Endocrine · Full case

Type 1 Diabetes

NICE NG17 CKS 2024

HbA1c ≤48Adult T1DM target (mmol/mol)

CBG 4–7Pre-meal target

<4 mmol/LHypoglycaemia threshold

Ketones ≥3.0DKA risk → 999

0.5–1 U/kgTotal daily insulin (typical)

50/50 splitMDI basal:bolus

TIR >70%CGM time-in-range target

9 care processesAnnual review

📋 Clinical Stem — New Presentation or Established T1DM in Primary Care

A patient presents with possible new-onset Type 1 diabetes, or with a question relating to existing insulin therapy

"A 24-year-old patient has booked an urgent appointment having noticed they are passing urine frequently, drinking constantly, losing weight despite eating, and feeling exhausted over the past three weeks. They have no significant past medical history. A finger-prick glucose taken by the practice nurse at reception was 22.4 mmol/L. They have come into your room looking thin, tired, and increasingly anxious about what this might mean."

This stem is intentionally broad — Type 1 diabetes presents across many primary-care scenarios. The same clinical reasoning pathway applies whether you are recognising new-onset disease, supporting someone newly discharged, or managing an established patient on insulin. Adapt your opening based on the specific setting given.

Scenario A — Classic new-onsetYoung adult with polyuria, polydipsia, weight loss, and finger-prick glucose >11 mmol/L. Risk of progressing to DKA within days — recognise and refer urgently.

Scenario B — Recent diagnosis reviewPatient discharged from hospital 2 weeks ago after T1DM diagnosis. Overwhelmed, fearful of hypos, asking about driving, work, future. Adjustment phase.

Scenario C — Established T1DM, poor controlLong-standing T1DM with HbA1c ≥75 mmol/mol. Recurrent hypoglycaemia, missed appointments, or diabetes burnout. Possible eating-related disorder (T1DE).

Scenario D — Pre-pregnancy or pregnancyWoman with T1DM planning pregnancy or recently pregnant. Tighter HbA1c target (≤48), folic acid 5mg, urgent specialist input required.

Scenario E — Sick day / intercurrent illnessPatient with T1DM presenting unwell with infection or vomiting. Ketones rising, oral intake poor — risk of DKA without correct sick-day rules.

Key variables to adapt forAge · Duration of diabetes · Ketone level · Current insulin regimen (MDI vs pump) · CGM use · Comorbidities (other autoimmune, CKD) · Pregnancy status · Driving / occupation · Mental health and eating-disorder history

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

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Why each question matters: Every question should change something — urgency, DDx, investigation, or management. Always start with an open question to let the patient set the agenda before moving to targeted questions. For Type 1 diabetes, the speed of onset, ketone risk, and psychosocial vulnerability (mental health, eating disorders, financial barriers) shape every decision that follows.

🎓 Consultation opener — use existing information first

"I've got the nurse's note here — your finger-prick sugar was 22.4 this morning. That's clearly very high, and I can see you've been unwell with the thirst and weight loss for a few weeks now. Before I explain what I think is going on, can you tell me in your own words how this has all started and how you're feeling about it right now?"

Re-asking the glucose value, the symptoms, or the duration that's already in the nurse's note costs Global Skills marks (Domain 1: avoids repetition). Acknowledging existing information and inviting the patient's story scores Relating to Others marks simultaneously.

1A — Start with an open question: let the patient lead, then move to targeted questions

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION — always start here"Tell me, in your own words, how this all started and what's been worrying you most since the symptoms began?"	Lets the patient describe symptom evolution, anxiety, and any specific fears. Opens up family history, mental health, prior healthcare experiences in a single move.Domain 1 (Tasks): efficient data gathering. Domain 2 (Relating to Others): patient-led agenda.	Sets diagnostic axisUncovers ICEFrames management tone
Onset and duration of polyuria, polydipsia, weight loss?"How long has the thirst been going on? Are you up at night to pass urine? How much weight have you lost?"	Classic osmotic symptoms over weeks — not months. Weight loss despite normal/increased eating is the hallmark distinguishing T1 from T2. Rapid weight loss + young age = high pre-test probability of T1DM.In children, onset is over weeks; in adults LADA may be more insidious.	T1DM vs T2DMRule out DKA risk
Nausea, vomiting, abdominal pain, breathlessness?"Have you been feeling sick or thrown up? Any tummy pain? Are you breathing more heavily than usual?"	Kussmaul respiration, abdominal pain, vomiting → DKA. Acetone breath is a late sign. Any one of these in a hyperglycaemic patient = same-day hospital.Children and young adults can progress from "unwell" to DKA in hours.	If present → 999Same-day admission
Personal or family history of autoimmune disease?"Have you or anyone in your family had thyroid problems, coeliac disease, vitiligo, Addison's, or Type 1 diabetes?"	Autoimmune clustering raises pre-test probability of T1DM. Coeliac and autoimmune thyroid disease are screened for at diagnosis and annually. FH of T1DM in a first-degree relative raises risk ~10-fold over background.Distinguishes T1DM from MODY (often FH of "diabetes" but with non-autoimmune pattern).	Screen TFTs, TTG-IgAT1DM vs MODY
Recent viral illness?"Have you had any colds, flu-like illnesses, or stomach bugs in the past few months?"	Coxsackie B, mumps, rubella, and other viruses are recognised triggers of autoimmune beta-cell destruction. Often the precipitant of clinical presentation in someone already developing T1DM.Useful explanatory point for patient: "Your immune system was probably preparing for this; the virus accelerated it."	Supports T1DM aetiologyExplains "why now"
Diet, appetite, and weight pattern?"What's a typical day's eating like? Has your appetite changed? Are you skipping meals?"	Establishes baseline for carbohydrate counting later. Identifies disordered eating, food insecurity, or restrictive patterns that affect insulin dosing safety. Critical for safe MDI prescribing.A history of restrictive eating + young female with T1DM = consider T1DE (diabulimia) at every review.	Sets carb counting planScreen for eating disorder
Mood, anxiety, and adjustment?"How are you feeling emotionally about all of this? Has the worry been affecting your sleep or mood?"	Diabetes distress and depression are 2–3× more prevalent in T1DM. Untreated mental health → worse glycaemic control → more complications. Recognising this at diagnosis prevents long-term burnout.PHQ-9 / GAD-7 at diagnosis and annually is best practice — Domain 1 mark.	Screen mental healthNHS Talking Therapies / DSN psychology
Alcohol intake?"How much alcohol do you drink in a typical week? Do you ever skip food when drinking?"	Alcohol blocks hepatic gluconeogenesis → severe overnight hypoglycaemia. Binge drinking without food is one of the highest-risk behaviours in T1DM. Plan must specifically address this — not generic "be sensible."A single binge can cause delayed hypoglycaemia up to 24 hours later.	Alters insulin adviceRisk of severe hypo
Occupation and driving?"What do you do for work? Do you drive? Do you hold a vocational licence?"	DVLA Group 1 (car) and Group 2 (HGV/PSV) have different rules. Occupational health implications — pilots, armed forces, drivers all require disclosure. Shift work disrupts insulin regimen dramatically.Treat-and-tell is a legal duty; failure to disclose can void insurance and may be a criminal offence.	DVLA disclosureOccupational adjustments
Pregnancy plans or current pregnancy?"Are you trying for a baby, planning one in the future, or could you be pregnant now?"	Pregnancy with poorly controlled T1DM = high risk of congenital malformations (×4), stillbirth, and pre-eclampsia. HbA1c <48 mmol/mol pre-conception is the goal. Folic acid 5mg pre-conception.Refer to combined diabetes-antenatal clinic urgently if confirmed pregnant.	Folic acid 5mg pre-conceptionCombined ante-natal clinic
Existing finger-prick monitoring or CGM use?"Do you currently check your sugars at home? With a finger-prick or a sensor?"	Establishes baseline self-management. Flash glucose (Libre 2/3) and CGM are now NICE-recommended for all adults with T1DM — patients should not be without one. Identifies missed prescriptions.A patient without CGM or willing self-monitoring is a major safety concern.	Prescribe CGMConfirms NICE adherence
Hypoglycaemia awareness and previous severe hypos?"Have you ever had a sugar so low you needed someone else's help? Do you still recognise the warning signs?"	Hypoglycaemia unawareness (Gold score ≥4, Clarke score ≥4) markedly raises severe-hypo risk and requires urgent specialist review. DVLA reporting is mandatory.Recurrent severe hypos = same-day or urgent specialist referral — never just titrate from primary care.	If recurrent severe → specialistDVLA notification

1B — Red flags: must not miss · must ask · must act

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Capillary glucose >11 mmol/L + ketones ≥3.0 mmol/L (blood) or ≥++ (urine)	Diabetic ketoacidosis (DKA) — pH may already be falling. Mortality ~1% in adults, higher in young adults. Time-critical.	999 / same-day admission
Kussmaul breathing, vomiting, abdominal pain, drowsiness, fruity breath	DKA in progress. Cerebral oedema risk in young patients with rapid fluid correction → hospital with specialist team only.	999 immediately
Hypoglycaemia <4 mmol/L with reduced consciousness or seizure	Severe hypoglycaemia — brain glucose deprivation. Risk of permanent neurological damage; risk of aspiration if vomiting.	999 + IM glucagon 1mg
Recurrent severe hypos + impaired awareness	Hypoglycaemia unawareness — Clarke/Gold score ≥4. Predicts severe hypo within 6 months. Driving illegal until reversed.	Same-day diabetes team
Suspected diabetic foot infection: ulcer + erythema, discharge, or systemic features	Charcot foot or limb-threatening infection. Same-day to specialist multidisciplinary foot service — >24h delay = amputation risk.	Same-day MDT foot
Pregnancy with HbA1c >86 mmol/mol or unrecognised hyperglycaemia in early pregnancy	Major congenital malformation risk × 4. Risk of miscarriage, stillbirth. Specialist combined clinic needed within days, not weeks.	Same-week combined clinic
Suspected new-onset T1DM in a child or young adult — even without DKA	Untreated rapid progression to DKA within hours. NG18: same-day paediatric diabetes admission — never community management of suspected new T1DM in <18y.	Same-day paediatric diabetes

🛡️

Safeguarding Considerations — Consider in Every Consultation

Type 1 diabetes can be a marker of harm. Insulin omission in a young person is one of the highest-lethality self-harm methods accessible at home, often hidden behind apparent "poor control." Children with T1DM are at increased risk of medical neglect. Always consider the wider context — especially in young adults presenting with recurrent DKA.

