Insulin-dependent diabetes - Treating type 1 diabetes

Monitoring blood glucose

An important part of your treatment is to make sure that your blood sugar level is as normal and stable as possible.

You'll be able to manage this using insulin treatment and by eating a healthy, balanced diet, but you will also have to regularly check your blood glucose levels to make sure they're not too high or too low.

Exercise, illness, stress, drinking alcohol, taking other medicines and, for women, changes to your hormone levels during your monthly period can all affect your blood sugar levels.

In most cases, you'll need to check your blood glucose levels during the day, both at home and at work or school, using a simple finger prick blood test. You may need to do this up to four or more times a day, depending on the type of insulin treatment you're taking. Your diabetes care team will talk to you about your ideal blood glucose level.

The normal blood sugar level is 4.0-7.0 mmol/l before meals and less than 9.0 mmol/l two hours after meals. Mmol/l means millimoles per litre, and it's a way of defining the concentration of glucose in your blood.

The Diabetes UK website has more information on testing your glucose levels.

Having your blood glucose levels checked

You'll be measuring your blood glucose yourself every day, to check your levels.

Your GP or diabetes care team will also carry out a different blood test every two to six months, called the HbA1c test.

This gives a clearer idea of how well your treatment plan is working, by measuring how stable your glucose levels have been over the past 6-12 weeks.

It measures the amount of haemoglobin, which is the oxygen-carrying substance in red blood cells that has glucose attached to it. A high HbA1c level may indicate that your blood glucose level is consistently high and that your diabetes treatment plan needs to be altered.

The ideal HbA1c target for people with diabetes is below 48 mmol/mol.

The Diabetes UK website has more information about blood glucose levels.

Treating hypoglycaemia (low blood glucose)

Hypoglycaemia can occur when your blood glucose level becomes very low. It's likely that you'll develop hypoglycaemia from time to time.

Mild hypoglycaemia (or a "hypo") can make you feel shaky, weak and hungry, and can be controlled by eating or drinking something sugary, such as a fizzy drink (not a diet version), sugar cubes or raisins. You may also be able to take pure glucose, in the form of a tablet or fluid, if you need to control the symptoms of a hypo quickly.

If you develop severe hypoglycaemia, you can become drowsy and confused, and you may even lose consciousness. If this occurs, you'll need assistance from another person who may be able to give you a glucose gel rubbed into your cheeks or an injection of glucagon into your muscle. Glucagon is a hormone that quickly increases your blood glucose levels.

Your diabetes care team may show several of your family members and close friends how to inject glucagon or give you glucose gel, should you need it.

Once you begin to come round, you'll need to eat something sugary when you're alert enough to do so. If you lose consciousness as a result of hypoglycaemia, there's a risk that it could happen again within a few hours, so you'll need to rest afterwards and have someone with you.

If the glucagon injection into your muscle doesn't work, and you're still drowsy or unconscious 10 minutes after the injection, you'll need urgent medical attention.

You'll need to have another injection of glucagon straight into a vein, which must be given by a trained healthcare professional.

If you have type 1 diabetes, it's recommended that you carry identification with you so that people are aware of the problem if you become hypoglycaemic.

Islet cell transplantation

Some people with type 1 diabetes may benefit from a fairly new procedure known as islet cell transplantation. It involves implanting healthy islet cells from the pancreas of a deceased donor into the pancreas of someone with type 1 diabetes.

In 2008, a government-funded islet cell transplant programme was introduced, and the procedure is now available through the NHS for people who satisfy certain criteria (see below).

You may be suitable for an islet cell transplant if you've had:

• two or more severe hypos within the last two years and you have a poor awareness of hypoglycaemia
• a working kidney transplant, severe hypos and poor hypoglycaemia awareness, or poor blood glucose control even after receiving the best medical treatment

You may not be suitable for an islet cell transplant if you:

• weigh over 85kg (13st 5.4lb)
• have poor kidney function
• need a lot of insulin – for example, over 50 units a day for a 70kg (11st) person

An islet cell transplant is a minor, low-risk procedure that's carried out under local anaesthetic.

