Diabetes theme: Knowing your patients with type 1 diabetes

It is strongly recommended that the linked articles are read before considering the questions.

• Understanding the role of insulin in the management of type 1 diabetes
• Knowing your patient with type 1 diabetes: the transition to self-management

Insulin treatment is an essential component of type 1 diabetes management. Achieving and maintaining good glycaemic control helps prevent the short-term adverse consequences of hyper- and hypoglycaemia and reduce the risk of long-term complications. Primary care can support patients with type 1 diabetes by understanding their insulin regimen, ensuring their treatment is optimised and identifying any issues with adherence.

Most people with type 1 diabetes use a basal-bolus regimen, i.e. a short-acting insulin administered before meals and an intermediate/long-acting insulin (basal) administered once or twice daily. These regimens are usually administered as a flexible dose but some patients may use a fixed dose, depending on their circumstances. Flexible dose regimens are adapted to the carbohydrate content of upcoming meals and require an understanding of carbohydrate counting.

New technology is changing the way some people with type 1 diabetes manage their blood glucose levels. Insulin pumps (funded with Special Authority approval) deliver a short-acting insulin continuously via subcutaneous infusion, replacing multiple daily injection regimens. Their use can be associated with improved HbA_1c levels, reduction in hypoglycaemia and higher patient satisfaction, however, if the pump malfunctions there is a risk of hyperglycaemia and diabetic ketoacidosis. People using insulin pumps need to test their blood glucose levels frequently to optimise their insulin regimen. Some people are choosing to self-fund continuous glucose monitors which can make the requirement for frequent monitoring easier.

Transitioning from parental or caregiver control to self-management can be a time of high risk for young people with type 1 diabetes, particularly in terms of adherence to insulin and maintaining glycaemic control. Primary care can be an important source of support even though the majority of people with type 1 diabetes are under the management of a specialist diabetes team.

A diagnosis of type 1 diabetes is life-changing for most people and their families/whānau. There are many day-to-day challenges, such as learning how to manage an insulin regimen and how to prevent hypo- or hyperglycaemia, as well as longer-term anxieties, such as complications of diabetes and how the illness may affect education, future employment opportunities, activities, sports, social life and relationships. A person with type 1 diabetes is never able to forget their illness or take a day off from their responsibilities for maintaining their health. Primary healthcare professionals can help to share this burden by knowing the stories of their patients with type 1 diabetes, providing education and advocacy, ensuring patients have access to the best treatments and devices available to them and providing “whole body and mind” health care to support them to live their best life.

Questions for discussion

1. Consider the patients with type 1 diabetes in your practice. How often do you see them and how comfortable do you feel when dealing with their health needs? Is it clear who takes the responsibility for providing treatment advice and prescriptions, for arranging investigations and ensuring that annual diabetic checks are undertaken?
2. If your patients with type 1 diabetes access the majority of their care via a specialist diabetic clinic, do you feel there could be more offered in primary care? What are the barriers that may be limiting your ability to do so?
3. How familiar are you with insulin pumps and continuous glucose monitors? Did the information in the articles help to upskill your team with regards to this new technology?
4. The ability to “carb count” is required for people with type 1 diabetes who have an insulin pump. Are you familiar with the concept of counting carbohydrates and would you feel confident explaining this to patients? Do you feel there are sufficient resources and assistance available to help with this? Are there educational courses available in your area?
5. Do you have any specific processes in place in your practice for supporting adolescents as they take over control of their diabetes from their parents/caregivers? For example, do you schedule a routine review of their treatment and overall health needs? Do you ensure they are confident with their treatment regimen and how to manage any problems that may arise?
6. The unrelenting burden of having type 1 diabetes can result in emotional distress, sometimes termed “diabetes distress”. How familiar are you with this term? Do you feel that this is something you consider during your consultations with people with type 1 diabetes? If not, after reading these articles, do you feel you may ask more questions about how your patient is coping and the challenges that they are facing?
7. Additional question for Community Pharmacists: How do you view your role in the care of people with type 1 diabetes? What support do you typically provide, and is there anything you might do differently after reading this article? For example, when younger patients pick up prescriptions related to insulin treatment, do you take extra time to ensure they are comfortable with their regimen and devices?