New guidelines issued by the British National Institute for Health and Care Excellence (NICE) on diagnosing and managing type 1 diabetes are calling for tighter blood glucose targets in adults.
“Nearly 400,000 adults in the [United Kingdom] are affected by type 1 diabetes, and around 27,000 children and young people have either type 1 or type 2 diabetes,” NICE explained in an article that describes the new guidelines. Most adults with this condition are not adequately controlling their blood glucose, putting themselves at risk for diabetes-related complications such as foot amputation, heart disease, kidney failure, and blindness.
Previous guidance had suggested a target HbA1C level of less than 7.5% to prevent microvascular disease and 6.5% or lower for individuals at high risk of developing peripheral arterial disease. The newly revised guidance recommends a target level of 6.5% or lower (48 mmol/mol) to prevent these types of complications.
NICE recommends measuring HbA1c levels in type 1 diabetes patients every 3 to 6 months. Measurements should take place more often if an individual experiences rapid changes in his or her blood glucose control. Methods calibrated by the International Federation of Clinical Chemistry and Laboratory Medicine should be used to measure HbA1c, NICE advises.
Individualized HbA1c targets can be set, provided that certain factors are taken into account, such as daily activities, an individual’s occupation, the possibility of complications, comorbidities, and history of hypoglycemia.
NICE is also recommending an HbA1c threshold of 6.5% (48 mmol/mol) or lower for children and young people.
“If a child or young person with type 1 diabetes does not have optimal blood glucose control, additional support or an alternative insulin regimen should be offered,” the guidelines recommend.
In addition to an HbA1c of 6.5% (48 mmol/mol) or lower, NICE defines optimal control as: fasting glucose level of 4–7 mmol/ L on waking; 4–7 mmol/L before meals at other times of the day; 5–9 mmol/L after meals; and at least 5 mmol/L when driving.
NICE, in conjunction with these new guidelines, also issued a guide for young people and families on how they can use various technologies to manage their diabetes. Topics range from insulin injections and pump therapy to length of needle injections, and blood glucose and blood ketone monitoring.
The guidelines recommend, for example, that “all children and young people should be offered a basal-bolus insulin regimen (also called a multiple daily injection or MDI regimen) from the time they are diagnosed. This involves taking a slow-acting ‘basal’ insulin once or twice a day; and a rapid-acting ‘bolus’ insulin with meals.”
In instances where injections are not plausible or appropriate (e.g., a child under 5 getting several injections a day), the child’s diabetes caregivers should consider an insulin pump as an alternative.