This National Institute for Health and Care Excellence (NICE) guideline covers the care and treatment of adults (aged 18 and over) with type 1 diabetes.
Type 1 diabetes affects over 370,000 adults in the UK. One of the most important roles of healthcare professionals providing diabetes care to adults with type 1 diabetes is to ensure that systems are in place to provide informed, expert support, education and training for insulin users, as well as a range of other more conventional biomedical services and interventions.
Reasons for the update
NICE last produced a guideline on type 1 diabetes in 2004 (NICE clinical guideline 15). Since then, life expectancy for adults living with type 1 diabetes has increased, but it remains significantly shorter than for people without diabetes. There remain important deficiencies in care provision, most adults with type 1 diabetes have HbA1c above target levels, and rates of diabetic ketoacidosis (the acute complication of insulin deficiency) and renal failure have increased. This update focuses on areas where new knowledge and treatment opportunities have arisen in the last decade. These include improvements in technology to support better glucose levels, that should result in improved outcomes for adults with type 1 diabetes. These changes also present more challenges in terms of the diversity and complexity of the tools that can now be provided, and this guideline describes evidence‑based best practice for their deployment.
Topics updated from the 2004 guideline include:
- diagnosing type 1 diabetes
- structured education programmes
- insulin preparations and regimens associated with improved glucose levels
- needle length for insulin injections
- new technologies for glucose monitoring and insulin delivery
- managing acute painful neuropathy associated with rapid blood glucose control, erectile dysfunction in men and gastroparesis
- primary prevention of cardiovascular disease.
The following topics were not included in 2004 and have been added:
- new insulin formulations
- identifying, quantifying and managing impaired awareness of hypoglycaemia
- monitoring for thyroid disease
- use of blood ketone measurement in preventing and monitoring diabetic ketoacidosis
- carbohydrate counting and glycaemic index diets
- referral criteria for transplantation therapies.
You can read the guideline on NICE's website.
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. [new 2015]
Blood glucose management
- 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. [new 2015]
- Agree an individualised HbA1c target with each adult with type 1 diabetes, taking into account factors such as the person's daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia. [new 2015]
- Support adults with type 1 diabetes to test at least four times a day, and up to 10 times a day if any of the following apply:
- desired target for blood glucose control, measured by HbA1c level, is not achieved
- frequency of hypoglycaemic episodes increases
- legal requirement to do so (such as before driving, in line with the Driver and Vehicle Licensing Agency (DVLA)
- during periods of illness
- before, during and after sport
- when planning pregnancy, during pregnancy and while breastfeeding (see the NICE guideline on diabetes in pregnancy)
- if there is a need to know blood glucose levels more than four times a day for other reasons (for example, impaired awareness of hypoglycaemia, high‑risk activities). [new 2015]
- Advise adults with type 1 diabetes to aim for:
- fasting plasma glucose level of 5–7 mmol/litre on waking
- plasma glucose level of 4–7 mmol/litre before meals at other times of the day. [new 2015]
Insulin therapy
- 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. [new 2015]
Awareness and management of hypoglycaemia
- Assess awareness of hypoglycaemia in adults with type 1 diabetes at each annual review. [new 2015]
Care of adults with type 1 diabetes in hospital
- Enable adults with type 1 diabetes who are hospital inpatients to self‑administer subcutaneous insulin if they are willing and able and it is safe to do so. [new 2015]