Modern strategies for management of glycaemia in type 1 diabetes Sankalpa Neupane Mark L Evans Abstract The last decade has seen significant advances in the management of type 1 diabetes. The usual management of type 1 diabetes involves ‘physio- logical’ basal bolus regimens with multiple daily insulin injections, but use of insulin pumps (continuous subcutaneous insulin infusion) is growing. Structured education programmes are of great importance in realizing the potential of the flexible insulin regimens that are now tech- nically possible; these now offer patients with type 1 diabetes standard- ized support and education in counting carbohydrates (and perhaps fat and protein) and in adjusting doses for other behavioural factors. Evolu- tion of continuous glucose monitors from being tools for ‘forensic’ retro- spective monitoring to ‘real-time’ devices for continuous use has led to major interest in strategies for glycaemic control that involve insulin pumps linked to continuous glucose monitoring, with the hope that this will provide increasing automation of insulin delivery. Data from many devices e meters, pumps and continuous glucose monitors e are downloadable and can be analysed and/or shared with healthcare pro- viders. In this chapter, we describe how modern glucose monitoring and insulin replacement can be used strategically together with education to manage glycaemia in type 1 diabetes. Keywords Continuous glucose monitoring; continuous subcutaneous insulin infusion; hypoglycaemia; insulin pumps; islet transplantation; pancreas transplantation; structured education Introduction Many technical and healthcare changes have occurred over the last few years in type 1 diabetes mellitus (T1DM). New insulin analogues (engineered either to act more rapidly or be more long lasting) continue to be developed and have been widely adopted in T1DM. The combination of rapid-acting ‘bolus’ insulin given before meals and/or as ad hoc doses to correct high blood glucose values, with long-acting background insulin replacement (by convention termed ‘basal’ if delivered by insulin pump) al- lows patients to use more ‘physiological’ basal bolus insulin regimens (Figure 1). Insulin therapy and blood glucose moni- toring are described in more depth in the article on Modern technologies for glucose monitoring and insulin replacement on pages 00e00 of this issue. Structured patient education The flexibility offered by modern variable insulin regimens pre- sents a challenge for patients, who need to learn and use many self-management skills beyond simply checking blood glucose concentration and administering insulin. For example, many people with T1DM adjust doses of meal-time rapid-acting insulin depending on the carbohydrate content of food, meaning that they need training to count carbohydrates accurately. Evidence-based structured educational packages have emerged in the UK over the last decade. The largest and best established of these is the DAFNE programme (Dose Adjustment For Normal Eating), described below, but a number of broadly similar smaller struc- tured education programmes are also being used in UK services. DAFNE is based on a patient education model developed in D€ usseldorf. In a randomized controlled trial, DAFNE improved blood glucose control and patient well-being. 1 It was introduced as clinical service in the UK in 2002. By June 2014, there were 75 What’s new? C Structured education gives patients freedom to adjust insulin doses to food and lifestyle C Insulin pumps are increasingly popular although used by less than 10% of patients with type 1 diabetes in UK C Continuous glucose monitoring is available but less established C Insulin pumps and continuous glucose monitoring can be coupled, and may incorporate a ‘threshold suspend’ feature that may benefit those with intractable hypoglycaemia C Pancreas and islet cell transplantation may give insulin inde- pendence but are reserved for those with complications and/or hypoglycaemia Figure 1 Sankalpa Neupane MBBS MRCP is a Clinical Research Fellow at Wellcome Trust/MRC Institute of Metabolic Science, University of Cambridge and Cambridge University Hospitals (Addenbrooke’s), Cambridge, UK. Conflicts of interest: none declared. Mark L Evans MD FRCP is University Lecturer/Honorary Consultant at Wellcome Trust/MRC Institute of Metabolic Science, University of Cambridge and Cambridge University Hospitals (Addenbrooke’s), Cambridge, UK. Conflicts of interest: none declared. MANAGING GLYCAEMIA IN DIABETES MEDICINE --:- 1 Ó 2014 Elsevier Ltd. All rights reserved. Please cite this article in press as: Neupane S, Evans ML, Modern strategies for management of glycaemia in type 1 diabetes, Medicine (2014), http://dx.doi.org/10.1016/j.mpmed.2014.09.006