🏠 Domestic Abuse / Intimate Partner Violence

Partner controlling food, medication, or finger-prick monitoring → withholding insulin = serious harm
Diabetes burnout in the context of an abusive relationship is common and often missed
Look for unexplained recurrent DKA, missed clinic appointments, partner attending and speaking over patient
Use a "by the way" line at the end of consultation to enable disclosure: "How are things at home generally? Is there anything else affecting your ability to manage this?"
Use DASH tool if concerned. Refer to IDVA / MARAC if high risk.

👴 Older Adults / Carer-related Concern

Carer omission of insulin (deliberate or through poor understanding) = medication-related harm
Hypoglycaemia in frail elderly carries higher mortality than mild hyperglycaemia — over-tight control may be neglect
Financial abuse → inability to afford CGM consumables, batteries, or specialist appointments
Unexplained weight loss, dehydration, or hypoglycaemia-related falls warrant adult safeguarding review
Refer to Adult Safeguarding if concern identified; document clearly

🧒 Children in the Household

Child with T1DM presenting in DKA repeatedly → consider parental medical neglect or capacity issues
Adult parent in DKA may have left a young child unsupervised — ask explicitly
Sibling of a child with T1DM has ~10× background risk — opportunistic education
School awareness, EHCP, glucagon kit access — failure to provide these is a child-protection concern
Refer to children's social care via Local Authority pathway if any concern

💊 Self-Harm / Medication Misuse Risk

T1DE (Type 1 Diabulimia): deliberate insulin omission for weight loss — highest mortality of any eating disorder
Insulin overdose is a lethal self-harm method — ask directly if you suspect deliberate hypos
Recurrent unexplained DKA in a young woman + body-image concerns = T1DE until proven otherwise
Screen with SCOFF + diabetes-specific tools (mDEPS-R if available). Refer to specialist eating disorder service WITH a diabetes team.
Document carefully; do not delay specialist referral while "monitoring."

If a safeguarding concern is identified: You do not need certainty — a concern is sufficient to act. Document clearly in records. Discuss with your safeguarding lead. Refer to the appropriate agency (IDVA, Adult Safeguarding, Children's Services, specialist ED service). Follow your organisation's policy. The patient's glucose number is never more important than their immediate safety — never let the diabetes agenda override a safeguarding concern.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
Autoimmune thyroid disease	Hashimoto's / Graves' clusters with T1DM in ~25%. Untreated thyroid disease worsens glycaemic stability.	Annual TFTs at every diabetic review; treat hypothyroidism with levothyroxine
Coeliac disease (diagnosed or suspected)	Co-existence rate ~5–10%. Gluten enteropathy causes erratic carb absorption → unpredictable insulin response.	TTG-IgA at diagnosis + every 3 years; strict gluten-free diet stabilises glucose
Addison's disease / adrenal insufficiency	Schmidt's syndrome (autoimmune polyendocrine): adrenal crisis presents like DKA. Steroid stress dose may be needed in illness.	9am cortisol if symptoms; steroid emergency card; sick-day rules expanded
CKD (any stage)	Reduced renal clearance of insulin → ↑ hypoglycaemia risk. Tighter targets may worsen outcomes. SGLT2i contraindicated if eGFR <45.	Lower total daily insulin requirement; relax HbA1c target if frail; ACEi/ARB if ACR ≥3
CVD / IHD / stroke	T1DM is independently atherogenic. Established CVD = secondary prevention statin regardless of QRISK.	Atorvastatin 80mg; aspirin only if proven CVD; intensify BP control
Eating disorder history (anorexia / bulimia / T1DE)	Insulin omission for weight loss has the highest mortality of any ED. Recurrent DKA + young female = high index of suspicion.	Specialist ED + diabetes psychology jointly; never solo GP management
Depression / anxiety	2–3× more prevalent in T1DM. Depression independently raises HbA1c by ~5 mmol/mol. Predicts non-adherence.	PHQ-9 / GAD-7 at diagnosis and annually; treat actively; NHS Talking Therapies or diabetes psychology referral
Pregnancy (current or planned)	HbA1c >86 mmol/mol → 4× congenital malformation risk. ACEi/ARB/statin teratogenic.	Folic acid 5mg pre-conception; stop ACEi/ARB/statin; combined clinic urgently
FH first-degree relative with T1DM	~10× background risk for offspring/siblings. Influences explanation, screening discussion.	Reassurance for siblings; no routine screening unless symptomatic
Hypoglycaemia unawareness (Gold/Clarke ≥4)	Predicts severe hypo within 6 months. Driving illegal until reversed (DVLA legal duty).	Same-day specialist referral; suspend driving; relax HbA1c target temporarily

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
Systemic corticosteroids	Marked insulin resistance — basal and bolus doses may need to double during course. Highest glucose rise after lunch with morning prednisolone.	Pre-emptively raise insulin; daily CBG; do not skip insulin even if eating poorly
Beta-blockers (non-cardioselective)	Mask hypo symptoms (tremor, tachycardia) but NOT sweating. Increases risk of severe hypo. Cardioselective (bisoprolol) safer.	Counsel re sweating as a hypo cue; consider CGM mandatory
Alcohol — binge / chronic	Blocks hepatic gluconeogenesis → severe overnight hypos. Particularly dangerous when drinking on an empty stomach.	Carb snack with alcohol; reduced basal that night; never drink alone if at risk
Recreational drugs (cocaine, MDMA, cannabis)	MDMA → hyperthermia + dehydration → DKA risk. Cannabis → "munchies" without dosing insulin. Cocaine masks hypo awareness.	Harm-reduction advice; non-judgemental; consider drug service referral
Shift work / irregular hours	Disrupts basal insulin timing. Increased hypo risk overnight. Night-shift workers benefit from pump or basal change.	Specialist input; consider Toujeo / Tresiba for flexibility; CGM essential
Smoking	Multiplies microvascular complications (retinopathy, nephropathy, neuropathy) and CVD risk. Cessation is the single highest-yield lifestyle intervention.	Every consultation: cessation advice + NRT + Stop Smoking Service referral
Financial hardship / food insecurity	Skipping meals to dose insulin already prescribed → hypoglycaemia. Inability to afford CGM consumables → safety risk.	Prescription prepayment certificate; food bank signposting; social prescribing
Travel / time-zone shifts	Basal insulin timing complex; air travel rules for needles, CGM, insulin. Climate affects insulin storage.	Pre-travel plan with DSN; airline letter; spare supplies; insulated wallet
Driving — Group 1 vs Group 2	Group 1 (car): CBG ≥5 to drive, finger-prick within 2h, glucose in car. Group 2 (HGV/PSV): full assessment, no severe hypo in past year.	Counsel both — disclosure is a legal duty; document advice given
Pregnancy plans / contraception	Unplanned pregnancy with HbA1c ≥86 mmol/mol = high-risk. Effective contraception until target achieved.	Discuss contraception openly; preconception counselling once planning

1D — ICE: Ideas · Concerns · Expectations — in every consultation, not just SCA

Type 1 diabetes is lifelong and requires the patient to make hundreds of self-management decisions every day — about food, exercise, sleep, alcohol, illness. Their internal model of what the diagnosis means, what they fear, and what they hoped for from this consultation will determine whether they engage with insulin, with CGM, with carbohydrate counting, or whether they quietly skip doses for years. Uncovering ICE early transforms the consultation from a clinical handover into a partnership the patient can sustain. In clinic, it shapes adherence for decades. In SCA, it earns Relating to Others marks.

💭 Ideas

"What do you think might be going on? Have you had any thoughts about what could be causing all this — the thirst, the weight loss, the exhaustion?"

Uncovers their model. Common ideas include "stress," "thyroid problems," "cancer," or — in someone with FH — "diabetes like my dad." Each requires a different starting point for explanation. If they've already worried it's diabetes, your job is gentler.

😟 Concerns

"What's been on your mind most about all of this? Is there a particular fear — about what this is, or what treatment might mean?"

Names the hidden fear. Common concerns: "Will I have to inject for the rest of my life?", "Does this mean I can't have children?", "Will I lose my job / licence?", "My aunt died of diabetes." Each fear must be named and addressed specifically in your plan, not glossed over.

🎯 Expectations

"What were you hoping I'd be able to do for you today — were you expecting a particular test, a referral, or something to take home?"

Validates the request. Many patients expect "just a tablet like my friend's diabetes." Positioning insulin as the only safe option — without lecturing — depends on knowing what they were hoping for. SCA: explicit shared-decision step earns Relating to Others marks.

1E — Psychosocial context: the person behind the diagnosis

Type 1 diabetes is a 24/7 self-management condition. Mental health, food security, family support, work patterns, and health beliefs all determine whether the patient can dose insulin safely tomorrow morning. These factors do not just affect "compliance" — they shape glucose variability, hypoglycaemia risk, and complication trajectory directly. Explore them at diagnosis, not as an afterthought. A regimen that ignores the patient's life will not be followed and may cause harm.

🧠 Mental Health & Diabetes Distress

Depression doubles the risk of severe hyperglycaemia and worsens HbA1c by ~5 mmol/mol. Diabetes-specific distress is distinct from depression — burnout from constant decisions about food, dosing, and numbers. Untreated → quiet insulin omission.

"How has your mood been since this all started? Has the worry been keeping you awake or affecting your appetite?"

If PHQ-9 ≥10 or diabetes distress prominent: refer to diabetes psychology service; consider NHS Talking Therapies; address before pushing tight HbA1c.

🍽️ Eating Behaviour & T1DE Risk

Disordered eating affects ~30% of young women with T1DM at some point. T1DE (insulin omission for weight loss) has the highest mortality of any eating disorder. Recurrent DKA, body-image concerns, or skipped boluses are red flags.

"How do you feel about food and your body right now? Have you ever skipped insulin because of how it might affect your weight?"

Joint referral to specialist eating disorder service + diabetes psychology. Do NOT push intensification of insulin alone — may worsen the pattern.

💰 Financial & Practical Barriers

Prescription costs (esp. multiple insulin pens, lancets, sensors), access to CGM, fridge storage, ability to attend specialist appointments, and food security all determine whether the regimen is achievable. Insulin omission for cost reasons is common and rarely volunteered.

"Are there any practical things — getting prescriptions, time off work, affording bits and pieces — that might make day-to-day management harder?"

Offer: NHS prescription prepayment certificate, exemption discussion, social prescribing, food bank signposting, DSN home visit if needed.

💑 Family & Relationships

A supportive partner / parent is the strongest predictor of long-term adherence and freedom from severe hypoglycaemia. Conversely, controlling partners or anxious parents can drive disordered behaviour. Sexual function, contraception, and pregnancy planning are commonly avoided topics.

"Who's at home with you? Who knows about the diagnosis? Is there anyone you'd want involved in your appointments or care planning?"

