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- Type of diabetes
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Thought I'd throw this question out there to both the newly diagnosed and those who have had T1D a lot longer as it's a question that I've been pondering over a long period seeing the experiences of newly diagnosed come through the forum doors.
Just to be clear here, T1D means every form of T1, from childhood onset through LADA.
So here's my thinking and feel free to give it a good kicking if you want, because it's a little controversial.
The NICE guidelines state that MDI is the preferred method for treating T1D, and we know that T1D has many forms and typically encompasses a honeymoon period. We also know that MDI is best done alongside carb counting and structured education to understand how you interact with the insulin you've been given.
The typical implementation of MDI as a newly diagnosed T1 in the UK is: "Take x units of long acting insulin once a day and x units with each meal, and eat carbs".
The result of such an approach is difficulty in managing glucose levels due to the pancreas firing out Insulin in fits and starts and this timing not being easy to handle alongside the necessary insulin injections that someone has to take.
In my mind, this approach is little different to the old approach to a new diagnosis where you were put on twice daily injections and told when to roughly eat. Yes you are feeding the insulin in this model, but so are you in MDI without education. The only major difference is the timing of meals is not structured based on when the two shots were taken.
Structured education is typically not offered until six to twelve months after diagnosis due to the pancreas' insulin release - whilst enough insulin is still produced, working out I:C ratios and Insulin Sensitivity Factors is nigh on impossible. Without these, managing carb counting for rapid acting insulin is extremely difficult, and we know that during the honeymoon period, these can change constantly.
Now at diagnosis, there is a huge amount going through your head. Many people don't necessarily want to know about carb counting, ISF, I:C ratio, etc, so the idea of providing set doses makes sense. It's in the period after this that the difficulties come in as many people don't understand why they are hypoing and what they can do about it, then end up here.
Given this set of statements, if we want fast turnaround on new diagnoses, should a psychological assessment be undertaken at diagnosis as to what a new patient can cope with, and treatment managed according to that, rather than brought in for a day, given two types of insulin, and sent on their merry way?
Personally, I think the best approach is still to make a new diagnosis an in-patient for a few days to give them and their family a chance to come to terms with it in a more supportive environment and to allow a better assessment of what would be the best regime for the patient during that period. Part of that determination should be a discussion with the patient of the options available and what the implications of it are. If it does turn out to be MDI, then help by providing a decent level of education as to how to use it, but if a fixed dose regime is elected, this shouldn't be an issue either.
So no, I don't think that MDI should always be the option at diagnosis. I think there are many that would opt for something simpler and more regimented. I expect that many disagree, but I'd love to know your thoughts!
Just to be clear here, T1D means every form of T1, from childhood onset through LADA.
So here's my thinking and feel free to give it a good kicking if you want, because it's a little controversial.
The NICE guidelines state that MDI is the preferred method for treating T1D, and we know that T1D has many forms and typically encompasses a honeymoon period. We also know that MDI is best done alongside carb counting and structured education to understand how you interact with the insulin you've been given.
The typical implementation of MDI as a newly diagnosed T1 in the UK is: "Take x units of long acting insulin once a day and x units with each meal, and eat carbs".
The result of such an approach is difficulty in managing glucose levels due to the pancreas firing out Insulin in fits and starts and this timing not being easy to handle alongside the necessary insulin injections that someone has to take.
In my mind, this approach is little different to the old approach to a new diagnosis where you were put on twice daily injections and told when to roughly eat. Yes you are feeding the insulin in this model, but so are you in MDI without education. The only major difference is the timing of meals is not structured based on when the two shots were taken.
Structured education is typically not offered until six to twelve months after diagnosis due to the pancreas' insulin release - whilst enough insulin is still produced, working out I:C ratios and Insulin Sensitivity Factors is nigh on impossible. Without these, managing carb counting for rapid acting insulin is extremely difficult, and we know that during the honeymoon period, these can change constantly.
Now at diagnosis, there is a huge amount going through your head. Many people don't necessarily want to know about carb counting, ISF, I:C ratio, etc, so the idea of providing set doses makes sense. It's in the period after this that the difficulties come in as many people don't understand why they are hypoing and what they can do about it, then end up here.
Given this set of statements, if we want fast turnaround on new diagnoses, should a psychological assessment be undertaken at diagnosis as to what a new patient can cope with, and treatment managed according to that, rather than brought in for a day, given two types of insulin, and sent on their merry way?
Personally, I think the best approach is still to make a new diagnosis an in-patient for a few days to give them and their family a chance to come to terms with it in a more supportive environment and to allow a better assessment of what would be the best regime for the patient during that period. Part of that determination should be a discussion with the patient of the options available and what the implications of it are. If it does turn out to be MDI, then help by providing a decent level of education as to how to use it, but if a fixed dose regime is elected, this shouldn't be an issue either.
So no, I don't think that MDI should always be the option at diagnosis. I think there are many that would opt for something simpler and more regimented. I expect that many disagree, but I'd love to know your thoughts!