How can I effectively monitor and follow up on patients with hyperglycaemia in a primary care setting?

Effective monitoring and follow-up of patients with hyperglycaemia in primary care involves individualized assessment and management based on the patient's type of diabetes, treatment regimen, and risk factors. For adults with type 2 diabetes, regular HbA1c testing is essential to assess glycaemic control and guide treatment adjustments, aiming for individualized HbA1c targets considering age, comorbidities, and risk of hypoglycaemia. Self-monitoring of blood glucose (SMBG) is generally not routinely recommended except for specific groups such as those on insulin therapy, those with hypoglycaemic episodes, or those on medications increasing hypoglycaemia risk (e.g., sulfonylureas), pregnant women, or when starting corticosteroids. When SMBG is used, regular review of the patient's skills, testing frequency, and interpretation of results should be conducted at least annually. Lifestyle advice and adherence to treatment should be reinforced at each follow-up, with timely intensification of therapy if targets are not met. Patients with symptomatic hyperglycaemia may require urgent specialist advice for possible insulin or sulfonylurea initiation. Monitoring should also consider the impact of intercurrent illness which can worsen hyperglycaemia, necessitating treatment review. For type 1 diabetes patients, more frequent SMBG or continuous glucose monitoring is recommended, with targets for fasting and pre-meal glucose levels, and individualized HbA1c goals. Driving advice and safety considerations should be addressed for patients self-monitoring blood glucose, especially those at risk of hypoglycaemia. Overall, follow-up should be structured, patient-centred, and include assessment of treatment effectiveness, side effects, and quality of life.