Partner education improves outcomes — invite them to a future appointment. Pregnancy planning conversation belongs at every review for women of reproductive age.

🏢 Work · Shift Patterns · Driving

Shift work disrupts basal insulin timing. Manual labour with unpredictable carb expenditure increases hypo risk. Driving licence and occupational disclosure are legal duties patients often try to avoid. Loss of HGV/PSV licence is a real and feared consequence.

"Tell me about your work — hours, physical demands, driving requirements. Have you thought about what telling your employer might mean?"

Document DVLA advice given. Occupational health referral via employer if needed. Reasonable adjustments are required by law under the Equality Act.

🌐 Health Beliefs & Cultural Context

Beliefs about insulin ("starts at insulin = end of the road"), about the meaning of a chronic diagnosis, fatalism, and previous bad healthcare experiences all shape engagement. Religious observance (Ramadan fasting) requires specific planning. Cultural diet shapes carb counting practicality.

"How do you feel generally about being on injections long-term? Are there any beliefs about diabetes — or experiences in your family — that might be on your mind?"

Shared decisions only work if the explanatory framework is acknowledged first. Ramadan fasting in T1DM needs a structured pre-Ramadan consultation — never improvise on day one.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I can see from the nurse's note your sugar was 22 this morning..."

"Tell me, in your own words, how this all started and how you're feeling about it..."

"What's been going through your mind most about what this might be?"

"How has all this been affecting your work, your eating, your mood, your sleep?"

Deductions (examiner flags)

Re-asking the glucose number or symptom duration already in the nurse's note (Domain 1 deduction)
Opening with closed SOCRATES-style Qs before an open question
Tick-box ICE without naming and exploring the specific fear (job loss, pregnancy, family member with diabetes)
Missing the ketone-symptom screen (vomiting / abdo pain / Kussmaul breathing) — DKA can be present without overt collapse
No psychosocial context gathered at all (work, mood, eating behaviour, finances)
Not considering eating disorder risk or safeguarding in a young person with diabetes

🔴 Red — failing

Ignores nurse's note; starts with closed Qs; no ICE; no psychosocial; doesn't screen for ketonaemia symptoms; doesn't ask about mood or eating; treats this as a routine "diabetes" consultation

🟠 Amber — borderline

Opens reasonably but ICE formulaic; some symptoms gathered but ketone-screen incomplete; psychosocial mentioned but not explored; pregnancy/driving not raised when relevant

🟢 Green — passing

Uses nurse's note; open Q first; ICE completed with the specific fear named; DKA-symptom screen explicit; psychosocial (mood, food, work, finance, driving) addressed; data gathering complete by 6–7 min

Step 2

Triage Engine — Emergency · Urgent · Routine

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The most important decision in every T1DM consultation. Before examination, investigations, or insulin choice — triage determines whether the patient leaves your room safely. A patient with new osmotic symptoms and ketones can progress from "looks unwell" to DKA-coma within hours. Getting this wrong = patient harm.

🔴 Emergency

999 or Same-Day Hospital

Call 999 / A&E now

DKA: glucose >11 + ketones ≥3.0 mmol/LEven one of: vomiting, Kussmaul breathing, drowsiness, abdo pain — call 999, IV access if possible, do NOT give insulin in community
Suspected new T1DM in child (<18y)NG18: same-day paediatric diabetes admission. Do not start insulin in primary care. Phone the paediatric team directly.
Severe hypoglycaemia (<4 + impaired consciousness or seizure)IM glucagon 1mg if no IV access; recovery position; 999
Suspected hyperosmolar state with severe dehydrationMore typical of T2DM but can occur in T1DM; signs of shock = 999
Diabetic foot infection with systemic features or rapid progressionLimb-threatening infection — same-day MDT foot service. >24h delay risks amputation.
DKA in pregnancy at any glucose levelPregnancy can produce DKA at lower glucose (euglycaemic DKA, esp. with SGLT2i) — 999 obstetric team

🟠 Urgent

Same-Day GP / Urgent Referral

Days to 2 weeks

New suspected T1DM in adult — clinically stable, ketones <3.0Same-day phone-call to specialist diabetes team; start insulin via specialist guidance only
Pregnancy with established T1DMCombined diabetes-antenatal clinic within days; not routine ante-natal pathway
Recurrent severe hypoglycaemia / impaired awarenessSame-day diabetes team; suspend driving; do not titrate insulin in primary care alone
HbA1c ≥86 mmol/mol in adultUrgent specialist review; high complication risk; possible insulin regime change required
Suspected T1DE / eating disorder + diabetesJoint specialist eating-disorder + diabetes pathway. Never solo GP management.
Diabetic foot ulcer (without systemic features)MDT foot service within 24h per NICE NG19

🟢 Routine

Manage in Primary Care

GP practice

Established T1DM, stable on MDI / pump, HbA1c approaching targetRoutine annual review with 9 care processes; QOF
Repeat insulin prescribing & consumablesVerify with specialist letter; ensure CGM access; co-prescribe sharps bin
Lifestyle / dietary advice in established T1DMCarb counting reinforcement; DAFNE referral if not yet attended
Statin / BP / contraception in established T1DMRoutine primary care role — atorvastatin per QRISK + comorbidities
Annual influenza, COVID, pneumococcal vaccinationMandatory in T1DM (pneumococcal once; flu annually; COVID per schedule)

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Say this before management

"Before we go any further, I want to make sure there's nothing urgent that needs hospital today — can I check a few specific things about how you've been feeling?"

"I'm going to do a quick ketone test on your blood — this tells me whether things are heading into a dangerous direction or whether we have time to plan properly."

Deductions

Going straight to "I'm going to refer you to the diabetes team" without verbalising the triage decision
Missing ketone measurement when glucose is >11 and the patient is symptomatic
Not considering DKA in a vomiting patient with diabetes
Failing to verbalise red-flag screen aloud — examiners can only mark what they hear

🔴 Red

Goes straight to management plan; no safety screen; doesn't check ketones in a symptomatic hyperglycaemic patient; misses DKA risk

🟠 Amber

Some red-flag questions asked but ketone-symptom screen incomplete; triage decision not verbalised explicitly

🟢 Green

All red flags screened and named aloud; correctly triages emergency/urgent/routine; rules in/out DKA explicitly before any management discussion

Step 3

Do I Need This Examination?

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"Will this examination change management?" is the key question before any clinical assessment. In T1DM, examination findings can move you from routine review to same-day admission within minutes. Every finding below has a direct management consequence.

Examination	Why it matters	What finding changes management	Changes management?
General appearance — hydration, alertness, weight	Dry mucous membranes, sunken eyes, lethargy = dehydration of DKA. Recent rapid weight loss is documented baseline for refeeding tracking.Weight loss >5% in weeks = T1DM until proven otherwise.	Dehydrated/drowsy/Kussmaul → 999. Document weight as baseline.	YES — always
Respiratory rate & pattern	Kussmaul respiration (deep, sighing, ~30/min) is metabolic acidosis compensation = DKA. Fruity (acetone) breath if you can smell it.	Kussmaul pattern → 999 + IV access	YES — urgency
Capillary glucose (point-of-care) — repeat in your room	Confirms nurse's reading; can be falsely high if finger contaminated with sugar. A second reading from a properly wiped finger is mandatory before acting on a "shock" value.	>11 confirmed + symptomatic → measure ketones now	YES — diagnostic
Capillary or urine ketones	Blood ketones (β-hydroxybutyrate) preferred — urine ketones lag. ≥3.0 mmol/L = DKA risk; 1.5–3.0 = significant; <0.6 = normal. NG17: every practice should be able to measure.	≥3.0 → 999. 1.5–3.0 → urgent specialist contact. <0.6 → safe for community planning.	YES — pivotal
BP — supine and standing	Hypotension + tachycardia = dehydration of DKA. Postural drop >20 mmHg in young adult = significant volume loss. Hypertension in established T1DM = baseline for nephropathy management.	Postural drop or hypotension in newly diagnosed → 999. Hypertension in established T1DM → ACEi if ACR ≥3.	YES — drug choice
Examination of injection sites (established T1DM)	Lipohypertrophy ("lumpy" sites) causes erratic insulin absorption and unexplained variability. Up to 50% of long-term users have lipohypertrophy and don't know.	Visible/palpable lumps → rotate sites; consider new sites; CGM mandatory	YES — adherence/variability
Foot examination — protective sensation, pulses, skin, deformity	Annual foot check is a QOF requirement and a NICE NG19 mandate. Lost monofilament sensation = neuropathy → high-risk classification. Charcot deformity is limb-threatening and often missed.	Loss of sensation + ulcer or erythema → same-day MDT foot service; no monofilament sensation → high-risk; education + footwear	YES — risk stratifies
Skin — acanthosis, vitiligo, lipohypertrophy, infections	Vitiligo points to autoimmune cluster (favours T1DM over T2DM). Acanthosis nigricans suggests insulin resistance (favours T2DM). Skin infection in poorly controlled T1DM = poor wound healing.	Vitiligo supports T1DM diagnosis; acanthosis prompts re-evaluation of classification	YES — diagnostic axis
Fundoscopy / refer to diabetic eye screening	Retinopathy is asymptomatic until late. Annual digital retinal photography is mandatory in T1DM ≥12y. New visual symptoms = urgent ophthalmology, not "wait for screening."	Background retinopathy → routine; pre-proliferative/proliferative/macular → urgent ophthalmology	YES — sight-saving
BMI / waist circumference	Helpful in classification — very thin newly-presenting young adult = classical T1DM; overweight + ketone-prone = atypical; consider MODY or T2DM. Tracks weight recovery after diagnosis.	Documented baseline; informs SGLT2i adjunct decision (BMI ≥27 only)	YES — classification

🎓 SCA Checkpoint — Step 3Tasks

How to propose examination

"There are a few things I'd really like to check — I'll repeat your blood sugar with a clean finger, I'll check for ketones in your blood, look at your breathing, and check your blood pressure both lying and standing. Each of these tells me whether this is something we can plan today or whether we need the hospital team involved straight away."

Deductions

Proposing examination without explaining rationale — loses Tasks mark
Failing to measure ketones in a symptomatic patient with hyperglycaemia
Not assessing for Kussmaul respiration or postural BP drop
Not examining feet at any T1DM review (annual QOF requirement)

🔴 Red

No examination proposed or rationale given; ketones never mentioned; no foot examination at established T1DM review

🟠 Amber

Examination proposed but rationale not explained; ketones measured but result not interpreted; postural BP missed

🟢 Green

Appropriate examination selected with rationale; ketones measured and interpreted; injection sites or feet checked appropriately; each finding linked to management change

Step 4

Do I Need This Investigation?

