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Overview

This Guidelines summary covers recommendations for the care and treatment of adults (aged 18 and over) with type 1 diabetes in primary care. It does not include recommendations on ketone monitoring and managing diabetic ketoacidosis, or caring for adults with type 1 diabetes in hospital. For the full set of recommendations, refer to the full guideline.

Further Guidelines summaries on NICE diabetes guidance:

This summary has been abridged for print. View the full summary at guidelines.co.uk/252655.article

Diagnosis and early care plan

Diagnosis

  • Diagnose type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia, bearing in mind that people with type 1 diabetes typically (but not always) have one or more of:
    • ketosis
    • rapid weight loss
    • age of onset under 50
    • body mass index (BMI) below 25 kg/m2
    • personal and/or family history of autoimmune disease
  • Do not discount a diagnosis of type 1 diabetes if an adult has a BMI of 25 kg/m2 or above or is aged 50 years or over
  • Do not routinely measure C-peptide and/or diabetes-specific autoantibody titres to confirm type 1 diabetes in adults
  • Consider further investigation (including measuring C-peptide and/or diabetes-specific autoantibody titres) if the adult:
    • has suspected type 1 diabetes, but with some atypical features (for example, age 50 or over, BMI of 25 kg/m2 or above, slow evolution of hyperglycaemia, or long prodrome) or
    • has been diagnosed with type 1 diabetes and has started treatment, but there is clinical suspicion of monogenic diabetes and C-peptide and/or autoantibody testing may guide the use of genetic testing or
    • classification is uncertain, and confirming type 1 diabetes would have implications for availability of therapy (for example, insulin pump therapy)
  • When measuring C-peptide or diabetes-specific autoantibody titres, take into account that:
    • autoantibody tests have their lowest false-negative rate at the time of diagnosis, and that the false-negative rate rises after this
    • C-peptide has better discriminative value the longer the test is done after diagnosis
    • with autoantibody testing, carrying out tests for two different diabetes-specific autoantibodies, with at least one being positive, reduces the false-negative rate.

Early care plan

  • At diagnosis (or, if necessary, after the management of critically decompensated metabolism), the diabetes professional team should work with adults with type 1 diabetes to develop a plan for their early care. This will generally require:
    • medical assessment to:
      • ensure the diagnosis is accurate
      • ensure appropriate acute care is given when needed
      • review medicines and detect potentially associated disease 
      • detect adverse vascular risk factors
    • environmental assessment to understand:
      • the social, home, work, and recreational circumstances of the person and their carers
      • their lifestyle (including diet and physical activity)
      • other relevant factors, such as substance use
    • cultural and educational assessment to:
      • find out what they know about diabetes
      • help with tailoring advice, and with planning treatments and diabetes education programmes
    • assessment of their emotional wellbeing to decide how to pace diabetes education
  • Use the results of the initial diabetes assessment to agree a future care plan. This assessment should include:
    • acute medical history
    • social, cultural, and educational history, and lifestyle review
    • complications history and symptoms
    • diabetes history (recent and long term)
    • other medical history
    • family history of diabetes and cardiovascular disease
    • medication history
    • vascular risk factors
    • smoking
    • general examination
    • weight and BMI
    • foot, eye, and vision examination
    • urine albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR)
    • psychological wellbeing
    • attitudes to medicine and self-care
    • immediate family and social relationships, and availability of informal support
  • Include the following in an individualised and culturally appropriate diabetes plan:
    • when and where they will have their diabetes education, including their dietary advice 
    • initial treatment, including guidance on insulin injection and insulin regimens 
    • self-monitoring and targets
    • symptoms, and the risk of hypoglycaemia and how it is treated
    • management of special situations, such as driving
    • communicating with the diabetes professional team (how often and how to contact them)
    • management of cardiovascular risk factors
    • implications for pregnancy and family planning advice (see NICE's guideline, Diabetes in pregnancy)
    • how often they will have follow-up appointments, and what these will cover (including review of HbA1c levels, experience of hypoglycaemia, and annual reviews)
  • After the initial plan is agreed, implement it without inappropriate delay. Based on discussion with the adult with type 1 diabetes, modify the plan as needed over the following weeks. 

