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MinnaKoivikko

Follow-Up of Type 1 Diabetes

Essentials

  • Key treatment goals include blood glucose levels as well as the prevention and treatment of cardiovascular diseases and microvascular complications.
  • The patient's overall situation and resources are considered.
    • The patient's lifestyle and self-care possibilities
    • Stage of diabetes and hypoglycaemia sensitivity
    • Other diseases and life expectancy
  • Treatment goals and methods are set individually together with the patient.
    • Would the patient benefit from group guidance or from more frequent support from a diabetes team/nurse?
    • Would the patient benefit from insulin pump therapy or continuous glucose monitoring (CGM, glucose sensing/sensoring)?

General lines of treatment

  • Treatment goals are set individually. General goals: see table T1

Treatment goals in type 1 diabetes

AspectGeneral goals that are adjusted individually based on, for example, advanced age, hypoglycaemia sensitivity or pregnancy
HbA1c<53 mmol/mol (7%)
Blood glucose level in self-monitoring4-7 mmol/l before meals and at night
<10 mmol/l after meal, generally
Continuous glucose monitoringTime within target range 3.9-10.0 mmol/l: > 70%
Time in hyperglycaemia > 10.0 mmol/l: < 25%
Time in hypoglycaemia < 3.9 mmol/l: < 5%
Glucose mean: < 8.6 mmol/l
Glucose variation CV %: ≤ 36 %
Glucose management indicator GMI: < 53 mmol/mol
Plasma LDL cholesterol<2.6 mmol/l - moderate risk patient:
  • young persons (< 35 y) without risk factors (smoking, hypertension, dyslipidaemia, obesity, hereditary predisposition) and the duration of type 1 diabetes (T1D) < 10 y
<1.8 mmol/l - high risk patient:
  • T1D > 10 y without target-organ damage
  • T1D and even one risk factor (smoking, hypertension, dyslipidaemia, obesity, hereditary predisposition)
<1.4 mmol/l - very high risk patient:
  • coronary artery disease or another atherosclerotic arterial disease
  • T1D and target-organ damage (albuminuria, renal failure, retinopathy)
  • T1D and 3 risk factors (smoking, hypertension, dyslipidaemia, obesity, insulin resistance, etc.)
  • T1D > 20 y
Blood pressure<140/80 mmHg (level in home measurements < 135/80 mmHg)
<130/80 mmHg (level in home measurements < 125/80 mmHg), if diabetic kidney disease and the target can be reached without adverse effects
WeightNormal (BMI < 25)
LifestyleEveryday activity and regular exercise
Food choices that promote cardiac health and glucose control
Sufficient rest and sleep
Not smoking
At maximum moderate alcohol use

Contents of physician visits

In all visits

  • Enquire about the patient's well-being and lifestyle issues (physical exercise, smoking, intoxicants)
  • Weight (self-reported or weighed during the visit)
  • Results of home monitoring (blood glucose and blood pressure)
  • Laboratory test results
  • Insulin doses used (units/day and units/kg), insulin-to-carbohydrate ratio (units/10g-of-carb) and insulin sensitivity (1 unit/mmol/l)
  • History of episodes of hypoglycaemia (especially hypoglycaemias that are severe or require help from other persons) and ketoacidosis
  • Blood pressure measurement, especially if the patient or a close relative has hypertension or the patient has albuminuria or dizziness
  • Foot examination, if the patient has symptoms or previous problems with feet (see Treatment of the Diabetic Foot)
  • Assess together with the patient whether the agreed-on treatment goals have been reached and whether there is a need for changing the goals.
    • If treatment goals have not been reached, consider together methods for reaching the goals.

Once a year

  • Heart and great arteries
  • Orthostatic test if indicated; see Brief Orthostatic Test
  • Examination of the feet: sense of touch (monofilament 10 g Diabetic Neuropathy, picture 1) and vibration, reflexes and pulses. If pulses cannot be felt, examine ankle pressure with doppler and determine the ABI index Doppler Stethoscopy in Diagnostics.
  • Check injection sites (e.g., lipohypertrophy, swelling, injection site reactions).
  • Weight
  • Fundus photography every 1-2 years depending on the earlier findings, blood glucose control and length of time since diagnosis Diabetic Retinopathy
  • Oral and dental health
  • Driving health

Laboratory examinations

On every examination (at 3-6 month intervals)

  • GHbA1c
  • Review the results of glucose self-monitoring (continuous glucose monitoring or fingertip measurements).

