Diabetes Type I – Diagnosis and Management

 

Type 1 diabetes affects over 370,000 adults in the UK. It results from destruction of the cells that normally make insulin. Loss of insulin secretion results in high blood glucose and other metabolic and haematological abnormalities, which have both short-term and long-term adverse effects on health. Over years, type 1 diabetes causes tissue damage which, if not detected and managed early, can result in disability: blindness, kidney failure and foot ulceration leading to amputation, as well as premature heart disease, stroke and death

Type 1 diabetes is treated by insulin replacement, supported by active management of other cardiovascular risk factors, such as hypertension and high circulating lipids. Modern insulin replacement therapy aims to recreate normal fluctuations in circulating insulin concentrations

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Diagnosis

Diagnose type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia, bearing in mind that people with type 1 diabetes typically (but not always) have one or more of:

  • ketosis
  • rapid weight loss
  • age of onset below 50 years
  • BMI below 25 kg/m2
  • personal and/or family history of autoimmune disease

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NOTE:  Do not discount a diagnosis of type 1 diabetes if an adult presents with a BMI of 25 kg/m2 or above or is aged 50 years or above

NOTE:  Do not measure C-peptide and/or diabetes-specific autoantibody titres routinely to confirm type 1 diabetes in adults

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Education and information

Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example the DAFNE (dose-adjustment for normal eating) programme.  Offer this programme 6-12 months after diagnosis

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Dietary management

  1. Offer carbohydrate-counting training to adults with type 1 diabetes as part of structured education programmes for self-management
  2. Do not advise adults with type 1 diabetes to follow a low glycaemic index diet for blood glucose control
  3. Offer dietary advice to adults with type 1 diabetes about issues other than blood glucose control, such as weight control and cardiovascular risk management, as indicated clinically

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Physical activity

Give adults with type 1 diabetes who choose to integrate increased physical activity into a more healthy lifestyle information about:

  • appropriate intensity and frequency of physical activity
  • role of self-monitoring of changed insulin and/or nutritional needs
  • effect of activity on blood glucose levels (likely fall) when insulin levels are adequate
  • effect of exercise on blood glucose levels when hyperglycaemic and hypoinsulinaemic (risk of worsening of hyperglycaemia and ketonaemia)
  • appropriate adjustments of insulin dosage and/or nutritional intake for exercise and post-exercise periods, and the next 24 hours

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HbA1C monitoring and targets

'Treatment Pathway for Adults with Type 1 Diabetes' (EKPG) Sept 2018

  1. Measure HbA1c levels every 3–6 months in adults with type 1 diabetes
  2. Inform adults with type 1 diabetes of their HbA1c results after each measurement and ensure that their most recent result is available at the time of consultation
  3. Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications

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Blood glucose monitoring

'Blood glucose monitoring and exercise' (EKPG) Dec 2018

  1. Advise routine self-monitoring of blood glucose levels for all adults with type 1 diabetes, and recommend testing at least 4 times a day, including before each meal and before bed
  2. Advise adults with type 1 diabetes to aim for:
    1. a fasting plasma glucose level of 5–7mmol/litre on waking and
    2. a plasma glucose level of 4–7mmol/litre before meals at other times of the day
  3. Advise adults with type 1 diabetes who choose to test after meals to aim for a plasma glucose level of 5–9 mmol/litre at least 90 minutes after eating
  4. Educate adults with type 1 diabetes about how to measure their blood glucose level, interpret the results and know what action to take. Review these skills at least annually

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NOTE:  Do not offer real-time continuous glucose monitoring routinely to adults with type 1 diabetes

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Click here for the EKPG Recommendation for the choice of blood glucose meters in adults

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Insulin therapy

Insulin regimens

  • Offer multiple daily injection basal–bolus insulin regimens, rather than twice-daily mixed insulin regimens, as the insulin injection regimen of choice for all adults with type 1 diabetes. Provide the person with guidance on using multiple daily injection basal–bolus insulin regimens

