The International Diabetes Federation ( European Region ) ( IDF (Europe) Additionally the European Diabetes Policy Group would like to thank Elizabeth …
A Desktop Guide
to
Type 1 Insulin-dependent
Diabetes Mellitus
European Diabetes Policy Group 1998
International Diabetes Federation
European Region
[ Inside cover ]
A Desktop Guide
to
Type 1 Insulin-dependent
Diabetes Mellitus
European Diabetes Policy Group 1998
International Diabetes Federation
European Region
1998, International Diabetes Federation Europe,
Brussels
Copyright and Reproduction
All rights reserved No part of this publication may be reproduced, stored
in a retrieval system or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without prior
permission of the copyright owner
The International Diabetes Federation European Region IDF Europe
nevertheless welcomes local reproduction of these Guidelines in whole or in
part, by governmental, charitable, and other non-profit making bodies
involved in the delivery of health-care Approved non-English language
versions of the Guidelines are being prepared, and must be used where
available Offers of assistance in translation into other languages are
welcome Any reproduction should be by written permission of IDF Europe,
and if modifications are made to suit local circumstances then this should
be made explicit
Commercial organizations in any sphere wishing to make use of these
Guidelines are invited to contact IDF Europe IDF Europe has an
agreement with the sponsors of this publication see Acknowledgements to
allow reproduction in appropriate circumstances at a premium to the support
level given by those sponsors No
permission will be given for any
reproduction in association with product marketing
Acknowledgements
The production of these Guidelines was made possible by the financial
support of a consortium of industry partners of the St Vincent Declaration
Initiative and IDF Europe The members of this consortium are :
Bayer Corporation, Diagnostics
Eli Lilly and Company
Glaxo Wellcome
Novo Nordisk
Roche Diagnostics
Zeneca Pharmaceuticals
Additionally the European Diabetes Policy Group would like to thank
Elizabeth Dempsey Becker of Novo Nordisk and Joachim Thiery of Roche
Diagnostics for their organizational assistance and advice, and their
companies for continuing their support of the original guidelines
The Group is grateful to Hazel Glass for administrative support
Style, content, and language editing of these Guidelines are by Elizabeth
Home
ISBN 0 7017 0080 7
International Diabetes Federation European Region
16 ave Emile de Mot
B 1000 Brussels
Belgium
Printed in Germany by Walter Wirtz Druck Verlag, August 1998
A Desktop Guide to Type 1 Insulin-dependent
Diabetes Mellitus
TOPIC FINDER page
Acknowledgements 2
Preface
4
How Do I :
Ensure effective delivery of care
1 Organize a persons diabetes care
2 Conduct a diabetes consultation
3 Monitor diabetes care
4 Monitor my performance
Promote effective self-care
5 Empower a person with diabetes
6 Provide skills, motivation and understanding
7 Provide self-monitoring and self-management skills
8 Advise on life-style travel / licences / insurance / jobs
Control blood glucose, blood lipids, arterial risk factors
9 Define and use blood glucose targets
10 Provide eating and drinking advice
11 Advise on physical exercise
12 Use insulin effectively initiate / adjust / analogues
13 Cope with hypoglycaemia problems
14 Detect and manage arterial risk factors / lipids
Detect and manage diabetes complications
15 Kidney damage and high blood pressure 21
16 Eye damage 22
17 Foot problems 23
18 Nerve damage 24-25
Manage special problems
19 Pregnancy in women with
diabetes
20 Surgery in people with diabetes
21 Ketoacidosis
European Diabetes Policy Group 35
Statement of duality of interest 35
Index 36
Preface
A desktop guide
In 1993 the European IDDM Policy Group published the Consensus Guidelines
for Management of Insulin-dependent Type 1 Diabetes on behalf of the St
Vincent Declaration Initiative
The current initiative builds on those earlier guidelines, in the light of
newer understandings, and attempts to provide a more direct and more
accessible format
Furthermore, we have tried to use language that can be followed by the
educated person with diabetes, remembering that the primary resource for
diabetes care is the person with diabetes themselves, supported by
enthusiastic and well-trained professionals
The special requirements of children are not addressed here
Evidence
The 1993 Consensus Guidelines were explicit about the knowledge base used
In an attempt to raise clarity, the current Desktop Guide is more
prescriptive However, we will also be publishing a source document in a
major journal; this will go even further than the previous Guidelines in
documenting the strength of the
recommendations given here
Aims of diabetes care
The aim to which these guidelines aspire is to enable a life of normal
length and fulfilment for people with diabetes through:
provision of skills to adapt insulin therapy to lifestyle;
development of understanding to allow coping with new challenges;
control of risk factors for eye, kidney, foot, and arterial damage;
early detection and management of any complications of diabetes
A way forward
The 1998 European Diabetes Policy Group worked on both the major types of
diabetes - there is a sister publication on Type 2 diabetes The working
group came from richer and poorer nations throughout Europe, and included
people with diabetes, as well as members of multi-disciplinary teams
We hope you will enjoy implementing these shared ideas The practice of
diabetes care is not always easy, but the human interest and gain to health
are potentially large
European Diabetes Policy Group, 1998
Correspondence:
Correspondence to: Professor Philip Home, Department of Medicine,
Framlington Place, Newcastle upon Tyne, NE2 4HH, UK E-mail:
philiphome@newcastleacuk
Electronic file: E-mail
diabetes@newcastleacuk; indicate if Word 6 or
Word 97 or HTML
1 Framework of Diabetes Care
A framework for quality diabetes care
2 The Diabetes Consultation
Consultation infrastructure
Consultation process
Annual Review
3 Organization of Clinical Monitoring
Schedule for clinical monitoring at different types of visit
4 Monitoring Quality of Care
Protocol for quality development and monitoring of performance
Indicators for quality development and monitoring
5 Patient Empowerment
Assessment of empowerment
Achieving empowerment
6 Patient Education
Assessment of patient education needs and achievements
Patient education targets
Provision of education
7 Self-monitoring of Blood Glucose