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Every investigation should answer a specific clinical question. Before requesting any test in suspected or established T1DM: what result will change my management?

Investigation	Clinical question it answers	What result changes management?
Random venous glucose	Confirms hyperglycaemia. ≥11 mmol/L + classical symptoms = diabetes (single reading sufficient if symptomatic). Asymptomatic needs 2 elevated readings.	≥11 + symptoms → diabetes confirmed → urgent classification (T1 vs T2). <11 + symptoms → exclude transient hyperglycaemia, reassess.
HbA1c	Reflects glycaemia over 8–12 weeks. ≥48 mmol/mol = diabetes (without symptoms). Less reliable in rapid-onset T1DM where weeks of hyperglycaemia may not yet be reflected.	≥48 → diabetes confirmed. <48 + symptoms + high glucose → don't rule out T1DM (HbA1c lags). Pregnant + ≥48 → urgent combined clinic.
Capillary or venous ketones (point-of-care)	Pivotal test in suspected new T1DM and in any unwell T1DM patient. β-hydroxybutyrate preferred over urine. Quantifies DKA risk in real time.	≥3.0 → 999. 1.5–3.0 → urgent contact specialist. <0.6 → safe to plan in community.
Islet autoantibodies (GAD-65, IA-2, ZnT8) — order at diagnosis	Distinguishes T1DM from T2DM and MODY when classification uncertain. Positive ≥1 antibody supports T1DM strongly. NICE recommends if classification ambiguous (e.g. older adult, overweight, slow onset).	Positive → confirms T1DM/LADA → insulin-based management. Negative + young + no FH → consider MODY, refer genetics.
C-peptide (paired with glucose)	Marker of endogenous insulin reserve. Useful 3–5 years after diagnosis to distinguish T1DM (very low) from T2DM/MODY. Not reliable at presentation in T1DM (may still produce some insulin in honeymoon).	Low (<200 pmol/L) after 3y supports T1DM. Preserved supports T2DM/MODY → consider switching to oral therapy under specialist guidance.
U&E + eGFR + creatinine	Baseline renal function. K⁺ may be falsely normal/high in DKA (insulin deficiency drives K⁺ out of cells). eGFR affects SGLT2i eligibility (>45 to start, monitor closely).	Hyperkalaemia in DKA = expected; falls with treatment → potassium replacement plan. eGFR <45 → SGLT2i contraindicated; eGFR <30 → avoid altogether.
TFTs + TTG-IgA (with total IgA)	Co-existing autoimmune thyroid disease (~25%) and coeliac disease (~5–10%) screened at diagnosis. Untreated thyroid disease worsens glycaemic stability; undiagnosed coeliac causes erratic carb absorption.	TFTs abnormal → treat hypothyroidism; refer hyperthyroidism. TTG-IgA positive → gastroenterology + duodenal biopsy.
Lipid profile (fasting if possible)	CVD risk in T1DM is markedly raised. Statin indicated regardless of QRISK if duration ≥10 years, age ≥40, or established complications.	Per NICE NG28/NG17: atorvastatin 20mg in adults with T1DM aged ≥40, OR duration >10y, OR established nephropathy, OR other CVD risk factors.
Urine albumin:creatinine ratio (first-morning sample)	Earliest sign of diabetic nephropathy. ACR ≥3 = microalbuminuria → ACEi/ARB regardless of BP. Annual after 5 years of diabetes (NG17).	ACR ≥3 → start ACEi/ARB; tighten BP target <130/80. ACR ≥30 → urgent renal review.
Annual retinal screening + foot screening + BP + weight + smoking status	The "9 care processes" — QOF and NG17 mandate at every annual review. Identifies asymptomatic complications. Omission of any one is a QOF failure and clinically negligent.	Each abnormal result triggers a specific specialist or pharmacological pathway (e.g. retinopathy → ophthalmology; smoking → Stop Smoking Service)

🎓 SCA Checkpoint — Step 4TasksRelating to Others

How to explain investigations to the patient

"I'd like to check your blood for ketones now — this is a small finger-prick that tells me whether the diabetes is heading anywhere dangerous today."

"I want to send some bloods today — checking the overall sugar control over the past few months, your kidneys, your thyroid, coeliac disease, and a special test that confirms which type of diabetes this is."

"And once you're stable, we'll arrange your eye screening and a check on a urine sample for kidney protection — these are protective things we do once a year for everyone with diabetes."

Deductions

Not measuring ketones at point of presentation with hyperglycaemia
Ordering tests without explaining why to the patient
Missing islet antibody / C-peptide when classification uncertain
Not initiating the 9 care processes at annual review

🔴 Red

No ketone test; orders bloods without explanation; classification axis not addressed; annual care processes not mentioned

🟠 Amber

Ketones requested but not explained; partial blood panel; care processes not all initiated

🟢 Green

Ketones explained + linked to action; full diagnostic panel rationalised; 9 care processes initiated; each test linked to a specific management question

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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Two types of diagnosis in primary care: conditions you can confidently diagnose and start a plan for (then refer for specialist insulin initiation), and conditions you suspect but must refer for confirmation. In Type 1 diabetes the GP role is recognition + safe triage + same-day specialist contact. Then explain the diagnosis in plain language and address the patient's own ideas about what is happening.

🗣️ Explaining the Diagnosis in Plain Language — say something like this

"What I think has happened is something called Type 1 diabetes. Your body has a small organ called the pancreas, and one of its jobs is to make insulin — a hormone that acts like a key, letting sugar from your food move out of the blood and into the cells of your body where it's used for energy. In Type 1 diabetes, the immune system has — by mistake — destroyed the cells that make insulin. That means sugar builds up in the bloodstream because it can't get into the cells, and your body starts breaking down fat for energy instead — that's why you're losing weight and feeling exhausted. This is not your fault, it isn't because of anything you ate or didn't eat, and it isn't the same condition you may have seen in older relatives. The treatment is to replace the insulin your body is no longer making. With modern injections, sensors, and proper support, almost everyone with this lives a full, normal life — but we need to get you started safely today."

💬 Addressing the patient's own explanation — why it may not be the full picture

"Surely this is just because I've been so stressed at work?"
"Stress can make sugar levels rise temporarily, and it absolutely could have brought things to a head — but the level of sugar we're seeing, the weight loss, and the speed it's all happened tells me this is something different. Your body has actually been heading this way for a while, and the stress probably accelerated the moment it became obvious. The good news is — now that we know — we can give your body exactly what it's missing."

"My nan had diabetes, so I'll just take a tablet like she did, won't I?"
"That's a really important question. There are two main types of diabetes, and they're very different. The kind your nan had — Type 2 — usually develops slowly, and the body still makes some insulin, just not enough or it doesn't work well, so tablets can help. The kind I think you have — Type 1 — happens when the body stops making any insulin at all. The only safe treatment is to put insulin back in, with injections or a pump. Tablets won't work here, and using them instead of insulin could be very dangerous. I know that sounds frightening — but injections today are much easier than people imagine, and the support team will go through every step with you."

A — Diagnosable in Primary Care

GP can diagnose

Established Type 1 Diabetes

Documented previous diagnosis, on insulin, established with specialist team. GP role: monitoring, complication screening, repeat prescribing, lifestyle support, annual review.

Hypoglycaemia (recognised, treatable)

CBG <4 mmol/L. Mild = patient self-treats with 15g rapid carb. Severe (impaired consciousness) = same-day review of regimen.

Mild hyperglycaemia in known T1DM

Glucose elevated but ketones <1.5, no systemic symptoms. Correction dose, fluid, monitor — re-attend if not settling.

B — Suspected — Refer

Refer for confirmation

New-Onset Type 1 Diabetes

Classical osmotic symptoms + glucose >11 + age typically <35. Recognise → same-day specialist contact. Do NOT start insulin alone in primary care.

LADA (Latent Autoimmune Diabetes in Adults)

Adult-onset, slowly progressive, often initially mistaken for T2DM. GAD-positive. Eventually requires insulin. Specialist endocrinology referral.

MODY (Maturity-Onset Diabetes of the Young)

Strong FH (3 generations), young onset, antibody-negative, often responds to sulfonylureas. Genetic confirmation needed — refer specialist diabetes / genetics.

Type 2 Diabetes (atypical presentation)

Especially in young South Asian patients with obesity. Pancreatic insufficiency, autoantibodies, and ketone trajectory help classify. Specialist input if uncertain.

C — Emergency — Act Now

Diagnose & act

Diabetic Ketoacidosis (DKA)

Glucose >11 + ketones ≥3.0 + acidaemia (pH <7.3 / HCO₃ <15). Vomiting, Kussmaul respiration, abdominal pain, drowsiness. Mortality 1–2%. 999 immediately.

Severe Hypoglycaemia with Impaired Consciousness

CBG <4 + reduced GCS / seizure / unable to self-treat. IM glucagon 1mg if no IV; 999. Recovery position; aspiration risk.

Hyperosmolar Hyperglycaemic State (HHS) — rare in T1DM

More typical of T2DM but possible in T1DM with very poor adherence. Glucose >30, osmolality >320, minimal ketones, profound dehydration. 999.

📊 Diagnostic Classification — Type 1 vs Type 2 vs MODY vs LADA

Feature	Type 1 DM	Type 2 DM	MODY	LADA
Typical onset	<35y (but any age)	>40y, may be earlier in some ethnicities	<25y, strong FH	30–50y, slowly progressive
Body habitus	Lean / recent weight loss	Often overweight / central	Usually lean	Often lean
Onset speed	Weeks (classical) or months	Months to years	Years	Months — initially "T2-like"
Ketosis at diagnosis	Common / prone	Rare unless severe stress	Rare	Late, eventually present
Islet antibodies (GAD/IA-2)	Positive (~90%)	Negative	Negative	Positive — diagnostic
C-peptide after 3y	Very low / undetectable	Preserved or raised	Preserved	Falling — eventually low
FH first-degree relative	~10–15%	40–50%	~3 generations (autosomal dominant)	Variable
Treatment	Insulin — lifelong, mandatory	Lifestyle → metformin → escalation	Often sulfonylureas (HNF1A/4A)	Eventually insulin

🎓 SCA Checkpoint — Step 5TasksRelating to Others

Verbalising diagnosis in plain language

"Your body has stopped making a hormone called insulin — think of insulin as a key that lets sugar from your food into your cells. Without it, sugar builds up in the blood and your body starts burning fat instead, which is why you've lost weight and feel exhausted."

"I know you may have seen relatives take tablets for diabetes — but their type and yours are very different conditions. Yours needs insulin from the very start, because the body has no way to make its own. Tablets won't work and can be unsafe."

