New National Institute for Clinical Excellence guidance covering issues for children/young people and adults who have type 1 diabetes (NICE, 2004a) has been published this week. The World Health Organization (1999) describes diabetes as a metabolic disorder of multiple aetiology, characterised by chronic hyperglycaemia. It highlights the characteristic symptoms of the disease as being thirst, polyuria, blurred vision and weight loss.
VOL: 100, ISSUE: 32, PAGE NO: 28
Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times
New National Institute for Clinical Excellence guidance covering issues for children/young people and adults who have type 1 diabetes (NICE, 2004a) has been published this week. The World Health Organization (1999) describes diabetes as a metabolic disorder of multiple aetiology, characterised by chronic hyperglycaemia. It highlights the characteristic symptoms of the disease as being thirst, polyuria, blurred vision and weight loss. Without treatment, in its severe forms diabetes may lead to coma and death. The long-term effects include: - Retinopathy, which can lead to blindness; - Nephropathy, which can result in renal failure; - Neuropathy, which leads to an increased risk of developing foot ulcers; - Increased risk of cardiovascular, peripheral vascular and/or cerebrovascular disease. Approximately 1.3 million people in the UK are diagnosed as having diabetes and about 15 per cent of these have type 1 diabetes (Department of Health, 2001). The new guidance therefore offers recommendations for a significant patient group. It provides long-awaited treatment targets (Strachan-Bennett, 2004) and when implemented will ensure high-quality care for adults, children and young people with type 1 diabetes, reducing the risks of diabetic complications. Diagnosis
The guidance recommends that the criteria to confirm diagnosis in adults should be a single laboratory blood glucose test if classic symptoms are present, or two laboratory blood glucose tests if they are not. It is suggested that HbA1C measurement may be used to support diagnosis. The evidence for these recommendations is based on expert opinion. In adults, a management plan should be agreed with the patient once a diagnosis has been confirmed. This should be based on individual assessment (Box 1), culturally appropriate and implemented without delay. In children and young people, diabetes normally presents with severe symptoms, very high blood sugar and glycosuria. Diagnosis can therefore usually be confirmed without delay (WHO, 1999). The guidelines highlight the need for urgent (same day) referral to a multidisciplinary paediatric diabetic team. A child or young person with ketoacidosis, extra social or emotional need, or who is under two years of age will require inpatient care. However, home-based care with 24-hour access to advice is adequate for most children and young people in the initial stages. Patient-centred care
The guidance recommends patient involvement both at the time of diagnosis and during ongoing care. Improving patient involvement is a recurring theme in today’s health care policy, and the recommendations in this NICE guidance continue the theme in standard three of the National Service Framework for Diabetes (DoH, 2001), entitled ‘Empowering people with diabetes’. This states that services should encourage partnership in decision-making and highlights the need for agreed and shared care plans. The adult guidance offers a concordance approach to diabetic management. Providing good patient information is essential and the guidance makes recommendations regarding lifestyle education in areas such as smoking, physical activity and diet. The principles of ongoing education, continually assessing the patient’s level of knowledge and building on it at each appointment are evident in the outline algorithm for adult care. This structured patient education approach is also seen in the NICE guidance on patient-education models for diabetes (NICE, 2003). This highlights how programmes such as DAFNE (Dose Adjustment for Normal Eating) can be used to enable people with type 1 diabetes to take better control of their diabetes. There is also additional supportive information for children/young people or adults with diabetes and their parents or carers in the form of understanding NICE guidance documents (NICE 2004b; 2004c. These use simple language to outline the recommendations and highlight the care that those with diabetes should expect. They include a section explaining medical terms (NICE, 2004b; 2004c). There are also useful suggestions in the main guidance for improving communication with patients such as referring to ‘HbA1c’ as ‘A1c’ when discussing test results. The patient-centred approach is also evident in the guidance for children/young people. This recommends providing ongoing education about diabetes to the child and their family to support informed decision-making. Clinical management
The guidance has been praised by nurses for setting clear clinical targets (Strachan-Bennett, 2004). For adults these targets include: - HbA1c maintained at <7.5 per cent; - In patients who have a risk of arterial disease, HbA1c should be maintained at ≤ 6.5 per cent; - Self-monitored blood glucose levels should be 4-7mmol/L pre-prandial and <9mmol/L post-prandial. In children and young people the targets are: - HbA1c <7.5 per cent as long as this does not result in frequent disabling hypoglycaemia; - Self-monitored glucose of 4-8mmol/L pre-prandial and less than 10mmol/L post-prandial. Recommendations for ongoing assessment are made for both children/young people and adults (Box 2). These are aimed at identifying problems and reducing the risk of complications. Based on evidence from randomised control trials, the guidance recommends that insulin prescribing should be via multiple injection regimes in an integrated package with education on food requirements, skills training and self-management. Based on expert opinion, recommendations are given for injection devices (normally pen) and sites (usually abdomen). Special considerations
Hypoglycaemia The aim of diabetes management is to avoid hypoglycaemia while preventing hyperglycaemia. The guidance for adults and children/young people recommends ensuring access to a suitable oral, simple carbohydrate if hypoglycaemia occurs. Education about the prevention and management of hypoglycaemia is essential, and should include training carers and parents in using glucagon. Arterial risk factors Thorough assessment and management of arterial risk is an important aspect of diabetic care in the adult guidance. Assessment should include: - Albumin excretion rates; - Smoking status; - Blood glucose control; - Blood pressure; - Lipid profile; - Age; - Family history; - Abdominal adiposity. The appropriate lipid-lowering medication and antihypertensive drugs should be prescribed, and particular drugs are recommended in the NICE guidance. Late complications Recommendations are made for the assessment and management of complications that commonly result from diabetes. Annual assessment should include monitoring for eye, foot and kidney damage (Box 2). Conclusion
This new NICE guidance provides valuable treatment targets for the care of patients who have type 1 diabetes. It continues the theme of patient-centred care already seen in the national service framework, and is supported by guidance published for patients. Implementation of these recommendations will help to ensure that all patients receive a consistently high standard of care in the management of their diabetes, reducing long-term complications and allowing them to improve their lifestyles. - This article has been double-blind peer-reviewed.