Use and assessment of self-monitoring
Achieving effective self-monitoring
8 Life-style Issues - Living with Diabetes
Assessment
Topics
9 Assessing Blood Glucose Control
Using assessment levels to set targets
Assessment of blood glucose control
Glucose control assessment levels
It can be dangerous to strive for non-diabetic glucose levels
10 Providing
Eating and Drinking Advice
Reviewing dietary management
Meal patterns
Healthy eating
11 Physical Exercise
Management
12 Using Insulin Effectively
121 Insulin, injections, and associated education
122 Insulin dose requirements - general considerations
123 Rapid-acting insulin analogue regimens
Our knowledge of the optimal use of rapid-acting and new long-acting
analogues is evolving month by month - we anticipate a need to modify
this advice early on
124 Insulin dose adjustment
This section deals with insulin dose adjustment for optimization of long-
term blood glucose control
Background basics
Dose adjustment for different insulin preparations
Algorithm for insulin adjustment when glucose levels are above target
Yes
No
Yes
No
Algorithm for insulin adjustment when glucose levels are below target
Yes
No
The insulin algorithms on this page :
do not address the use of rapid-acting analogues
cannot cope with more complex regimens when two insulins are
injected together
should be used only in the context of the material on the previous
three pages
13 Hypoglycaemia Problems
14 Managing Arterial Risk Factors and Ischaemic Heart Disease
Managing arterial risk
Blood lipid control targets
Blood pressure control targets
Smoking cessation and control
15 Kidney Damage
Detection and surveillance
Blood pressure management if raised albumin excretion rate
Other management
16 Eye Damage
Detection and surveillance
Eye disease management
17 Foot Problems
Detection and surveillance
Foot management - preventative
Foot management - advanced disease
18 Nerve Damage
for Foot problems see above
Detection and surveillance
Management of painful neuropathy
Management of autonomic neuropathy
19 Pregnancy and Contraception in Women with Diabetes
Contraception
Pre-pregnancy management
Pregnancy care
20 Management of Diabetes during Surgery
Organization
Management
Glucose-insulin-potassium GIK regimens
21 Management of Diabetic Ketoacidosis
Organizational
Management
European Diabetes Policy Group
1998
Participating members
M Aguilar Cadiz, Spain
K G M M Alberti joint chairman Newcastle upon Tyne, UK
S A Amiel London, UK
J Azzopardi Gwardamangia, Malta
C Berne Uppsala, Sweden
R W Bilous Middlesbrough, UK
K Borch-Johnsen Gentofte, Denmark
G Cathelineau Paris, France
P V M Cromme Twello, The Netherlands
A Dawson London, UK
R Elphick Brussels, Belgium
A Ericsson Loderup, Sweden
D R Hadden Belfast, Northern Ireland
R J Heine Amsterdam, The Netherlands
P D Home joint chairman Newcastle upon Tyne, UK
I Kalo Copenhagen, Denmark
T Kangas Vantaa, Finland
R Landgraf Munich, Germany
T Lauritzen Aarhus, Denmark
M Massi-Benedetti Perugia, Italy
A Mitrakou-Fanariotou Athens, Greece
T Pieber Graz, Austria
A Pruijs-Brands Zeist, The Netherlands
H Schatz Bochum, Germany
W Scherbaum Düsseldorf, Germany
A Serhiyenko Lviv, Ukraine
J Sieradzki Krakow, Poland
P Swift Leicester, UK
L Uccioli Rome, Italy
P Van Crombrugge Aalst, Belgium
W H J M Wientjens Waddinxveen, The Netherlands
M T Yilmaz
Istanbul, Turkey
H Yki-Järvinen Helsinki, Finland
Statement of Duality of Interest
A number of members of the Policy Group, personally or through their
employers, hold research contracts with, or provide consultation to,
governmental and commercial organizations including the sponsors with
an interest in areas covered by these Guidelines
While travel and subsistence costs of the Policy Groups consensus meeting
were covered by a grant to the University of Newcastle upon Tyne by the
sponsors, no member of the Group has received any fee in connection with
this activity A fee commensurate with the editorial work performed was
however received by the spouse of one of the Chairmen
Index
Albumin excretion rate 22,24
Annual Review 5,6,7
Arterial risk factors 22,23
Autonomic neuropathy 28
Blood glucose control targets 14
Blood glucose monitoring 12
Blood pressure hypertension 22,24
Blood pressure targets 22,23,24
Care delivery organization 5,7
Care team 5
Consultation 6,7
Contraception 29
Diet 15,16
Driving licences 13
Education of patients 9,10,11
Employment 13
Empowerment 9
Exercise 16
Eye damage retinopathy 25
Foot problems 26,27
GIK 31
Glucagon
21
Glycated haemoglobin 14
Heart disease 22
Hypertension 22,24
Hypoglycaemia 20,21
Hypoglycaemia unawareness 21
Impotence 28
Insulin therapy 17,18,19,20
Ischaemic heart disease 22
Ketoacidosis 32
Ketones 12
Kidney damage nephropathy 24
Lipids 22,23
Living with diabetes 13
Microalbuminuria 22,24
Nephropathy 24
Nerve damage neuropathy 28
Nocturnal hypoglycaemia 21
Nutritional management 15,16
Pregnancy 29,30
Quality development 8
Retinopathy 25
Self-management 9,10,11
Self-monitoring 12
Smoking 23
Surgical management 31
Targets for glucose control 14
Targets for lipid control 23
Teams 5
Travel 13
[ Inside cover end ]
[ Outside cover end ]
DIABETES TYPE 1 DESKTOP GUIDELINES
EUROPEAN DIABETES POLICY GROUP 1998
———————–
Guidelines for
Diabetes Care
Ensure provision of the following :
A diabetes team professionals with up-to-date skills
doctors
educators diabetes nurse specialists
nutritionists dieticians
podiatrists chiropodists
Structure
easy access for people with diabetes
protocols for diabetes care
facilities for education
information for people with diabetes
structured records
recall system for Annual Review / eye surveillance
database / software for quality monitoring and development
continuing education for professional staff
Process
service for regular review
service for Annual Review
education service
foot care service
emergency advice line
joint obstetric / medical pregnancy and pre-pregnancy service
adolescent service
access to related professionals heart, renal, eye, vascular
specialists
Feedback from people with diabetes on service performance
Regular review of service performance
Make available for consultations the following :
necessary members of the diabetes team
adequate time and adequate space
records and information for the individual with diabetes
means of communication to other health professionals involved in the
individuals care
Include the
following in any diabetes consultation :
Welcome
1 Friendly greeting of the individual and early establishment of
rapport
Problems review
2 Understanding of any recent events disturbing the persons life-style