Support and individualised care

  • Take account of any disabilities, including visual impairment, when planning and delivering care for adults with type 1 diabetes
  • Advice to adults with type 1 diabetes should be provided by a range of professionals with skills in diabetes care working together in a coordinated approach. A common environment (diabetes centre) is an important resource in allowing a diabetes multidisciplinary team to work and communicate efficiently while providing consistent advice
  • Provide adults with type 1 diabetes with:
    • access to services by different methods (including phone and email) during working hours
    • information about out-of-hours services staffed by people with diabetes expertise
  • View each adult with type 1 diabetes as an individual, rather than as a member of any cultural, economic, or health-affected group (about the cultural preferences of individual adults with type 1 diabetes)
  • Jointly agree an individual care plan with the adult with type 1 diabetes. Review this plan annually and amend it as needed, taking into account changes in the person's wishes, circumstances, and medical findings
  • Individual care plans should include:
    • diabetes education, including dietary advice
    • insulin therapy, including dosage adjustment
    • self-monitoring
    • avoiding hypoglycaemia and maintaining awareness of hypoglycaemia
    • family planning, contraception, and pregnancy planning (see the NICE guideline on Diabetes in pregnancy)
    • cardiovascular risk factor monitoring and management
    • complications monitoring and management
    • communicating with the diabetes team (how often and how to contact them)
    • how often they will have follow-up appointments, and what these will cover (including review of HbA1c levels, experience of hypoglycaemia, and annual reviews)
  • Use population, practice-based, and clinic diabetes registers (as specified by the National service framework for diabetes: standards) to assist programmed recall for annual review and assessment of complications and cardiovascular risk
  • At the time of diagnosis and periodically after this, give adults with type 1 diabetes with up-to-date information about diabetes support groups (local and national), how to contact them, and their benefits. 

Education and information

  • Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example the DAFNE (dose-adjustment for normal eating) programme
  • Offer the structured programme 6–12 months after diagnosis. For adults who have not had a structured education programme by 12 months, offer it at any time that is clinically appropriate and suitable for the person, regardless of duration of type 1 diabetes
  • For adults with type 1 diabetes who are unable or prefer not to take part in group education, provide an alternative of equal standard
  • Ensure that any structured education programme for adults with type 1 diabetes:
    • is evidence-based, and suits the needs of the person
    • has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge, and skills to self-manage diabetes
    • has a structured curriculum that is theory-driven, evidence-based, and resource-effective, has supporting materials, and is written down
    • is delivered by trained educators who:
      • have an understanding of educational theory appropriate to the age and needs of the person and
      • are trained and competent to deliver the principles and content of the programme
    • is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency
    • has outcomes that are audited regularly
  • Explain to adults with type 1 diabetes that structured education is an integral part of diabetes care
  • Provide information about type 1 diabetes and its management to adults with type 1 diabetes at all opportunities from diagnosis onwards. Follow the principles in the NICE guideline on Patient experience in adult NHS services
  • Consider the Blood Glucose Awareness Training programme for adults with type 1 diabetes who are having recurrent episodes of hypoglycaemia (see also the section, Awareness and management of hypoglycaemia)
  • Carry out an annual review of self-care and needs for all adults with type 1 diabetes. Decide what to cover each year by agreeing priorities with the adult with type 1 diabetes. 

For recommendations on education and information, view the full summary at guidelines.co.uk/252655.article

Dietary management

Carbohydrate counting

  • Offer carbohydrate-counting training to adults with type 1 diabetes as part of structured education programmes for self-management
  • Consider carbohydrate-counting courses for adults with type 1 diabetes who are waiting for a more detailed structured education programme or who are unable to take part in a stand-alone structured education programme.

Glycaemic index diets

  • Do not advise adults with type 1 diabetes to follow a low glycaemic index diet for blood glucose control.

Dietary advice

  • Offer dietary advice to adults with type 1 diabetes about issues other than blood glucose control (such as managing weight and cardiovascular risk), as needed
  • From diagnosis, provide nutritional information that is sensitive to personal needs and culture of each adults with type 1 diabetes
  • Provide nutritional information individually and as part of a structured education programme (see the section, Education and information). Include advice from professionals who are trained and accredited to provide dietary advice to people with health conditions
  • Offer opportunities to recieve dietary advice at intervals agreed between adults with type 1 diabetes and their healthcare professionals
  • Discuss the hyperglycaemic effects of different foods the adult with type 1 diabetes wants to eat in the context of the insulin regimens chosen to match those food choices
  • Provide education programmes for adults with type 1 diabetes to help them with:
    • healthy eating and a balanced diet
    • changing their insulin dosage to reduce glucose excursions when varying their diet
  • Discuss snacks with the adults with type 1 diabetes:
    • cover the choice of snack, the quantity, and when to eat them
    • explain the effects of eating different food types, and how long these effects last
    • explain which insulin regimens are available to match different food types
    • discuss changes in choice of snack if needed, based on the results of the self-monitoring tests
  • Provide information on:
    • the effects of different alcohol-containing drinks on blood glucose excursions and calorie intake
    • use of high-calorie and high-sugar 'treats'
  • As part of dietary education after diagnosis (and as needed after this), provide information on how healthy eating can reduce cardiovascular risk. Include information about fruit and vegetables, types and amounts of fat, and how to make the appropriate dietary changes

