AD 6th Oct issue | Page 23

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Most adults with type 1 diabetes or their carers also assess the adequacy of treatment by undertaking regular and frequent monitoring of blood glucose levels . These tests are generally performed on capillary glucose ( obtained by fingerprick ) 4-6 times daily using a glucometer — typically before meals and before bed . Individuals with poor glycaemic control or frequent hypoglycaemic events may require more frequent monitoring , especially if they have impaired hypoglycaemia awareness or they are undertaking high-risk activities . Additional monitoring may also be appropriate with exercise , as a legal requirement for driving , during periods of illness and when an insulin regimen has been recently changed to reduce the risk of hypoglycaemia . Adults with type 1 diabetes registered on the National Diabetes Services Scheme ( NDSS ) are eligible to receive significantly subsidised glucose testing strips .

Most adults with type 1 diabetes can safely target capillary glucose levels ( see box 5 ) that correspond to HbA1c targets of less than 7.0 % ( less than 53mmol / mol ). However , the benefits of aiming for these targets must be weighed against the risk of hypoglycaemia and challenges of adherence and personalised for each individual . Biofeedback from monitoring also helps to increase a patient ’ s autonomy , self-confidence and self-efficacy and helps them to understand how diet , activity and illness affect their glucose levels and reduce their risk of hypoglycaemia .

Real-time glucose monitoring systems can provide additional support for some adults with type 1 diabetes . These may provide continuous readouts of interstitial glucose levels ( so-called CGM ) or intermittent scanned ( so-called flash ) monitoring . These devices are worn on the skin and periodically measure the glucose concentration in interstitial fluid , which reflects capillary blood glucose concentrations with a time delay between five and 10 minutes . An attached transmitter sends data wirelessly to a receiver for graphic display or downloading using a software package . 18 , 22 These devices can have advantages over a glucometer , particularly as they avoid the need for regular fingerpricks and increase the frequency of glucose level readings , especially at night ( see box 6 ).

From July 2022 , CGM and flash glucose monitoring devices became available under the NDSS for all people with type 1 diabetes aged 21 or older who do not already have access . The maximum co-contribution is $ 32.50 a month for those without concessional status . Only an endocrinologist , credentialled diabetes nurse educator , nurse practitioner , physician or paediatrician can certify the required application form . Therefore , a referral by the GP to the appropriate specialist is required .

DIET AND LIFESTYLE MANAGEMENT

DIET and lifestyle , and their co-ordination with insulin therapy , play an important role in achieving and maintaining optimal glucose control . At first , this may be very confusing and frustrating for patients . Additional support from practitioners ,

Figure 5 . Continuous subcutaneous insulin infusion .

nurses , educators and accredited dietitians , alongside education programs , can greatly help patients with their self-management goals . In particular , carbohydrate‐counting training and other structured programs — for example , dose adjustment for normal eating ( DAFNE ) can be useful for adults with type 1 diabetes . Weight control is often challenging in adults with type 1 diabetes as dieting and exercise regimens that assist in weight loss may also increase the risk of hypoglycaemia , while insulin adherence may lead to unwelcome weight gain .

All adults with type 1 diabetes should be encouraged to maintain at least a moderate level of physical activity and fitness as part of a healthy lifestyle . But it is important to always individualise the intensity and frequency of this physical activity , particularly with respect to patients risks , including underlying cardiovascular disease and hypoglycaemia . In some individuals , additional support from accredited exercise physiologists with experience in adults with type 1 diabetes may be appropriate .

All smokers with type 1 diabetes should be encouraged and assisted to quit . Excessive and / or binge drinking is associated with an increased risk of ketoacidosis and hypoglycaemia . All adults with type 1 diabetes should also be counselled and , where necessary , assisted to moderate their alcohol intake .

PREVENTION OF HYPOGLYCAEMIA

THE risk of dangerously low blood glucose levels ( hypoglycaemia ) is an ever-present companion to insulin use in type 1 diabetes , and its mitigation is a management priority . Most adults with type 1 diabetes will experience mild hypoglycaemia at least every week . As a result , practitioners are advised to ensure all adults with type 1 diabetes can minimise their risk of hypoglycaemia ( see box 7 ) and be trained to manage it when it occurs .