3 Enquiry after general well-being and identification of new
difficulties
4 Review of self-monitored results, and discussion of their meaning
5 Review of dietary behaviours and physical activity
6 Review of diabetes education, skills, and foot care
7 Review of insulin therapy and experience of hypoglycaemia
8 Review of other medical conditions and therapy affecting diabetes
9 Management of arterial risk factors identified at Annual Review
10 Management of complications and other problems identified at Annual
Review
Analysis and planning
11 Summary of, and agreement on, main points covered in consultation
12 Agreement on targets for future months
13 Agreement on, and explanation of, changes in therapy
14 Agreement on interval to next consultation
Recording
15 Completion of a structured record / patient-held record of the
consultation
Review topics
3-yearly if previously normal
not required if proteinuria
Psychological problems
Provide
counselling, as required, by appropriately skilled members of the
diabetes care team
appropriate education see Patient education to alleviate some of
the concerns underlying the diagnosis of diabetes or development of
complications
Initial review / referral
Regular
review
Annual
Review
Self-monitoring skills / results
Diabetes understanding / self-management
Long-term and / or recent diabetes history
Social history / lifestyle review
If problem
If problem
If problem
If problem
Urine albumin excretion
Urine protein
Lipid profile
Glycated haemoglobin
Blood pressure
Eye / vision examination
Foot examination / injection sites
General examination
Weight / body mass index
Drug history / current drugs
Family history diabetes / arterial disease
Other medical history / systems review
Smoking
Complications history and / or symptoms
Aggregate
the data gathered at Annual Review onto a computerized database
Choose
indicators see below to
reflect outcome as well as process of
care
Analyse
data in line with published recommendations
Compare
performance with pre-determined standards or other providers of
diabetes care
Review
performance at regular meetings of your diabetes team
Discuss
the performance of education programmes
Measure Calculate
Intermediate outcomes
HbA1c Percent 75 Hb
Albumin excretion Percent abnormal albumin excretion
Eye damage Percent with retinal damage
True outcomes
Amputation above ankle Incidence
Myocardial infarction Incidence
Stroke Incidence
Foot ulceration Incidence
Risk factor control
Hypertension Percent 135/85 mmHg
Smoking Percent people still smoking
Process of care
Eyes screened Percent people examined in year
Education performed Percent people seeing nurse educator in year
Feet examined Percent people examined in year
These are examples; many other indicators are possible
A salient goal for diabetes care is to enable each person with diabetes to
lead the health-care team involved in the management of their
diabetes
Assess whether the person with diabetes :
has the knowledge, behavioural skills, and sense of awareness
necessary for optimum self-care
makes early and effective responses to everyday problems
has the confidence to obtain the best input from the diabetes health-
care team
Ensure that empowerment is :
a primary objective of your consultations and education programme
supported by availability of diabetes publications and other
information sources
the active policy of your diabetes service
Provide :
positive encouraging responses to requests for information and
understanding
a copy of the European Patients Charter
or a similar national or local statement of rights and roles
a copy of the persons diabetes health-care record
information on the results and meaning of all investigations
It is the right of each person with diabetes to become empowered to derive
the maximum benefit from the health-care system
It is the responsibility of the diabetes team to ensure that the person
with diabetes can follow the life-style of their educated choice,
based on
the three elements of empowerment: knowledge, behavioural skills, and self-
responsibility
Use :
review of diabetes skills
self-monitoring, injections, hypoglycaemia management, food
identification
biomedical measures changes in body weight, glycated haemoglobin
evidence of appropriate behaviours
footwear, use of injection sites, membership of diabetes associations
assessment of life-style, emotional adjustment, and perceptions of
barriers to life-style activities and self-care
perceptions of desired short-term goals glucose control, weight ,
and long-term vulnerability to late tissue damage
knowledge as a basic measure
diabetes-specific well-being and health profile assessments as
global measures
Perform :
as part of routine care visits, by direct enquiry
as part of Annual Review, or first contact, more formally
The aims of education and training are to provide information in an
acceptable form, in order that people with diabetes develop the knowledge
to self-manage their diabetes and empower them to make informed
choices in
their life
Aim to optimize :
knowledge of diabetes, and the aims of its management
motivation
attitudes to self-care
behaviours which interact with diabetes management
empowerment in handling health-care and other professionals
Aim to provide skills :
to ensure optimal and appropriate use of insulin therapy
to deal with the social and life-style consequences of insulin
therapy
to be able to detect and manage hypoglycaemia and other complications
of therapy
to be able to monitor the results of therapy and act appropriately on
the results
to manage effectively nutrition and exercise
to enable appropriate self-management during intercurrent illness
to be able to formulate and agree health-care targets and strategies
for meeting them
to use the professional members of the diabetes care team effectively
to understand and cope appropriately with the late tissue damage of
diabetes
to make appropriate responses to unpredicted and new problems in
diabetes care
to avoid self-destructive behaviours and
deal adequately with stress
Integrate into regular clinical care by providing your own curriculum
and programme
Ensure your diabetes team has adequately trained personnel
Assess special needs of each individual see above
Be aware of needs of special groups young people, pregnant women, the
elderly
Provide education within three time frames :
At and shortly after diagnosis :
the minimum skills to obtain control over the new situation
supportive information on the nature and outcomes of diabetes
basic information on self-injection, self-monitoring,
hypoglycaemia, dietary carbohydrate distribution
