Tighter blood glucose targets for people with type 1 diabetes

New diabetes guidance includes tighter targets for blood sugar levels to help reduce variation in the management and care of condition.

Nearly 400,000 adults in the UK are affected by type 1 diabetes, and around 27,000 children and young people have either type 1 or type 2 diabetes.

Currently, most adults with type 1 diabetes are not maintaining the level of glucose in the blood. This means they are at increased risk of a range of complications over time such as blindness, kidney failure, heart disease and foot problems that can lead to amputation.

NICE has published a suite of guidance which together aims to prevent these risks from occurring through new recommendations on blood sugar targets and insulin replacement therapy.

The guidance covers type 1 diabetes in adults, type 1 and type 2 diabetes in children and young people, and diabetic foot care.

Lower HbA1c target for type 1 diabetes

The treatment of diabetes relies on blood sugar control, and type 1 diabetes is typically diagnosed and managed with a HbA1c test. The test provides average blood glucose levels over the past two to three months.

Most adults with type 1 diabetes currently have HbA1c scores that are above target levels. This means that they are at increased risk of long-term potentially life-threatening complications.

To tackle this, updated guidelines recommend supporting adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower.

All adults with type 1 diabetes should be offered a structured education programme of proven benefit. These programmes can provide people with the skills needed to manage their condition, such as estimating carbohydrates in meals and injecting correct doses of insulin.

Examples include the DAFNE (dose-adjustment for normal eating) programme, which is a collaborative of diabetes services from NHS Trusts and Health Boards across the UK and Southern Ireland.

In addition, all adults with type 1 diabetes should be offered multiple daily injection basal–bolus insulin regimens, rather than twice-daily mixed insulin regimens, as the insulin injection regimen of choice.

Children with diabetes should have HbA1c targets near normal range

Type 1 diabetes is the most common form of the condition among children. Yet increasing rates of obesity among children means that type 2 diabetes is also on the rise.

As with adults, poor management of blood glucose levels can lead to serious complications and long–term health problems.

NICE’s national guidelines on type 1 type 2 diabetes in children and young people recommend that children and young people should aim for a HbA1c target near normal range, and nearly normal daily blood glucose readings.

This can be done through daily injections or through the use of insulin pumps from diagnosis, and through dietary management, such as counting carbohydrates.

Children and young people with suspected type 1 diabetes should be referred on the same day to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care.

Elsewhere, recommendations cover education and information for children and young people with diabetes, continuous glucose monitoring for children with type 1 diabetes, and access to mental health professionals to deal with psychological and social issues.

Diabetic foot problems are potentially life-threatening

Around 1 in 10 people with diabetes will have a diabetic foot ulcer at some point in their lives. The ulcers occur due to nerve damage or degeneration due to high blood sugar levels, or peripheral arterial disease, or both.

If the foot becomes infected it is possible that this can lead to amputation or even death, with up to 70 per cent of people dying within 5 years of having an amputation.

Updated guidelines on diabetic foot care say that if a patient has a limb-threatening or life-threatening diabetic foot problem, they should be referred immediately to acute services. A multidisciplinary foot care service should also be informed so they can be assessed and an individualised treatment plan put in place.

For all other active diabetic foot problems, patients should be referred within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day

Sir Andrew Dillon, Chief Executive of NICE, said. “The standard of diabetes care varies across the NHS. These updated guidelines are designed to help more people to receive the best treatment and support.

“They recommend effective and cost effective care and advice to NHS organisations on such things as setting up specialist services to reduce risk of diabetes-related amputation. Implementing these recommendations will help prevent serious illnesses linked to diabetes.”

The standard of diabetes care varies across the NHS. These updated guidelines are designed to help more people to receive the best treatment and support.

Sir Andrew Dillon, Chief Executive of NICE