Long-acting insulin

  • Offer twice-daily insulin detemir as basal insulin therapy for adults with type 1 diabetes

Rapid-acting insulin

  • Offer rapid-acting insulin analogues injected before meals, rather than rapid-acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes

Mixed insulin

  • Consider a twice-daily human mixed insulin regimen for adults with type 1 diabetes if a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is chosen

Insulin delivery

  • Advise adults with type 1 diabetes to rotate insulin injection sites and avoid repeated injections at the same point within sites
  • Check injection site condition at least annually and if new problems with blood glucose control occur

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Referral for islet or pancreas transplantation

  1. Consider referring adults with type 1 diabetes who have recurrent severe hypoglycaemia that has not responded to other treatments.  Islet and/or pancreas transplantation is performance at King's College Hospital, London
  2. Consider islet or pancreas transplantation for adults with type 1 diabetes with suboptimal diabetes control who have had a renal transplant and are currently on immunosuppressive therapy

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Awareness and management of hypoglycaemia

  1. Assess awareness of hypoglycaemia in adults with type 1 diabetes at each annual review
  2. Ensure that adults with type 1 diabetes with impaired awareness of hypoglycaemia have had structured education in flexible insulin therapy using basal–bolus regimens and are following its principles correctly
  3. Explain to adults with type 1 diabetes that a fast-acting form of glucose is needed for the management of hypoglycaemic symptoms or signs in people who are able to swallow
  4. If hypoglycaemia becomes unusually problematic or of increased frequency, review the following possible contributory causes:
    1. inappropriate insulin regimens (incorrect dose distributions and insulin types)
    2. meal and activity patterns, including alcohol
    3. injection technique and skills, including insulin resuspension if necessary
    4. injection site problems
    5. possible organic causes including gastroparesis

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Ketone monitoring and management of diabetic ketoacidosis (DKA)

  1. Consider ketone monitoring (blood or urine) as part of 'sick-day rules' for adults with type 1 diabetes, to facilitate self-management of an episode of hyperglycaemia
  2. Give intravenous insulin by infusion to adults with DKA
  3. In the management of DKA in adults, once the plasma glucose concentration has fallen to 10–15 mmol/litre, give glucose-containing fluids (not more than 2 litres in 24 hours) in order to allow continued infusion of insulin at a sufficient rate to clear ketones (for example, 6 units/hour monitored for effect)

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NOTE Do not generally use phosphate replacement in the management of DKA in adults

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Managing complications

Eye disease

  • On diagnosis, GPs should immediately refer adults with type 1 diabetes to the local eye screening service. Perform screening as soon as possible and no later than 3 months from referral. Arrange repeat structured eye screening annually

Diabetic kidney disease

  • Ask all adults with type 1 diabetes with or without detected nephropathy to bring in the first urine sample of the day ('early morning urine') once a year. Send this for estimation of albumin:creatinine ratio. Estimation of urine albumin concentration alone is a poor alternative. Serum creatinine should be measured at the same time
  • Start angiotensin-converting enzyme (ACE) inhibitors and, with the usual precautions, titrate to full dose in all adults with confirmed nephropathy (including those with moderately increased albuminuria ['microalbuminuria'] alone) and type 1 diabetes

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Autonomic neuropathy

  • In adults with type 1 diabetes who have unexplained diarrhoea, particularly at night, the possibility of autonomic neuropathy affecting the gut should be considered

Gastroparesis

  • Advise a small-particle-size diet (mashed or pureed food) for symptomatic relief for adults with type 1 diabetes who have vomiting caused by gastroparesis
  • Consider continuous subcutaneous insulin infusion (CSII or insulin pump) therapy for adults with type 1 diabetes who have gastroparesis

Acute painful neuropathy of rapid improvement of blood glucose control

  • Reassure adults with type 1 diabetes that acute painful neuropathy resulting from rapid improvement of blood glucose control is a self-limiting condition that improves symptomatically over time

Thyroid disease monitoring

  • Measure blood thyroid-stimulating hormone (TSH) levels in adults with type 1 diabetes at annual review

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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