  • Modify nutritional recommendations to adults with type 1 diabetes to take account of associated features of diabetes, including:
    • excess weight and obesity
    • underweight
    • disordered eating
    • hypertension
    • renal failure
  • Healthcare professionals giving dietary advice to adults with type 1 diabetes should be able to advise about common topics of concern and interest, and should seek advice from specialists when needed. Suggested common topics include:
    • body weight, energy balance, and obesity management
    • cultural and religious diets, feasts, and fasts
    • foods sold as 'diabetic'
    • sweeteners
    • dietary fibre intake
    • protein intake
    • vitamin and mineral supplements
    • alcohol
    • matching carbohydrate, insulin and physical activity
    • salt intake in hypertension
    • comorbidities, including nephropathy and renal failure, coeliac disease, cystic fibrosis, or eating disorders
    • peer support groups.

Physical activity

  • Advise adults with type 1 diabetes that physical activity can reduce their enhanced cardiovascular risk in the medium and long term
  • For adults with type 1 diabetes who choose to increase their level of physical activity as part of a healthier lifestyle, provide information about:
    • appropriate intensity and frequency of physical activity
    • self-monitoring their changed insulin and/or nutritional needs
    • the effect of physical activity on blood glucose levels (which are likely to fall) when insulin levels are adequate
    • the effect of physical activity on blood glucose levels when hyperglycaemic and hypoinsulinaemic (there is a risk of worsening of hyperglycaemia and ketonaemia)
    • appropriate adjustments of insulin dosage and/or nutritional intake for periods during and immediately after physical activity, and the 24 hours after this
    • interactions of physical activity and alcohol
    • further contacts and sources of information.

Blood glucose management

HbA1c measurement and targets

Measurement

  • Measure HbA1c levels every 3–6 months in adults with type 1 diabetes
  • Consider measuring HbA1c levels more often in adults with type 1 diabetes if their blood glucose control is suspected to be changing rapidly; for example, if the HbA1c level has risen unexpectedly above a previously sustained target
  • Measure HbA1c using methods calibrated according to International Federation of Clinical Chemistry standardisation
  • Tell adults with type 1 diabetes their HbA1c results after each measurement and have their most recent result available at consultations. Follow the principles in NICE's guideline, Patient experience in adult NHS services
  • If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:
    • fructosamine estimation
    • quality-controlled blood glucose profiles
    • total glycated haemoglobin estimation (if abnormal haemoglobins).

Targets

  • Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications
  • Agree an individualised HbA1c target with each adult with type 1 diabetes. Take into account factors such as their daily activities, aspirations, likelihood of complications, comorbidities, occupation, and history of hypoglycaemia
  • Ensure that aiming for an HbA1c target is not accompanied by problematic hypoglycaemia in adults with type 1 diabetes
  • Diabetes services should document the proportion of adults with type 1 diabetes in a service who reach an HbA1c level of 53 mmol/mol (7%) or lower.

Self-monitoring of blood glucose

Frequency of self-monitoring of blood glucose

  • Advise adults with type 1 diabetes to routinely self-monitor their blood glucose levels, and to test at least four times a day (including before each meal and before bed)
  • Support adults with type 1 diabetes to test at least four times a day, and up to 10 times a day:
    • if their target for blood glucose control, measured by HbA1c level is not reached
    • if they are having more frequent hypoglycaemic episodes
    • if there is a legal requirement to do so, such as before driving (see the Driver and Vehicle Licensing Agency's Assessing fitness to drive: a guide for medical professionals)
    • during periods of illness
    • before, during, and after sport
    • when planning pregnancy, during pregnancy, and while breastfeeding (see the NICE guideline, Diabetes in pregnancy)
    • if they need to know blood glucose levels more than four times a day for other reasons (for example, impaired hypoglycaemia awareness, or they are undertaking high-risk activities)
  • Enable additional blood glucose testing (more than 10 times a day) for adults with type 1 diabetes if this is necessary because of:
    • the person's lifestyle (for example, they drive for long periods of time, they undertake high-risk activities or have a high-risk occupation, or they are travelling) or
    • impaired hypoglycaemia awareness.