In the months following diagnosis on a one-to-one basis :
a comprehensive coverage
topics covered previously, plus
coping with illness, targets of insulin therapy, healthy eating
complications of diabetes, associated risk factors, foot care
employment or schooling, insurance, driving and travel
pregnancy, genetic counselling, contraception
In the long term :
reinforcement periodically after annual evaluation see above
Include family members
and significant others as appropriate
Use group education to uncover problems and provide solutions and
behavioural change through peer example
The tools of diabetes care can only be used effectively and optimally
when combined with the process of patient education and
with continuing evaluation of the outcomes of care
Advise use of self-monitoring for : insulin dose self-adjustment;
education on effects of life-style on blood glucose; coping with illness
and new situations; hypoglycaemia management and avoidance
Assess ability to use self-monitored information as part of routine care
Assess skills yearly or if self-monitoring problems
Check meters yearly or if self-monitoring problems
Evaluate reliability of self-test results if indicated by :
assessment of self-test technique
comparison with acute results obtained at consultation
consistency with the results of glycated haemoglobin estimation
review of the quality of self-test record diaries
Use
for all people with Type 1 diabetes
reagent strips with or without meters, or electrode strips
Provide appropriate training and regular
review of technique
Recommend :
results are recorded with date and time, insulin dose,
hypoglycaemia to provide a cumulative record as a basis for day-to-
day changes in therapy
different patterns of testing according to need :
four or more times a day during illness, life-style changes, pre-
conception, in pregnancy, with hypoglycaemia unawareness
at night 0200-0400 h if unrecognized night-time hypoglycaemia
is suspected
one or two multi-point profiles a week on different types of day
once daily testing is the minimal acceptable frequency different
times of day
day-time tests preprandially and 1-2 h after meals
regular bed-time tests in people prone to nocturnal hypoglycaemia
testing to cope with variations in eating or activity
special equipment for those with visual impairment
urinalysis for glucose where blood glucose monitoring is not possible
or the patient does not wish to continue with it
urinalysis for ketones when hyperglycaemia, illness, or vomiting is
present
Ask regularly about diabetes interfering with
:
employment or studies
social / sports activities
travel
Employment
Provide :
individualized advice
counselling and contacts for those whose aspirations are frustrated
special advice for shift work, high-risk occupations
employer contact on request of the person with diabetes
Insurance
Be aware of where appropriate and up-to-date premiums can be obtained
Provide advice to patients wishing to enter into insurance contracts
Driving licences
Provide :
sympathetic and supportive advice where driving is no longer
reasonable
individual assessment for people with hypoglycaemia unawareness
rapid and appropriate reports on request
Review :
patterns of food intake and patterns of physical activity
previous experience of insulin therapy as a guide to :
total insulin dose requirement do not use weight-determined
insulin doses
diurnal variations in insulin requirement
experience of hypoglycaemia
state of injection sites
Expect :
overnight basal requirements to require up to 50 of total dose
unmodified insulin
to last for 6-8 hours, and therefore sometimes to
overlap into the next meal or into the night; reduce doses
accordingly
high pre-breakfast insulin requirements, due to insulin deficiency at
the end of the night
young peoples insulin requirements to be high and changing
Monitor :
achieved control and hypoglycaemia; empathy with insulin injections;
impact of insulin injections on life-style; understanding and needs;
acquisition of injection skills; injection sites; at intervals
determined by individual needs and wishes
Adjust :
insulin doses to meet agreed targets and experience of hypoglycaemia
see below
Attention to the non-metabolic target of diabetes interfering little with
the patients general and social well-being will help metabolic control
Use the published assessment levels :
as an integral part of diabetes care - never manage diabetes on
symptoms
to indicate need for further intervention
as the basis for short-term and longer-term individualized targets
as an educational tool to help the person with diabetes
Ask questions of yourself continually :
Is it possible for the individual to approach each target more
closely, without a counter-balancing deterioration in quality of
life?
For what percentage of patients is the service achieving these
targets?
Be concerned about targets :
Failure to attempt to approach the targets more closely is inadequate
care, unless this would lead to deterioration in quality of life
Do not attempt to approach target levels too closely where this
adversely affects the quality of life of the person with diabetes
Measure glycated haemoglobin 2-4 monthly in every patient depending
how stable
Think of hypoglycaemia if glycated haemoglobin level is normal or close
to normal
Use the assessment levels below to set blood glucose targets
HbA1c DCCT standardized
Hb
Self-monitored blood glucose
Fasting/pre-prandial
mmol/l
mg/dl
Post-prandial peak
mmol/l
mg/dl
Pre-bed
mmol/l
mg/dl
Non-diabetic Adequate Inadequate
75
65
120
90
160
75
135
62-75
51-65
91-120
76-90
136-160
60-75
110-135
61
40-50
70-90
40-75
70-135
40-50
70-90
Make recommendations and review eating :
at diagnosis
on adjustment or change to insulin regimens
on change in professional advisor
every other year as a routine, or more often as required
on request
Review dietary management regularly :
Is healthy eating see box a normal part of life-style?
Does calorie distribution reflect the patients
life-style and
desires, as well as insulin regimen and local circumstances?
Is calorie intake appropriate to desired body weight?
Are regular meals and snacks taken at appropriate times?
Is money being spent unnecessarily on special diabetes food
products?
Is alcohol intake moderate? Could it be exacerbating hypertension or
hypertriglyceridaemia? Could it be contributing to early or late
hypoglycaemia? Is this understood by the person with diabetes?
Do kidney damage or raised blood pressure suggest a benefit from
special recommendations protein intake 08 g/kg, salt intake 7
g/day, respectively ?