"None of this is your fault. It's not from anything you ate or any choice you made. It's your immune system attacking the wrong cells — like an allergy gone wrong inside the pancreas."

Deductions

Medical jargon ("autoimmune", "beta cells", "ketogenic") without lay equivalent
Conflating Type 1 and Type 2 — or saying "you've got diabetes" without specifying type
Not addressing the patient's specific fear (lifelong injections, pregnancy, work loss)
Failing to verbalise the working diagnosis aloud and ask if it makes sense
Starting insulin without specialist contact (Tasks fail in adult; clear deduction in child)

🔴 Red

Jargon throughout; doesn't distinguish T1 from T2; patient's specific fear not addressed; treats it as a "tablet diabetes" conversation

🟠 Amber

Some lay language but patient's own beliefs not specifically challenged; T1 vs T2 mentioned but not clearly explained; specialist role implied but not named

🟢 Green

Insulin-as-key analogy or equivalent; patient's fear (e.g. lifelong injections, pregnancy, work) directly addressed; T1 vs T2 distinction shared in plain language; "not your fault" framing; specialist same-day contact explained

Step 6

If Referral Is Needed — What the GP Does Before & During

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Most platforms say "refer" and stop there. The gap between deciding to refer and the patient arriving in secondary care is where GP care has the biggest impact — and the biggest medico-legal risk in T1DM. In suspected new-onset disease, what you do in the next 30 minutes determines whether your patient walks into the diabetes clinic tomorrow — or arrives by ambulance in DKA tonight.

Condition	Urgency	What GP does before referral	What GP must NOT do
DKA (any age)	999 now	Phone 999 + send blue-light. IV access if competent. Saline if very dehydrated. Stay with patient.	Do NOT give insulin in community. Do NOT delay for further bloods. Do NOT let patient drive home.
Suspected new T1DM in child / young person (<18y)	Same-day paediatric admission	Phone paediatric diabetes team directly. Send to paediatric ED — not adult. Document conversation with name.	Do NOT start insulin. Do NOT send via routine OPD. Do NOT delay because patient "looks well."
Suspected new T1DM in adult, stable, ketones <3.0	Same-day specialist contact	Phone adult diabetes team. Take CBG, ketones, U&E, HbA1c, islet antibodies, C-peptide. Safety-net specifically for DKA symptoms.	Do NOT start insulin without specialist input. Do NOT discharge without same-day team contact.
Pregnancy with established T1DM	1–2 weeks (urgent combined clinic)	Folic acid 5mg (not 400 µg) daily. Stop ACEi / ARB / statin if pregnant. Refer to combined diabetes-antenatal clinic urgently. Re-emphasise CGM use.	Do NOT continue teratogenic drugs. Do NOT delay referral to routine ante-natal pathway.
Recurrent severe hypoglycaemia / impaired awareness	1–2 weeks	Document Gold/Clarke score. Suspend driving (legal duty if Group 1; mandatory if Group 2). Reduce basal/bolus cautiously. Same-day diabetes team contact.	Do NOT continue current regimen unchanged. Do NOT ignore DVLA reporting duty.
Suspected T1DE (eating disorder + diabetes)	1–2 weeks	Joint referral: specialist eating disorder service + diabetes psychology. Document carefully and non-judgmentally. Address physical risk (electrolytes, weight, BMI).	Do NOT solo manage. Do NOT push insulin intensification alone — may worsen behaviour.
Diabetic foot ulcer with active infection	Same-day MDT foot service	Dress and offload. Take swab if exudate. Antibiotics per local protocol (often flucloxacillin + amoxicillin or co-amoxiclav). Tetanus check.	Do NOT debride sharply. Do NOT delay beyond 24h. Do NOT manage as routine cellulitis.
Pump dysfunction / CGM failure with hyperglycaemia	1–2 weeks / same-day if unstable	Revert to MDI temporarily if patient knows how. Contact specialist pump team directly. Ensure ketone check.	Do NOT advise stopping insulin altogether. Do NOT troubleshoot pump from primary care — refer.

🎓 SCA Checkpoint — Step 6TasksGlobal Skills

How to explain referral to the patient

"What I want to do is phone the specialist diabetes team right now while you're with me. They'll either see you in the hospital today or arrange to start your insulin safely with someone there to walk you through it. I'll keep you here while I make that call. In the meantime, here's what to watch out for — and exactly what to do if any of these happen on the way home."

Deductions

Sending a suspected new T1DM patient home with a routine clinic appointment
Starting insulin in primary care without specialist input — especially in a child
Not explaining why the referral is urgent — patients with no symptoms may underestimate
Failing to provide named-symptom safety-netting before the patient leaves

🔴 Red

Refers without same-day contact; sends home with leaflet; misses the urgency entirely; no safety-net for DKA symptoms

🟠 Amber

Correct urgency for referral but patient not told reason; interim safety-netting vague; doesn't phone team directly

🟢 Green

Correct urgency; phones specialist team during consultation; reason and pathway explained in plain language; specific DKA safety-netting before patient leaves; "do not" actions identified and documented

Step 7

Management — Expectation · Goals · Lifestyle · Drug Selector · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

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7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan

Validate — name their expectation

Acknowledge what they came hoping for — typically "a tablet" or "a tablet now and insulin later." Don't make them feel naive for asking. This earns trust before you have to deliver harder news.

"I completely understand why you were hoping this might be the kind that's managed with tablets — that's what most people picture when they hear the word diabetes, and I'd have hoped the same."

Explain — share your clinical reasoning

Offer the reason behind the plan without lecturing. Frame insulin as the safe, evidence-based option for this specific type of diabetes — not as bad news or a worst-case escalation.

"With this particular type, your body has stopped making any insulin at all — tablets work by helping a body that's still making insulin, so they don't have anything to work with here. Putting insulin back in is what we know works safely and lets you live exactly the life you want."

Negotiate — offer something today

Never leave with nothing agreed. Even when the bigger plan involves specialist input, you must own the next 24 hours — same-day contact, safety-netting, named follow-up.

"What I'm going to do right now is phone the specialist team. They'll start the insulin safely with you today, and there's a diabetes specialist nurse who'll teach you everything — most people are doing the injections themselves within an hour. I'll call you tomorrow to make sure you're settled."

Key principle: A new diagnosis of Type 1 diabetes is a life-changing moment for the patient. They will remember how you delivered it for decades. A plan arrived at through validation and shared reasoning is the foundation of every consultation that follows — for the rest of their life with diabetes.

7B — Why treatment matters: goals tailored to this patient

Treatment goals

↓ Microvascular complications by ~60%↓ Macrovascular events Avoid DKAAvoid severe hypoglycaemia Preserve sight (retinopathy)Preserve kidneys (nephropathy) HbA1c ≤48 (or ≤53 if hypo-prone)Time-in-range >70% on CGM

Motivational language — tailored to the patient

"Tight, well-managed control from the very start makes a huge difference — it cuts the risk of eye, kidney, and nerve problems by more than half over decades. We have time on our side, and the work you put in now pays off for the rest of your life."

"The aim isn't perfect numbers all the time — that's not realistic and not safe. The aim is staying mostly in range, avoiding the dangerous lows, and getting on with everything you want to do — work, sport, kids one day, holidays, all of it."

7C — Non-medication management: mechanism + evidence + tailored advice

Never give generic lifestyle advice. In Type 1 diabetes, lifestyle is not an alternative to insulin — it is the daily framework that lets insulin work safely. Each intervention below has a specific mechanism and a concrete behaviour to recommend. Tailor it to what this patient's life actually looks like, and agree one change today rather than five they won't follow.

🍞

Carbohydrate Counting

DAFNE course; 1U per ~10g carb (individualised)

Mechanism

Carb intake is the main driver of post-prandial glucose. Matching bolus insulin to grams of carbohydrate gives much tighter control than fixed doses. Improves HbA1c by ~5–10 mmol/mol.

Practical

Refer to local DAFNE (Dose Adjustment For Normal Eating) structured education programme. Apps: Carbs & Cals, MyFitnessPal. Start with one staple meal counted accurately.

↓ HbA1c 5–10 mmol/mol + flexibility

🏃

Exercise & Activity

150 min/wk aerobic + resistance × 2/wk

Mechanism

Exercise improves insulin sensitivity for up to 48 hours. Reduces total insulin requirement, CVD risk, and improves mental health. Risk: delayed hypoglycaemia overnight after evening exercise.

Practical

Check CBG before, during (if >1h), and after exercise. 15–30g carb if CBG <7. Reduce bolus before planned exercise by ~25–50%. CGM essential.

↑ Insulin sensitivity + ↓ CVD risk

🍺

Alcohol Awareness

≤14 units/week, spread, with food

Mechanism

Alcohol blocks hepatic gluconeogenesis → severe overnight + next-day hypoglycaemia, especially after binge drinking on an empty stomach. A single binge can cause delayed hypos up to 24h later.

Practical

Always eat carbs alongside alcohol. Tell someone (partner/friend) you have T1DM. Carry glucose. Lower the bedtime basal slightly after drinking. Avoid drinking alone.

Prevents severe overnight hypo

🚭

Smoking Cessation

Complete cessation

Mechanism

Smoking multiplies microvascular complications (retinopathy, nephropathy, neuropathy) and CVD risk in T1DM. Endothelial damage compounds hyperglycaemia damage.

Practical

Every consultation: brief advice + Stop Smoking Service referral + NRT/varenicline. Vape considered harm-reduction. Quit-date set within 4 weeks for motivated patients.

↓ CVD risk 50% within 1yr

🤒

Sick Day Rules

Never stop insulin during illness

Mechanism

Illness raises insulin requirements via cortisol and inflammatory cytokines. Stopping insulin → DKA within hours, even with poor appetite. Most preventable cause of DKA.

Practical

"Sick day rules": continue basal; check CBG every 2h; check ketones if CBG >13; small sips of sugary fluids if not eating; correction doses per personal plan; seek help if ketones rising or vomiting persistent.

Prevents avoidable DKA admissions

😴

Sleep & Stress Management

7–9h/night; daily stress reset

Mechanism

Sleep deprivation raises cortisol → insulin resistance → hyperglycaemia. Chronic stress increases glucose variability. Nocturnal hypo also disrupts sleep, creating a feedback loop.

Practical

Use CGM alarms for night-time lows. Apps: Headspace, Calm. Refer to NHS Talking Therapies if anxiety or low mood. Mindful self-management courses available via Diabetes UK.

