inspection of the skin to assess its integrity.
2. Examination for erythema, deformities, tissue damage, or callus formation.
3. Assessment of gait and joint mobility.
4. Assessment of pedial and popliteal pulses.
5. Assessment for loss of protective sensation with a 10-g monofilament in addition to testing for 1 of the following: vibration perception threshold; sensation to pinprick; vibration (using a 128-Hz tuning fork); or ankle reflexes.

Screen for Peripheral arterial disease (PAD) if:

• Diabetes with >50 years age
• <50 years age with other risk factors for PAD (hypertension, hyperlipidemia, smoking, or diabetes for >10 years)

PAD screening:

1. History of claudication
2. Pedial pulse assessment
3. Ankle-brachial index

Blood pressure

Target: <140/90 mmHg

Aspirin

75-162 mg/day (or Clopidegrol 75 mg/day) if: Women >60 years and Men >50 years with additional risk factors:

• Family history of CVD
• Albuminuria
• Smoking
• Dyslipidemia
• Hypertension

Dental checks

Biannual dental examination

Summarised from:

A Practitioner’s Simple Mnemonic for Managing Diabetes: “GLUCOSE BAD” – Jennifer Grace Ziliotto McCrudden, FNP-C, CDE, Beatrice Janulyte Hull, MD