management of type I diabetes (IDDM)

Last edited 11/2018 and last reviewed 03/2021

The management of type 1 diabetes (IDDM) involves a multidisciplinary team comprising diabetologist, ophthalmologist, GP, diabetic nurse and dietician.

Patients with symptoms and signs suggestive of diabetic ketoacidosis should be admitted to the hospital as an emergency. If diabetic ketoacidosis is not suspected, insulin may be commenced in the community or in secondary care (1).

• in the recent past it was common to hospitalise newly diagnosed diabetics for 7 to 10 days but in the majority of centres this period has been considerably reduced and in some centres newly diagnosed patients are not hospitalised at all.
• the Scottish Intercollegiate Guidelines Network (SIGN) recommends home-based programme for initial management and education of children with diabetes and their families is an appropriate alternative to a hospital-based programme (2)

Glycemic targets

• maintaining recommended glycemic targets has been shown to be associated with improved metabolic control (which reduces both the onset and progression of diabetes-related complications) (3) 
• there is no agreed single target for glycaemic control in T1D patients. Targets recommended by different authorities vary between 6.5-7.5% (48-58 mmol/mol)
• NICE recommends that adults with type 1 diabetes should aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long‑term vascular complications (4).
• targets can also vary within an individual even over a very short period of time depending on a variety of clinical and non-clinical circumstances (2)

Insulin therapy

• is the mainstay of medical management of T1D
• choice of insulin regimen depends on several factors e.g. - child’s age, duration of diabetes, family lifestyle, school support, socioeconomic factors  etc.
• after the honeymoon period (characterized by target glycemic control and low insulin requirements (<0.5 units/kg/day)), which may last up to 2 years after diagnosis, patient may require more intensive regimens to meet glycemic targets  e.g. –
• basal-bolus regimens - long-acting basal insulin analogues and rapid-acting bolus insulin analogues
• continuous subcutaneous insulin infusion (CSII) therapy (3)

Longterm follow up is essential in type 1 diabetes (IDDM) to consolidate patient education, monitor glycaemic control and screen for longterm complications. To achieve these aims every diabetic should have the following investigations on a regular basis:

• glycosylated haemoglobin
• urinalysis for microalbuminaemia
• fundoscopy
• plasma creatinie, lipids, LFTs

Patients should also have easy access to professional advice from:

• community-based diabetes nurses
• hospital based diabetologists
• GP's
• hospital-based dieticians
• national diabetic organisations, for example, the British Diabetic Association

Education and information for patients with type 1 diabetes (1)

• 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 6-12months after diagnosis
  
• if a structured education programme has not been undertaken by an adult with type 1 diabetes by 12 months after diagnosis, offer it at any time that is clinically appropriate and suitable for the person, regardless of duration of type 1 diabetes
  
• provide an alternative of equal standard for any adult with type 1 diabetes unable or unwilling to participate in group education

Dietary management in type 1 diabetes (1)

Carbohydrate counting

• carbohydrate-counting training should be offered to adults with type 1 diabetes as part of structured education programmes for self-management
• consider carbohydrate-counting courses for adults with type 1 diabetes who are waiting for a more detailed structured education programme or are unable to take part in a stand-alone structured education programme

Glycaemic index diets

• do not advise adults with type 1 diabetes to follow a low glycaemic index diet for blood glucose control

Reference:

• (1) The Association of British Clinical Diabetologists (ABCD) 2016. Standards of care for management of adults with type 1 diabetes   
• (2) Scottish Intercollegiate Guidelines Network (SIGN) 2010. Management of diabetes. A national clinical guideline  
• (3) Diabetes Canada Clinical Practice Guidelines Expert Committee, Wherrett DK et al. Type 1 Diabetes in Children and Adolescents. Can J Diabetes. 2018;42 Suppl 1:S234-S246.  
• (4) NICE (August 2015). Type 1 diabetes in adults: diagnosis and management