↓ Glucose variability + burnout

7D — Prescribing guide: what to start, in what order, and why

NICE NG17 multi-dose insulin (MDI / basal-bolus) regimen is the gold-standard for adults with T1DM. A long-acting basal insulin once or twice daily replaces basal physiological insulin secretion; a rapid-acting bolus insulin matched to carbohydrates at each meal replaces prandial insulin. CGM (Libre 2/3 or Dexcom) is now standard for all adults. Continuous subcutaneous insulin infusion (pump / hybrid closed-loop) is reserved for specific NICE indications. Prescribing in adults follows initial specialist initiation; ongoing repeat prescription in primary care.

Step 1 — MDI (basal-bolus): the gold standard

Basal-bolus regimen: long-acting basal + rapid-acting bolus with each meal.

Basal: insulin degludec (Tresiba), glargine (Lantus / Toujeo U-300), or detemir (Levemir). Once daily preferred; twice daily for some. Typically ~50% of total daily dose.
Bolus: insulin aspart (NovoRapid / Fiasp), lispro (Humalog), glulisine (Apidra). 1U per ~10g carb to start, individualised. Inject 15 min before meal (or with first bite for Fiasp).
CGM: Flash glucose (Libre 2/3) or rtCGM offered to ALL adults with T1DM per NG17.

Review at 1, 2, 4, 12 weeks. Titrate basal first to fasting target; then meal-time bolus.

Step 2 — Premixed (biphasic) insulin: only if MDI unsuitable

Twice-daily fixed-ratio mix of short and intermediate insulin. Reserved for patients who cannot manage 4+ injections per day or carb counting.

NovoMix 30, Humalog Mix 25/50: 30%/25%/50% rapid + remainder intermediate.
Less flexibility than MDI — meals must be eaten at fixed times in fixed quantities.
Higher risk of mid-morning and night-time hypoglycaemia.
NG17: only after MDI considered and rejected — discuss specifically with specialist team.

Suboptimal for most adults — only for select patients with fixed routine and dexterity issues.

Step 3 — Pump / CSII / Hybrid Closed-Loop

Continuous Subcutaneous Insulin Infusion (CSII) — specialist-initiated, primary care continues.

NICE TA151 (and recent NG17 update): pump considered if disabling hypos OR HbA1c persistently ≥69 despite MDI optimisation.
Hybrid closed-loop (HCL): pump + CGM with algorithm. NICE TA943 recommends HCL for all adults with HbA1c >58 mmol/mol despite MDI, and for children.
Primary care role: repeat prescriptions for cannulas, reservoirs, sensors; recognise pump failure → revert to MDI temporarily.

Specialist initiated only. Pump failure + hyperglycaemia = revert MDI + ketone check.

Step 4 — Adjunct therapy: dapagliflozin (SGLT2i) — use with caution

NICE TA597: dapagliflozin 5mg adjunct to insulin in T1DM is technically licensed but the licence was withdrawn by manufacturer in 2021 due to euglycaemic DKA risk. It is no longer routinely available in UK practice. Knowledge of this is high-yield.

If a patient is on it (e.g. transferred from another system): specialist-only. BMI ≥27. eGFR ≥60. NEVER start in primary care for T1DM.
Euglycaemic DKA — DKA with glucose <14 mmol/L. High mortality, easily missed. Stop SGLT2i in any acute illness.
Glucagon emergency kit must be available. Sick-day rules formalised.

⚠️ SGLT2i in T1DM = specialist initiation only. Euglycaemic DKA risk. Stop in any illness.

When NOT to prescribe / special cases

Children <18y: all insulin initiation via paediatric diabetes team. Adjust analogue choice for pump compatibility. NG18 governs.
Pregnancy / planning: use insulin only (no SGLT2i, no metformin off-label). Aspart and lispro are licensed. Detemir preferred basal; glargine acceptable. Tight target HbA1c <48; folic acid 5mg.
Severe renal impairment (eGFR <30): reduced insulin clearance — lower TDD by 25–50%. CGM essential. No SGLT2i.
Honeymoon period: insulin requirement may transiently fall after diagnosis. Do not stop — reduce. Always specialist supervised.
Ramadan / religious fasting: structured pre-Ramadan consultation 6–8 weeks ahead — never improvise. Consider switch to once-daily basal + flexible bolus. CGM essential.

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Medication selection tool — choose patient characteristics for tailored drug recommendations

Select patient characteristics — Insulin regimen recommendation appears below

New-onset T1DM (adult, stable) Pregnancy / planning pregnancy Hypoglycaemia unawareness Child / adolescent (<18y) Frail / elderly (>75y) Shift work / irregular meals HbA1c persistently ≥69 on MDI Recurrent severe hypos despite optimised MDI Manual dexterity issues / cannot manage 4+ injections

Recommended approach

Select patient characteristics above. Default for new adult T1DM: MDI basal-bolus + CGM. Refer all to specialist diabetes team for initiation. Hybrid closed-loop pump if HbA1c persistently ≥58 mmol/mol or disabling hypos on optimised MDI.

7F — Drug reference cards: insulin classes, regimens & safety profile

Long-acting (Basal) Insulin

Degludec (Tresiba) · Glargine (Lantus / Toujeo U-300) · Detemir (Levemir)

✓ Recommended

MDI Backbone~50% TDD

✓ Prefer when

All adult T1DM — once-daily basal preferred (Tresiba / Toujeo)

Tresiba: ultra-long action (>42h), flat profile — best for shift workers

Detemir: twice-daily, weight-neutral — preferred basal in pregnancy

Toujeo U-300: high-volume daily users; reduced nocturnal hypo vs glargine U-100

✗ Avoid if

Lipohypertrophy at sole injection site — rotate sites; consider new sites

Glargine in pregnancy: detemir preferred (more data)

Cost — biosimilars (Abasaglar, Semglee) reduce price without losing efficacy

⚠ Side effects

Hypoglycaemia — especially nocturnal. CGM mandatory.

Lipohypertrophy at sites → erratic absorption → variable control

Weight gain (~2–4 kg first year) — common, expected, manage proactively

🔬 Monitor

CBG fasting (target 5–7) to titrate basal. Adjust by 1–2U every 3 days.

Time-in-range >70% on CGM is the modern target — HbA1c is a backup.

💬 Counselling

"This is your 'background' insulin — it's working steadily in the background even when you're not eating, keeping your sugar level overnight and between meals. Take it at the same time every day."

Never stop basal during illness even if not eating — stopping basal is the most common preventable cause of DKA. High-yield exam point.

Rapid-acting (Bolus) Insulin

Aspart (NovoRapid · Fiasp) · Lispro (Humalog) · Glulisine (Apidra)

✓ Recommended

MDI Backbone~50% TDD across meals

✓ Prefer when

All adults on MDI — with each carbohydrate-containing meal

Fiasp / Lyumjev: faster onset — closer to physiological response — useful in pump and post-meal injection

Lispro / aspart: well-established, licensed in pregnancy

For correction doses for hyperglycaemia (1U lowers ~3 mmol/L — individualised)

✗ Avoid if

Hypoglycaemia (CBG <4) — treat low first, then dose

Active vomiting / not eating — defer meal bolus; continue basal

Lipohypertrophy at site → unpredictable absorption

⚠ Side effects

Hypoglycaemia — especially if mis-counting carbs or injecting when not eating

Post-meal spike if injected too close to first bite — inject 10–15 min pre-meal

Lipohypertrophy if not rotating

🔬 Monitor

Post-meal CBG / CGM — peak 1–2h after eating. Target <9 at 2h.

Insulin:carb ratio review every 3 months — typical 1U per 8–12g carb

💬 Counselling

"This is your meal insulin — match the dose to the carbs you're about to eat. Inject 10–15 minutes before your first mouthful — that timing makes a huge difference. If you're not going to eat, don't dose."

Skipping meals does not mean skipping all insulin — never stop basal. SCA: knowing this distinction is a Tasks mark.

Premixed (Biphasic) Insulin

NovoMix 30 · Humalog Mix 25/50 · Humulin M3

✓ Recommended

Limited roleBD, fixed ratio

✓ Prefer when

Patient unable to manage 4+ injections daily (cognitive / dexterity / preference)

Highly fixed daily routine (same meals, same times)

After explicit specialist conversation that MDI is unsuitable

✗ Avoid if

Variable meal timing / size — premixed cannot be adjusted dynamically

Pregnancy / planning — use MDI for flexibility and tight control

Honeymoon phase or rapidly changing requirements

⚠ Side effects

Mid-morning & nocturnal hypoglycaemia — common with biphasic

Forces patient to eat fixed amounts at fixed times — psychologically restrictive

Higher overall HbA1c than MDI in most studies

🔬 Monitor

CBG before each main meal + bedtime

If hypo pattern emerging: reconsider MDI suitability

💬 Counselling

"This tablet works best when life is fairly predictable — same meals, same times. It's a simpler regime but slightly less flexible than MDI."

NG17 states MDI is the preferred regimen for adults with T1DM. Premixed is a backup, not a first choice. Knowing this is a high-yield exam point.

Glucagon Rescue Therapy

Glucagon (GlucaGen) IM kit · Baqsimi (intranasal)

✓ Recommended

Emergency1mg IM / 3mg nasal

✓ Prefer when

All patients on insulin should have a glucagon kit available at home

Severe hypoglycaemia: CBG <4 + impaired consciousness or unable to swallow

Baqsimi (nasal): no needle — easier for partner/family/colleague to administer

Particularly important in: hypo unawareness, alcohol-related risk, lone-living patients

✗ Avoid if

Phaeochromocytoma — releases catecholamines

Insulinoma — paradoxical rebound hypo

Severe hepatic disease — limited glycogen reserves; effect attenuated

⚠ Side effects

Nausea and vomiting — common after recovery

Brief headache, abdominal discomfort

Allergic reaction — rare

🔬 Monitor

Check expiry annually — replace expired kits.

Always 999 / hospital review after IM glucagon administration — recurrence risk.

💬 Counselling

"This is your safety net. Show someone you live with how to use it. After the injection, sugar will come back up but they MUST call 999 — the effect is temporary and you'll need follow-up oral sugar and a hospital check."

Glucagon kit availability is a CQC and NG17 requirement at every annual review. Asking about it earns Tasks marks.

