NICE have published three new guidelines covering the management of type 1 diabetes in adults, type 1 and type 2 diabetes in children and young people (CYP) and diabetic foot problems. The recommendations update previous guidance published in 2004 and 2011. Guidelines on the management of type 2 diabetes in adults have been delayed until October while they undergo a second consultation.
Type 1 diabetes in adults: diagnosis and management (NG17)
Key changes to the 2004 guidelines include the following:
- Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example, DAFNE (Dose Adjustment for Normal Eating). Offer this programme 6–12 months after diagnosis.
- Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications.
- Offer multiple daily injection (MDI) basal–bolus insulin regimens, rather than twice-daily mixed insulin regimens, as the insulin injection regimen of choice. Provide the individual with guidance on using these regimens.
Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18)
The new guidelines for CYP cover both type 1 and type 2 diabetes, as type 2 diabetes remains quite rare in CYP, with only 500 cases reported in the 2013–2014 National Diabetes Audit. Updates from the 2004 guidelines include the following:
- Refer CYP with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care.
- Offer ongoing real-time continuous glucose monitoring with alarms to CYP with type 1 diabetes who have frequent severe hypoglycaemia or impaired hypoglycaemia awareness associated with adverse consequences (e.g. seizures or anxiety) or inability to recognise or communicate about symptoms of hypoglycaemia (e.g. because of cognitive or neurological disabilities).
- Offer CYP with type 2 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics: HbA1c monitoring and targets; the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control; the aims of metformin therapy and possible adverse effects; and the complications of type 2 diabetes and how to prevent them.
Diabetic foot problems: prevention and management (NG19)
Updates from the 2011 guidance include the following:
- If a person has a limb-threatening or life-threatening diabetic foot problem (e.g. ulceration with fever or any signs of sepsis, or with poor blood supply to the limb; possible deep-seated soft tissue or bone infection; gangrene), refer them immediately to acute services and inform the multidisciplinary foot care service so they can be assessed and an individualised treatment plan put in place.
- For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day.
- Provide information and clear explanations about the risk of developing a diabetic foot problem to people with diabetes and/or their family members or carers when diabetes is diagnosed, during assessments, and if problems arise. Information should include basic foot care advice and the importance of foot care; foot emergencies and who to contact; footwear advice; and the person’s current individual risk of developing a foot problem.
Commenting on the guidelines, 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.”
