Recent NICE recommendations mean that primary care will have a greater role to play in the routine care of adults with type 1 diabetes, says Dr Roger Gadsby


   

The recently published NICE guidelines on the management of type 1 diabetes are the first evidence-based national guidelines to be published for this condition.

Because management of children and young people differs significantly from that of adults, two multidisciplinary guideline development groups were set up. Both groups used internationally recognised standards to assess evidence and produce recommendations and both met together periodically to ensure consistency across the two guidelines.

The care of individuals with type 1 diabetes has in the past taken place largely in secondary care. Today, increasing numbers of patients are receiving part, or in some cases all, of their routine care in the community. The practice diabetes team will play an increasingly important part in this routine care of adults with type 1 diabetes who are well controlled.

The diagnosis and management of children with type 1 diabetes is likely to remain the responsibility of secondary care.

This article will discuss the adult guideline.

The guideline emphasises the need for care to be patient-centred (see Box 1, below) and delivered by multidisciplinary teams in which primary care needs to play a part.

Such teams should include members with training and interest in the following areas of care: education and information giving, nutrition, therapeutics, identification and management of complications, foot care, counselling, and psychological care.

Box 1: Patient education

Care should be patient centred – the views and preferences of individuals with type 1 diabetes should be integrated into their healthcare. Diabetes services should be organised, and staff trained, to allow and encourage this.

Culturally appropriate education should be offered after diagnosis to all adults with type 1 diabetes (and to those with significant input into the diabetes care of others). It should be repeated as requested and according to annual review of need.This should encompass the necessary understanding, motivation and skills to manage appropriately:

  • blood glucose control: insulin, self-monitoring, nutrition
  • arterial risk factors: blood lipids, blood pressure, smoking
  • late complications: feet, kidneys, eyes, heart

How robust is the evidence?

The guideline development process was extremely thorough. Some aspects of the management of type 1 diabetes, for example the need for good glycaemic control to reduce complications and the use of ACE inhibitor therapy in patients with microalbuminuria, are supported by a strong evidence base.

Other areas have not been so well researched and therefore many recommendations are graded level D (see Figure 1, below), based on the consensus views of the expert multidisciplinary guideline development group. The guideline therefore gives recommendations for further research, so that the areas where evidence is at present weak can be strengthened.

Figure 1: Key to evidence statements and grades of recommendations
Reproduced from NICE Clinical Guideline 15. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults by kind permission of NICE

Figure 2 (below) shows the outline algorithm of care for adults with type 1 diabetes.

Figure 2: Outline algorithm of care for adults with type 1 diabetes
Reproduced from NICE Clinical Guideline 15. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults by kind permission of NICE

Clinical monitoring of blood glucose control

The guideline recommends measuring HbA1c using a high-precision Diabetes Control and Complications Trial (DCCT) aligned method every 2 to 6 months, either before or during the consultation. This enables up to date information to be communicated and discussed in the consultation.

Most laboratories in the UK are able to measure HbA1c using a DCCT aligned method. Those that cannot yet do so may feel under pressure to meet this recommendation.

The guideline supports the use of continuous glucose monitoring systems if there are consistent glucose control problems, in particular repeated hyperglycaemia or hypoglycaemia at the same time of day, or if there is hypoglycaemia unawareness unresponsive to conventional insulin dose adjustment.

The target for DCCT aligned HbA1c is below 7.5%, the level of glycaemic control necessary to minimise the risk of microvascular complications.

For those at increased arterial risk, the target HbA1c to reduce the risk of macrovascular complications is at or below 6.5%.

Some individuals may find these targets difficult or undesirable to achieve.They should be advised that any improvement in HbA1c is beneficial even if target levels are not reached, and the greater the improvement the greater the benefit.

Self-monitoring of blood glucose

The guideline stresses the need for self-monitoring and education to be part of an integrated package. It advocates the use of strips and meters to suit individual needs, but does not recommend any other site than the fingertips for self-monitoring.

Patients should be advised that the optimal frequency of testing should depend on the insulin treatment regimen, the characteristics of the individual’s blood glucose control and personal preferences.

The targets recommended are a preprandial blood glucose level of 4-7 mmol/l and a postprandial level of less than 9 mmol/l.

The guideline cautions against inappropriately pursuing tight blood glucose control if the individual’s quality of life is compromised despite otherwise optimal care, or if the risk of hypoglycaemia is significant to the individual.

Choice of insulin regimen

The guideline recommends that the insulin regimen should be appropriate for the individual and allow optimum wellbeing. It advocates multiple injection regimens in adults who prefer them, in association with an integrated package of education, food and skills training as well as appropriate self-monitoring. One such package is the DAFNE (dose adjustment for normal eating) programme which is already being used in many parts of the UK.1

The guideline advocates twice-daily regimens in patients for whom the number of daily injections is important for their quality of life, for those who find lunch-time insulin injections difficult and for adults with learning difficulties who may need help with injections.