Nutritional management is an integral part of initial and continuing
education programmes
Multiple injection regimens :
Advise snacks will help to attain better blood glucose control, but use
self-monitoring to learn what is necessary and desirable
Advise on flexibility to adjust meal timing and content together with
insulin doses without affecting blood glucose control But warn
about the temptations of extra total calories
Rapid-acting insulin
analogue regimens :
Advise snacks only if self-monitoring suggests a need; check
particularly if a high insulin analogue dose is needed to correct
hyperglycaemia present pre-prandially
Advise carbohydrate intake should be higher, and fat intake lower than that
of most Europeans, but not different from recommendations for the
population in general
The proposed contribution to energy intake should be :
Fat : saturated fat 10 ; replace excess saturated fat with
monounsaturates, or polyunsaturates up to 10 , or carbohydrate
Carbohydrate : around 50-55 Use foods containing soluble fibre in
a carbohydrate rich diet Simple sugars need not be rigorously
excluded from the diet, but often need to be limited
Protein : around 15 or less
Recommend a high intake of fresh fruit and vegetables five items a day
Advise that physical exercise :
can benefit insulin sensitivity, hypertension, and blood lipid
control
should be taken at least every 2-3 days for optimum effect
may increase the risk of acute and delayed hypoglycaemia
Manage physical exercise using :
self-monitoring to
learn about the exercise response, and the effects
of insulin and dietary changes on this
a prospective reduction in insulin dose for regular exercise
additional carbohydrate as necessary
warnings :
about delayed hypoglycaemia, especially with more prolonged,
severe, or unusual exercise, and a possible need for less insulin
overnight and the next day
that exercise during insulin deficiency will raise blood glucose
and ketone levels
that alcohol may exacerbate the risk of hypoglycaemia after
exercise
Advise :
the use of unmodified soluble, regular human insulin before each
meal, and human NPH insulin in combination unless :
multiple injection therapy is not wanted by the person with
diabetes
flexibility of life-style is not important
insulin secretory capacity is high honeymoon period
insulin analogue therapy is indicated see below
the use of pen systems for insulin delivery
the use of the abdominal wall for meal-time injections, and the thigh
for extended-acting insulin; advise also rotation of sites
within
these areas
Enable the person with diabetes to :
handle the injection device proficiently and confidently, including
re-suspension of NPH crystals, insulin storage, and disposal
self-monitor accurately and easily at appropriate times
place insulin consistently into deep subcutaneous tissue, usually by
means of a lifted skin flap with the injection device at a 45 angle
prevent, recognize and manage hypoglycaemia
understand the absorption characteristics of the two insulin
preparations used, and changes of insulin requirement with meal size
and physical activity, thus allowing them to learn insulin dose self-
adjustment
access the diabetes professional team freely for advice
manage sickness and travel successfully
Make the following changes when using rapid-acting analogues compared to
unmodified human insulin :
monitor the effect of a short-acting analogue post-prandially at 1-
2 h , and always less than 4 h after injection
expect to use lower pre-meal insulin doses than with human insulin
use combined NPH analogue injection before meals, if the between-
meal interval is to be greater than 5 h
use a higher late-evening NPH dose unless the aim is specifically
to deal with a problem of night-time hypoglycaemia
use late-evening NPH no longer than 4 h after the evening analogue
injection
Anticipate different diurnal profiles of blood glucose control and
hypoglycaemia than for human insulin, and thus a need for different dose
regimens and different monitoring schemes
Give careful attention to these details, as any improvement in glycated
haemoglobin concentration will be dependent on this
Review first :
the match of education, doses, meals, and activity to the Insulin,
injections, and associated education box given above
the individuals perception and experience of hypoglycaemia and
hyperglycaemia
Review section 13 below if hypoglycaemia problems
Ensure then that :
the person with diabetes has confidence in your advice
self-monitoring and HbA1c data are available to you, and are reliable
you are familiar with the persons life-style habits, in particular
eating and activity patterns, and times of insulin
injections
injection skills and injection sites are in good order
Consider the previous two pages first
Short-acting unmodified insulin
Consider :
the median glucose level at the time of the injection to be
adjusted
the median glucose level at the time of the next injection
the experience of hypoglycaemia or subnormal glucose levels 40
mmol/l; 70 mg/dl between the two injections
If :
glucose levels are high at the beginning of the relevant period
review the insulin dose affecting the previous time period first
Otherwise if :
glucose levels are above target, and hypoglycaemia is not an issue
increase insulin dose by 10 ; arrange to monitor and review
result
Otherwise if :
hypoglycaemia is an issue or glucose levels 40 mmol/l 70
mg/dl
decrease insulin dose by 10 ; arrange to monitor and review
result
Otherwise :
no simple adjustment is possible; consider more complex
adjustment, or accept the status quo
Rapid-acting insulin analogues
Read the box on insulin analogues above
Consider the median post-prandial 2-4 h glucose level /
hypoglycaemia experience and not the next pre-prandial / pre-
injection level
Proceed otherwise as for short-acting unmodified insulin see above
Extended-acting NPH insulin at bed-time
Consider
the median glucose level at bed-time
the median glucose level before breakfast
any information on glucose levels during the night
Adjust insulin dosage as for short-acting unmodified insulin see above
Extended-acting NPH insulin at other times
Consider
the blood glucose profile over the 12 h after the injection
the experience of hypoglycaemia or subnormal glucose levels 40
mmol/l; 70 mg/dl over the same time period
