Challenges in Managing T1D

Topics: Insulin, Diabetes mellitus, Diabetes Pages: 40 (9001 words) Published: January 27, 2013

Practical steps to improving the management of type 1
diabetes: recommendations from the Global Partnership
for Effective Diabetes Management
P. Aschner,1 E. Horton,2 L. A. Leiter,3 N. Munro,4 J. S. Skyler,5 on behalf of the Global Partnership for Effective Diabetes Management*
Linked Comment: Del Prato et al. Int J Clin Pract 2010; 64: 295–304.

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the ‘real world’ EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.


What’s known
• Considerable gaps in the care of adult patients
with type 1 diabetes remains, with a high
proportion of patients developing diabetes-related
• The majority of patients do not achieve glycaemic
goals because of barriers related to insulin dose
adjustment, self-monitoring of blood glucose and
fear of hypoglycaemia.
• Living with diabetes is not easy, and achievement
of glycaemic goals requires the patient to
undertake self-care behaviours with relentless
• Structured education supported by a
multidisciplinary team approach can play an
integral role in helping overcome these barriers.

What’s new
• This article provides guidance on where gaps in
care remain and how to address them based on
recent evidence.

Introduction: current challenges in
type 1 diabetes
Diabetes affects 246 million people worldwide and, of
these, approximately 22 million adults and 0.4 million
children have type 1 diabetes (1). The impact of diabetes-related complications on patients and healthcare systems is significant, with reported cumulative incidences of proliferative retinopathy, nephropathy and cardiovascular disease (CVD) of 47%, 17% and 14%,

respectively, after 30 years of diabetes (2).
Type 1 diabetes is an autoimmune disease, in which
environmental factors are thought to trigger the autoimmune destruction of pancreatic b-cells in genetically susceptible individuals. Although great progress has
been made to date in identifying genetic markers
(3,4), widespread genetic screening for susceptibility
to the disease is not yet possible. In young adults, there
is evidence that the onset of type 1 diabetes may be
progressive and characterised by a slower decline in

b-cell function compared with children and adolescents (5). Importantly, data from the Diabetes Control and Complications Trial (DCCT) suggest that residual
b-cell function is associated with improved outcomes,
such as better glycaemic control and lower risk for
hypoglycaemia and chronic complications (6).
Evidence also shows that optimisation of glycaemic
control at an early stage significantly reduces the risk
of microvascular and macrovascular complications, as
clearly demonstrated in the DCCT and its long-term
follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC) trial (7–9). Despite the clear benefits of intensive glycaemic control, there is still a large gap between evidence and practise, with the majority of...
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