Type 1 diabetes in adults: diagnosis and management

Make an initial diagnosis of type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia. Bear in mind that people with type 1 diabetes typically (but not always) have 1 or more of:

• ketosis

• rapid weight loss

• age of onset under 50 years

• body mass index (BMI) below 25 kg/m²

• personal and/or family history of autoimmune disease. [2015, amended 2022]

Do not use age or BMI alone to exclude or diagnose type 1 diabetes in adults. [2022]

Take into consideration the possibility of other diabetes subtypes and revisit the diagnosis at subsequent clinical reviews. Carry out further investigations if there is uncertainty (see recommendations 1.1.7 and 1.1.8). [2022]

Measure diabetes-specific autoantibodies in adults with an initial diagnosis of type 1 diabetes, taking into account that:

• the false negative rate of diabetes-specific autoantibody tests is lowest at the time of diagnosis

• the false negative rate can be reduced by carrying out quantitative tests for 2 different diabetes-specific autoantibodies (with at least 1 being positive). [2022]

Do not routinely measure serum C‑peptide to confirm type 1 diabetes in adults. [2022]

In people with a negative diabetes-specific autoantibody result, and if diabetes classification remains uncertain, consider measuring non-fasting serum C‑peptide (with a paired blood glucose). [2022]

At subsequent clinical reviews, consider using serum C‑peptide to revisit the diabetes classification if there is doubt that type 1 diabetes is the correct diagnosis. [2022]

Take into account that the discriminative value of serum C‑peptide to diagnose type 1 diabetes increases the longer the test is done after initial diagnosis of diabetes. [2022]

For people aged 60 and over presenting with weight loss and new-onset diabetes, follow recommendations on assessing for pancreatic cancer in the section on pancreatic cancer in the NICE guideline on suspected cancer: recognition and referral. [2022]

At diagnosis (or, if necessary, after managing critically decompensated metabolism), the diabetes professional team should work with adults with type 1 diabetes to develop a plan for their early care. This will generally require:

• medical assessment to:

  • ensure the diagnosis is accurate (see recommendations 1.1.1 to 1.1.5)

  • ensure appropriate acute care is given when needed

  • review medicines and detect potentially associated disease

  • detect adverse vascular risk factors

• environmental assessment to understand:

  • the social, home, work and recreational circumstances of the person and their carers

  • their lifestyle (including diet and physical activity)

  • other relevant factors, such as substance use

• cultural and educational assessment to:

  • find out what they know about diabetes

  • help with tailoring advice, and with planning treatments and diabetes education programmes

• assessment of their emotional wellbeing to decide how to pace diabetes education. [2004]

Use the results of the initial diabetes assessment to agree a future care plan. This assessment should include:

• acute medical history

• social, cultural and educational history, and lifestyle review

• complications history and symptoms

• diabetes history (recent and long term)

• other medical history

• family history of diabetes and cardiovascular disease

• medication history

• vascular risk factors

• smoking

• general examination

• weight and BMI

• foot, eye and vision examination

• urine albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR)

• psychological wellbeing

• attitudes to medicine and self‑care

• immediate family and social relationships, and availability of informal support. [2004, amended 2021]

Include the following in an individualised and culturally appropriate diabetes plan:

• when and where they will have their diabetes education, including their dietary advice (see the sections on education and information and dietary management)

• initial treatment, including guidance on insulin injection and insulin regimens (see the sections on insulin therapy and insulin injection delivery)

• self‑monitoring and targets (see the section on blood glucose management)

• symptoms, and the risk of hypoglycaemia and how it is treated

• management of special situations, such as driving

• communicating with the diabetes professional team (how often and how to contact them)

• management of cardiovascular risk factors (see the section on control of cardiovascular risk)

• implications for pregnancy and family planning advice (see NICE's guideline on diabetes in pregnancy)

• how often they will have follow‑up appointments, and what these will cover (including review of HbA1c levels, experience of hypoglycaemia, and annual reviews). [2004, amended 2015]

After the initial plan is agreed, implement it without inappropriate delay. Based on discussion with the adult with type 1 diabetes, modify the plan as needed over the following weeks. [2004]

Offer carbohydrate‑counting training to adults with type 1 diabetes as part of structured education programmes for self‑management (see the section on education and information). [2015]