Hypoglycaemia is defined by a blood glucose concentration below 4.0mmol / L . Most patients recognise it by the presence of typical symptoms that may include adrenergic ( autonomic ) symptoms , such as sweating , shaking , palpitations , feeling anxious and pale skin ; as well as neuroglycopenic symptoms , such as fatigue , difficulty concentrating , confusion and inappropriate behaviour , seizures and loss of consciousness .

However , symptoms can vary

Figure 6 . Continuous glucose monitoring .

among patients and even be absent in some individuals prior to the onset of neuroglycopenia ( so-called hypoglycaemia unawareness ). Older patients may be less likely to experience adrenergic symptoms .

Hypoglycaemia is often the result of an unanticipated reduction in insulin requirements , including those listed in box 8 .

Most hypoglycaemic events are readily corrected by the patients themselves by repeated glucose consumption until blood glucose levels return to the normal range . However , severe hypoglycaemia or neuroglycopenia is a medical emergency requiring the assistance of others or urgent medical support to administer glucose or IM or intranasal glucagon . Sometimes , severe hypoglycaemia requires emergency hospitalisation . 24 Following severe hypoglycaemia , efforts should be made to determine the cause , with a dietary review and education about prevention and management , as well as consideration as to whether the patient ’ s insulin dose needs to be adjusted . Fitness for work and , in particular , driving should also be assessed .

DRIVING AND TYPE 1 DIABETES

ALL adults with type 1 diabetes who

Alamy apply for or hold a driver ’ s licence must inform the driving licence authority of their condition and have regular medical reviews by their treating clinician . The frequency of reviews varies according to their treatment regimen , risk of hypoglycaemia and whether they possess a private or commercial vehicle licence . Laws vary in different states and territories of Australia ; however , an annual review by a treating specialist is usually required .

In people with type 1 diabetes , driving ability may be affected by both acute episodes of hypoglycaemia or from chronic diabetic complications , including peripheral retinopathy affecting vision , peripheral neuropathy or cardiovascular disease . Educate patients about the potential effects of driving with low blood glucose levels .

The NDSS recommends that blood glucose concentration be checked before driving and every two hours while driving to ensure a level of greater than 5mmol / L . 25 After an episode of severe hypoglycaemia , a patient must not drive until they have been assessed and recommended for resumption of driving by their diabetes

Box 5 . Targets in type 1 diabetes

• First morning and pre-meal blood glucose in the range of 4-7mmol / L .

• Blood glucose in the range of 5-9mmol / L two hours after eating .

Box 6 . Targets in type 1 diabetes with a CGM

• Time in range : greater than 70 %.

• Time below range : less than 4 %.

• Time above range : less than 25 %.

• Glycaemic variability : 36 % or less . Source : Battelino T et al 2019 23

Box 7 . Patient factors limiting the occurrence and severity of hypoglycaemia

• Education to understand the common risks for hypoglycaemia ( see box 8 ) and identify unique individual risks related to their own activities and behaviours .

• Recommendation to be especially vigilant , undertaking additional glucose monitoring and appropriately adjusting insulin doses or food intake where necessary in high-risk settings .

• Training to recognise , prevent and manage hypoglycaemia , including an established action plan for hypoglycaemic events .

• Encouragement to maintain easy access to a hypoglycaemic kit , including a fast-acting glucose source and glucagon , for emergency treatment of hypoglycaemia .

• Encouragement to inform their family , friends and coworkers of their condition and how to manage unanticipated hypoglycaemic events .

• Wearing a medical alert bracelet and carrying an alert card to assist medical support in case of a hypoglycaemic emergency .

specialist . 26 Reporting episodes of hypoglycaemia varies between different Australian states and territories , and reinstatement by a licensing authority usually takes a minimum of six weeks . 26

ADJUNCTIVE MEDICAL THERAPY

ACHIEVING and maintaining optimal glucose control is only one element of the multifactorial management of type 1 diabetes in adults . Because of the elevated cardiovascular and renal risk associated with type 1 diabetes , most adults will require additional medical therapy ( see box 9 ).

While oral glucose-lowering agents can also be effective , all are currently contraindicated in adults with type 1 diabetes because of the risk of harm , including diabetic ketoacidosis , hypoglycaemia and insulin non-adherence .

MULTIDISCIPLINARY MANAGEMENT

TYPE 1 diabetes in general practice is best managed with the support of a multidisciplinary diabetes team ( see figure 8 ). This team may include those listed in box 10 .

PROGNOSIS

ADULTS with type 1 diabetes who