The procedure has been shown to be effective at reducing the risk of severe hypos. So far, the results of islet cell transplants carried out in the UK have shown a significant reduction in the number of hypos, from 23 per person per year before transplantation to less than one per person per year afterwards.

The Diabetes UK website has more information about islet cell transplants and hypoglycaemia.

Pancreas transplant

People with type 1 diabetes who are having a kidney transplant from a donor may also be offered a pancreas transplant at the same time.

Others may be offered a pancreas transplant after they've had a kidney transplant because they’re already on anti-rejection tablets.

If you're having repeated, severe and life-threatening hypoglycaemic attacks, a pancreas transplant may also be recommended.

During the procedure, your faulty pancreas will be replaced with a healthy pancreas from a donor. This will allow you to get a new source of insulin.

Pancreas transplants are complicated operations and, like other types of major surgery, there's a risk of complications. In the UK, about 200 pancreas transplants are carried out each year, with more than 300 people on the waiting list.

The waiting time for a pancreas transplant is one to two years, because there's a shortage of suitable donor organs.

Treating hyperglycaemia (high blood glucose)

Hyperglycaemia can occur when your blood glucose levels become too high. It can happen for several reasons, such as eating too much, being unwell or not taking enough insulin.

If you develop hyperglycaemia, you may need to adjust your diet or your insulin dose to keep your glucose levels normal. Your diabetes care team can advise you about the best way to do this.

If hyperglycaemia isn't treated, it can lead to a condition called diabetic ketoacidosis, where the body begins to break down fats for energy instead of glucose, resulting in a build-up of ketones (acids) in your blood.

Diabetic ketoacidosis is very serious and, if not addressed quickly, it can lead to unconsciousness and, eventually, death.

The signs of diabetic ketoacidosis include:

• frequently passing urine
• thirst
• tiredness and lethargy (lack of energy)
• blurry vision
• abdominal (stomach) pain
• nausea and vomiting
• deep breathing
• smell of ketones on breath (described as smelling like pear drops)
• collapse and unconsciousness

Read more about the symptoms of diabetic ketoacidosis.

Your healthcare team will educate you on how to decrease your risk of ketoacidosis by testing your own blood for ketones using blood ketone sticks if you're unwell.

If you develop diabetic ketoacidosis, you'll need urgent hospital treatment. You'll be given insulin directly into a vein (intravenously). You may also need other fluids given by a drip if you're dehydrated, including salt solution and potassium.

The Diabetes UK website has more information about diabetic ketoacidosis.

Other treatments

Type 1 diabetes can lead to long-term complications. If you have the condition, you have an increased risk of developing heart disease, stroke and kidney disease. To reduce the chance of this, you may be advised to take:

• anti-hypertensive medicines to control high blood pressure
• a statin – such as simvastatin – to reduce high cholesterol levels
• low-dose aspirin to prevent stroke
• angiotensin-converting enzyme (ACE) inhibitor – such as enalapril, lisinopril or ramipril if you have the early signs of diabetic kidney disease

Diabetic kidney disease is identified by the presence of small amounts of a protein called albumin in your urine. It's often reversible if treated early enough.

Care standards for diabetes

The aim of treating diabetes is to help people with the condition control their blood glucose levels and minimise the risk of developing future complications.

The Department of Health has set out national standards for NHS organisations and professionals covering diabetes care and prevention.

The Diabetes National Service Framework was developed by diabetes clinical experts and patients with diabetes. Good diabetes care includes:

• access to information and appropriate support for people with type 1 diabetes, including access to a structured education programme – such as Dose Adjustment for Normal Eating (DAFNE)
• an agreed care plan, helping all people with diabetes to manage their care and lead a healthy lifestyle – including a named contact for their care
• information, care and support to enable all people with diabetes to control their blood glucose, maintain an acceptable blood pressure and minimise other risk factors for developing complications
• access to services to identify and treat possible complications – such as screening for diabetic retinopathy (where high blood glucose levels damage the retina at the back of the eye) and specialised foot care
• effective care for all people with diabetes admitted to hospital, for whatever reason

The Diabetes UK website has more information about care from healthcare professionals.