Type 1 diabetes describes a condition in which the pancreas is no longer able to produce sufficient insulin due to the destruction of the pancreatic β cells by an autoimmune process. It is a condition which occurs predominantly in younger people from childhood to young adults and is increasing in the population particularly in the under 5 age group.
See other type 1 diabetes resources.

Initial assessment

The successful management of the diabetic patient depends on working in partnership with the patient and all members of the team responsible for the various elements of their care. Before a management plan can be agreed, an initial assessment of the health and lifestyle of the patient must be undertaken with particular reference to:¹

History

• Diabetic history, both recent and historical
• Symptoms of potential complications e.g. deterioration in eyesight
• Other medical conditions
• Drug history, current medications
• Family history
• Occupation and social history e.g. level of exercise, type of diet, smoking history, use of alcohol and recreational drugs
• Prior knowledge of, attitudes to and concerns about the condition.

Examination

• General examination
• Height/ weight/ BMI
• Examination of feet (e.g. ulcers, loss of sensation)
• Examination of eyes (e.g. cataracts, diabetic retinopathy)
• Blood pressure measurement
• Examination of peripheral pulses

Investigations

Consideration should be given to performing the following investigations depending on age and previous history of the condition:

• Urine albumin excretion (microalbuminuria is albumin loss of 30-300mg/day)
• Urine protein (diabetic nephropathy- albumin loss of > 300mg/day)
• HbA1c
• U&Es, estimated Glomerular Filtration Rate (eGFR)
• TFTs in young diabetic until transferred to adult service²
• Serum cholesterol - aim for total cholesterol level below 4.0mmol/l, LDL levels < 2.0mmol/l, HDL levels 1.0mmol/l or above in men and 1.2mmol/l or above in women and triglyceride levels 1.7mmol/l or less
• ± Islet cell antibodies/ C peptide deficiency (N.B. Although these tests should not be routinely performed, they may be useful in differentiating between type 1 and type 2 diabetes in a young diabetic who is obese and/or from a non Caucasian ethnic group.)
• Test for coeliac disease in young diabetic - then at 3 yearly intervals until transfer to adult service²

Initial management plan

Referral

Initial urgent referral is advisable for the following groups:

• Children
• Pregnant women
• Patients who are unwell
• Blood sugar >20mmol/l
• Patients who have ketones in their urine

Lifestyle issues

• Discuss diet and give dietary advice taking into account other factors e.g. obesity, hypertension, renal impairment - offer referral to dietician.
• Advise that regular physical activity can reduce arterial risk in the medium to long term³ and where appropriate discuss adjustments to insulin regime or calorie intake during exercise.
• Give advice and support on smoking cessation where appropriate.
• Ask patient to consider wearing "medic alert" or similar.
• If appropriate, advise of need to contact DVLA to inform of diagnosis.
• Advise to carry insulin in hand luggage if travelling.

Insulin therapy and blood glucose monitoring

Patients with type 1 diabetes should be started on insulin rather than oral hypoglycaemic agents.⁴

• Discuss patient preferences for twice daily or multiple injection regimes.
• Arrive at regime in partnership with the patient, as patients arriving at informed shared decisions with their practitioner are more likely to be successfully controlled with the chosen regime.
• Twice daily regimes using isophane (NPH) insulin or long acting insulin analogues (insulin glargine) may be more suitable for those who require assistance, or have a dislike of injecting.⁴
• Multiple injection regimes using unmodified or "soluble" insulin or rapid-acting insulin analogues, are suitable for well motivated individuals with a good understanding of disease control, or those with active or erratic lifestyles.⁴
• Patients should be given instruction in injection technique using a device best suited to the patient's requirements.
• Where appropriate, advise use of self monitoring of blood glucose (aim for pre-prandial blood glucose 4.0-7.0 mmol/l, post prandial <9.00mmol/l).
• Give advice on how to change the regime in case of illness.
• Consider a Dose Adjustment For Normal Eating (DAFNE) programme.⁵
• Give advice on how to recognise a hypoglycaemic episode and what action to take.
• Advise patients to carry a source of glucose in case of hypoglycaemic episodes.
• Consider training partner/parent in the administration of glucagon.
• Patients should be made aware of contact numbers for advice and it may be helpful to provide written information and/or details of how to access further information if required.

Review assessment

All diabetics should be reviewed at least annually and more frequently if there are any factors which may cause concern to the patient or their doctor.
The aim of regular review should be to assess and decrease the risk of known complications of diabetes such as peripheral vascular disease, nephropathy and retinopathy.
A review appointment may involve many health care workers such as dietician, optometrist, podiatrist or other appropriately trained members of staff. Use of a review protocol will ensure that all areas are covered.
A review appointment should include:⁴

• Glycaemic control and any perceived problems:
  • Reinforce need for lifestyle measures
  • BMI
  • HbA1c - excellent control defined as<6.5% currently⁶
• Full lipid profile
• Level of urinary albumin
• ± U& Es
• BP measurement - maintain below 130/80⁷
• Examination of eyes for signs of retinopathy and cataracts
• Examination of feet for ulceration/sensation/peripheral pulses
• Examination of injection sites
• If male ask about impotence
• Females will need pre-conception advice when appropriate⁸

NB: Recent work suggests no benefit in life expectancy when glycaemic control is tightened further.⁹

Prognosis

Optimal treatment and good glycaemic control will reduce the long term sequelae of type 1 diabetes, however currently life expectancy is reduced by an average of 20 years.¹⁰

Document references

1. SIGN. Management of Diabetes.; November 2001
2. Diagnosis and management of type 1 diabetes in children, young people and adults, NICE Clinical Guideline (July 2004)
3. Department of Health; Diabetes policy and guidance including NSF; Links to useful resources
4. Klapproth J, Yang VW, Celiac Sprue - eMedicine 2007
5. DAFNE; Homepage and access to information for patients and professionals on the course.
6. Diabetes UK
7. No authors listed, JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005 Dec;91 Suppl 5:v1-52.
8. McElvy SS, Miodovnik M, Rosenn B, et al; A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels. J Matern Fetal Med. 2000 Jan-Feb;9(1):14-20. [abstract]
9. Skyler JS, Bergenstal R, Bonow RO, et al; Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Circulation. 2009 Jan 20;119(2):351-7. Epub 2008 Dec 17.
10. Department of Health; National Service Framework; Diabetes.

Internet and further reading

• NICE; Type 1 diabetes in adults, quick reference guide; July 2004
• Children with Diabetes; The online community for kids, families and adults with diabetes 2008.
• DH - National Service Framework Statement; Diabetic Retinopathy Screening Statement (April 2008).
• National Clinical Audit Support Programme (NCASP); Diabetes.

Acknowledgements