the expected effect of other insulin used in the same time
interval
Adjust insulin dosage as for short-acting unmodified insulin see above
If Median blood glucose 70 mmol/l, or
Median pre-prandial glucose 50-70 mmol/l and 80 of values 40-80
mmol/l, or
Median post prandial glucose 10 mmol/l 15-20 h after meal
Recurrent hypoglycaemia
at a particular time or times of day implies a mismatch of
insulin
therapy to meal pattern and/or physical activity :
Review whether a repeated change in meal or activity behaviour is
occurring; if so advise on a specific insulin adjustment for that
change
Consider change in underlying insulin sensitivity age / renal /
endocrine
Refer to the insulin dose adjustment section
Erratic hypoglycaemia
needs thorough assessment of a range of possible causes :
Consider :
missed / varied meals or snacks rotation between injection
sites
erratic physical activity errors in insulin administration /
dose
alcohol inappropriate dose distribution
injection site abnormalities gastroparesis
Hypoglycaemia unawareness
is often partially reversible; hypoglycaemia can induce hypoglycaemia
unawareness :
Consider by self-testing the possibility of undetected night-time or
other hypoglycaemia, especially if HbA1c is lower than average
Use adjustment of insulin doses or food intake to ameliorate such
problems
Avoid any glucose excursion to 40 mmol/l 70 mg/dl
Provide education and training in recognizing
early cognitive
dysfunction for people with the problem and their carers
Provide counselling on any resultant life-style problems; caution over
driving
Nocturnal hypoglycaemia
can be ameliorated by careful attention to insulin therapy :
Consider :
reduction in evening unmodified insulin dose if large or late;
this is a major contributor to 2400-0300 h hypoglycaemia
taking the evening NPH insulin as late as possible - thus
separating the effects of the evening unmodified and NPH insulin
preparations
taking a slowly absorbed carbohydrate snack as late as possible
using a rapid-acting insulin analogue before the main evening meal
Hypoglycaemic coma / fitting :
Give 20 glucose IV if unconscious, or 1 mg glucagon IM Beware of
poor glucagon effect in the starved or inebriated patient Follow
with oral carbohydrate and review for possible relapse
Train carers to use glucagon if recurrent, unresolved problem; ensure
supplies remain in date
Review arterial risk factors :
blood lipid profile blood pressure albumin excretion rate
smoking
family history arterial / heart symptoms
at diagnosis
at 18 years of age
three-yearly for lipids if all risk factors consistently normal
yearly
more frequently if abnormal or treated
Educate people :
about the risks of heart disease from the time of diagnosis
about not smoking and smoking cessation programmes see box
about healthy eating see Healthy eating
Prescribe :
a programme of regular physical exercise
healthy eating
lipid lowering therapy if profile is abnormal see box and another
risk factor present
ACE inhibitors if indicated by kidney damage see Kidney damage
anti-hypertensives if blood pressure remains 135/85 mmHg but see
Kidney damage if raised albumin excretion rate
low-dose aspirin for those with known arterial problems
selective -adrenergic blockers if known ischaemic heart disease
hormone replacement therapy post-menopausally if agreed
Diagnose :
silent myocardial ischaemia in higher risk patients
Manage :
smoking aggressively see box
ischaemic heart disease and other arterial disease otherwise as for
the
non-diabetic person
Identify smoking habits :
at diagnosis and referral
as a routine part of Annual Review
Emphasize importance :
at diagnosis and if critical events occur
regularly on a face-to-face basis
Provide information on :
health risks and benefits of stopping / reducing
techniques for reducing tobacco consumption
use of pharmacological substitutes
Low risk At risk
High risk
60
230
40
155
10
39
22
200
48-60
185-230
30-40
115-155
10-12
39-46
17-22
150-200
48
185
30
115
12
46
17
150
Serum total cholesterol
mmol/l
mg/dl
Serum LDL cholesterol
mmol/l
mg/dl
Serum HDL cholesterol
mmol/l
mg/dl
Serum triglycerides
mmol/l
mg/dl
Check for proteinuria yearly using reagent strips
Measure urinary albumin excretion yearly if not proteinuric using :
pre-breakfast albumin:creatinine ratio, or
pre-breakfast urinary albumin concentration
if ratio 25 mg/mmol 30 mg/g in men or 35 mg/mmol 40 mg/g
in women
or concentration 20 mg/l :
Repeat to confirm
Monitor progression of kidney damage by more frequent measurement
Check for infection and consider other renal disease if proteinuria
positive
exclude infection with leucocyte strips and mid-stream urine
microscopy / culture
Measure serum creatinine yearly more often if abnormal
Measure blood pressure yearly for
surveillance purposes sitting,
1st/5th sounds, 5 min rest
Treat aggressively with a target of 130/80 mmHg or lower if easily
attained
stop smoking
reduce salt intake
reduce protein intake with target of 08 g/kg
use ACE inhibitors as first-line drug therapy
add loop diuretics, -blockers, other agents if necessary
avoid the combination of -blockers and thiazides if dyslipidaemia
Maintain good blood glucose control and tight arterial risk factor
control see above
Treat urinary infections aggressively; consider papillary necrosis if
recurrent
Arrange early evaluation by a nephrologist at creatinine 200-300
mol/l 25-35 mg/dl
No patient should be excluded from renal replacement
programmes solely on the basis of having diabetes
Organize a recall system to ensure it occurs regularly for every
individual
Measure or assess yearly :
visual acuity glasses or pinhole
the lens and vitreous ophthalmoscopy
the retina dilated pupils, retinal photography or skilled
ophthalmoscopy
related factors smoking /
blood pressure
Reassess after shorter interval 3-6 mo if :
pregnant see below
new or progressive early or moderate non-proliferative retinopathy
blood glucose control recently improved
Refer to ophthalmologist if :
severe non-proliferative retinopathy
proliferative retinopathy
macular oedema or exudative maculopathy
visual disability from cataract
unexplained deterioration of visual acuity
other eye disease of visual significance
unrecognized eye lesions
Review and intensify management of :
diabetic kidney disease
blood pressure target 135/85 mmHg, or lower if kidney damage
blood glucose control