Consider carbohydrate‑counting courses for adults with type 1 diabetes who are waiting for a more detailed structured education programme or who are unable to take part in a standalone structured education programme. [2015]

Do not advise adults with type 1 diabetes to follow a low glycaemic index diet for blood glucose control. [2015]

Offer dietary advice to adults with type 1 diabetes about issues other than blood glucose control (such as managing weight and cardiovascular risk), as needed. [2015]

From diagnosis, provide nutritional information that is sensitive to the personal needs and culture of each adult with type 1 diabetes. [2004]

Provide nutritional information individually and as part of a structured education programme (see the section on education and information). Include advice from professionals who are trained and accredited to provide dietary advice to people with health conditions. [2004]

Offer opportunities to receive dietary advice at intervals agreed between adults with type 1 diabetes and their healthcare professionals. [2004]

Discuss the hyperglycaemic effects of the different foods the adult with type 1 diabetes wants to eat in the context of the insulin regimens chosen to match those food choices. [2004]

Provide education programmes for adults with type 1 diabetes to help them with:

• healthy eating and a balanced diet

• changing their insulin dosage to reduce glucose excursions when varying their diet. [2004, amended 2015]

Discuss snacks with the adult with type 1 diabetes:

• Cover the choice of snack, the quantity, and when to eat them.

• Explain the effects of eating different food types, and how long these effects last.

• Explain which insulin regimens are available to match different food types.

• Discuss changes in choice of snack if needed, based on the results of self‑monitoring tests. [2004]

Provide information on:

• the effects of different alcohol‑containing drinks on blood glucose excursions and calorie intake

• high‑calorie and high‑sugar 'treats'. [2004, amended 2015]

As part of dietary education after diagnosis (and as needed after this), provide information on how healthy eating can reduce cardiovascular risk. Include information about fruit and vegetables, types and amounts of fat, and how to make the appropriate dietary changes. [2004, amended 2015]

Modify nutritional recommendations to adults with type 1 diabetes to take account of associated features of diabetes, including:

• excess weight and obesity

• underweight

• disordered eating

• hypertension

• renal failure. [2004, amended 2021]

Healthcare professionals giving dietary advice to adults with type 1 diabetes should be able to advise about common topics of concern and interest, and should seek advice from specialists when needed. Suggested common topics include:

• body weight, energy balance and obesity management

• cultural and religious diets, feasts and fasts

• foods sold as 'diabetic'

• sweeteners

• dietary fibre intake

• protein intake

• vitamin and mineral supplements

• alcohol

• matching carbohydrate intake, insulin and physical activity

• salt intake in hypertension

• comorbidities, including nephropathy and renal failure, coeliac disease, cystic fibrosis or eating disorders

• peer support groups. [2004, amended 2015]

Offer adults with type 1 diabetes a choice of real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash'), based on their individual preferences, needs, characteristics, and the functionality of the devices available. See box 1 for examples of factors to consider as part of this discussion. [2022]

When choosing a continuous glucose monitoring (CGM) device:

• use shared decision making to identify the person's needs and preferences, and offer them an appropriate device

• if multiple devices meet their needs and preferences, offer the device with the lowest cost. [2022]

CGM should be provided by a team with expertise in its use, as part of supporting people to self-manage their diabetes. [2015, amended 2022]

Advise adults with type 1 diabetes who are using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). Explain that this is because:

• they will need to use capillary blood glucose measurements to check the accuracy of their CGM device

• they will need capillary blood glucose monitoring as a back-up (for example, when their blood glucose levels are changing quickly or if the device stops working).
  
  Provide them with enough test strips to take capillary blood glucose measurements as needed. [2022]

If a person cannot use or does not want rtCGM or isCGM, offer capillary blood glucose monitoring. [2022]

Include CGM in the structured education programme provided to all adults with type 1 diabetes (see the section on education and information), and ensure that people are empowered to use CGM devices (see the section on empowering people to self-monitor blood glucose). [2022]

Monitor and review the person's use of CGM as part of reviewing their diabetes care plan (see recommendations 1.1.7, 1.2.5 and 1.2.6 on what to consider when agreeing a care plan and what a care plan should cover). [2022]

If there are concerns about the way a person is using the CGM device:

• ask if they are having problems using their device

• look at ways to address any problems or concerns to improve their use of the device, including further education and emotional and psychological support. [2022]
  