Measurements to be performed once a year or more frequently if needed

  • Basic blood count with platelet count, plasma cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, creatinine, estimated glomerular filtration rate (eGFR), morning urine albumin/creatinine ratio and, if needed, overnight urine albumin excretion, as well as plasma potassium and sodium if the patient is on antihypertensive medication

Other follow-up measurements

  • ECG and capacity for physical performance every 1 to 3 years
  • Thyrotrophin (TSH) every 1 to 2 years or when indicated according to the symptoms
  • Coeliac antibodies Coeliac Disease when indicated (e.g. if the patient loses weight or has symptoms from the gastrointestinal tract or microcytic anaemia)
  • Morning plasma cortisol concentration, as necessary, to exclude Addison's disease if there are problems with hypoglycaemia. Cortisol deficiency usually leads to difficult-to-manage hypoglycaemic tendency because cortisol is an insulin antagonist.

Home monitoring

  • Weight
  • Blood pressure
  • Plasma glucose (monitored regularly, see below)

Blood (plasma) glucose measurements at home

  • Sufficient information on the 24-hour glucose profile can usually be obtained from (4-)8 samples:
    • Fasting (morning) plasma glucose value to determine whether the dose of the long-acting basal insulin is sufficient. A high fasting (morning) value suggests an insufficient dose and a low value suggests a too high a dose. Fasting (morning) hyperglycaemia, see also Type 1 Diabetes: Treatment.
    • The adequacy of the dose of rapid acting insulin is evaluated with paired measurements of plasma glucose performed before a meal and 1.5-2 hours after the meal. The dose and timing of injection are correct if blood glucose rises at maximum 2 mmol/l compared with the level before meal.
    • Samples before lunch, dinner and bedtime to determine whether the dose of the morning long-acting insulin (detemir, glargin 100 units/ml divided into morning and evening doses, NPH) or the dose of long-acting insulin administered once a day (degludec, glargin 100 units/ml or glargin 300 units/ml, once a day) is sufficient. High values usually suggest the need to increase the dose of the long-acting insulin, if blood glucose does not remain elevated after meals (meal pair measurements).
  • The required measurement frequency varies individually. Basic monitoring that fits most patients includes measurements before meals (4 measurements), when going to bed and when needed. Special situations (e.g. sick days, exercise, driving a car, pregnancy) and glucose balance that exceeds the treatment target usually always require an increase in measurement frequency.
  • See also Type 1 Diabetes: Treatment.

Tissue glucose monitoring

Blood pressure

  • Blood pressure level should remain below 140/80 mmHg.
    • Even a lower level (< 130/80 mmHg) may be aimed at, provided that it does not cause any adverse effects.
  • In kidney damage (GFR < 60 ml/min/m2 or albuminuria present), the blood pressure target is < 130/80 mmHg.
  • Non-pharmacological therapy is the primary option.
    • Salt intake is restricted to less than 5 g daily.
    • Alcohol intake is restricted. The average weekly consumption should not exceed 14 alcohol units for men and 7 units for women. This recommendation is based on a unit of 12 g of pure alcohol. The definition of unit or "standard drink" varies across countries; check local definition and recommendations.
    • Regular exercise should be practised (moderate-effort endurance exercise, for example brisk walking, 150 minutes a week).
    • Smoking is stopped.
    • If needed, weight reduction and/or weight maintenance is commenced (5-10% reduction from initial weight).

Pharmacotherapy for hypertension

Dyslipidaemias

  • Type 1 diabetes increases the risk of arterial disease, especially when associated with microalbuminuria, other microvascular disease or other risk factors.
  • See table T1 and Treatment of Dyslipidaemias.