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 beta 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 also separate article Diabetes Mellitus.
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Type 1
diabetes accounts for over 90% of diabetes in young people aged under 25 years.
12-15% of young people aged under 15 years with diabetes have an affected
first-degree relative. Children are three times more likely to develop diabetes
if their father has diabetes than if their mother has diabetes.
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:
History
- Diabetic history, both recent and historical.
- Symptoms of potential complications - eg, deterioration in eyesight.
- Other medical conditions.
- Drug history, current medications.
- Family history.
- Occupation and social history - eg, 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 (eg, ulcers, loss of sensation).
- Examination of eyes (eg, 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 30-300 mg/day).
- Glycated haemoglobin (HbA1c).
- U&Es, estimated glomerular filtration rate (eGFR).
- TFTs in a young person with diabetes until transferred to adult service.
- Serum cholesterol - aim for total cholesterol level below 4.0 mmol/l, LDL levels <2.0 mmol/L, HDL levels 1.0 mmol/L or above in men and 1.2 mmol/L or above in women and triglyceride levels 1.7 mmol/L or less
- Islet cell antibodies/C peptide deficiency: although these tests should not be routinely performed, they may be useful in differentiating between type 1 and type 2 diabetes in a young person with diabetes who is obese and/or from a non-Caucasian ethnic group
- Test for coeliac disease in a young person with diabetes - then at three-yearly intervals until transfer to adult service.
Initial management plan
Referral
When type
1 diabetes has been diagnosed, initial referral to hospital is often required.
Urgent referral is essential if the person is unwell or for pregnant women.
However, if the person is well and sufficient expertise, care and support are
available then the initial care and management can be provided at home. SIGN
has recommended that a home-based programme for initial management and
education of children with diabetes and their families is an appropriate
alternative to a hospital-based programme.
Lifestyle issues
- Discuss diet and give dietary advice taking into account other factors - eg, obesity, hypertension, renal impairment; offer referral to dietician.
- Advise that regular physical activity can reduce arterial risk in the medium to long term and, where appropriate, discuss adjustments to insulin regime or calorie intake during exercise.
- Give advice and support on smoking cessation where appropriate.
- Ask the patient to consider wearing MedicAlert® or similar.
- If appropriate, advise of the need to contact the DVLA to inform them of the diagnosis.
- Advise the patient to carry insulin in their hand luggage if they are travelling.
Insulin therapy and blood glucose monitoring
Patients
with type 1 diabetes require insulin therapy.
- Discuss patient preferences for twice-daily or multiple injection regimes.
- Arrive at the 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 insulin (neutral protamine Hagedorn (NPH) insulin) or long-acting insulin analogues (insulin glargine) may be more suitable for those who require assistance, or have a dislike of injecting.
- 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.
- Patients should be given instruction in injection technique using a device best suited to each patient's requirements.
- Where appropriate, advise use of self-monitoring of blood glucose (aim for preprandial blood glucose 4.0-7.0 mmol/L, postprandial <9.00 mmol/L).
- Give advice on how to change the regime in case of illness.
- Consider a Dose Adjustment For Normal Eating (DAFNE) programme - see separate article Diabetes Education and Self-management Programmes.
- 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 a 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 arterial disease, nephropathy and retinopathy. A review appointment may involve many
healthcare workers, such as the 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:
- Glycaemic control and any perceived problems:
- Reinforce the need for lifestyle measures; see also separate article Diabetes Diet and Exercise.
- BMI.
- HbA1c - excellent control is defined as less than 48 mmol/mol (6.5%). Studies suggest that there is no benefit in life expectancy when glycaemic control is tightened further.
- Full lipid profile.
- Level of urinary albumin.
- ± U&Es.
- BP measurement - maintain below 130/80 mm Hg.
- Examination of eyes for signs of retinopathy and cataracts.
- Examination of feet for ulceration/sensation/peripheral pulses.
- Examination of injection sites.
- If the patient is male, ask about impotence.
- Females will need pre-conception advice when appropriate.
Prognosis
- More than 60% of patients with type 1 diabetes do not develop serious complications over the long term, but many of the rest experience blindness, end-stage renal disease (ESRD), and, in some cases, early death.
- Patients with type 1 diabetes who survive the period 10-20 years after disease onset, without serious complications, have a high probability of maintaining reasonably good health.
- Although mortality from early-onset type 1 diabetes (onset up to the age of 14 years) has declined, the same may not be true for later-onset type 1 diabetes.
- Control of blood glucose,
HbA1c, lipids, blood pressure and weight significantly improves prognosis
and greatly reduces the risk of both microvascular and macrovascular
complications. However, the benefits of optimal glycaemic control have to
be balanced against the risk of hypoglycaemia and the sometimes severe
detrimental effect on quality of life.
