3: Management of diabetes

Section 3 Management of diabetes




Type 1 diabetes – initiating therapy


Home-based instruction of the newly diagnosed child or young person appears to be at least as effective as inpatient instruction in terms of glycaemic control, acceptable to the family and/or carers and cost-effective. There is no evidence for a sustained effect of any specific insulin regimen on glycaemic control during the first few months after diagnosis.


Dietary advice as part of a comprehensive management plan is recommended to improve glycaemic control. A dietitian should give specialist dietetic advice with expertise in type 1 diabetes, and all patients should be able to access such training locally and, ideally, at their own diabetes clinic.




Insulin regimens


Evidence regarding the impact of an intensive insulin regimen upon long-term control is derived principally from the Diabetes Control and Complications Trial (DCCT), which also involved a comprehensive patient support element (diet, exercise plans and monthly visits). Intensive insulin therapy (four injections or more per day, or insulin pump) significantly improved glycaemic control over a sustained period compared with conventional insulin therapy (two injections per day). However, it is difficult to separate the benefits of intensive insulin therapy from the intensive support package.


The choice of insulin regimen and dose depends on several factors: what type of diabetes a person has; their weight; their age; how often they check or intend to check their blood glucose; and, finally, what goals they are trying to achieve.


The principle of insulin replacement is to mimic insulin secretion in a person without diabetes and to achieve the best possible control of blood glucose without causing significant hypoglycaemia. After eating, there is normally a rapid rise in insulin to limit glucose levels after meals. Overnight, low steady levels of insulin (the background or ‘basal’ insulin level) are sufficient to limit glucose production by the liver.


Appropriate combinations of the above insulins can be tailored to the individual; a certain element of this will be trial and error, but close liaison with the health-care provider usually results in the right regime for that person (Table 3.1). The pre-mixed insulins are a popular starting regimen, and the timing of onset, peak and duration of action will depend on the component parts.



Conventional therapy for type 1 diabetes (twice-daily insulin with support from a multidisciplinary health-care team and regular diabetes and health monitoring) is associated with variable results.


Both basal (e.g. glargine and detemir) and rapid-acting (e.g. lispro, aspart and glulisine) insulin analogues are prescribed widely in the management of type 1 diabetes.




Different insulin delivery systems


There are four main devices for insulin injection: needle and syringe; insulin pens (now most commonly used); jet injection devices; and external pumps.





Jet injection device


These are expensive but good for people who cannot perform the injection for themselves. The device holds a large quantity of insulin to be used for multiple treatments. After dialing up the amount of insulin to be delivered, the device is held against the skin and, on pressing a button, a jet of air forces the insulin through the skin into the tissue underneath. The device is occasionally leaky, with insulin staying above the skin; others report that the injection can be painful.


Traditionally patients are advised to rotate the location of their injection sites; this helps to avoid local reactions to insulin, which are, principally:



Patients occasionally complain of recurrent minor local bleeding or bruising, which rarely presents any real cause for concern.





Altering insulin doses


Patients vary in their capacity and willingness to adjust their own insulin doses. Some will never make an adjustment; the advice of the specialist nurse can be helpful in such cases and close telephone contact is reassuring. Other patients alter doses too frequently according to their latest home capillary readings – this can lead to a ‘roller-coaster’ effect with glycaemic instability, and is best avoided. Although there are some general principles to be followed, there are no hard-and-fast rules; caution and common sense are guiding principles.




Unwanted effects of insulin therapy








Severe insulin resistance


The definition is arbitrary. When daily insulin doses (in excess of 200 units) were needed to control glycaemia, it was considered to reflect severe insulin resistance; this is now largely of historical interest. The concept of insulin resistance is discussed in Section 1.




Insulin regimens


This is the schedule of insulin that a person will decide upon with their health-care professional, and is based on the type of diabetes, physical needs and lifestyle (in particular eating patterns and activity). The variables include type of insulin, timing and dose (Fig. 3.2). There are many regimens, but the most common examples are:












Continuous subcutaneous insulin infusion therapy


Continuous subcutaneous insulin infusion (CSII) or ‘insulin pump’ therapy allows programmed insulin delivery with multiple basal infusion rates and flexible bolus dosing of insulin with meals. In developed countries its usage is increasing in patients with type 1 diabetes who are expert at carbohydrate counting or have undertaken an appropriate structured education course. Carbohydrate counting is an essential skill to support intensified insulin management in type 1 diabetes, by either multiple daily injections (MDI) or CSII. CSII therapy requires considerable input from the patient along with the diabetes nurse specialists and dietitians, in addition to the purchase of a pump and consumables.


Pumps are often the size of a pager and are worn on a belt or in the clothing, with thin plastic tubing coming from the pump to a needle that penetrates the skin, usually in the abdomen. It is in place 24 hours a day, and this device is as close as one can get to the constant gradual administration of insulin that is taking place in the body.





Disadvantages of pumps





However, in patients with type 1 diabetes, CSII therapy has been associated with an improvement in glycaemic control with reported mean falls in HbA1c of between 0.2% and 0.4% (2.2–4.4 mmol/mol) or greater mean treatment satisfaction scores.


CSII therapy should be considered for patients unable to achieve their glycaemic targets and in patients who experience recurring episodes of severe hypoglycaemia. Pump therapy management requires a local multidisciplinary pump clinic for patients who have undertaken structured education. Patients using CSII therapy should agree targets for improvement in HbA1c and/or reduction in hypoglycaemia with their multidisciplinary diabetes care team. Progress against targets should be monitored and, if appropriate, alternative treatment strategies should be offered.





Type 2 diabetes – initiating therapy


The immediate purpose of lowering blood glucose is to provide relief from symptoms (thirst, polyuria, nocturia and blurred vision). Thereafter, the aim is to prevent microvascular complications: retinopathy, nephropathy and neuropathy.


Hyperglycaemia, along with hypertension and dyslipidaemia, is associated with macrovascular complications (myocardial infarction (MI), stroke and peripheral arterial disease). The effects of glucose-lowering therapies on cardiovascular morbidity and mortality are therefore of major importance (and not just on glucose-lowering).


Mar 10, 2017 | Posted by in ENDOCRINOLOGY | Comments Off on 3: Management of diabetes

Full access? Get Clinical Tree

Get Clinical Tree app for offline access