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Glycaemic targets should be individualised for each patient and reviewed at least annually
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HbA1c is the most practical target tool as reflects glycaemic control over the previous 3 months
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Should be measured 3 monthly until to target and then 6 monthly if stable control
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The target HbA1c in most patients with diabetes is < 53 mmol/mol
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A lower target HbA1c < 48 mmol/mol is appropriate when the risk of hypoglycaemia is low (i.e. not on insulin and/or sulfonylureas) and in patients who are either:
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Young
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Considering pregnancy or pregnant
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Have diabetic microvascular complications (particularly retinopathy and nephropathy)
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A higher HbA1c target (e.g. 54 – 70 mmol/mol) may be more appropriate when the risks of hypoglycaemia likely outweigh the benefits of tight glycaemic control such as:
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Life expectancy is limited by non-diabetes related comorbidities
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Previous episodes of severe hypoglycaemia
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Significant hypoglycaemic unawareness
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Frail elderly and/or with cognitive impairment
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Functionally dependent
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NB: Hypoglycaemia usually only occurs in patients treated with insulin and/or sulfonylureas
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Self-monitoring of blood glucose levels (SMBG) are recommended when:
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Considering starting or already on sulfonylurea or insulin therapy
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Concerns over hypoglycaemia on any therapy
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Planning pregnancy and during pregnancy
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Measurement of HbA1c is unreliable
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An HbA1c may be unreliable in:
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Any haemoglobinopathy e.g. sickle cell anaemia, thalassemia
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Altered red cell turnover e.g. bleeding, haemolysis, significant iron deficiency etc.
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Post blood transfusion
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Second and third trimesters of pregnancy
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Each patient should be provided with a CareSens N or N POP glucometer and CareSens N glucose test strips (the CareSens N voice glucometer may be useful if visual impairment)
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The frequency of SMBG should be individualised according to what information is required for medication changes and patient safety, and ideally should include:
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Whenever symptomatic of hypoglycaemia or hyperglycaemia
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Fasting glucose levels when on nocte basal insulin
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To check for 3 days before a dose change
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To check for 3 days before a dose change
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Periodic checking of glucose levels at other times of the day
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Checking levels before meals and bed on 1-2 days per week is often preferable to sporadic checks at different times on different days
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Pre and 1 or 2 hour post glucose levels at all meals during pregnancy
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More frequent monitoring may be required to ensure safety from hypoglycaemia and the necessary information for dose changes. Patients may also choose to monitor more frequently to improve their glycaemic control.
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Flash or continuous glucose monitoring may be beneficial in patients with type 2 diabetes at high risk of hypoglycaemia, but as of 2020 this is not funded.
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Monitoring of capillary ketone levels is only recommended in patients who are unwell and have:
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Type 1 diabetes
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Diabetes due to loss of pancreatic function
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Type 2 diabetes on an SGLT2 inhibitor and/or previous diabetic ketoacidosis (DKA) when unwell
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NB: These patients require a CareSens Dual glucometer with CareSens Pro glucose test strips and KetoSens ketone test strips. At present, patients with type 2 diabetes on a SGLT2 inhibitor do not qualify for a funded CareSens Dual glucometer