3.        Annual         

Serum Creatinine - The serum creatinine is used to screen for renal insufficiency.  Obtain a serum             creatinine yearly and then use a formula to estimate Glomerular Filtration Rate (GFR). GFR should be used   to stage chronic kidney disease. Estimated GFR <60 ml/min/1.73m2 should prompt evaluation for anemia (Hgb), metabolic bone disease (Ca, Phosphorus, alkaline phosphatase, PTH) and malnutrition (albumin).

Complete UA/Microalbuminuria - A test for urine protein should be performed yearly.  If negative, a screening test for microalbuminuria should be performed (by A/C ratio or dipstick test). Dipstick-positive microalbuminuria should be confirmed on a separate specimen using an A/C ratio (abnormal microalbumin is 30-299 mcg/mg; overt proteinuria is > 300 mcg/mg) or 24 hour urine.  

ACE inhibitors and angiotensin receptor blockers (ARBs) should be considered in patients with microalbuminuria or proteinuria, even if normotensive.

 

Lipid Profile

Risk factors for atherosclerosis include LDL >100 mg/dl, HDL <40 mg/dl in men and <45 mg/dl in women, and TG >150 mg/dl.  Even lower LDL and TG values represent increased risk in persons with previously documented atherosclerosis.  These risk factors, especially elevated LDL, should be treated aggressively.  Caution should be used when considering agents that aggravate hyperglycemia.  

A lipid panel should be performed annually (TC, LDL, HDL, TG).  Consider direct LDL measurements, especially if TG >400 mg/dl or if the specimen is to be obtained non-fasting. Elevated TC, LDL, TG and low HDL confer greater risk for atherosclerosis. Optimal LDL cholesterol levels for adults with diabetes are <100 mg/dl. All patients with LDL >100 mg/dl require Medical Nutrition Therapy and other lifestyle modifications.  Pharmacologic intervention is recommended if dietary interventions and lifestyle modifications are ineffective in lowering LDL to <100 mg/dl or immediately if LDL >160 mg/dl.  The Heart Protection Study indicates that people with diabetes may benefit significantly from statin therapy even if their LDL is below 100 mg/dL.  Read more about the Heart Protection Study in the July 6, 2002 issue of Lancet, available on the following website: www.thelancet.com.

Information regarding the management of dyslipidemia in children and adolescents with diabetes may be found in the new American Diabetes Association Consensus Statement: "Management of Dyslipidemia in Children and Adolescents with Diabetes," published in the July 2003 issue of Diabetes Care. It reviews how frequently lipid levels should be monitored, how abnormal levels should be treated, and what additional research is needed.  Or visit the ADA web site at http://americandiabetesassn.org.

   

Eye Exam - Retinal exam through dilated pupils or stereo fundus photo.   People with type 2 diabetes should receive an initial exam at diagnosis and yearly thereafter. 

 

Dental Exam - Annual screen for periodontal disease and other oral pathology.

 

Complete Foot Exam - Risk assessment to include pulse check and sensory evaluation with monofilament, identification of foot deformity, and documentation of history of foot ulcers or amputation. More frequent follow-up foot care may be required based on clinical findings.

 

Screen for Neuropathy - By history and physical; include sensory, motor and autonomic evaluation.