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Chapter25

Type1diabetesmellitus

Guideline: This chapter was based on: NICE NG17 (Type 1 diabetes in

adults: diagnosis and management, updated December 2020):

https://www.nice.org.uk/guidance/ng17. Since the chapter was written, the

guideline has been updated to: NICE NG17 (Type 1 diabetes in adults: diagnosis andmanagement,updatedAugust2022). Pleaseseetheapproach to management and target blood pressure measurements in NG17, updated August2022.

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

T1DM is a condition caused by autoimmune destruction of the cells that synthesize insulin.Overtime,highbloodsugarlevelsduetoalackofinsulinleadtotissuedamage. If untreated or poorly treated, this can cause microvascular and macrovascular complicationsincludingretinopathy,nephropathy,neuropathy,cardiovascular,peripheral vascular,andcerebrovasculardisease.

Diagnosis

Diagnosticcriteria

HbA1c≥48mmol/mol(6.5%)OR Fastingglucose≥7mmol/LOR Randomglucose≥11.1mmol/L.

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In the absence of symptoms of hyperglycaemia, a second testshould be performed on anotherdaytoconfirmthediagnosis.

History

Symptoms—polydipsia, polyuria, unexplained weight loss, lethargy (4 ‘T’s—thirst, toilet, tiredness,thinner) Personal±familyhistoryofT1DMorotherautoimmunedisease.

Examination

Typicalage<50yearsandBMI<25kg/m²(butnotalways!) Signsofweightlossordehydration UnwellifpresentingwithDKA.

Investigations

Bloodglucose—capillaryandvenous Bloodketones Antibodies—sendtoconfirmdiagnosis,particularlywhentheremaybediagnosticdoubt.

DonotsendC-peptide,unlessthereisdiagnosticdoubt.

Management

Atdiagnosis,apatientshouldundergoathoroughmedical,environmental,emotional, cultural, and educational assessment in order to create an individualized holistic management plan. If the patient presents with DKA, refer to Chapter 15 for more information.

Patienteducation

Within 6–12 months of diagnosis, all adults with T1DM must be offered a structured educationprogrammeofprovenbenefit.

Lifestyleandsimpleinterventions

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Dietary

Mustreferfordieticianreview.Keypointstodiscussinclude:

Carbohydratecounting Weightcontrol Effectofalcoholonglycaemiccontrol Avoidanceofhypoglycaemia.

Physicalactivity

Encouragephysicalactivity,butensurepatientsare aware ofitseffectonbloodglucose levelsandunderstandhowtoadjustnutritionalintakeandinsulindosesappropriately.

Psychologicalinterventions

Many people with T1DM will require additional psychological support. Diabetes can directly affect mental health, e.g. causing anxiety or depression. Mental health can also directly affect the abilityof the person to manage their diabetes. Psychologicalsupport shouldbeofferedtoallpatientswithT1DM.

Pharmacologicalmanagement

Insulin

Multiple daily injection basal-bolus insulin regimens combining long-acting (basal) and rapid-acting(bolus)insulinsarethefirst-lineregimenfor alladultswithT1DM. Sample regimensaresuggestedinTable25.1.Ifthistypeofregimenisnotavailableordoesnot achieve good glycaemic control, other regimens (e.g. mixed insulins) should be considered.

SeeBox25.1foradviceoninsulindosecalculations.

Box25.1Insulindosecalculations

The insulin dose may be calculated from the total insulin required during the last 6 hours on a VRII. The totalinsulin should be divided by6 to give the hourly insulin requirement and then multiplied by 20 to give the total daily insulin requirement. Alternatively, the dose may be estimated from the patient’s weight (0.3 units/kg for newlydiagnoseddiabetes).Askforspecialistadvicebeforecommencinginsulin.

For a basal-bolus regimen, 50% of the insulin is given as basal and the remainder dividedintobolusdoses.Foramixedregimen,60%oftheinsulinisgivenatbreakfast and40%givenintheevening.

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Table25.1Samplebasal-bolusinsulinregimens

Long-acting Rapid-

acting(TDS withmeals)

DetemirBD ODalternativessuchasglargineordegludecmaybepreferableforpatientswhoneedhelp fromcarerstoadministerinjectionsorwithconcernsaboutnocturnalhypoglycaemia

PLUS Humalog®

OR NovoRapid®

OR Apidra

Continuoussubcutaneousinsulininfusion(pumptherapy)

Consider1if:

EscalatinginsulindosestobringdownHbA1cresultsinseverehypoglycaemiaor HbA1cremains≥69mmol/moldespiteescalationofinsulindoses.

