Updated NICE guidance 2016.  Characteristics:

• random glucose >11,
• polyuria, polydipsia,
• excessive tiredness,
• weight loss.

WHO 1999 criteria – fasting normally <5.6, >7 diagnostic.  Random >11 diagnostic (assuming there’s nothing sticky on the finger tested!!!).  Glucose tolerance test (starts with fasting level) 2hr level >11.1 diagnostic, 7.8-11.1 is impaired glucose tolerance.

False positives – infection, recent surgery, uncontrolled thyroid disorder, starvation.

50% of T1DM presents in children. 30-50% risk in identical twins.

Epidemiology

Increasing rates in Europe. Scotland rate second only to Scandinavia.  Marked increase in under 5s.

Screening?

UK 25% of new diabetes presents in DKA – higher in pandemic, 65% in NHSL. And more severe DKA.

Some evidence that diabetes presenting with DKA (and recurrent) has poorer outcome. Not causal link – psychosocial?

Public health awareness campaigns have worked in some cases (Italy, Australia), but not others (Wales, Austria).

Check HbA1c? Not very sensitive. Abnormal (non diabetic range) HbA1c can persist for  2 years before actual diabetes. False positive/negative if short RBC life, splenomegaly, drugs, high lipids, renal/liver disease.

Islet cell antibodies help predict onset of diabetes viz anti GAD, insulin, IA2, zinc transporter 8. NHSL tests for 3. 

With just 1 positive, 10-15% risk at 15 years (higher for anti-IA2).

With 2+ antibodies, but normal OGTT, 44% 5yr risk but 80-90% risk at 15 yrs, and probably inevitable…

Elevated BMI increases risk, age under 3, IA2 higher risk. 

5yr risk 75% if abnormal OGTT – “stage 2 disease”.

Antibodies can also revert to negative (but risk remains double baseline).

Screening programmes using autoantibodies in Bavaria and Colorado reduced DKA significantly. And better psychological adjustment to diagnosis. But evidence of increased anxiety, especially if multiple antibodies. “Interventions are needed to improve understanding of the purpose, procedures and consequences of screening, what it means to be at risk, and ways to cope with associated anxiety.”

Age? 4-5yrs will miss a third.

Dietary changes?

Fast vs slow progressors?

NICE has approved teplizimab (anti-CD3) for 8yr+ delaying progression to diabetes – 14/7 IV! 3 years benefit. £11K a vial.

See BSPED guidance 2025.

Subtypes

Type 2 more often in S Asian, Hispanic, Afro-Caribbean.  Clue is raised c-peptide – as this is co-produced with insulin, it means there is still endogenous insulin being produced (and cleared at more consistent rate than insulin, so more reliable, esp if on exogenous insulin).  C-peptide also used to look for insulinoma or factitious hypoglycaemia.  May also predict glycaemia control, complications and response to hypoglycaemic agents.

LADY – latent autoimmune diabetes of the young. More common? Different HLA type. Antibody positive but insulin sensitive and slow progress.

MODY – inability to produce insulin but normal beta cells.  Eg KIR 6.2 mutations, within months of birth.

Management

Reduced ideal HbA1c target – 48mmol/l (6.5%).  

No DAPHNE for kids.

Multiple daily injections from diagnosis, with level 3 carbohydrate (CHO) counting education, blood ketone testing strips.  Other regimens eg BD, TDS only for where problems with compliance.  See also pumps.

NICE guidance now includes Type 2 – suspect if strong FH, obesity, black/Asian origin, minimal insulin requirements (<0.5u/kg after “partial remission phase”), evidence of insulin resistance (viz acanthosis nigricans).

Optimal blood glucose range is 4-7 on waking and between meals; 5-9 after meals; 5+ when driving.  At least 5 tests per day recommended, more frequently during physical activity and illness.But take into account:

• risk of hypoglycaemia;
• competitive sports;
• need to lose weight;
• life goals (careers, exams, foreign travel);
• any relevant co-morbidity.

UK aDapt study found motivational therapy at diagnosis worsened outcomes! Possibly combined with CBT helpful…

Monitoring

Annual thyroid, hypertension, albuminuria checks from diagnosis; retinopathy testing from age 12.  Type 2 don’t need thyroid but do need dyslipidaemia.

School

Most schools happy to give insulin. But no legal requirement. Lancets for school retract into cartridge.

Self-Efficacy

Encourage ownership of meters etc, downloading at home. Over 14 to get access to SCI-DC, as adults.