The guideline committee has made the following recommendations for research.
What methods and interventions are effective in increasing the number of adults with type 1 diabetes who achieve the recommended HbA1c targets without risking severe hypoglycaemia or weight gain?
The evidence that sustained near‑normoglycaemia substantially reduces the risk of long‑term complications in adults with type 1 diabetes is unequivocal. Current methods for achieving such blood glucose control require skills in glucose monitoring and insulin dose adjustment, injection technique and site management, and the ability to use such self‑management skills on a day‑to‑day basis life‑long. Fear of hypoglycaemia and of weight gain are major barriers to success, as is fitting diabetes self‑management into busy lifestyles. Everyone struggles to meet optimised targets and some people are more able to meet them than others. Research into new interventions ranging from more effective education and support, through improved technologies in terms of insulin replacement and glucose monitoring, and including use of cell‑based therapies, is urgently needed. It is also important to ensure that adults with type 1 diabetes are able to engage with such methodologies.
In adults with type 1 diabetes who have chronically poor control of blood glucose levels, what is the clinical and cost effectiveness of continuous glucose monitoring technologies?
Current continuous glucose monitoring systems were found not to be cost effective in the de novo analysis carried out for this guideline, even in people who had impaired hypoglycaemia awareness. In adults with type 1 diabetes who have high HbA1c values, there still may be some value in using continuous glucose monitoring systems, and further research is needed to determine whether newer technologies would prove to be cost effective, particularly in this group.
In adults with type 1 diabetes, what methods can be used to increase the uptake of structured education programmes and to improve their clinical outcomes (particularly achieving and sustaining blood glucose control targets)?
Structured education programmes in flexible insulin therapy have been shown to improve diabetes control (lower HbA1c and less hypoglycaemia), but achieving and sustaining optimal diabetes control to avoid complications remains challenging. Some people do not reach ideal targets for blood glucose control, others reach but are not able to maintain them, and still others are not offered or do not access structured education at all. There is therefore a need to develop and test: (1) more effective ways of engaging adults with type 1 diabetes in education; (2) improvements in the delivery of education to increase the number of people meeting targets for diabetic control; and (3) enhanced support for adults with type 1 diabetes to sustain good diabetic control over time. If the uptake and delivery of clinically and cost‑effective education and support for adults with type 1 diabetes can be improved, it should be possible to achieve a reduction in short‑term and long‑term complications.
Can a risk stratification tool be used to aid the setting of individualised HbA1c targets for adults with type 1 diabetes?
Strict blood glucose control early in the history of type 1 diabetes has been shown to reduce the development and progression of long‑term complications, but it is not possible to determine who is at particular risk of glucose‑driven poor outcomes. Furthermore, there is a dearth of evidence of the risk:benefit ratio of strict blood glucose control in people who already have diabetes complications. Since achieving and maintaining near‑normal blood glucose concentrations is complicated, a risk stratification tool to calculate the modifiable individual risk of complications will allow blood glucose targets to be tailored for each person and appropriate support to be provided.
5 Technologies for preventing and treating impaired hypoglycaemia awareness in adults with type 1 diabetes
For adults with type 1 diabetes, what are the optimum technologies (such as insulin pump therapy and/or continuous glucose monitoring, partially or fully automated insulin delivery, and behavioural, psychological and educational interventions) and how are they best used, in terms of clinical and cost effectiveness, for preventing and treating impaired hypoglycaemia awareness?
Impaired hypoglycaemia awareness renders adults with type 1 diabetes susceptible to sudden unexpected deteriorations of conscious level and irrational behaviour, and increases their risk of severe hypoglycaemia 6‑fold. Impaired hypoglycaemia awareness and severe hypoglycaemia creates barriers to many aspects of daily living, and can cause enormous stress for family and friends. Severe hypoglycaemia can also cause fear of hypoglycaemia great enough to prevent a person meeting the glucose targets that are associated with minimal risk of complications. Impaired hypoglycaemia awareness results from overexposure to hypoglycaemia in daily life, and awareness can be much improved by avoiding hypoglycaemia. Developing technologies in glucose monitoring and insulin delivery have not been rigorously tested in adults with type 1 diabetes and impaired hypoglycaemia awareness. Research is needed formally to document the extent to which existing technologies can help adults with type 1 diabetes and impaired hypoglycaemia awareness to avoid hypoglycaemic episodes and regain awareness for occasional episodes. Research is also needed to develop new technologies. Research is also needed into how to engage adults with type 1 diabetes and impaired hypoglycaemia awareness with treatment strategies designed to improve awareness.