  For guidance on CGM for pregnant women, see the NICE guideline on diabetes in pregnancy. [2022]

Commissioners, providers and healthcare professionals should address inequalities in CGM access and uptake by:

• monitoring who is using CGM

• identifying groups who are eligible but who have a lower uptake

• making plans to engage with these groups to encourage them to consider CGM. [2022]

Offer multiple daily injection basal–bolus insulin regimens as the insulin injection regimen of choice for all adults with type 1 diabetes. Provide guidance on using this regimen. [2015]

Do not offer adults newly diagnosed with type 1 diabetes non‑basal–bolus insulin regimens (that is, twice‑daily mixed, basal only or bolus only). [2015]

Offer twice‑daily insulin detemir as basal insulin therapy for adults with type 1 diabetes. [2021]

Consider 1 of the following as an alternative basal insulin therapy to twice-daily insulin detemir for adults with type 1 diabetes:

• an insulin regimen that is already being used by the person if it is meeting their agreed treatment goals (such as meeting their HbA1c targets or time in target glucose range and minimising hypoglycaemia)

• once-daily insulin glargine (100 units/ml) if insulin detemir is not tolerated or the person has a strong preference for once‑daily basal injections

• once-daily insulin degludec (100 units/ml) if there is a particular concern about nocturnal hypoglycaemia

• once-daily ultra-long-acting insulin such as degludec (100 units/ml) for people who need help from a carer or healthcare professional to administer injections.
  
  There is a risk of severe harm and death due to inappropriately withdrawing insulin from pen devices. See NHS England's patient safety alert for further information. [2021]

When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost. [2021]

Ensure the risk of medication errors with insulins is minimised by following Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed combination and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar. [2021]

When people are already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar. Make a shared decision with the person after discussing their preferences. [2021]

Consider other basal insulin regimens for adults with type 1 diabetes only if the regimens in recommendations 1.7.3 and 1.7.4 do not meet their agreed treatment goals. When choosing an alternative insulin regimen, take account of:

• the person's preferences

• comorbidities

• risk of hypoglycaemia and diabetic ketoacidosis

• any concerns around adherence

• acquisition cost. [2021]

When prescribing, ensure that insulins are prescribed by brand name. [2021]

Offer rapid‑acting insulin analogues that are injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes. [2015]

Do not advise routine use of rapid‑acting insulin analogues after meals for adults with type 1 diabetes. [2015]

If an adult with type 1 diabetes has a strong preference for an alternative mealtime insulin, respect their wishes and offer the preferred insulin. [2015]

Consider a twice‑daily human mixed insulin regimen for adults with type 1 diabetes if a multiple daily injection basal–bolus insulin regimen is not possible and a twice‑daily mixed insulin regimen is used. [2015]

Consider a trial of a twice‑daily analogue mixed insulin regimen if an adult using a twice‑daily human mixed insulin regimen has hypoglycaemia that affects their quality of life. [2015]

For adults with type 1 diabetes who inject insulin, provide their preferred insulin injection delivery device (this often means using one or more types of insulin injection pen). [2004]

For adults with type 1 diabetes and special visual or psychological needs, provide injection devices or needle‑free systems that they can use independently for accurate dosing. [2004]

Offer needles of different lengths to adults with type 1 diabetes who are having problems such as pain, local skin reactions and injection site leakages. [2015]

After taking clinical factors into account, choose needles with the lowest acquisition cost to use with pre‑filled and reusable insulin pen injectors. [2015]

Advise adults with type 1 diabetes to rotate insulin injection sites and avoid repeated injections at the same point within sites. [2015]

Provide adults with type 1 diabetes with:

• suitable containers for collecting used needles and other sharps

• a way to safely get rid of these containers.
  