Choice of insulin

The guideline recommends that meal-time insulin is provided by injecting unmodified (‘soluble’) insulin before main meals, or rapid-acting analogues where nocturnal or late interprandial hypoglycaemia is a problem and to avoid the need for snacks while maintaining equivalent blood glucose control.

Long-acting insulin analogue (insulin glargine) is recommended when:

  • nocturnal hypoglycaemia is a problem on isophane (NPH) insulin;
  • morning hyperglycaemia on isophane (NPH) insulin results in difficulties in blood glucose control during the day;
  • rapid-acting insulin analogues are used for meal-time blood glucose control.

Management of arterial risk

Patients with type 1 diabetes should undergo annual assessment of arterial risk factors, consisting of assessment of smoking status, blood glucose control, blood pressure, full lipid profile, albumin excretion rate (microalbuminuria or proteinuria), age, family history of arterial disease and abdominal adiposity.

Patients with microalbuminuria or two or more features of the metabolic syndrome should be managed as though they had type 2 diabetes or declared arterial disease.

Patients with type 1 diabetes who have had a myocardial infarction or stroke should be managed intensively according to relevant guidelines.

The new GMS contract’s diabetes indicators cover most of these risk factors, so they should be routinely assessed under the quality and outcomes framework.2

Arterial risk tables, equations and risk engines underestimate the risk for patients with type 1 diabetes, so should not be used.

Individuals with type 1 diabetes may be classified as at low, moderate or high arterial risk using the algorithm contained in the guideline (Figure 3, below). Those who are found to be at high or moderate arterial risk should be prescribed aspirin 75 mg daily and a statin at the standard dose.

Figure 3: Algorithm for the management of arterial risk in adult patients with type 1 diabetes
Reproduced from NICE Clinical Guideline 15. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults by kind permission of NICE

Blood pressure control

The guideline recommends a blood pressure level of 135/85 mmHg for intervention or 130/80 mmHg if there is a raised albumin excretion rate or two or more features of the metabolic syndrome.

Multiple drug therapy may be needed. However, a trial of a low-dose thiazide diuretic should be the first-line therapy unless the patient is already taking a renin-angiotensin system blocking drug for nephropathy. Patients with nephropathy should be given an ACE inhibitor titrated to full dose, or if this is not tolerated, an angiotensin 2 receptor antagonist.

Surveillance and management of late complications

Patients with type 1 diabetes should be assessed for early markers and features of eye, kidney, nerve, foot and arterial damage at annual intervals. According to assessed need, they should be offered appropriate interventions and/or referral in order to reduce the progression of these late complications into adverse health outcomes affecting quality of life.

Eye screening, using digital photography, should begin from diagnosis and, depending on the findings, should be followed by a routine review annually or more frequently, or referral to an ophthalmologist.

Structured foot surveillance should take place at yearly intervals and include skin condition, shape and deformity, sensory nerve function and vascular supply including peripheral pulses as well as an assessment of the patient’s shoes.

Just as in type 2 diabetes, diabetic nephropathy in type 1 diabetes is assessed by annual measurement of albumin:creatinine ratio in a first-pass morning urine specimen, serum creatinine should be measured concurrently. This is also covered by the GMS contract’s diabetes indicators.

The guideline contains a section on erectile dysfunction, recommending that men with type 1 diabetes should be asked annually whether they have erectile problems.

Those with problems should be offered a phosphodiesterase-5 inhibitor drug, unless contraindicated. If phosphodiesterase-5 inhibitors are inappropriate or unsuccessful, referral to a service offering other medical or surgical management should be discussed.

The guideline contains brief sections on other neuropathic problems including gastroparesis, diarrhoea, orthostatic hypotension and painful neuropathy.

A stepwise approach is recommended for painful neuropathy starting with simple analgesics and local measures such as bed cradles.

How will the guideline improve patient care?

Quick reference versions of the guideline will be widely circulated to healthcare professionals. Together with the National Service Framework for Diabetes and the new quality and outcomes framework of the new GP contract, the guideline will promote best practice and improve patient care.

Formats in which the guidelines are published:

Two full guidelines, one on children and one on adults, which contain all the evidence considered in developing the guidelines.

Two quick reference guides containing the key messages and recommendations.

Two ‘information for the public’ leaflets written for people without specialist medical knowledge.

One NICE guideline covering both children and adults, which contains the recommendations for the NHS, available only electronically: www.nice.org.uk

References

  1. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Br Med J 2002; 325: 746.
  2. NHS Confederation, British Medical Association. Investing in General Practice: The New GMS Contract. www.bma.org.uk

Click here for a checklist to aid implementation of the NICE guideline on diagnosis and management of type 1 diabetes in adults which you can download and keep

Guidelines in Practice, September 2004, Volume 7(9)
© 2004 MGP Ltd
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