NICE recommends tighter blood sugar control in diabetes to reduce risk of complicationsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4612 (Published 26 August 2015) Cite this as: BMJ 2015;351:h4612
The National Institute for Health and Care Excellence (NICE) has recommended tighter blood sugar control for patients with diabetes, to minimise the risk of long term vascular complications.
An updated NICE guideline on diagnosing and managing type 1 diabetes in adults recommends a target HbA1c level of 48 mmol/mol (6.5%) or less1: this is lower than the clinical guideline on type 1 diabetes published in 2014, which recommended an HbA1c target of less than 7.5% for prevention of microvascular disease and 6.5% or less in patients at increased risk of arterial disease.2
A target HbA1c target level of 48 mmol/mol (6.5%) or lower is also recommended in children and young people with type 1 or 2 diabetes to minimise the risk of long term complications, says an updated guideline specifically on managing the condition in this age group.3 Previously, a target of less than 7.5% was recommended for this group.2
Other recommendations in the updated guideline on managing type 1 diabetes in adults are that all patients should be offered a structured education programme, such as the DAFNE (Dose Adjustment for Normal Eating) programme, 6-12 months after diagnosis. Multiple daily injection basal-bolus insulin regimens, rather than twice daily mixed insulin regimens, should be the insulin injection regimen of choice and offered to all adults with type 1 diabetes, the guideline said, and adults with newly diagnosed type 1 diabetes should not be offered non-basal-bolus insulin regimens, such as twice daily mixed, basal only, or bolus only.1
Stephanie Amiel, professor of diabetic medicine at King’s College, London and chair of the NICE group that developed the type 1 guideline, said, “Currently most adults with type 1 diabetes do not maintain the average amount of glucose in their blood (HbA1c) associated with fewer complications: life expectancy is reduced by over 10 years and rates of kidney failure have increased.”
Children and young people with diabetes and their families should be offered a continuing programme education from diagnosis, the updated guideline for that age group says.3 It adds that ongoing real time continuous glucose monitoring with alarms should be offered to children and young people with type 1 diabetes who have frequent severe hypoglycaemia or impaired awareness of hypoglycaemia that may be associated with adverse consequences, such as seizures or anxiety.
Julie Edge, consultant in paediatric diabetes at Oxford Children’s Hospital and a member of the group that developed the NICE guideline on diabetes in children and young people, said, “This national guideline is the first for children and young people with diabetes to recommend attempting to reach an HbA1c level near the normal range and nearly normal daily blood glucose readings.
“Achieving this tight control needs intensive insulin management from the time type 1 diabetes is diagnosed, which means multiple daily injections or insulin pump therapy. This is in addition to carbohydrate counting, which means matching the amount of insulin with the amount of carbohydrate eaten.”
She added, “Because the ideal HbA1c target level of 48 mmol/mol (6.5%) or lower is hard to achieve, it is important that children and young people do not feel pressurised and individual targets are discussed.”
An updated guideline on preventing and managing foot problems in diabetes, published at the same time, says that patients with life or limb threatening foot problems (such as ulceration with fever or any signs of sepsis or with poor blood supply to the limb; possible deep seated soft tissue or bone infection; or gangrene) should be referred immediately to acute services.4 All other active foot problems in diabetes should be referred within one working day and triaged within one further working day, it adds.
Updated guidance on type 2 diabetes in adults is due to be published before the end of the year.
Cite this as: BMJ 2015;351:h4612