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

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

Effective monitoring and follow-up of patients with hyperglycaemia in primary care involves:

  • Regular measurement of HbA1c to assess average blood glucose control over 2–3 months, aiming for individualized targets that balance reducing long-term complications and minimizing hypoglycaemia risk. For adults with type 2 diabetes, a common target is around 53 mmol/mol (7.0%), but this should be tailored based on age, comorbidities, and patient preferences ,,.
  • Self-monitoring of blood glucose (SMBG) is generally not routinely recommended for all type 2 diabetes patients but should be offered to those on insulin, with hypoglycaemia risk, or during specific clinical scenarios such as corticosteroid initiation or pregnancy ,,. For type 1 diabetes, SMBG or continuous glucose monitoring (CGM) is essential, with recommendations to measure at least 4 times daily or use CGM devices based on patient preference and clinical need ,,.
  • Timely review and adjustment of treatment if HbA1c targets are not met, including reinforcing lifestyle advice, assessing medication adherence, and intensifying pharmacotherapy as appropriate, starting with metformin unless contraindicated ,,.
  • Structured annual assessment for patients self-monitoring blood glucose to evaluate effectiveness and safety of monitoring practices .
  • Consideration of individual patient factors such as frailty, comorbidities, risk of hypoglycaemia, and personal preferences when setting targets and planning follow-up ,,.
  • Use of continuous glucose monitoring (CGM) in type 1 diabetes and selected cases to detect glycaemic variability and prevent hypoglycaemia, with support to address device use issues and ensure equitable access ,,.

In summary, effective monitoring and follow-up in primary care requires individualized HbA1c targets, selective use of SMBG or CGM, regular review of treatment adherence and effectiveness, and structured annual assessments to optimize glycaemic control and reduce complications.

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