Continuous / Flash Glucose Monitor (CGM)

FreeStyle Libre 2 · Libre 3 · Dexcom G7 · Medtronic Guardian

✓ Recommended

Universal in T1DMSensor 10–14 days

✓ Prefer when

All adults with T1DM — NG17 universal recommendation

Hypoglycaemia awareness reduced — CGM with alarms is essential

Pregnancy or planning pregnancy — rtCGM (Dexcom) preferred

Hybrid closed-loop pump users — sensor integrated

✗ Avoid if

Severe skin reactions / contact dermatitis to adhesive — patch test alternatives

MRI scan — remove sensor before scan; new sensor after

DKA-active — point-of-care blood test more reliable; sensors can lag

⚠ Side effects

Skin irritation / contact dermatitis at sensor site

Sensor inaccuracy in rapid glucose change — confirm hypo with finger-prick before treating

Data overload / anxiety — counsel "what to do with the number"

🔬 Monitor

Time-in-range (3.9–10) — target >70%; time-below-range (<3.9) — target <4%

Review CGM data every 3 months at structured review

💬 Counselling

"This sensor changes how you live with diabetes — you'll see trends, not just numbers. Always confirm with a finger-prick before treating a low if you feel fine, and when in doubt — finger-prick."

Asking about CGM access and providing a prescription if not in place = Tasks domain mark and high-yield exam pearl.

Insulin Pump / Hybrid Closed-Loop

Tandem t:slim X2 + Control-IQ · Omnipod 5 · Medtronic 780G · CamAPS

✓ Recommended

Specialist initiatedContinuous basal + manual bolus

✓ Prefer when

HbA1c persistently ≥58 mmol/mol despite optimised MDI (NICE TA943 — HCL pumps for adults)

Disabling hypoglycaemia (frequent or severe) on optimised MDI

Children and adolescents with T1DM (NG18 + TA943) — first-line consideration

Pregnancy — improves time-in-range, reduces severe hypo

✗ Avoid if

Lack of capability or willingness to engage — pump failure with disengagement → DKA fast

Active eating disorder / T1DE — pump can facilitate covert omission

Severe needle phobia — paradoxically pump cannulas still painful for some

⚠ Side effects

Pump failure / occlusion → rapid DKA (no basal depot, unlike MDI) — within hours

Infusion-site infection, scarring, lipohypertrophy

Cost, accessibility, dependence on hardware

🔬 Monitor

Time-in-range >70% target; HCL typically achieves 70–80% TIR

Cannula site rotation every 2–3 days; ketones if pump alarm or unexplained hyperglycaemia

💬 Counselling

"Pumps are powerful but unforgiving. If the pump fails — say it disconnects — you'll go into ketones within hours because there's no long-acting backup. Always have a back-up basal pen and a ketone meter at home."

Pump-failure response: revert to MDI, check ketones, contact pump team — knowing this protocol is a Tasks + Safety mark.

7G — Psychosocial impact of the diagnosis: driving, work, relationships & daily life

🫂

A diagnosis of Type 1 diabetes reshapes everything — driving, work, relationships, sex, travel, insurance, identity. Address it proactively.

T1DM is a 24/7 condition with very real implications across every domain of life. Addressing these directly — at diagnosis and at every review — prevents future crises (loss of licence, employment disclosure problems, unrecognised diabetes distress) and builds the long-term trust that makes safe self-management possible. Raise these topics before the patient goes home wondering.

🚗

Driving — DVLA Legal Duties

T1DM patients must inform the DVLA. Group 1 (car): full assessment; CBG ≥5 mmol/L before driving; finger-prick within 2h; glucose in car; do not drive if hypo unawareness. Group 2 (HGV/PSV/bus): far stricter — no severe hypo in 12 months, full awareness, CGM data review.

Severe hypo with impaired awareness = legal duty to suspend driving and notify DVLA. Failure to disclose can void motor insurance and may be a criminal offence.

Document advice given at every consultation — this is medico-legally essential.

"You will need to tell the DVLA about the diabetes — I can help you with the paperwork. Once you are on insulin, there are rules about checking your sugar before driving — let me explain what you will need to do."

💼

Work & Occupation

The Equality Act 2010 covers T1DM — employers must make reasonable adjustments (breaks for finger-prick, food access, fridge for insulin). Disclosure is the patient's choice except for safety-critical roles (HGV, pilot, armed forces, train driver, certain emergency services).

Shift work disrupts insulin regimen dramatically — a specific pre-shift plan with the DSN is essential. Occupational health referral via employer may be needed.

Fear of job loss is a major hidden agenda — patients may hide a diagnosis for years. Address it explicitly and compassionately.

"Tell me a bit about your work — hours, physical demands, whether you can access food and a fridge during the day. Have you thought about whether to tell your employer? There are legal protections, and I can help."

💑

Relationships, Sex & Pregnancy

A supportive partner / family member is the strongest predictor of long-term well-being. Glucagon training for a partner is part of safe self-management and should be offered proactively.

Sexual function: erectile dysfunction in poorly controlled T1DM (vascular and neuropathic). Address directly, non-judgementally. Both partners welcomed to appointments.

Pregnancy: HbA1c ≤48 pre-conception ideal; folic acid 5mg daily; combined diabetes-antenatal clinic essential. Contraception until ready. Discuss at every review for women of reproductive age.

"Diabetes can affect intimate relationships and sexual function — I want to mention it now so you can ask if you ever need to. And when it comes to having children, there is specific advice we will go through in plenty of time."

✈️

Travel & Time Zones

Airlines accept needles and insulin in cabin baggage with a doctor's letter. Insulin must travel in cabin (hold luggage freezes). CGM sensors are generally airport-scanner safe — confirm with the manufacturer.

Time-zone shifts of more than 5 hours require a specific basal adjustment plan from the DSN pre-travel. Hot climates affect insulin storage — insulated wallet essential.

Pre-travel checklist: GP travel letter, meds list, double supplies, emergency contacts, travel insurance declared.

"Travelling is completely fine with diabetes — but takes a bit of planning. We will give you a letter for the airport, work out the time-zone adjustment, and make sure you have spares of everything."

💰

Insurance & Financial

T1DM must be declared for life insurance, income protection, and travel insurance — this may affect premiums. NHS medical exemption certificate (MedEx) gives free prescriptions — apply at diagnosis.

CGM consumables (Libre / Dexcom) now covered on NHS prescription following NICE recommendation — escalate to ICB if denied. Sharps disposal: free yellow bin from GP or pharmacy.

PIP/DLA rarely awarded for T1DM alone but possible with significant complications. Diabetes UK helpline supports benefit claims.

"You will be exempt from prescription charges — I will give you the form now. CGM sensors are funded on the NHS. If any pharmacy ever queries it, ask them to check the current NICE guidance."

🧘

Mental Health, Burnout & Identity

Depression and anxiety are 2–3× more common in T1DM. Diabetes-specific distress (burnout from constant decisions) is distinct from depression and often missed. Body-image issues plus insulin can drive T1DE.

Screen with PHQ-9 / GAD-7 at diagnosis and annually. Diabetes psychology referral if available; NHS Talking Therapies as a route. Language matters — "I have diabetes" is different from "I am diabetic."

Offer time to grieve the version of life imagined. Normalise the adjustment phase — it is expected and manageable.

"This is a huge thing to take in — it is completely normal to feel overwhelmed, angry, or low about it. We have psychologists who work specifically with diabetes — would it help if I arranged that contact?"

7H — Follow-up schedule

Same day — specialist diabetes team contact

Phone the diabetes team while patient is with you. Patient seen in hospital or by DSN within 24h. Insulin initiated under specialist supervision. CGM provided and set up.

Within 1 week — GP review + DSN call

Confirm patient seen by specialist; check CBG diary; ensure CGM is functioning; check emotional coping. Confirm sick-day rules understood. Document DVLA advice given.

SCA: specific named contact + commitment earns marks across all 3 domains

2–4 weeks — first dose adjustment review

Review basal-bolus titration with DSN. CGM data review (time-in-range). Address early hypoglycaemia patterns. Reinforce carbohydrate counting approach.

Most hypos occur in first 4 weeks — proactive titration is safety-critical

3-monthly — structured HbA1c-driven review

HbA1c, weight, BP, CGM review (TIR). Hypo log. Medication review. PHQ-9 / GAD-7 if mood concerns. DAFNE course referral if not yet attended.

Annual — 9 care processes (QOF + NG17)

HbA1c · BP · BMI · Cholesterol · Smoking status · Urine ACR · eGFR · Foot examination · Eye screening referral. PLUS: mental health screen, contraception/pregnancy planning, immunisations (flu, COVID, pneumococcal), CGM review, hypo awareness assessment.

7I — Monitoring: the T1DM core rule + glycaemic targets

Memory rule

HbA1c every 3 months until stable, then 6-monthly | CGM data review every 2 weeks initially, then 3-monthly | Annual 9 care processes + retinal screening + foot review | Renal screen (eGFR + ACR) annually from 5 years post-diagnosis (or earlier if pubertal or poor control)

Drug class	Test	Timing	Action threshold
Basal & Bolus Insulin	HbA1c / CGM TIR	3-monthly	HbA1c >58 or TIR <70% → specialist review for regimen change
All insulin users	Hypo log / Gold or Clarke score	Every consultation	Severe hypo or impaired awareness → same-day specialist contact; suspend driving; document DVLA advice
All T1DM	U&E + eGFR + urine ACR	Annually (from 5yr post-dx)	ACR ≥3 → start ACEi/ARB regardless of BP; eGFR falling → renal referral; eGFR <30 → adjust insulin dose
All T1DM	TFTs · TTG-IgA (total IgA)	At diagnosis + every 3yr	Hypothyroid → levothyroxine. Positive TTG-IgA → gastroenterology + biopsy
All T1DM	Digital retinal photography	Annually from age 12	Pre-proliferative or maculopathy → urgent ophthalmology referral

Patient group	HbA1c target	CGM Time-in-Range target
Adult, stable, no significant hypo	≤48 mmol/mol (6.5%)	>70% (3.9–10 mmol/L)
Adult, hypoglycaemia-prone	≤53 mmol/mol (7.0%)	>70% + TBR <4%
Pre-conception / early pregnancy	≤48 mmol/mol	>70% (3.5–7.8 mmol/L in pregnancy)
Established CVD or microvascular complications	Individualised — risk-benefit discussion	>70%
Frail / elderly / limited life expectancy	Relaxed ≤64 — avoid hypo	>50% sufficient
Child / adolescent (NG18)	≤48 mmol/mol (avoiding hypos)	>70%; very low TBR critical

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Medico-legal protection: documented DKA advice = defence if patient deteriorates at home

Patient empowerment: 24/7 self-management requires knowing exact thresholds — not vague guidance

Earlier escalation: ketone-threshold phrasing drives faster 999 activation, lower DKA mortality

GMC Good Medical Practice: patients must understand emergency action plans before leaving

Adherence to sick-day rules reduces DKA admissions by ~30% — prevention is cheaper than ITU admission

Reduces anxiety: proactive safety-netting reduces fear of the unknown at a vulnerable time

Same daySpecialist diabetes team contacted while patient is with you

Within 1 weekNamed GP / DSN review of how you are getting on

3-monthlyHbA1c + CGM review until target stable

📋 SCA Consultation Scorecard — self-assess your T1DM consultation

🎔 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

"Let me summarise what we have agreed today so it is completely clear..."