  See also the section on safe use and disposal of sharps in NICE's guideline on healthcare-associated infections: prevention and control in primary and community care. [2004, amended 2015]

Check injection site condition at least annually, and whenever new problems with blood glucose control occur. [2004, amended 2015]

For adults with erratic and unpredictable blood glucose control (hyperglycaemia and hypoglycaemia at no consistent times), consider the following rather than changing a previously optimised insulin regimen:

• injection technique

• injection sites

• self-monitoring skills

• knowledge and self‑management skills

• lifestyle

• mental health and psychosocial problems

• possible organic causes, such as gastroparesis. [2004, amended 2015]

Give clear guidelines and protocols ('sick‑day rules') to all adults with type 1 diabetes, to help them adjust insulin doses appropriately when they are ill. [2004]

Continuous subcutaneous insulin infusion (insulin pump) therapy is recommended as an option in NICE technology appraisal guidance for treating some adults with type 1 diabetes. For full details, see the guidance on continuous subcutaneous insulin infusion (TA151, 2008). [2015]

Hybrid closed loop systems are recommended as an option in NICE technology appraisal guidance for managing blood glucose levels in type 1 diabetes for adults who have an HbA1c of 58 mmol/mol (7.5%) or more, or have disabling hypoglycaemia, despite best possible management with at least 1 of the following: continuous subcutaneous insulin infusion, real-time continuous glucose monitoring, or intermittently scanned continuous glucose monitoring. For full details and information about an NHS England implementation plan, see the guidance on hybrid closed loop systems (TA943, 2023).

Consider adding metformin to insulin therapy for adults with type 1 diabetes if:

• they have a BMI of 25 kg/m² or above (23 kg/m² or above for people from South Asian and related family backgrounds) and

• they want to improve their blood glucose control while minimising their effective insulin dose.
  
  In August 2015, this was an off-label use of metformin. See NICE's information on prescribing medicines. [2015]

Assess hypoglycaemia awareness in adults with type 1 diabetes at each annual review. [2015]

Use the Gold score or Clarke score to quantify hypoglycaemia awareness in adults with type 1 diabetes, checking that the questionnaire items have been answered correctly. [2015]

Explain to adults with type 1 diabetes that impaired awareness of the symptoms of plasma glucose levels below 3 mmol/litre is associated with a significantly increased risk of severe hypoglycaemia. [2015]

Ensure that adults with type 1 diabetes and impaired hypoglycaemia awareness have had structured education in flexible insulin therapy using basal–bolus regimens, and are following its principles correctly. [2015]

Offer additional education focusing on avoiding and treating hypoglycaemia to adults with type 1 diabetes who still have impaired hypoglycaemia awareness after structured education in flexible insulin therapy. [2015]

Avoid relaxing individualised blood glucose targets to address impaired hypoglycaemia awareness for adults with type 1 diabetes. [2015]

For adults with type 1 diabetes and impaired hypoglycaemia awareness who are using lower target blood glucose levels than recommended in this guideline, encourage them to use the recommended targets (see the recommendations on blood glucose targets). [2015]

Review insulin regimens and doses, and prioritise ways to avoid hypoglycaemia in adults with type 1 diabetes with impaired hypoglycaemia awareness, including:

• reinforcing the principles of structured education

• offering an insulin pump

• offering real‑time continuous glucose monitoring. [2015]

If, despite these interventions, an adult with type 1 diabetes has impaired hypoglycaemia awareness that is associated with recurrent severe hypoglycaemia, consider referring them to a specialist centre. [2015]

Explain to adults with type 1 diabetes that a fast‑acting form of glucose is needed for managing hypoglycaemic symptoms or signs in people who can swallow. [2004, amended 2015]

Adults with type 1 diabetes who have a decreased level of consciousness because of hypoglycaemia and so cannot safely take oral treatment should be:

• given intramuscular glucagon by a family member or friend who has been shown how to use it (intravenous glucose may be used by healthcare professionals skilled in getting intravenous access)

• checked for response at 10 minutes, and then given intravenous glucose if their level of consciousness is not improving significantly

• then given oral carbohydrate when it is safe to administer it, and put under continued observation by someone who has been warned about the risk of relapse. [2004, amended 2015]

Explain to adults with type 1 diabetes that:

• it is very common to experience some hypoglycaemic episodes with any insulin regimen

• they should use a regimen that avoids or reduces the frequency of hypoglycaemic episodes, while maintaining the most optimal blood glucose control possible. [2004]

Make hypoglycaemia advice available to all adults with type 1 diabetes, to help them find the best possible balance with any insulin regimen. (See the sections on insulin therapy and insulin injection delivery.) [2004]

If hypoglycaemia becomes unusually problematic or increases in frequency, review the following possible causes:

• inappropriate insulin regimens (incorrect dose distributions and insulin types)

