This is an updated guideline from NICE on Type 1 diabetes in adults. It is a huge guideline. Most patients will be managed in secondary care, so I've tried to pull out the bits that are most relevant to us or that seemed new to me. If you do a lot with these patients, the guideline is well worth a read.
Diagnosis - telling type 1 from type 2 diabetes
Type 1 diabetics normally have 1 or more of:
- Rapid weight loss
- BMI < 25
- Family history of autoimmune disease
- Age under 50
But don't discount the possibility of type 1 diabetes if their BMI is > 25, or if they are over 50.
There are blood tests that can help distinguish the two, but they should not be routinely used. Autoantibody tests have fewer false negatives the closer to diagnosis they are measured, but c-peptide is more accurate the further post diagnosis you test.
Should be done every 3 - 6m.
Target should be 48 (6.5), though should be tailored to the individual.
Routinely this should be done 4 times a day, but can be advised 10 times a day or more if needed (eg doing sport, driving, hypoglycaemia etc)
Continuous glucose monitoring shouldn't be used routinely. The guideline gives specific criteria for it's use, but basically it's where there is troublesome hypoglycaemia or persistent hyperglycaemia.
- Long acting insulin - 1st line BD detemir (Levemir). 2nd line OD detemir or OD glargine.
- Rapid acting insulins - 1st line use analogues (rather than soluble or animal insulins).
- When to inject - advise injection before meals, rather than after.
- Mixed insulins - if used, use human insulins first line and analogues second line.
Consider if they have a BMI > 25 (23 if of Asian origin) if you want to lower insulin requirements.
Islet cell or pancreas transplants
Consider if the patient has had a renal transplant and is on immunosuppression.
Consider if they have recurrent severe hypoglycaemia not responding to other treatments.
The Clarke score or the Gold score should be used to assess awareness (I couldn't find any easy to use scores online for these).
Continuous glucose monitoring should be offered where it is particularly troublesome.
A pump should be offered where it is particularly troublesome.
Other Autoimmune Diseases
- Coeliac disease - beware in people losing weight or with a low BMI.
- TSH - monitor annually.
- Others - be aware that Addison's, pernicious anaemia etc are all more common in type 1 diabetic patients.
Aspirin - don't offer for primary prevention.
Statin - consider atorvastatin 20mg in all patients, and offer if:
- > 40
- Had diabetes > 10 years
- Have established nephropathy
- Have other CV risk factors
Hypertension - choice of medication
- ACEi first line
- β-blockers are OK to use
- Thiazides can be used in low dose and in combination with β-blockers.
- Calcium channel blockers - use longer acting ones.
Beware that this as a problem in diabetic patients with persistent vomiting. There is little evidence for any antiemetics, but some patients gain benefit from domperidone, erythromycin or metoclopramide. Because of the safety profile of domperidone, they suggest trying alternating erythromycin with metoclopramide (they don't advise how exactly to do this).
Acute painful neuropathy due to rapid improvement of blood glucose levels.
I wasn't aware that this could happen. It's self-limiting and does improve with time, but can take weeks or months. Use simple analgesia first, then try bed cradles, then use neuropathic medications if needed. Warn patients that medications can take weeks to work.