A novel approach to basal-bolus insulin initiation in adults with newly diagnosed type 1 diabetes: an observational cohort study of a service redesign

Authors

  • Helen E Hopkinson Greater Glasgow and Clyde Health Board http://orcid.org/0000-0002-4218-4384
  • Anna D White University of Glasgow
  • Peter Nightingale University Hospitals Birmingham NHS Foundation Trust
  • Parth Narendran University of Birmingham

DOI:

https://doi.org/10.15277/bjd.2018.175

Keywords:

Diabetes mellitus, type 1, insulin, HbA1c

Abstract

Aims: The National Institute for Health and Care Excellence (NICE) recommendation for insulin in newly diagnosed type 1 diabetes is a ‘basal-bolus’ regimen of prandial insulin with twice-daily basal insulin initiated at diagnosis. We developed an insulin initiation programme that embraces the contribution of endogenous insulin to glycaemic control in adults newly diagnosed with type 1 diabetes. Our aim was to embed carbohydrate counting skills and dose adjustment very early on to mitigate against the decline in glycaemic control that is commonly seen post honeymoon.

Methods: We designed a novel insulin initiation programme that focused initially on prandial insulin replacement using the lowest possible dose of basal insulin. The approach also facilitates carbohydrate counting and bolus insulin dose adjustment behaviours from diagnosis.

Results: Prior to implementing the new programme, the mean HbA1c at 12 months was 64 mmol/mol (8.0%) (95% CI 60 to 69 (7.6% to 8.4%)). This reduced to 55 mmol/mol (7.1%) (95% CI 51 to 58 (6.9% to 7.4%)), p<0.001 with the new programme. The improved HbA1c persisted to 3 years of follow-up (p<0.001). There were no episodes of diabetic ketoacidosis or severe hypoglycaemia associated with this novel approach.

Conclusions: We suggest that using minimal basal insulin and focusing on prandial bolus insulin replacement in adults newly diagnosed with type 1 diabetes is safe, more physiological and may be better able to achieve lasting glycaemic control than the currently proposed national guidelines. This approach will need to be tested formally in an adequately designed randomised controlled clinical trial.

Author Biographies

Helen E Hopkinson, Greater Glasgow and Clyde Health Board

Consultant Physician

Anna D White, University of Glasgow

Specialist Registrar in Diabetes, Institute of Cardiovascular and Medical Sciences

Peter Nightingale, University Hospitals Birmingham NHS Foundation Trust

Medical Statistician

Parth Narendran, University of Birmingham

Reader and Honorary Consultant Physician

References

National Institute for Health and Care Excellence (NICE) Guideline NG 17 Type 1 diabetes in adults: diagnosis and management. Updated July 2016. https://www.nice.org.uk/guidance/ng17 (accessed 5 July 2017).

Leicester Foundation Group. Successful implementation of structured education for newly diagnosed type 1 diabetes. Practical Diabetes 2012;29:149–52. https://doi.org/10.1002/pdi.1679

Eisenbarth GS. Type 1 diabetes mellitus. N Engl J Med 1986;314:1360-8. https://doi.org/10.1056/NEJM198605223142106

Sosenko JM, Skyler JS, Beam CA et al. Type 1 Diabetes TrialNet and Diabetes Prevention Trial–Type 1 Study Groups. Acceleration of the loss of the first-phase insulin response during the progression to type 1 diabetes in diabetes prevention trial-type 1 participants. Diabetes 2013; 62:4179-83. https://doi.org/10.2337/db13-0656

Greenbaum CJ, Harrison LC. Immunology of Diabetes Society. Guidelines for intervention trials in subjects with newly diagnosed type 1 diabetes. Diabetes 2003;52:1059-65. https://doi.org/10.2337/diabetes.52.5.1059

. Bloomgarden Z. Fear of hypoglycemia. J Diabetes 2017;9:108-10. https://doi.org/10.1111/1753-0407.12491

Greenbaum CJ, Beam CA, Boulware D et al. Fall in C-peptide during first 2 years from diagnosis: evidence of at least two distinct phases from composite type 1 Diabetes TrialNet data. Diabetes 2012;61:2066–73. https://doi.org/10.2337/db11-1538

Jackson C, Wernham EM, Elder CJ, Wright NP. Early glycaemic control is predictive of longterm control: a retrospective observational study. Practical Diabetes 2013;30:16–18. https://doi.org/10.1002/pdi.1734

Jorde R, Sundesfjord J. Intra-individual variability and longitudinal changes in glycaemic control in patients with type 1 diabetes mellitus. Diabet Med 2000;17:451–6. https://doi.org/10.1046/j.1464-5491.2000.00295.x

Chmelova H, Cohrs CM, Chouinard JA, et al. Distinct roles of beta cell mass and function during type 1 diabetes onset and remission. Diabetes 2015;64:2148–60. https://doi.org/10.2337/db14-1055

Hanan A, Gottlieb P. The honeymoon phase: intersection of metabolism and immunology. Curr Opin Endocrinol Diabetes Obes 2009;16:286–92. https://doi.org/10.1097/MED.0b013e32832e0693

Taylor C, Hopkinson H, Elliott J. Which insulin regimens are used in adults newly diagnosed with type 1 diabetes? Results of an electronic survey of healthcare professionals in the UK and Ireland. Br J Diabetes 2016;16:A1–4. https://doi.org/10.15277/bjd.2016.085

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Published

2018-06-21

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Learning from practice

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