Plasmaglucosetesting

Encouragepatientstotestbloodglucoseatleastfourtimesaday.Moreoftenmayberequired— seeBox25.2.Somepatientsmaybeeligibleforcontinuousglucosemonitoringdevices. Targets:

5–7mmol/Lfastinglevelonwaking 4–7mmol/Lbeforemealsatothertimesofday 5–9 mmol/L before bedtime and at least 90 minutes after eating (ifthe patient chooses to

monitorpost-prandiallevels).

Box25.2Patientswhoshouldtestbloodglucoseuptotentimesaday

TargetHbA1cnotachieved Legalrequirement,e.g.DVLA Before,during,andaftersport Impairedawarenessofhypoglycaemia Increasingfrequencyofhypoglycaemicepisodes Duringillness Planningpregnancy,pregnancy,andbreastfeeding High-riskactivities.

Isletcellreplacement

Islet cell or pancreas transplantation may be an option for those with recurrent severe

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hypoglycaemiaorsuboptimalcontrol.

Complications

Hypoglycaemia

SeeChapter21formoreinformation.

Adverseeffectofinsulintherapy Emergencytreatmentiswithfast-actingglucoseforthoseabletoswallowandIMglucagonorIV dextroseinthosewitha↓GCSscore Hypoglycaemia awarenessisakeypartofanydiabeteseducation programmeandthisshouldbe assessedateachannualreview.

Labileglycaemicmeasurements

If levels are erratic, assess sites of insulin injection and technique. Reassess patient’s understanding of insulin therapy and possible lifestyle causes or complications, e.g. gastroparesis.

Diabeticketoacidosis

SeeChapter15.

Monitoringandfollow-up

Keycareprocesses

ThereareninekeycareprocessesthatpatientswithT1DMshouldreceiveatleastyearly:

Cholesteroltest Creatininetest Smokingstatusdiscussion Bodymassindex(BMI)measurement Footexamination Bloodpressurecheck HbA1ctest Urinealbumintest(ACR) Retinalscreening.

HbA1c

Checkevery3–6months HbA1ctargetsarediscussedinBox25.3.

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Box25.3HbA1ctargets

HbA1c targets should be set individually based on lifestyle, occupation, risk of complications, comorbidities, and history of hypoglycaemia. An HbA1c level ≤48mmol/molminimizestheriskoflong-termvascularcomplications.

TSH

MeasureTSHlevelsannually.

Microvascularcomplications

Nephropathy:performACR5yearsafterdiagnosisandthenannually,alongwithserumcreatinine. Thefirstvoidedurinesampleofthedayshouldbetested:

Startarenin–angiotensinsystem(RAS)blockingdrug ifmicroalbuminuria oralbuminuria is found, e.g. ramipril 2.5mg OD. If not tolerated, switch to an angiotensin-2 blocker, e.g. losartan25mgOD

Refertoanephrologistifglomerularfiltrationrate(GFR)<30mL/min/1.73m

Neuropathy:examinefeetateverydiabeticreviewandaskaboutsymptomsofgastroparesisand autonomicneuropathy,e.g.nocturnaldiarrhoea,orthostatichypotension,anderectiledysfunction Retinopathy:ensurepatientshaveannualretinalscreening.Thefirstscreeningshouldbeassoonas possiblefollowingdiagnosis.Classificationrangesfrombackgroundretinopathy(leastsevere),to pre-proliferativeretinopathy,proliferativeretinopathy,andmaculopathy(mostsevere).

Macrovascularcomplications

Ischaemicheartdiseaseandcerebrovasculardiseasemayoccurasaconsequenceofdiabetes Vascular risk factors, including cholesterol levels and smoking status, should be assessed at clinicalreviewandsmokingcessationencouragedifappropriate Bloodpressuretarget:<135/85mmHgor<130/80mmHgifalbuminuriaonACRtestingortwoor morefeaturesofmetabolicsyndrome:

ARASblockingdrugisfirstlinefortreatinghypertension,e.g.ramipril2.5mgOD.