• meal and activity patterns, including alcohol

• injection technique and skills, including insulin resuspension if necessary

• injection site problems

• possible organic causes, including gastroparesis

• changes in insulin sensitivity (including drugs affecting the renin–angiotensin system and renal failure)

• mental health problems

• previous physical activity

• lack of appropriate knowledge and skills for self‑management. [2004]

Manage nocturnal hypoglycaemia (symptomatic or detected on monitoring) by:

• reviewing knowledge and self‑management skills

• reviewing current insulin regimen, evening eating habits and previous physical activity

• choosing an insulin type and regimen that is less likely to cause low glucose levels at night. [2004, amended 2015]

If early cognitive decline occurs in adults on long‑term insulin therapy, then in addition to normal investigations consider possible brain damage from overt or covert hypoglycaemia, and the need to manage this. [2004]

Consider ketone monitoring (blood or urine) as part of 'sick‑day rules' for adults with type 1 diabetes, to help with self‑management of hyperglycaemia. [2015]

In adults with type 1 diabetes presenting to emergency services, consider capillary blood ketone testing if:

• diabetic ketoacidosis (DKA) is suspected or

• the person has uncontrolled diabetes during an illness, and urine ketone testing is positive. [2015]

Consider capillary blood ketone testing (incorporated into a formal protocol) for inpatient management of DKA in adults with type 1 diabetes. [2015]

Professionals managing DKA in adults should have adequate and up-to-date training, and be familiar with all aspects of DKA management that are associated with mortality and morbidity. These topics should include:

• fluid balance

• acidosis

• cerebral oedema

• electrolyte imbalance

• that DKA can affect the results of standard diagnostic tests (white cell count, body temperature, electrocardiogram [ECG])

• respiratory distress syndrome

• cardiac abnormalities

• precipitating causes

• infection management, including opportunistic infections

• gastroparesis

• use of high dependency and intensive care units

• recommendations 1.10.5 to 1.10.12 in this guideline.
  
  Management of DKA in adults should be in line with local clinical governance. [2004]

Use isotonic saline for primary fluid replacement in adults with DKA, not given too rapidly except in cases of circulatory collapse. [2004]

Do not generally use bicarbonate for managing DKA in adults. [2004, amended 2015]

Give intravenous insulin by infusion to adults with DKA. [2004]

When the plasma glucose concentration has fallen to 10 to 15 mmol/litre in adults with DKA, give glucose‑containing fluids (not more than 2 litres in 24 hours) so that the insulin infusion can be continued at a sufficient rate to clear ketones (for example, 6 units/hour, monitored for effect). [2004, amended 2015]

Begin potassium replacement early in DKA in adults, with frequent monitoring for hypokalaemia. [2004]

Do not generally use phosphate replacement when managing DKA in adults. [2004, amended 2015]

In adults with DKA who have reduced consciousness, think about:

• inserting a nasogastric tube and

• monitoring urine output using a urinary catheter and

• giving venous thromboembolism (VTE) prophylaxis. [2004, amended 2021]

To reduce the risk of catastrophic outcomes in adults with DKA, use continuous monitoring and frequent reviews that cover all aspects of clinical management. [2004, amended 2015]

Do not offer aspirin for the primary prevention of cardiovascular disease in adults with type 1 diabetes. [2015]

Assess cardiovascular risk factors annually, including:

• estimated glomerular filtration rate (eGFR) and urine albumin:creatinine ratio (ACR)

• smoking

• blood glucose control

• blood pressure

• full lipid profile (including high-density lipoprotein [HDL] and low-density lipoprotein [LDL] cholesterol, and triglycerides)

• age

• family history of cardiovascular disease

• abdominal adiposity. [2004, amended 2015 and 2021]

For guidance on tools for assessing risk of cardiovascular disease in adults with type 1 diabetes, see the recommendations on full formal risk assessment in NICE's guideline on lipid modification. [2015]

For guidance on the primary prevention of cardiovascular disease in adults with type 1 diabetes, see the section on primary prevention for people with type 1 diabetes in NICE's guideline on lipid modification. [2015]

Give adults with type 1 diabetes who smoke advice on stopping smoking and stop smoking services, including NICE guidance‑recommended therapies (see the NICE topic page on smoking and tobacco). Reinforce these messages annually for people who currently do not plan to stop smoking, and at all clinical contacts if there is a prospect of the person stopping. [2004]

Advise adults who do not smoke never to start smoking. [2004, amended 2021]

Provide intensive management for adults who have had myocardial infarction or stroke, according to relevant non‑diabetes guidelines. For angina or other ischaemic heart disease, beta-blockers should be considered (for insulin use in these circumstances, see the section on caring for adults with type 1 diabetes in hospital). For guidance on secondary prevention of myocardial infarction, see NICE's guideline on acute coronary syndromes. [2004, amended 2015]

In adults with type 1 diabetes aim for blood pressure targets as follows:

• For adults with a urine albumin:creatinine ratio (ACR) less than 70 mg/mmol, aim for a clinic systolic blood pressure less than 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure less than 90 mmHg.