Blood glucose targets

  • Advise adults with type 1 diabetes to aim for:
    • a fasting plasma glucose level of 5–7 mmol/litre on waking and
    • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day
  • Advise adults with type 1 diabetes who choose to test after meals to aim for a plasma glucose level of 5–9 mmol/litre at least 90 minutes after eating. (This timing may be different in pregnancy—for guidance on plasma glucose targets in pregnancy, see NICE's guideline, Diabetes in pregnancy)
  • Agree bedtime target plasma glucose levels with each adult with type 1 diabetes. Take into account the timing of their last meal and the related insulin dose, and ensure the target is consistent with the recommended fasting level on waking.

Empowering people to self-monitor blood glucose

  • Teach self-monitoring skills at the time of diagnosis and the start of insulin therapy
  • When choosing blood glucose meters:
    • take the needs of the adult with type 1 diabetes into account
    • ensure that meters meet current ISO standards
  • Teach adults with type 1 diabetes about how to measure their blood glucose level, interpret the results, and take appropriate action. Review these skills at least annually
  • Support adults with type 1 diabetes through structured education to make the best use of data from self-monitoring of blood glucose.

Sites for self-monitoring of blood glucose

  • Monitoring blood glucose using sites other than the fingertips cannot be recommended as a routine alternative to conventional self-monitoring of blood glucose.

Continuous glucose monitoring

  • Do not offer real-time continuous glucose monitoring (CGM) routinely to adults with type 1 diabetes
  • Consider real-time CGM for adults with type 1 diabetes who are willing to commit to using it at least 70% of the time and to calibrate it as needed, and who have any of the following despite optimised insulin therapy and conventional blood glucose monitoring:
    • more than one episode a year of severe hypoglycaemia with no obviously preventable cause
    • complete loss of hypoglycaemia awareness
    • frequent (more than two episodes a week) asymptomatic hypoglycaemia that is causing problems with daily activities
    • extreme fear of hypoglycaemia
    • hyperglycaemia (HbA1c level of 75 mmol/mol [9%] or higher) that persists despite testing at least 10 times a day. Continue real-time CGM only if HbA1c can be sustained at or below 53 mmol/mol (7%) and/or there has been a fall in HbA1c of 27 mmol/mol (2.5%) or more
  • For adults with type 1 diabetes who are using real-time CGM, use the principles of flexible insulin therapy, with either a multiple daily injection regimen or an insulin pump
  • Real-time CGM should be provided by a centre with expertise in its use, as part of a strategy to optimise a person's HbA1c levels and reduce the frequency of hypoglycaemic episodes.

Insulin therapy

Insulin regimens

  • Offer multiple daily injection basal–bolus insulin regimens as the insulin injection regimen of choice for all adults with type 1 diabetes. Provide guidance on using this regimen
  • Do not offer adults newly diagnosed with type 1 diabetes non-basal–bolus insulin regimens (that is, twice-daily mixed, basal only, or bolus only).

Long-acting insulin

  • Offer twice-daily insulin detemir as basal insulin therapy for adults with type 1 diabetes
  • Consider one of the following as an alternative to basal insulin therapy for adults with type 1 diabetes:
    • an insulin regimen that is already being used by the person if it is meeting their agreed treatment goals (such as meeting their HbA1c targets or time in target glycose range and minimising hypoglycaemia)
    • once-daily insulin glargine (100 units/ml) if insulin detemir is not tolerated or the person has a strong preference for once-daily basal injections
    • once-daily insulin degludec (100 units/ml) if there is a particular concern about nocturnal hypoglycaemia
    • once-daily ultra long-acting insulin such as degludec (100 units/ml) for people who need help from a carer or healthcare professional to administer injections.

There is a risk of severe harm and death due to inappropriately withdrawing insulin from pen devices. See NHS England's patient safety alert for further information. 

  • When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost
  • Ensure the risk of medication errors with insulins is minimised by following Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed-combination, and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar
  • When people are already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar. Make a shared decision with the person after discussing their preferences
  • Consider other basal insulin regimens for adults with type 1 diabetes only if the regimens above do not meet their agreed treatment goals. When choosing an alternative insulin regimen, take account of:
    • the person's preferences
    • comorbidities
    • risk of hypoglycaemia and diabetic ketoacidosis
    • any concerns around adherence
    • acquisition cost
  • When prescribing, ensure that insulins are prescribed by their brand name. 

