Practical Steps to Improving the Management of Type 1 Diabetes: Recommendations from the Global Partnership for Effective Diabetes Management

P. Aschner, E. Horton, L. A. Leiter, N. Munro, J. S. Skyler, on behalf of the Global Partnership for Effective Diabetes Management

Disclosures

Int J Clin Pract. 2010;64(3):305-315.

Abstract and Introduction

Abstract

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

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Abstract and Introduction
Introduction: Current Challenges in Type 1 Diabetes
Managing Hyperglycaemia in Type 1 Diabetes
Insulin Therapy
A Team Approach to Diabetes Care
Conclusion
References
Sidebar

Table 1. Practical recommendations for the management of adults with type 1 diabetes
Aim for as good glycaemic control as possible while minimising the risk of hypoglycaemia.
Ensure regular and appropriate monitoring for complications.
Initiate an intensive basal-bolus insulin regimen as early as possible.
Provide all patients with a structured educational programme at initiation of insulin and thereafter.
Ensure that self-monitoring is universally adopted as an integral part of insulin therapy.
Provide education about prevention, recognition and treatment of hypoglycaemia at initiation of insulin therapy and thereafter.
Manage all cardiovascular risk factors.
Explore psychological issues associated with type 1 diabetes and treat/refer as appropriate.
Adopt a multidisciplinary team approach with shared goals and recommendations.

Table 2. Glycaemic targets for individuals with type 1 diabetes
	ADA^[16]	CDA^[17]	IDF^[51]	NICE (UK)^[18]
HbA_1c	< 7.0%	≤ 7.0%	6.2–7.5%	≤ 6.5–7.5%
Fasting preprandial glucose, mg/dl (mmol/l)	70–130 (3.9–7.2)	72–126 (4.0–7.0)	91–120 (5.1–6.5)	72–144 (4.0–8.0)
Postprandial glucose, mg/dl (mmol/l)	< 180* (< 10.0)	90–180^† (5.0–10.0)	136–160^‡ (7.6–9.0)	< 180^‡ (< 10.0)

ADA, American Diabetes Association; CDA, Canadian Diabetes Association; IDF, International Diabetes Federation; NICE, National Institute for Health and Clinical Excellence.
The CDA guidelines note that HbA_1c goals and strategies must be tailored to the individual with diabetes, with consideration given to individual risk factors.
ADA and CDA glycaemic targets are for type 1 and type 2 diabetes.
*Peak postprandial capillary plasma glucose.
^†90–144 mg/dl (5.0–8.0 mmol/l) if HbA_1c target not being met.
^‡Capillary postprandial glucose 1–2 h after meal.

Table 3. Screening for complications in adults with type 1 diabetes; recommendations from the American Diabetes Association ^[16]
Care	Screening
Retinopathy	Refer for an initial dilated and comprehensive eye examination within 5 years after diabetes onset and annually thereafter. Consider less frequent examination (every 2–3 years) following one or more normal eye examinations. More frequent examinations required if retinopathy is progressive.
Chronic kidney disease	Perform an annual urine albumin excretion test in patients with type 1 diabetes of ≥ 5 years' duration. Measure serum creatinine at least annually, regardless of degree of urine albumin excretion.
Neuropathy	Screen all patients for distal symmetrical polyneuropathy at diagnosis and at least annually thereafter using simple clinical tests such as pinprick sensation, vibration perception (using a 128 Hz tuning fork), 10 g monofilament pressure sensation at the distal plantar aspect of both great toes and metatarsal joints, and assessment of ankle reflexes. Institute screening for signs and symptoms of cardiovascular autonomic neuropathy 5 years after diagnosis of type 1 diabetes.
Dyslipidaemia	Measure fasting lipid profile at least annually in most adult patients. Aggressively treat lipid and blood pressure abnormalities.

Table 4. Pharmacokinetics of human insulin and analogues ^[87] (may depend on local availability)
Class of insulin	Formulation	Onset (min)	Peak (h)	Duration (h)
Basal insulins
Long-acting analogues	Insulin glargine	66	–	Up to 24
	Insulin detemir	48–120	–	Up to 24
Intermediate-acting human	NPH, human	60–120	6–14	16–24
Prandial insulins
Rapid-acting analogues	Insulin lispro	15–30	0.5–2.5	3–6.5
	Insulin aspart	10–20	1–3	3–5
	Insulin glulisine	10–15	1–1.5	3–5
Short-acting human	Regular, human	30–60	1–5	6–10
Premixed insulins
Premixed analogues	BiAsp 70/30	10–20	1–4	Up to 24
	Insulin lispro 75/25	15–30	1–6.5	Up to 24
	Insulin lispro 50/50	15–30	0.75–13.5	Up to 24
Premixed human	70% NPH/30% regular	30–60	2–16	Up to 18–24

BiAsp, biphasic insulin aspart; NPH, neutral protamine Hagedorn.