• For adults with an ACR of 70 mg/mmol or more, aim for a clinic systolic blood pressure less than 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure less than 80 mmHg.

• In adults aged 80 or more, whatever the ACR, aim for a clinic systolic blood pressure less than 150 mmHg and a clinic diastolic blood pressure less than 90 mmHg.
  
  Use clinical judgement for adults with frailty, target organ damage (damage to organs because of diabetes, for example, to nerves or eyes) or multimorbidity. See NICE's guideline on multimorbidity. [2004, amended 2022]

Discuss the following with adults with type 1 diabetes who have hypertension to help them make an informed choice:

• reasons for the choice of intervention level

• the substantial potential gains from small improvements in blood pressure control

• any possible negative consequences of therapy. [2004, amended 2015]

Start a trial of a renin–angiotensin system blocking drug as first‑line therapy for hypertension in adults with type 1 diabetes. [2004, amended 2015]

Provide information to adults with type 1 diabetes on how lifestyle changes can improve their blood pressure control and associated outcomes, and offer help to achieve their aims in this area. [2004]

Do not allow concerns over potential side effects to inhibit advising and offering the necessary use of any class of drugs, unless side effects become symptomatic or otherwise clinically significant. In particular:

• do not avoid selective beta-blockers for adults on insulin if these are indicated

• low-dose thiazides may be combined with beta‑blockers

• when prescribing calcium channel antagonists, only use long‑acting preparations

• ask adults directly about potential side effects of erectile dysfunction, lethargy and orthostatic hypotension with different drug classes. [2004, amended 2015]

Deleted.

Aim for a target plasma glucose level of 5 to 8 mmol/litre for adults with type 1 diabetes during surgery or acute illness. [2015]

Establish a local protocol for controlling blood glucose levels in adults with type 1 diabetes during surgery or acute illness to reach the target level. [2015]

Use intravenous rather than subcutaneous insulin regimens for adults with type 1 diabetes if:

• they are unable to eat or are predicted to miss more than 1 meal or

• an acute situation is expected to result in unpredictable blood glucose levels – for example, major surgery, high‑dose steroid treatment, inotrope treatment or sepsis or

• insulin absorption is expected to be unpredictable, for example, because of circulatory compromise. [2015]

Consider continuing the person's existing basal insulin regimen (including basal rate if they are using insulin pump therapy) together with protocol‑driven insulin delivery for controlling blood glucose levels in adults with type 1 diabetes during surgery or acute illness. [2015]

Use subcutaneous insulin regimens (including rapid‑acting insulin before meals) if an adult with type 1 diabetes and acute illness is eating. [2015]

Enable adults with type 1 diabetes who are hospital inpatients to self‑administer subcutaneous insulin if they are willing and able and it is safe for them to do so. [2015]

From admission, provide ongoing advice to adults with type 1 diabetes and the team caring for them from a trained multidisciplinary team with expertise in diabetes. [2004]

Throughout inpatient admission, respect the personal expertise of adults with type 1 diabetes in managing their own diabetes and incorporate this into routine ward‑based blood glucose monitoring and insulin delivery. [2004, amended 2015]

Throughout inpatient admission, support adults with type 1 diabetes to make their own food choices based on their personal knowledge of their dietary needs, except when illness or medical or surgical intervention significantly disturbs those requirements. [2004]

Provide optimal insulin therapy, which can be achieved using intravenous insulin and glucose, to all adults with type 1 diabetes with threatened or actual stroke. Critical care and emergency departments should have a protocol for such management. [2004, amended 2011]

Advise adults with type 1 diabetes at their annual review of self‑care and needs that:

• they are at higher risk of periodontitis

• if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia. [2022]