Insulin pumps

For guidance on the use of insulin pumps for adults with type 1 diabetes, see NICE's technology appraisal guidance, Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus

Rapid-acting insulin

  • Offer rapid-acting insulin analogues that are injected before meals, rather than rapid-acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
  • Do not advise routine use of rapid-acting insulin analogues after meals for adults with type 1 diabetes
  • If an adult with type 1 diabetes has a strong preference for an alternative mealtime insulin, respect their wishes and offer the preferred insulin.

Mixed insulin

  • Consider a twice-daily human mixed insulin regimen for adults with type 1 diabetes if a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is used
  • Consider a trial of a twice-daily analogue mixed insulin regimen if an adult using a twice-daily human mixed insulin regimen has hypoglycaemia that affects their quality of life.

Optimising insulin therapy

  • For adults with erratic and unpredictable blood glucose control (hyperglycaemia and hypoglycaemia at no consistent times), consider the following rather than changing a previously optimised insulin regimen:
    • injection technique
    • injection sites
    • self-monitoring skills
    • knowledge and self-management skills
    • lifestyle
    • mental health and psychosocial problems
    • possible organic causes such as gastroparesis
  • Give clear guidelines and protocols ('sick-day rules') to all adults with type 1 diabetes to help them adjust insulin doses appropriately when they are ill. 

Adjuncts

  • Consider adding metformin to insulin therapy for adults with type 1 diabetes if:
    • they have a BMI of 25 kg/m2 or above (23 kg/m2 for people from South Asian and related minority ethnic backgrounds) and
    • they want to improve their blood glucose control while minimising their effective insulin dose.[A]

For guidance on the use of dapagliflozin with insulin for treating type 1 diabetes in adults with a BMI of at least 27 kg/m2 see NICE's technology appraisal guidance, Dapagliflozin with insulin for treating type 1 diabetes.

Insulin delivery

  • For adults with type 1 diabetes who inject insulin, provide their preferred insulin injection delivery device (this often means using one or more types of insulin injection pen)
  • For adults with type 1 diabetes and special visual or psychological needs, provide injection devices or needle-free systems that they can use independently for accurate dosing
  • Offer needles of different lengths to adults with type 1 diabetes who are having problems such as pain, local skin reactions, and injection site leakages
  • After taking clinical factors into account, choose needles with the lowest acquisition cost to use with prefilled and reusable insulin pen injectors
  • Advise adults with type 1 diabetes to rotate insulin injection sites and avoid repeated injections at the same point within sites
  • Provide adults with type 1 diabetes with:
    • suitable containers for collecting used needles and other sharps
    • a way to safely get rid of these containers
  • Check injection site condition at least annually and whenever new problems with blood glucose control occur.

Referral for islet or pancreas transplantation

  • For adults with type 1 diabetes who have recurrent severe hypoglycaemia that has not responded to other treatments (see the section on Hypoglycaemia awareness and management), consider referral to a centre that assesses people for islet and/or pancreas transplantation
  • Consider islet or pancreas transplantation for adults with type 1 diabetes with suboptimal diabetes control, if they have had a renal transplant and are currently on immunosuppressive therapy.

For recommendations on referral for islet or pancreas transplantation, view the full summary at guidelines.co.uk/252655.article

Hypoglycaemia awareness and management

Identifying and quantifying impaired hypoglycaemia awareness

  • Assess hypoglycaemia awareness in adults with type 1 diabetes at each annual review
  • Use the Gold score or Clarke score to quantify hypoglycaemia awareness in adults with type 1 diabetes, checking that the questionnaire items have been answered correctly
  • Explain to adults with type 1 diabetes that impaired awareness of the symptoms of plasma glucose levels below 3 mmol/litre is associated with a significantly increased risk of severe hypoglycaemia.

Managing impaired hypoglycaemia awareness

  • Ensure that adults with type 1 diabetes with impaired hypoglycaemia awareness have had structured education in flexible insulin therapy using basal–bolus regimens, and are following its principles correctly
  • Offer additional education focusing on avoiding and treating hypoglycaemia to adults with type 1 diabetes who still have impaired hypoglycaemia awareness after structured education in flexible insulin therapy
  • Avoid relaxing individualised blood glucose targets to address impaired hypoglycaemia awareness for adults with type 1 diabetes
  • For adults with type 1 diabetes and impaired hypoglycaemia awareness who are using lower target blood glucose levels than recommended in this guideline, encourage them to use the recommended targets (see the section, Blood glucose targets)
  • Review insulin regimens and doses and prioritise ways to avoid hypoglycaemia in adults with type 1 diabetes with impaired hypoglycaemia awareness, including:
    • reinforcing the principles of structured education
    • offering an insulin pump
    • offering real-time CGM
  • If, despite these interventions, an adults with type 1 diabetes has impaired hypoglycaemia awareness that is associated with recurrent severe hypoglycaemia, consider referring the person to a specialist centre.