blood lipid control if hard exudates
smoking
Attend to the psychological and social aspects of visual impairment where
it develops
The primary management of diabetic eye disease
is by careful attention to blood glucose control
targets from the time of diagnosis
Organize a recall system to ensure it occurs regularly for every
individual
Examine yearly :
foot shape, deformity, and shoes
foot
skin condition fragility, cracking, oedema, callus, ulceration
foot and ankle pulses
sensitivity to monofilament or vibration, and pin prick
Assess yearly :
history of foot problems since last review
visual and mobility problems preventing self-foot care
self-care behaviours and knowledge of foot care
Categorize as :
foot ulcer : active foot ulceration
or high risk : neuropathy or vascular disease or previous ulcer
or at risk : deformity or self-care problem or simple skin problem
or low current risk
Monitor related factors blood glucose control, claudication, drug
therapy, smoking
High risk foot
Involve a specialist in diabetes foot care
Provide :
regular foot assessment
local preventative attention to callus
relief of pressure using foam spacers, bespoke shoes, shoe inserts
regular foot care education - the commandments of foot care
vascular surgical referral if symptoms or critical arterial supply
At risk foot
Provide :
routine foot care according to need
advice on appropriate footwear
foot care education at
routine visits
advice to carers
Established foot ulceration / infection
Involve your local diabetes foot team without delay
Use local measures including :
debridement and trimming of callus foot casts to relieve
pressure
dressings to absorb exudate surgical drainage
Use systemic and proximal measures including :
intravenous or oral antibiotic therapy - usually staphylococcal
coverage, plus wider spectrum, anaerobes, or streptococcal as
specifically indicated
vascular referral, investigation, and reconstruction / angioplasty
if indicated
Reserve amputation for :
uncontrolled pain secondary to vascular disease
debilitating, long-term, non-healing ulceration
a useless and disabling Charcot foot
Foot ulceration is usually preventable
Amputation, even if foot ulceration occurs, is nearly always preventable
Enquire yearly for :
painful and other symptomatic neuropathy
erectile impotence in men
Enquire for other manifestations of autonomic neuropathy if :
other complications especially
kidney
before anaesthesia
erratic blood glucose control
Counsel for the depressing and disabling nature of the condition
Consider initially :
bed foot cradles for night-time problems
simple analgesia taken in advance of diurnal symptoms
contact dressings
Consider therapeutic trials of :
tricyclic drugs amitriptyline
carbamazepine at high doses 600-1200 mg/day
phenytoin
capsaicin cream
Erectile impotence
sildenafil may be helpful if not contraindicated
intracavernosal alprostadil can be useful in some men
referral to professionals with specialist expertise can be useful for
:
advice on mechanical or surgical prostheses
vascular investigation and reconstruction
psychological assistance
Gastroparesis
investigation using radiological or radioisotope methods may help in
diagnosis
investigation of cardiovascular autonomic neuropathy may help
diagnosis
cisapride, metoclopramide, and domperidone are worth a trial
Diabetic nocturnal diarrhoea
investigation must exclude other causes of intestinal upset
codeine,
loperamide, or diphenoxylate in high doses may help
Gustatory sweating
explanation and counselling are often required
try topical or oral anticholinergic agents
0200 h hyperglycaemia, and
bed-time 70 mmol/l 125 mg/dl
Morning, or afternoon, or evening hyperglycaemia
0200 h hyperglycaemia, and
bed-time 70 mmol/l 125 mg/dl
Avoid destroying the normal experience of pregnancy through
overzealous application of medical technology
But good blood glucose control from before conception is critically
important
Enquire :
as to need for contraceptive advice if pregnancy not intended
Advise :
on barrier methods, or low-dose oral contraceptives if low arterial
risk see above
not to discontinue contraception until adequate metabolic control
achieved
Enquire as part of Annual Review as to pregnancy intentions :
emphasize repeatedly the need for pregnancy planning
educate about diabetic pregnancy, including risks to fetus
Start folic acid 400 g daily
Stop statins
Optimize blood glucose control :
targets: pre-prandial 35-55 mmol/l
65-100 mg/dl
post-prandial 50-80 mmol/l 90-145 mg/dl
recommend highly purified human / pork insulin preparations
Assess and normalize blood pressure :
replace ACE inhibitors with methyldopa / nifedipine / labetolol
Assess retina and treat as indicated
Review education and repeat as needed
Urge to stop smoking
Organize joint obstetric care in a designated centre
include a diabetologist, a diabetes teaching nurse, a dietician, an
obstetrician, a midwife, and a neonatologist
Provide support for continuing good blood glucose control :
frequent review every 1-2 weeks
appropriate educational support
regular self-monitoring of blood glucose with reliable system
target blood glucose as close to normal as possible, while avoiding
hypoglycaemia
fasting blood glucose : 35-55 mmol/l 65-100 mg/dl
post-prandial blood glucose : 50-80 mmol/l 90-145 mg/dl
glycated haemoglobin close to the upper limit of normal
multiple insulin injection regimen with highly purified human / pork
insulin
food intake
adequate to maintain maternal and fetal
nutrition
frequent small meals may facilitate improved blood glucose control
Examine eyes each trimester
Provide regular obstetric care :
ultrasound examination early and repeated for dates and fetal
malformation
fetal monitoring in later stages
frequent antenatal review
Provide a normal safe delivery :
deliver at term unless obstetric or diabetes risk
deliver vaginally unless obstetric or diabetes risk
provide optimal neonatal care :
access to specialized neonatal intensive care
neonatologists warned of expected delivery
good blood glucose control during / after labour
IV infusion of glucose and insulin with frequent blood glucose
measurement
rapid return to pre-pregnancy insulin requirements at delivery
Provide easily accessible advice for post-pregnancy blood glucose
control
Caution about hypoglycaemia risk if breast feeding; may need further
insulin dose reduction