Advise adults with type 1 diabetes to have regular oral health reviews (their oral healthcare or dental team will tell them how often, in line with the NICE guideline on dental checks: intervals between oral health reviews). [2022]

For guidance for oral healthcare and dental teams on how to provide oral health advice, see the NICE guideline on oral health promotion.[2022]

For adults with type 1 diabetes who have been diagnosed with periodontitis by an oral healthcare or dental team, offer dental appointments to manage and treat their periodontitis (at a frequency based on their oral health needs). [2022]

When adults are diagnosed with type 1 diabetes, refer them immediately to the local eye screening service. [2004, amended 2020]

Encourage adults to attend eye screening, and explain that it will help them to keep their eyes healthy and help to prevent problems with their vision. Explain that the screening service is effective at identifying problems so that they can be treated early. [2004]

Arrange emergency review by an ophthalmologist for:

• sudden loss of vision

• rubeosis iridis

• pre-retinal or vitreous haemorrhage

• retinal detachment. [2004, amended 2015]

Refer to an ophthalmologist in accordance with the UK National Screening Committee criteria and timelines for any large sudden unexplained drop in visual acuity. [2004, amended 2020]

For guidance on managing kidney disease in adults with type 1 diabetes, see NICE's guideline on chronic kidney disease. [2015]

Ask all adults with type 1 diabetes, with or without detected nephropathy, to bring in the first urine sample of the day ('early morning urine') once a year. Send this for estimation of albumin:creatinine ratio (estimating urine albumin concentration alone is a poor alternative) and measure eGFR at the same time. See NICE's guideline on chronic kidney disease. [2004, amended 2021]

Suspect other renal disease if:

• progressive retinopathy is absent

• blood pressure is particularly high

• proteinuria develops suddenly

• significant haematuria is present (see NICE's guideline on chronic kidney disease)

• the person is systemically unwell. [2004]

If albuminuria is found, discuss with the person what this means. [2004, amended 2015]

For guidance on medicines for managing chronic kidney disease, see the section on pharmacotherapy for CKD in adults, children, and young people with related persistent proteinuria in the NICE guideline on chronic kidney disease. [2022]

Maintain the person's blood pressure (see recommendation 1.12.8 for blood pressure targets) by adding other anti‑hypertensive drugs if necessary. [2004]

Advise adults with type 1 diabetes and nephropathy about the advantages of avoiding a high‑protein diet. [2004]

Referral criteria for tertiary care should be agreed between local diabetes specialists and nephrologists. See NICE's guideline on chronic kidney disease. [2004]

For guidance on managing chronic painful diabetic neuropathy in adults with type 1 diabetes, see NICE's guideline on neuropathic pain in adults. [2015]

Think about the possibility of autonomic neuropathy affecting the gut if adults with type 1 diabetes have unexplained diarrhoea, particularly at night. [2004]

When prescribing antihypertensive medicines, take care not to increase the risk of orthostatic hypotension from the combined effects of sympathetic autonomic neuropathy and blood pressure lowering medicines. [2004]

For adults with type 1 diabetes who have bladder emptying problems, investigate the possibility of autonomic neuropathy affecting the bladder, unless another explanation is found. [2004]

When managing the symptoms of autonomic neuropathy, include specific interventions for the manifestations encountered (for example, for abnormal sweating and postural hypotension). [2004, amended 2015]

Anaesthetists should be aware of the possibility of parasympathetic autonomic neuropathy affecting the heart in adults with type 1 diabetes who:

• are listed for procedures under general anaesthetic and

• have evidence of somatic neuropathy or other manifestations of autonomic neuropathy. [2004]

Advise adults with type 1 diabetes who have vomiting caused by gastroparesis to follow a small‑particle‑size diet (mashed or pureed food) to relieve their symptoms. [2015]

Be aware that gastroparesis needing specific therapy can only be diagnosed in the absence of hyperglycaemia at the time of testing, because hyperglycaemia delays gastric emptying. [2015]

Consider insulin pump therapy for adults with type 1 diabetes who have gastroparesis. [2015]

For adults with type 1 diabetes who have vomiting caused by gastroparesis, explain that:

• there is no strong evidence that any available antiemetic therapy is effective

• some people have had benefit with domperidone (see the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on domperidone: risks of cardiac side effects), erythromycin or metoclopramide (see the MHRA guidance on metoclopramide: risks of neurological adverse effects)

• the strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines.
  