Preventing and managing hypoglycaemia

  • Explain to adults with type 1 diabetes that a fast-acting form of glucose is needed for managing hypoglycaemic symptoms or signs in people who can swallow
  • Adults with type 1 diabetes with a decreased level of consciousness because of hypoglycaemia and so cannot safely take oral treatment should be:
    • given intramuscular glucagon by a family member or friend who has been shown how to use it (intravenous glucose may be used by healthcare professionals skilled in getting intravenous access)
    • checked for response at 10 minutes, and then given intravenous glucose if their level of consciousness is not improving significantly
    • then given oral carbohydrate when it is safe to administer it, and put under continued observation by someone who has been warned about the risk of relapse
  • Explain to adults with type 1 diabetes that:
    • it is very common to experience some hypoglycaemic episodes with any insulin regimen
    • they should use a regimen that avoids or reduces the frequency of hypoglycaemic episodes while maintaining the most optimal blood glucose control possible
  • Make hypoglycaemia advice available to all adults with type 1 diabetes, to help them find the best possible balance with any insulin regimen
  • If hypoglycaemia becomes unusually problematic or increases in frequency, review the following possible contributory causes:
    • inappropriate insulin regimens (incorrect dose distributions and insulin types)
    • meal and activity patterns, including alcohol
    • injection technique and skills, including insulin resuspension if necessary
    • injection site problems
    • possible organic causes including gastroparesis
    • changes in insulin sensitivity (including drugs affecting the renin–angiotensin system and renal failure)
    • mental health problems
    • previous physical activity
    • lack of appropriate knowledge and skills for self-management
  • Manage nocturnal hypoglycaemia (symptomatic or detected on monitoring) by:
    • reviewing knowledge and self-management skills
    • reviewing current insulin regimen, evening eating habits, and previous physical activity
    • choosing an insulin type and regimen that is less likely to induce low glucose levels at night
  • If early cognitive decline occurs in adults on long-term insulin therapy, then in addition to normal investigation consider possible brain damage resulting from overt or covert hypoglycaemia, and the need to manage this. 

Associated illness

  • In adults with type 1 diabetes who have unexplained weight loss, assess for coeliac disease. For guidance on testing for coeliac disease, see NICE's guideline, Coeliac disease: recognition, assessment and management
  • Be alert to the possibility of other autoimmune disease in adults with type 1 diabetes (including Addison's disease and pernicious anaemia).

Control of cardiovascular risk

Aspirin

  • Do not offer aspirin for the primary prevention of cardiovascular disease in adults with type 1 diabetes.

Identifying cardiovascular risk

  • Assess cardiovascular risk factors annually, including:
    • eGFR and ACR
    • smoking
    • blood glucose control
    • blood pressure
    • full lipid profile (including high- and low-density lipoprotein cholesterol and triglycerides)
    • age
    • family history of cardiovascular disease
    • abdominal adiposity.

For guidance on tools for assessing risk of cardiovascular disease in adults with type 1 diabetes, see the NICE guideline, Cardiovascular disease: risk assessment and reduction, including lipid modification.

Interventions to reduce risk and manage cardiovascular disease

  • For guidance on the primary prevention of cardiovascular disease in adults with type 1 diabetes, see the NICE guideline, Cardiovascular disease: risk assessment and reduction, including lipid modification
  • Give adults with type 1 diabetes who smoke advice on stopping smoking and stop smoking services, including NICE guidance-recommended therapies. Reinforce these messages annually for people who currently do not plan to stop smoking, and at all clinical contacts if there is a prospect of the person stopping
  • Advise adults who do not smoke never to start smoking
  • Provide intensive management for adults who have had myocardial infarction or stroke, according to relevant non-diabetes guidelines. For angina or other ischaemic heart disease, beta-blockers should be considered. For guidance on secondary prevention of myocardial infarction, see the NICE guideline, Acute coronary synrdomes.

