Treatment Pathway Positive Decision Negative Decision Treatment Pathway

Treatment Pathway Positive Decision Negative Decision Treatment Pathway for Adults with Type 1 Diabetes YES NO Existing adult patients with Type 1 diabetes Hb. A 1 c ≤ 48 mmol/L (6. 5%) or agreed targets? NO New adult patients with Type 1 diabetes (refer to structured education course KAT 1 E within 6 -12 months) Is patient able and willing to administer Multiple Daily Injections (MDI)? NO YES Basal-bolus regime First line: Long-acting twice daily (or once daily if twice daily not acceptable) insulin detemir (Levemir) PLUS Rapid acting insulin analogue (novorapid, Humalog or Apidra) BEFORE meals. Adjust dose according to blood glucose levels Mixed Insulin regime Second line: Twice daily mixed insulin regime. Dose adjusted according to Hb. A 1 C and blood glucose levels Is patient experiencing repeated unpredictable disabling hypoglycaemia OR Hb. A 1 c levels remain ≥ 69 mmol/L (8. 5%) despite a high level of care and insulin pump therapy is being considered OR risk of hypoglycaemia because of reduced awareness OR more than 2 episodes of documented DKA related admissions in the last 12 months? Basal-bolus regime Second line: Long-acting once daily insulin glargine 100 units/m. L (Abasaglar, OR Toujeo) PLUS Rapid acting insulin analogue (novorapid, Humalog or Apidra) BEFORE meals. Adjust dose according to blood glucose levels If detemir not tolerated or acceptable or if problematic lipodystrophy and/or lipohypertrophy Hb. A 1 c ≤ 48 mmol/L (6. 5%) or agreed targets? NO NO NOTE: Consider adding metformin to insulin therapy if an adult with BMI ≥ 25 kg/m 2 (23 kg/m 2 for people of South Asian and related minority ethnic groups) or above wants to improve their blood glucose control while minimising their effective insulin dose. YES Continue current therapy and monitor Hb. A 1 C every 3 -6 months. Ensure annual review NB. Please prescribe insulin by brand. Patient familiarity with the same brand is important; training is required in the use of specific devices for self-injection. Reference: UK Medicines Information YES Tier 2 Accredited Practitioner with Specialist Interest in diabetes or Tier 3 Diabetes Specialist consultant/nurse initiated: Third line once daily either Toujeo or insulin degludec (Tresiba) PLUS short/rapid acting insulin analogue BEFORE meals. Adjust dose according to blood glucose levels. Continue current therapy and monitor Hb. A 1 C every 3 -6 months. Ensure annual review YES Hb. A 1 c ≤ 48 mmol/L (6. 5%) or agreed targets? NO NO Is patient still experiencing repeated disabling hypoglycaemia after 6 months treatment OR Hb. A 1 c remains >69 mmol/L (8. 5%) OR have severe needle phobia? YES Refer to Tier 3 for consideration of continuous subcutaneous insulin infusion.