Diabetes Type 1
Diabetes mellitus is a metabolic disorder characterized by persistent hyperglycaemia (random plasma glucose more than 11 mmol/L) with disturbances of carbohydrate, protein, and fat metabolism resulting from defects in insulin secretion (leading to insulin deficiency), insulin action (leading to insulin resistance), or both. In type 1 diabetes, an absolute insulin deficiency causes persistent hyperglycaemia.
Risk factors:
Environmental factors
Genetic factors
Diagnosis: Adults
Do not discount a diagnosis of type 1 diabetes if an adult presents with a BMI of 25 kg/m2 or above, or is aged 50 years or older.
If type 1 diabetes is diagnosed, refer the person immediately (on the same day) to a diabetes specialist team to confirm the diagnosis and provide immediate care.
Diagnose type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia (random plasma glucose more than 11 mmol/L), bearing in mind that adults with type 1 diabetes typically (but do not always) have one or more of the following: Ketosis, Rapid weight loss, age on onset younger than 50 years, BMI below 25, personal/family history of autoimmune disease.
Do not routinely measure C-peptide and/or diabetes-specific autoantibody titres to confirm the diagnosis of type 1 diabetes.
Diagnosis: Children
When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of other types of diabetes.
If type 1 diabetes is suspected, refer the child or young person immediately (on the same day) to a multidisciplinary paediatric diabetes care team with the competencies needed to confirm the diagnosis and provide immediate care.
Features of type 2 include: a strong family history of type 2, obesity, black or Asian family origin, no insulin requirement or have insulin requirement of <0.5units/kg body weight, evidence of insulin resistance.
Features of other types of diabetes: diabetes in the first year of life, rarely or never develop ketones bodies in the blood during episodes of hyperglycaemia, associated features such as optic atrophy, retinitis pigmentosa, deafness or features of another systemic illness or syndrome.
Suspect type 1 diabetes in a child or young person presenting with hyperglycaemia (random plasma glucose more than 11 mmol/L) and the characteristic features of: polyuria, polydipsia, weight loss and excessive tiredness.
Ketoacidosis (DKA)
Suspect in a person with known diabetes or significant hyperglycaemia (finger-prick blood glucose level greater than 11 mmol/L) and the following clinical features:
Persistent vomiting and/or diarrhoea
Abdominal disturbance
Inability to tolerate fluids
Visual disturbance
Weight loss
Lethargy and/or confusion
Increased thirst and urinary frequency
Fruity smell of acetone on breath
Dehydration - mild, moderate or severe
Acidotic breathing - deep sighing
Shock: tachycardia, poor peripheral perfusion, hypotension, lethargy, drowsiness, decreased level of consciousness and reduced urine output.
If suspected
Assess for precipitating factors such as: infection, physiological stress, non-adherence to insulin treatment or regimen, other medication conditions or drug treatment.
Test for ketones. Ketones are high if above 2+ in the urine or above 3 mmol/L in the blood.
Consider the possibility of DKA in all people with type 1 diabetes who are unwell, bearing in mind that: hyperglycaemia may not always be present and low blood ketones levels do not always exclude DKA.
Hypoglycaemia
Tremor
Weakness or lethargy
Palpitations
Impaired vision
Tingling lips
Incoordination
Sweating
Reduced orientation
Anxiety or irritability
Confusion
Hunger
Emotional lability
Deterioration of cognitive function
Severe: Convulsions, inability to swallow, loss of consciousness and coma.
Management: Adults
Support those with type 1 diabetes to aim for a HbA1c of 48mmol/mol or lower, to minimize the risk of long-term vascular complication. This target should be individualized dependent on daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia.
HbA1c should be measured every 3-6 months.
Insulin therapy should be initiated and managed by healthcare professionals with the relevant expertise and training.
Self-monitoring skills should be taught at the time of diagnosis and at the time of initiation of insulin therapy, and should be reviewed at least annually: they should be aware how to use their BM machine, when to test and how to asesss/respond to test results.
Provide information on communicating with the diabetes team.
Advise routine self-monitoring of blood glucose levels at least 4 times a day (including before meals and before bed). More frequent monitoring (up to 10 times per day or more) may be required in certain circumstances.
Provide up-to-date information of diabetes support groups.
Advise on optimal targets of: Fasting plasma glucose level of 5–7 mmol/L on waking, Plasma glucose level of 4–7 mmol/L before meals at other times of the day and For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.
Referral to the diabetic specialist team should be made on diagnosis to allow for an individualised plan of care and offer a structured education programme such as DAFNE (dose adjustment for normal eating).
Advise on lifestyle management, providing information on diet, exercise, alcohol intake and substance substance misuse.
Assess and manage cardiovascular risk appropriately (a risk assessment tool should not be used to assess cardiovascular disease risk in those with type 1 diabetes).
Monitor for complications. At every review appointment check: HbA1c and glucose targets, height, weight, waist circumference, asses for anxiety, depression, eating disorders, smoking status and monitor neuropathy and associated complications. Yearly: check injections sites, assess cardiovascular risk, ensure screening for eye disease, kidney disease and foot problems, ensure screening for thyroid disease. Be alert for the possibility of developing other autoimmune diseases.
Management:
After recovery discuss factors that may have led to episode and provide general information on reducing the risks of future episodes.
Admit immediately for confirmation
Ensure that the person is given appropriate information on how to manage diabetes during a period of illness ('sick-day rules').
Management: Sick Day Rules
Consider checking blood or urine ketone levels regularly, for example every 3–4 hours including through the night, and sometimes every 1–2 hours depending on results.
Maintain their normal meal pattern (where possible) if appetite is reduced.
Check blood glucose more frequently, for example every 1–2 hours including through the night.
Aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration - glucose levels normal, water/sugar free fluids, glucose levels low - drinks containing glucose are required.
Never stop or omit insulin - doses may need to altered, seek advise from diabetes team if unsure.
Seek urgent medical advice if they are violently sick, drowsy, or unable to keep fluids down.
When feeling better, continue to monitor their blood glucose carefully until it returns to normal.
Management: Children
Manage lifestyle issues, such as diet, exercise, and smoking.
Provide up-to-date information on diabetes support groups (local and national), including information on how to contact them and the benefits of membership.
Provide advise on how to communicate with the paediatric diabetes team.
Insulin therapy should only be initiated and managed by healthcare professionals with the relevant expertise and training.
Encourage children and young people with type 1 diabetes and/or their family/carers to: have annual influenza vaccination, wear of carry something that identifies type 1 diabetes and discuss concerns/questions with diabetes team.
Explain to children and young people with type 1 diabetes and/or their family/carers that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimize the risk of long-term complications of type 1 diabetes. Agree an individualised target.
Ensure that they are offered a continuing programme of education.
Self-monitoring skills should be taught at the time of diagnosis and at the time of initiation of insulin therapy, and should be reviewed at least annually.
Ensure that children and young people with type 1 diabetes are offered an ongoing integrated package of care provided by a multidisciplinary paediatric diabetes team.
During illness consider if admission or specialist advise is required. Follow sick day rules if admission not required.
Children and young people with type 1 diabetes should have regular surveillance for the complications of type 1 diabetes such as psychological and social problems, eye disease, diabetic kidney disease and diabetic foot problem. Most children will be managed in secondary care and any concerns should be highlighted.
Explain to young people with type 1 diabetes who are preparing for transition to adult services that some aspects of diabetes care will change at transition, for example clinic time and location, diabetes specialist team, and self-monitoring blood glucose targets.