Blood pressure management

  • Recommend blood pressure management at 135/85 mmHg for adults with type 1 diabetes. If they have albuminuria or two or more features of metabolic syndrome, recommend blood pressure management at 130/80 mmHg. See also the recommendations on diabetic kidney disease and NICE's guideline, Hypertension in adults
  • Discuss the following with adults with type 1 diabetes who have hypertension to help them make an informed choice:
    • reasons for choice of intervention level
    • the substantial potential gains from small improvements in blood pressure control
    • any possible negative consequences of therapy
  • Start a trial of a renin–angiotensin system blocking drug as first-line therapy for hypertension in adults with type 1 diabetes
  • Provide information to adults with type 1 diabetes on how lifestyle changes can improve their blood pressure control and associated outcomes, and offer to help achieve their aims in this area
  • Do not allow concerns over potential side effects to inhibit advising and offering the necessary use of any class of drugs, unless the side effects become symptomatic or otherwise clinically significant. In particular:
    • do not avoid selective beta-blockers for adults on insulin if these are indicated
    • low-dose thiazides may be combined with beta-blockers
    • when prescribing calcium-channel antagonists, only use long-acting preparations
    • ask adults directly about potential side effects of erectile dysfunction, lethargy, and orthostatic hypotension with different drug classes.

For guidance on blood pressure management in adults with type 1 diabetes and evidence of renal involvement, see the NICE guideline, Chronic kidney disease in adults: assessment and management.

For recommendations on managing complications, view the full summary at guidelines.co.uk/252655.article

Managing complications

Eye disease

  • When adults are diagnosed with type 1 diabetes, refer them immediately to the local eye screening service
  • Encourage adults to attend eye screening, and explain that it will help them to keep their eyes healthy and help to prevent problems with their vision. Explain that the screening service is effective at identifying problems so that they can be treated early
  • Arrange emergency review by an ophthalmologist for:
    • sudden loss of vision 
    • rubeosis iridis 
    • pre-retinal or vitreous haemorrhage 
    • retinal detachment
  • Refer to an ophthalmologist in accordance with the National Screening Committee criteria and timelines for any large sudden unexplained drop in visual acuity.

Diabetic kidney disease

For guidance on managing kidney disease in adults with type 1 diabetes, see the NICE guideline, Chronic kidney disease in adults: assessment and management.

  • Ask all adults with type 1 diabetes, with or without detected nephropathy, to bring in the first urine sample of the day ('early morning urine') once a year. Send this for estimation of ACR (estimating urine albumin concentration alone is a poor alternative) and measure eGFR at the same time
  • Suspect other renal disease if:
  • If albuminuria is found, discuss with the person what this means
  • Start angiotensin-converting enzyme (ACE) inhibitors and, with the usual precautions, titrate to full dose in all adults with type 1 diabetes who have confirmed nephropathy with ACR greater than or equal to 3 mg/mmol
  • If ACE inhibitors are not tolerated, substitute angiotensin 2 receptor antagonists. Do not offer combination therapy
  • Maintain the person's blood pressure below 130/80 mmHg by adding other antihypertensive drugs if necessary
  • Advise adults with type 1 diabetes and nephropathy about the advantages of avoiding a high-protein diet.

Chronic painful diabetic neuropathy

For guidance on managing chronic painful diabetic neuropathy in adults with type 1 diabetes, see the NICE guideline, Neuropathic pain—pharmacological management.

Autonomic neuropathy

  • Think about the possibility of autonomic neuropathy affecting the gut if adults with type 1 diabetes have unexplained diarrhoea, particularly at night
  • When prescribing antihypertensive medicines, take care not to increase the risk of orthostatic hypotension from the combined effects of sympathetic autonomic neuropathy and blood pressure lowering medicines
  • For adults with type 1 diabetes who have bladder emptying problems, investigate the possibility of autonomic neuropathy affecting the bladder, unless another explanation is found
  • When managing the symptoms of autonomic neuropathy, include specific interventions for the manifestations encountered (for example, for abnormal sweating and postural hypotension).

Gastroparesis

  • Advise adults with type 1 diabetes who have vomiting caused by gastroparesis to follow a small-particle-size diet (mashed or pureed food) to relieve their symptoms
  • Be aware that gastroparesis needing specific therapy can only be diagnosed in the absence of hyperglycaemia delays gastric emptying
  • Consider insulin pump therapy for adults with type 1 diabetes who have gastroparesis
  • For adults with type 1 diabetes who have vomiting caused by gastroparesis, explain that:
    • there is no strong evidence that any available antiemetic therapy is effective
    • some people have had benefit with domperidone,[B],[C] erythromycin,[C] or metoclopramide[D]
    • the strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk, and potential interactions with other medicines
  • To treat vomiting caused by gastroparesis in adults with type 1 diabetes:
    • consider alternating use of erythromycin[C] and metoclopramide[D]
    • consider domperidone[B],[C] only in exceptional circumstances (that is, when it is the only effective treatment) and in accordance with MHRA guidance
    • Refer adults with type 1 diabetes who have gastroparesis for specialist advice if the interventions in recommendations above are not beneficial or not appropriate.

