NICE

What’s new for type one diabetics?

NICE have released their new guidelines for type one adults. This paper was given some prominence in September’s BMJ as well as other papers that could be of interest to diabetics, their carers and health professionals.

In many respects the adult guidelines are similar to the children’s guidelines. Structured education gets support as does advice to aim for a hba1c of 6.5% (48) or lower provided hypos can be minimised. Of course this is virtually impossible if a high carb diet is followed but is much easier if the low carb dietary advice and precision meal to insulin matching as we describe in our book is done.

Levemir twice a day is the recommended basal insulin for all new patients and Lantus is advised only for those who refuse to use a twice daily bolus or perhaps need assistance from others for injection. We know that Lantus has some gaps in coverage as a 24 hour insulin and that it is less stable in heat and light than Levemir. It also stings on injection. Levemir also gives fewer hypos. Of course if someone is happy with Lantus, they can stay on it.

Life expectancy for type ones is currently 13 years less than for people without the condition. Fewer than 30% of adults achieve a hba1c of 7.5% or less.

Although the Cochrane collaboration noted a small degree of success with a low glycaemic diet strategy for type twos, this was not seen in the research that NICE looked at for type ones and therefore they don’t recommend low glycaemic as a dietary strategy.

Blood sugar targets are suggested to be ideally 5-7 first thing in the morning, 4-7 before meals and 5-9 at least 90 minutes after meals. Adults are advised that 4-10 blood sugar tests may be required each day. Before each meal and before bedtime are minimum testing times.

NICE want type ones to stick to their finger tips for blood sugar testing. This is the most accurate as hypos can be missed if other parts of the upper limb are used.

It is recommended that hypos are evaluated at least annually by a scoring system. The idea is to seek out those people for whom these are a problem and then fix it. NICE say this should not involve simply raising blood sugar targets. The obvious thing is to match insulin to meals, activity and basal needs more closely. If structured education around this appears to fail then the person should be considered for pump therapy and real time glucose monitoring.

Meal insulin boluses are recommended before meals. After meals is a strategy that works for toddlers but adults are expected to be able to adjust their insulin to meals and that means that they must be able to carb count.

So what can we expect from the implementation of these guidelines? There is still no clarity over diet and exactly how patients will get near normal blood sugars just by carb counting without actually restricting the amount they consume isn’t explained. There certainly will be a lot more adults who could be considered for pumps. But these are relatively expensive and require a lot of training. Setting strict blood sugar targets and hoping that technology will solve the problem has been going on for decades now. Why should it work now? NICE admits it hasn’t worked so far with more than 70% of type one adults having wildly high blood sugars. I would have been very interested to know what percentage of adults with diabetes achieved the target blood sugars of 6.5% or 48.

NICE do admit that to implement their proposals the medical workforce will need to be sufficiently trained to deliver the structured education and to help individual diabetics with their problems.

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