Specialconsiderations

Hospitaladmission

AllowpatientswithT1DMtoself-administerSCinsulinifwillingandableandsafe Aimforaplasmaglucoselevelof5–8mmol/Lduringsurgeryoracuteillness Use an VRII (‘sliding scale’) if a patient is ‘nil by mouth’, unable to eat, or their illness is expectedtoleadtounpredictablebloodglucoselevelsandinsulinabsorption Donotstopapatient’sbasalinsulin,evenwhenonaVRII.

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Surgery

SeeChapters92and93forthemanagementofdiabetesinpatientsundergoingsurgery.

Eatingdisorders

Bealerttothepossibilityofbulimia,anorexia,andinsulindosemanipulationinthosewhoshow excessive concern regarding their body shape and weight. Other risk factors include very low BMI,recurrenthypoglycaemia,andpoorglucosecontrol SeealsoChapter39.

Pregnancy

See Box25.2. Ensure the patientis booked into a high-risk multidisciplinary diabetes– obstetricsclinic.

Forfurtherdetailsaboutdiabetesinpregnancy,seeChapter59.

Age>60years

If age >60 years and presenting with new-onsetdiabetes and weight loss, consider the possibilityofpancreaticcancer.SeeChapter110.

Furtherreading

1.NICE(2008).Continuoussubcutaneousinsulininfusionforthetreatmentofdiabetesmellitus(TA151). Availableat:https://www.nice.org.uk/guidance/ta151

2.NICE(2008). Allogeneic pancreaticisletcelltransplantationfor type1 diabetes mellitus (IPG257). Availableat:https://www.nice.org.uk/guidance/ipg257

1NICE.Continuoussubcutaneousinsulininfusionforthetreatmentofdiabetesmellitus(TA151)2008.

Availableat:https://www.nice.org.uk/guidance/ta151

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Chapter26

Type2diabetesmellitusanddiabeticfootproblems

Guidelines: NICE NG28 (Type 2 diabetes in adults: management):

https://www.nice.org.uk/guidance/ng28

NICE NG19 (Diabetic foot problems: prevention and management):

https://www.nice.org.uk/guidance/ng19

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

T2DM is a chronic metabolic condition affecting >285 million people worldwide. It is characterizedbyinsulinresistanceandaprogressivelackofinsulinproduction.T2DMis associated with obesity, hypertension, multimorbidity, sedentary lifestyles, and poor dietary habits, therefore its management requires multidisciplinary input. This chapter referstoT2DMinnon-pregnantadults.T1DMinadultsiscoveredinChapter25,diabetes inpregnancyiscoveredinChapter59,anddiabetesinchildreniscoveredinChapter77.

Diagnosis

History

Identifypatientswithriskfactorssuchasobesity,familyhistory(heritabilityofT2DMis approximately 25%) or African, Afro-Caribbean, or South Asian ethnicity. Patients are oftendiagnosedthroughscreeningprogrammesorthroughcoincidentalinvestigationsfor tirednessorotherillnesses.

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Characteristicdiabetessymptomsofpolyuria,polydipsia,blurredvision,lethargy,andweight lossarenotusuallypresentinT2DMandwouldpointtoadiagnosisofT1DM.

Examination

Veryfewfindingsmaybeseenondiagnosis:

Hypertension HighBMIwithconcentrationaroundtheabdomen(centralobesity) Signsofinsulinresistance,e.g.acanthosisnigricans,Candidainfections.

Latersignsmayinclude:

Footsigns:dryfeet,footulcers Peripheralneuropathy Peripheralvasculardisease Diabeticretinopathy:haemorrhages,exudates,andneovascularization.

Investigations

Bedside

Capillarybloodglucose Urinalysistoassessforglucose,proteins,andketones.

Bloods

DiagnosticbloodtestsarediscussedinBox26.1.

Box26.1Diagnosticbloodtests

Fastingglucose≥7mmol/LOR Randomglucose≥11.1mmol/LOR HbA1c≥48mmol/molOR 2houroralglucosetolerancetest≥11.1mmol/L In theabsenceofsymptoms of hyperglycaemia, a secondtestshould be performedonanother occasiontoconfirmthediagnosis.

Management

https://t.me/med1917

ThegeneralapproachtomanagementofpatientswithT2DMissummarizedinFig.26.1. HbA1ctargetsarelistedinTable26.1.

Fig.26.1MultifacetedmanagementapproachforpatientswithT2DM.

MR,modifiedrelease.

https://t.me/med1917

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