1. Treatment Pathway for Adults with Type 1 Diabetes
Positive Decision
Negative Decision
Treatment Pathway for Adults with Type 1 Diabetes
Yes No
Yes
Existing adult patients with Type 1 diabetes
HbA1c ≤ 48mmol/L (6.5%) or agreed targets?
Continue current therapy and monitor HbA1C every 3-6 months. Ensure annual review No
New adult patients with Type 1 diabetes (refer to structured education course KAT1E within 6-12 months)
Basal-bolus regime
First line:
Long-acting twice daily (or once daily if twice daily not acceptable) insulin detemir (Levemir) PLUS
Rapid acting insulin analogue (novorapid, Humalog or Apidra) BEFORE meals. Adjust dose according to blood glucose levels
Basal-bolus regime
Second line:
Long-acting once daily insulin glargine 100units/mL (Abasaglar, OR Toujeo) PLUS
Rapid acting insulin analogue (novorapid, Humalog or Apidra) BEFORE meals. Adjust dose according to blood glucose levels
If detemir not tolerated or acceptable or if problematic lipodystrophy and/or lipohypertrophy
Is patient able and willing to administer Multiple Daily Injections (MDI)?
Yes No
Mixed Insulin regime
Second line: Twice daily mixed insulin regime. Dose adjusted according to HbA1C and blood glucose levels
HbA1c ≤ 48mmol/L (6.5%) or agreed targets?
NOTE: Consider adding metformin to insulin therapy if an adult with BMI ≥25kg/m2 (23kg/m2 for people of South Asian and related minority ethnic groups) or above wants to improve their blood glucose control while minimising their effective insulin dose. No
Yes
Is patient experiencing repeated unpredictable disabling hypoglycaemia OR HbA1c levels remain ≥ 69mmol/L (8.5%) despite a high level of care and insulin pump therapy is being considered OR risk of hypoglycaemia because of reduced awareness OR more than 2 episodes of documented DKA related admissions in the last 12 months?
Continue current therapy and monitor HbA1C every 3-6 months. Ensure annual review No
NB. Please prescribe insulin by brand. Patient familiarity with the same brand is important; training is required in the use of specific devices for self-injection.
Reference: UK Medicines Information
Yes
Tier 2 Accredited Practitioner with Specialist Interest in diabetes or Tier 3 Diabetes Specialist consultant/nurse initiated: Third line once daily either Toujeo or insulin degludec (Tresiba) PLUS short/rapid acting insulin analogue BEFORE meals. Adjust dose according to blood glucose levels.
Yes
HbA1c ≤ 48mmol/L (6.5%) or agreed targets? No No
Yes
Refer to Tier 3 for consideration of continuous subcutaneous insulin infusion.
Is patient still experiencing repeated disabling hypoglycaemia after 6 months treatment OR HbA1c remains >69mmol/L (8.5%) OR have severe needle phobia?