  In August 2015, this was an off-label use of erythromycin and many higher doses or treatment durations of domperidone. See NICE's information on prescribing medicines. [2015]

To treat vomiting caused by gastroparesis in adults with type 1 diabetes:

• consider alternating erythromycin and metoclopramide (see the MHRA guidance on metoclopramide: risks of neurological adverse effects)

• consider domperidone only in exceptional circumstances (that is, when it is the only effective treatment) and in accordance with the MHRA guidance on domperidone: risks of cardiac side effects.
  
  In August 2015, this was an off-label use of erythromycin and many higher doses or treatment durations of domperidone. See NICE's information on prescribing medicines. [2015]

Refer adults with type 1 diabetes who have gastroparesis for specialist advice if the interventions in this section have not helped or are not appropriate. [2015]

Reassure adults with type 1 diabetes that acute painful neuropathy resulting from rapid improvement of blood glucose control is a self‑limiting condition and symptoms improve over time. [2015]

Explain to adults with type 1 diabetes that the specific treatments for acute painful neuropathy resulting from rapid improvement of blood glucose control:

• aim to make symptoms tolerable until the condition resolves

• may not relieve pain immediately and may need to be taken regularly for several weeks to be effective. [2015]

Use simple analgesics (paracetamol, aspirin) and local measures (bed cradles) as a first step to treat acute painful neuropathy, and if these do not help, try other measures. [2004, amended 2021]

Do not relax diabetes control to address acute painful neuropathy resulting from rapid improvement of blood glucose control in adults with type 1 diabetes. [2015]

If simple analgesia does not provide sufficient pain relief for adults with type 1 diabetes who have acute painful neuropathy resulting from rapid improvement of blood glucose control, offer treatment as described in NICE's guideline on neuropathic pain in adults. Simple analgesia may be continued until the effects of additional treatments have been established. [2015]

When offering medicines for managing acute painful neuropathy resulting from rapid improvement of blood glucose control to adults with type 1 diabetes, be aware of the risk of dependency associated with opioids. For more information, see NICE's guideline on medicines associated with dependence or withdrawal symptoms. [2015]

For guidance on preventing and managing foot problems in adults with type 1 diabetes, see NICE's guideline on diabetic foot problems. [2015]

Offer men with type 1 diabetes the opportunity to discuss erectile dysfunction as part of their regular review. [2015]

Offer a phosphodiesterase‑5 inhibitor to men with type 1 diabetes with isolated erectile dysfunction unless contraindicated. Choose the phosphodiesterase‑5 inhibitor with the lowest acquisition cost. [2015]

Consider referring men with type 1 diabetes to a service offering further assessment and other medical, surgical or psychological management of erectile dysfunction if phosphodiesterase‑5 inhibitor treatment is unsuccessful or contraindicated. [2015]

Measure blood thyroid‑stimulating hormone (TSH) levels in adults with type 1 diabetes at their annual review. [2015]

Members of diabetes professional teams providing care or advice to adults with type 1 diabetes should be alert to possible clinical or subclinical depression and/or anxiety, particularly if someone reports or appears to be having difficulties with self‑management. [2004]

Diabetes professionals should:

• ensure they have appropriate skills to identify and provide basic management of non‑severe mental health problems in people from different cultural backgrounds

• be familiar with appropriate counselling techniques and drug therapy, while arranging prompt referral to specialists for people whose mental health problems continue to interfere significantly with their wellbeing or diabetes self‑management.
  
  See also the:

• NICE guideline on common mental health problems

• NICE guideline on generalised anxiety disorder and panic disorder in adults

• NICE guideline on depression in adults with a chronic physical health problem. [2004, amended 2015]

Members of diabetes professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and disordered eating in adults with type 1 diabetes with:

• over-concern with body shape and weight

• low BMI

• hypoglycaemia

• suboptimal overall blood glucose control.
  
  See also NICE's guideline on eating disorders. [2004, amended 2021]

Think about making an early (or if needed, urgent) referral to local eating disorder services for adults with type 1 diabetes with an eating disorder. [2004, amended 2021]

From diagnosis, the diabetes professional team should provide regular high-quality support and counselling about lifestyle and diet for all adults with type 1 diabetes (see the sections on education and information and dietary management). [2004]