Prepare a local care protocol
Disseminate the protocol to relevant professionals
Optimize blood glucose control pre-operatively see Assessing metabolic
control above
Delay major surgery if possible when HbA1c 90 or
fasting glucose 100 mmol/l 180 mg/dl , or
post-prandial 130 mmol/l 230 mg/dl
Screen for complications which may affect surgery risk; alert the
surgical team :
heart or kidney problems
autonomic or peripheral nerve damage
proliferative retinopathy
Manage blood glucose / insulin :
use IV glucose-insulin-potassium infusion GIK
start at 0800 h and continue until eating normally
monitor blood glucose before, during, and after 1-4 hourly
surgery
use a quality-assured method
aim for blood glucose levels of 60-100 mmol/l 110-180 mg/dl
treat hypoglycaemia with glucose and restart GIK at lower insulin
dose
never stop intravenous insulin infusions
return to normal timing of insulin injections as soon as practicable
Encourage supervised self-management while in hospital
Surgical glucose-insulin-potassium GIK regimens
Use 500 ml 10 100 g/l glucose dextrose containing :
unmodified soluble, regular human insulin 16 U
potassium chloride 10 mmol
Infuse
at 80 ml/h from a volumetric pump
Consider higher dose 20 U if obese, or initial blood glucose high
Consider lower dose 12 U if very thin, or usual insulin dose low
Adjust dose by -4 U if glucose falling and normal or low
Adjust dose by 4 U if glucose rising or high
Continue the GIK infusion until 30-60 min after first meal
Use higher strength glucose solutions if water volume a problem
Check for dilutional hyponatraemia daily
Prepare a local care protocol
Disseminate the protocol to relevant professionals
Fluid replacement :
give 2 litres of isotonic saline 015 mol/l over the first 4 h
give 2 litres over the next 8 h, then 1 litre every 8 h
consider colloid if systolic blood pressure 100 mmHg after 2 h
use hypotonic saline only very cautiously plasma Na 155 mmol/l, 1
litre over 8 h
monitor central venous pressure if cardiac disease
be more cautious in the elderly
Insulin :
infuse initially at 6 U/h alternatively 20 U IM followed by 6-10 U
each hour
check pump and infusion lines and double dose if no response in 2 h
Potassium :
give 20 mmol/h
from the time of initiation of insulin infusion
discontinue temporarily if laboratory K 60 mmol/l
check every 20 h as a routine
if potassium falls to 40 mmol/l, increase accordingly
continuously monitor ECG
Bicarbonate :
only use if pH is 69 or less
if indicated, give 100 mmol with 20 mmol K over 30 min
repeat blood gases and plasma K 30 min later
Infection :
arrange urinalysis, chest X-ray, blood cultures
do not rely on temperature and leucocytosis
use antibiotics even if uncertain
General care
when glucose 130 mmol/l 230 mg/dl :
start glucose-insulin-potassium regimen :
500 ml 10 glucose dextrose 24 U insulin 20 mmol K, at
80 ml/h
aim for blood glucose 100-130 mmol/l 180-230 mg/dl
by change of insulin dose
start SC insulin therapy when able to eat
insert a nasogastric tube if the patient is comatose
insert a urinary catheter if no urine passed within 3 h
heparinize if coma, hyperosmolar, other risk factors
Review cause to reduce risk of recurrence
5
6
7
8
9
10-11
12
13
29-30
31
32
14
15-16
16
17-20
21
22-23
24
25
26-27
28
Guidelines for
Diabetes Care
Include additionally, at Annual Review, surveillance of the following:
1 Symptoms of ischaemic heart disease, peripheral vascular disease,
neuropathy, impotence
2 Feet including footwear, deformity or poor skin condition, ischaemia,
ulceration, absent pulses, sensory impairment see Foot problems
3 Visual acuity
4 Retinopathy by ophthalmoscopy / retinal photography see Eye damage
5 Kidney damage by albumin excretion and serum creatinine see Kidney
damage
6 Hypertension see Kidney damage
7 Dyslipidaemia see Arterial risk factors
8 Injection sites
9 Attendance at podiatry / ophthalmology / other if indicated
Unreliable records suggest a failure of patient education by the diabetes
health-care team
If problem
If problem
Manage arterial risk aggressively in people with Type 1 diabetes
if any other risk factor is abnormal including family history of arterial
disease
Detection and surveillance of kidney problems and blood pressure
are a routine part of Annual Review
Detection and surveillance of eye problems are a routine part of Annual
Review
Detection and surveillance of foot problems are a routine part of Annual
Review
Detection and surveillance of nerve damage are a routine part of Annual
Review
Increase night-time NPH insulin
Pre-breakfast hyperglycaemia, and
0200 h glucose 60 mmol/l 110 mg/dl
? Stress / illness transient hyperglycaemia
No change
treat acutely if indicated
? Hypoglycaemia symptoms or measured, or
Some tests 40 mmol/l 70 mg/dl
No change Review diet and reasons for hypoglycaemia
Pre-breakfast hyperglycaemia, and
0200 h glucose 60 mmol/l 110 mg/dl
Increase relevant unmodified insulin
Increase evening unmodified insulin
No change
No change Review diet and evening unmodified insulin
If Hypoglycaemia requiring assistance and unexplained
or hypoglycaemia inconveniencing the person with diabetes
or measured glucose 40 mmol/l 70 mg/dl
If Median blood glucose 70 mmol/l 125 mg/dl
or median pre-prandial 50-70 mmol/l 90-125 mg/dl and 80
40-80
mmol/l 70-145 mg/dl
or median post prandial 100 mmol/l 180 mg/dl 15-20 h after meal
No change Review diet and reasons for hypoglycaemia
? Isolated / non-recurrent, and
median glucose 70 mmol/l 125 mg/dl
Decrease relevant unmodified insulin
Day-time or evening
Decrease pre-dinner unmodified insulin
Night-time 2300-0300 h, and
pre-bed glucose levels low
Increase evening unmodified insulin
Night-time 0300-0800 h, or
Pre-bed glucose levels high
Serum creatinine
If problem
Travelling
Provide advice on :
insulin dosage and food intake during travel
transport of insulin and monitoring and injection equipment in hand-
luggage
special health risks in visited countries
differences in insulin types and concentrations between countries
the need for valid travel insurance
Review coping skills for acute illness, especially gastroenteritis
Give written details of a persons condition when appropriate
and contact telephone numbers
Normal albumin excretion rate 135/85
Abnormal albumin excretion rate 130/80, or lower if easily attained
Kidney status
mmHg
Source:staff.newcastle.ac.uk