Authors and Disclosures

P. Aschner,¹ E. Horton,² L. A. Leiter,³ N. Munro,⁴ J. S. Skyler,⁵ on behalf of the Global Partnership for Effective Diabetes Management*

¹Javeriana University School of Medicine, Bogota, Colombia
²Joslin Diabetes Center, Boston, MA, USA
³St Michael's Hospital and University of Toronto, Toronto, ON, Canada
⁴Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, UK
⁵University of Miami and Diabetes Research Institute, Miami, FL, USA

Correspondence to
Professor Jay S. Skyler, MD, MACP, Diabetes Research Institute, University of Miami, Miller School of Medicine, 1450 NW 10th Avenue, Suite 3054 [P.O. Box 016960 (D-110)], Miami, FL 33101-6960, USA Tel.: + 305 243 6146 Fax: + 305 243 4484 Email: jskyler@miami.edu

*Global Partnership for Effective Diabetes Management Members: George Alberti, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK; Pablo Aschner, Javeriana University School of Medicine, Bogota, Colombia; Cliff Bailey, Aston University, Birmingham, UK; Lawrence Blonde, Ochsner Medical Center, New Orleans, LA, USA; Stefano Del Prato, University of Pisa, Pisa, Italy (Chair); Anne-Marie Felton, Federation of European Nurses in Diabetes, London, UK; Ramon Gomis, Hospital Clinic, Barcelona, Spain; Edward Horton, Joslin Diabetes Center, Boston, MA, USA; James LaSalle, Medical Arts Research Collaborative, Excelsior Springs, MO, USA; Hong-Kyu Lee, Seoul National University, College of Medicine, Seoul, Korea; Lawrence A. Leiter, St Michael's Hospital and University of Toronto, Toronto, ON, Canada; Stephan Matthaei, Diabetes-Center Quakenbrück, Quakenbrück, Germany; Marg McGill, Diabetes Centre, Royal Prince Alfred Hospital, Sydney, Australia; Neil Munro, Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, UK; Richard Nesto, Lahey Clinic, Burlington, MA, USA; Paul Zimmet, Baker IDI Heart and Diabetes Institute, Caulfield, Australia; Bernard Zinman, Samuel Lunefield Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.

Disclosures
Pablo Aschner: PA has received honoraries from GSK for his participation in board meetings and other related scientific activities. He has also has participated in advisory panels and provided ad hoc consultancy to Sanofi-Aventis, Merck Sharp & Dohme, Novartis and Astra-Zeneca. Edward Horton: EH has received fees for consulting and advisory boards from Abbott, AstraZeneca, Bristol-Myers Squibb, Daiichi-Sankyo, Medtronic, Merck, Metabasis, Novartis, Roche, Sanofi-Aventis, Takeda and Tethys; is on the speakers bureau for Merck and has received research support from Amylin and Eli Lilly. Lawrence A Leiter: LAL has received research funding from, has provided CME on behalf of, and/or has acted as an consultant to AstraZeneca, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, Merck, Merck Schering Plough, Novartis, Novo Nordisk, Pfizer, Sanofi-Aventis, Servier, and Solvay. Neil Munro: NM has received fees for serving as a speaker, a consultant or an advisory board member for Eli Lilly, Novo Nordisk, GlaxoSmithKline, Takeda, Bristol-Myers Squibb, AstraZeneca, MSD, LifeScan, Medtronic, Novartis, Pfizer, Servier, Sankio and Roche. Jay S Skyler: JSS has received research funding from Bayhill Therapeutics, Halozyme Inc., and Osiris Therapeutics Inc.; is on the Board of Directors of Amylin Pharmaceuticals, DexCom Corporation and Moerae Matrix Inc.; has received fees for serving as a consultant or an advisory board member from BD Technologies, Ideal Life, Johnson & Johnson, MannKind Corporation, Medingo Ltd., Merck, NovoNordisk, Patton Medical Devices, Salutria, sanofi-aventis, Tandem Diabetes Care, Tethys Bioscience, Teva, and Valeritas LLC.

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