Doctors should aim in the long term to get patients’ HbA1c levels down to the ‘very tough target’ of 48mmol/mol (6.5%) or lower in order to minimise their risk of long-term vascular complications, says new NICE guidance.
But they should agree on ‘appropriate’, more attainable goals with individual patients to help more improve their blood glucose levels, as current data show that ‘most adults with type 1 diabetes have HbA1c above target levels’.
The revised adult type 1 diabetes guideline replaces similar recommendations made in 2004, offering clinicians an ‘up-to-date’ toolkit to bring about ‘tighter blood sugar control’ in patients.
It comes as health charities warned of large ‘postcode lottery’ of variation in diabetes care, with the proportion of patients with controlled diabetes ranging from 27% in the lowest performing CCG areas to 48% at the highest.
Type 1 diabetes NICE guidance
GP Professor Roger Gadsby, who was part of the guideline development group, told GPonline: ‘There are a number of people with type 1 diabetes who are, for various reasons, no longer attending secondary care services and are receiving the majority of their routine care in general practice – and therefore there’s a real role for GPs in supporting and helping people with type 1 diabetes.’
The guideline recommends that patients should be monitoring their blood glucose levels at least four – and up to 10 – times a day to help drive down their HbA1c levels, and GPs should ensure they provide them with right numbers of materials to do so, he said.
The guideline also recommends the multiple injection basal-bolus insulin regime as best practise of insulin control, as opposed to twice-daily mixed insulin regimens. Professor Gadsby said evidence suggested that this scheme – which sees patients given a dose of short-acting insulin with each meal and two long-lasting basal insulin per day – was ‘the best way to get as good a glucose control as possible’.
NICE specifies for the first time that patients should be offered a spot on structured education courses – specifically citing the DAFNE (dose-adjustment for normal eating) programme as an example – to help educate them on managing their condition.
This should generally be offered to adult patients between six and 12 months following diagnosis of type 1 diabetes.
‘Often, in the first few months after diagnosis of type 1 diabetes, there is a period of adjustment and coming to terms with the diagnosis, meaning it is not be best time for them to assimilate new information and education,’ said Professor Gadsby.
‘The evidence shows that after six months, you’ve come to terms with the new diagnosis and that is the time when it’s most favourable to receive and work on new information to control your diabetes as well as possible.’
He recommended that GPs should offer to refer all adults with the disease who have never attended an education programme.
Updated diabetes guidelines for diabetes in children specify that all children and young people with suspected type 1 diabetes should have a same-day referral to a paediatric diabetes team.