Acute painful neuropathy from rapid improvement of blood glucose control

  • Reassure adults with type 1 diabetes that acute painful neuropathy resulting from rapid improvement of blood glucose control is a self-limiting condition and symptoms improve over time
  • Explain to adults with type 1 diabetes that the specific treatments for acute painful neuropathy resulting from rapid improvement of blood glucose control:
    • aim to make symptoms tolerable until the condition resolves
    • may not relieve pain immediately and may need to be taken regularly for several weeks to be effective
  • Use simple analgesics (paracetamol, aspirin) and local measures (bed cradles) as a first step to treat acute painful neuropathy, and if these do not help, try other measures
  • Do not relax diabetes control to address acute painful neuropathy resulting from rapid improvement of blood glucose control in adults with type 1 diabetes
  • If simple analgesia does not provide sufficient pain relief for adults with type 1 diabetes who have acute painful neuropathy resulting from rapid improvement of blood glucose control, offer treatment as described in the NICE guideline, Neuropathic pain—pharmacological management. Simple analgesia may be continued until the effects of additional treatments have been established
  • When offering medicines for managing acute painful neuropathy resulting from rapid improvement of blood glucose control to adults with type 1 diabetes, be aware of the risk of dependency associated with opioids.

Diabetic foot problems

For guidance on preventing and managing foot problems in adults with type 1 diabetes, see the NICE guideline, Diabetic foot problems: prevention and management.

Erectile dysfunction

  • Offer men with type 1 diabetes the opportunity to discuss erectile dysfunction as part of their regular review
  • Offer a phosphodiesterase-5 inhibitor to men with type 1 diabetes with isolated erectile dysfunction unless contraindicated. Choose the phosphodiesterase-5 inhibitor with the lowest acquisition cost
  • Consider referring men with type 1 diabetes to a service offering further assessment and other medical, surgical, or psychological management of erectile dysfunction if phosphodiesterase-5 inhibitor treatment is unsuccessful or contraindicated.

Thyroid disease monitoring

  • Measure blood thyroid-stimulating hormone levels in adults with type 1 diabetes at their annual review.

Mental health problems

  • Members of diabetes professional teams providing care or advice to adults with type 1 diabetes should be alert to possible clinical or subclinical depression and/or anxiety, particularly if someone reports or appears to be having difficulties with self-management
  • Diabetes professionals should:
    • ensure that they have appropriate skills to identify and provide basic management of non-severe mental health problems in people from different cultural backgrounds
    • be familiar with appropriate counselling techniques and drug therapy, while arranging prompt referral to specialists for people whose mental health problems continue to interfere significantly with wellbeing or diabetes self-management.

See also the NICE guidelines on Common mental health problems, Generalised anxiety disorder and panic disorder, and Depression in adults with a chronic physical health problem.

Eating disorders and disordered eating

  • Members of diabetes professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa, and disordered eating in adults with type 1 diabetes with:
    • over-concern with body shape and weight
    • low BMI
    • hypoglycaemia
    • suboptimal overall blood glucose control.

    See also the NICE guideline, Eating disorders: recognition and treatment

  • Think about making an early (or if needed, urgent) referral to local eating disorder services for adults with type 1 diabetes with an eating disorder
  • From diagnosis, the diabetes professional team should provide regular high-quality support and counselling about lifestyle issues and diet for all adults with type 1 diabetes.

Footnotes

[A] In August 2015, this was an off-label use of metformin. See NICE's information on prescribing medicines

[B] See the MHRA guidance, Domperidone: risk of cardiac side effects

[C] In August 2015, this was an off-label use of erythromycin and many higher doses or treatment durations of domperidone. See NICE's information on prescibing medicines

[D] See the MHRA guidance, Metoclopramide: risk of neurological adverse effects

 

© NICE 2021. Type 1 diabetes in adults: diagnosis and management. Available from: nice.org.uk/ng17. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Published date: 26 August 2015.

Last updated: 21 July 2021. 

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Read the Guidelines in Practice article Type 1 diabetes in adults: new recommendations support coordinated care for more information on the implementing NICE Guideline 17: Type 1 diabetes in adults: diagnosis and management.