"I am going to phone the diabetes team now while you are here — they will arrange to see you today and start you on insulin safely with someone walking you through every step."

"Before you go — if at any point you start vomiting, feel very drowsy, or your ketone meter reads 3 or above — call 999 immediately."

"We have talked about your driving and work — please do come back if anything needs clarifying as things develop."

"Is there anything I have said that is unclear, or anything else on your mind right now?"

Deductions — closing

Sending home with a routine outpatient referral letter for suspected new T1DM
"Come back if you feel worse" — too vague, fails safety-netting mark
No specific DKA symptoms named in safety net
Not summarising the agreed plan back to the patient
No written sick-day rules or hypo plan provided
Not closing with "anything else?"
DVLA advice not documented or mentioned

Tasks domain — full criteria

Follows NICE NG17 and NG18 throughout
Ketone measurement and DKA screen complete
Specialist team contacted same-day (not a letter)
Safety-netting: 999 named, DKA symptoms specific, sick-day rules
DVLA counselling documented; CGM prescribed; annual care processes initiated

Relating to Others — full criteria

Patient expectation ("just a tablet") validated BEFORE insulin discussion
ICE used throughout — not just at start; fear addressed in plan
T1DM vs T2DM explained in plain language — analogy used
"Not your fault" framing given explicitly
Shared decision: patient involved in naming next steps
Driving, work, mental health, and family impact raised proactively

🔴 Red — failing

No DKA screen; no ketones; sends home with OPD letter; explains as "tablet diabetes"; fear not addressed; no sick-day rules; no DVLA mention; consultation feels like a data dump not a shared plan

🅐 Amber — borderline

DKA screen partial; T1 vs T2 mentioned but not clearly explained; specialist referral suggested but not actioned; fear noted but not addressed in plan; safety-net vague; DVLA not raised

🟢 Green — passing

DKA screen explicit; T1 vs T2 in lay language with analogy; specialist phoned during consultation; fear named and woven into plan; sick-day rules given verbally; DVLA counselled; closes with "anything else?"

"I've been feeling absolutely awful — I've been drinking water constantly, I'm getting up three times a night, and I've lost nearly a stone in three weeks. I just need to know what's going on."

Who you are

24-year-old secondary school teacher. Fit, active, no past medical history. Partner is a nurse. Father has Type 2 diabetes — managed on tablets. You assumed this would be the same. CBG 22.4 taken by the practice nurse. You are frightened but presenting as composed.

Hidden agenda

You are terrified of needles. The idea of daily injections is your biggest fear — bigger than the diagnosis itself. You want tablets "like Dad's." You are also secretly worried about losing your driving licence, and whether you can still have children. You will not raise these unless specifically asked.

Symptoms if asked directly

Polyuria (up 3x per night), polydipsia, weight loss 6kg over 3 weeks
Mild fatigue, no vomiting, no abdominal pain, no visual change
No headache, no chest pain, no shortness of breath at rest
Occasional mild nausea but eating normally

Lifestyle + bonus details

Teacher — drives to work daily; standard car licence
Partner is a nurse — supportive, willing to learn glucagon
Non-smoker; drinks socially 4–5 units/week
Father's Type 2 diabetes managed on metformin (patient thinks "all diabetes = tablets")
Bonus: trying for a baby — reveals only if pregnancy/contraception is raised

"But my dad has diabetes and he just takes a tablet — why can't I do the same? And will I be able to drive? I've just got a new job across town and I can't afford to lose my licence."

Resolution: Accept management plan only when: (1) needle fear acknowledged specifically and addressed with reassurance about modern devices AND (2) T1DM clearly distinguished from T2DM in lay language AND (3) DVLA licence question answered factually AND (4) specialist same-day contact confirmed. Pregnancy detail rewards observant candidates who raise it.

🏥

Clinic Quick Reference

Type 1 Diabetes — Clinical Decision Framework

NICE NG17 · CKS 2024 · New Presentation & Established

▼expand

🚦 1 — Triage System

T1DM suspected or established patient presenting unwell — assess DKA risk first

↓

🔴 999 — DKA / Severe Hypo

Glucose >11 + ketones ≥3.0 mmol/L
Kussmaul breathing / vomiting / drowsiness
Severe hypo (CBG <4 + reduced GCS / seizure)
New T1DM in child <18y (even if clinically stable)
DKA in pregnancy at any glucose

999 · Do NOT give insulin in community · IV access if possible

🅐 Urgent — same-day specialist

New T1DM adult, stable, ketones <3.0 — phone team now
Recurrent severe hypo / impaired awareness
Pregnancy — combined clinic within days
HbA1c ≥86 mmol/mol — urgent specialist review

Phone diabetes team · Do NOT start insulin alone · Safety-net before they leave

🟢 Routine GP

Established T1DM, stable — annual review
Repeat insulin / CGM prescriptions
Lifestyle, mental health, complication monitoring
Vaccination, statin, ACEi review

9 care processes · CGM review · Hypo awareness check · DVLA status

🔬 2 — Diagnostic Pathway

Classification — T1DM vs others

Glucose >11 + symptoms → diabetes confirmed — classify type

T1DM signals: young, lean, rapid onset, ketosis-prone, positive islet antibodies, low C-peptide after 3y

LADA: adult-onset, slowly progressive, GAD-positive, initially T2-like — refer specialist

MODY: 3-generation FH, antibody-negative, young — genetics referral

Bloods at diagnosis: HbA1c, U&E, TFTs, TTG-IgA, islet antibodies (GAD/IA-2), C-peptide, lipids, ACR

Baseline investigations

Capillary ketones — pivotal: ≥3.0 = 999; 1.5–3.0 = urgent; <0.6 = safe

HbA1c + islet antibodies + C-peptide — classifies type

TFTs + TTG-IgA — autoimmune cluster screening

ACR + eGFR — renal baseline; repeat annually from year 5

Lipids — atorvastatin if age ≥40 or duration >10y (NG17)

DKA in primary care: do not give insulin, do not delay hospital. Phone 999 + stay with patient. IV access if trained.

📊 3 — Key Numbers

HbA1c ≤48

Adult target (mmol/mol)

Ketones ≥3.0

DKA threshold — 999

CBG <4

Hypoglycaemia threshold

TIR >70%

CGM time-in-range target

TBR <4%

CGM time-below-range (safety)

0.5–1 U/kg

Typical total daily dose

50/50

Basal:bolus MDI split

15g carb

Hypo treatment — 15–15 rule

CBG ≥5

Safe to drive (Group 1)

5mg folic acid

Pre-conception dose (not 400 µg)

9 processes

Annual care processes (QOF)

3yr

TFTs + TTG-IgA re-screen interval

💊 4 — Insulin Regimen & Choice

Step therapy — NICE NG17

Step 1 MDI: Basal (degludec / glargine) + rapid-acting bolus (aspart / lispro) with each meal + CGM (Libre 2/3 or Dexcom). Gold standard for all adults.

Step 2 Premixed (BD): NovoMix 30 / Humalog Mix 25. Only if MDI genuinely unsuitable. Fixed routine required. Less flexible.

Step 3 CSII / Hybrid closed-loop: NICE TA943 — HbA1c ≥58 or disabling hypos on MDI. Specialist initiated. Children: first-line consideration (NG18).

Adjunct: SGLT2i (dapagliflozin) licence withdrawn in UK 2021. Specialist only if still prescribed.

✖ Never start insulin alone in primary care · ✖ Never stop basal during illness · ✖ No SGLT2i in T1DM in primary care · ✖ No premixed in pregnancy

Insulin choice by situation

Standard adult → Degludec (Tresiba) basal OD + aspart (NovoRapid) bolus. CGM (Libre 2).

Shift worker → Tresiba ultra-long (flexible timing). CGM with alarms essential.

Pregnancy → Detemir (Levemir) preferred basal. Aspart or lispro bolus licensed. Dexcom rtCGM.

Hypo unawareness → Consider pump (CSII) or hybrid closed-loop. Relax HbA1c target temporarily.

Pump failure → Revert to MDI. Check ketones every 2h. Phone pump team.

CKD (eGFR <30) → Reduced total daily dose (25–50% less). CGM essential. No SGLT2i.

Steroids → Double basal + aggressive correction bolus. Monitor CBG every 2h.

⚠ 5 — Safety Netting & Follow-Up

Follow-up timeline

Same day: Specialist team phoned. Insulin initiation under specialist. CGM provided.

1 week: GP review. CBG diary check. CGM functioning. Sick-day rules confirmed. DVLA advice documented.

2–4 weeks: First titration review with DSN. CGM data (TIR). Hypo pattern addressed.

3-monthly: HbA1c. CGM review. Hypo log. Medication review. PHQ-9 if indicated. DAFNE referral.

Annual: 9 care processes: HbA1c, BP, BMI, cholesterol, smoking, ACR, eGFR, foot screen, retinal screen + mental health, immunisations.

📌 DVLA: CBG ≥5 to drive (Group 1). Severe hypo → suspend driving + notify DVLA. HGV: full formal assessment.

🔬 6 — Monitoring & Red Flags

Monitoring area	Test	Timing	Action threshold
Glycaemic control	HbA1c / CGM TIR	3-monthly until stable, then 6-monthly	HbA1c >58 or TIR <70% → specialist review. TBR >4% → hypo focus urgently.
Renal	eGFR + ACR	Annually (from 5yr post-dx)	ACR ≥3 → start ACEi/ARB regardless of BP. eGFR falling → renal referral.
Autoimmune screen	TFTs + TTG-IgA	At diagnosis, then every 3yr	Hypothyroid → levothyroxine. TTG-IgA positive → gastroenterology.
Retinal screening	Digital retinal photography	Annually (from age 12)	Background → routine. Pre-proliferative / macular → urgent ophthalmology.
Foot screening	Monofilament + Doppler	Annually	Loss of sensation → high-risk classification. Ulcer → same-day MDT foot.
Lipids / CVD	Fasting lipids	At diagnosis, then per QRISK	Atorvastatin 20mg if age ≥40, duration >10y, or complications. 80mg if CVD established.
Mental health	PHQ-9 / GAD-7	At diagnosis, then annually	PHQ-9 ≥10 or diabetes distress prominent → diabetes psychology / NHS Talking Therapies.

999 red flags: Ketones ≥3.0 · Kussmaul breathing / vomiting / drowsiness · Severe hypo with impaired consciousness · Diabetic foot infection with systemic features · DKA in pregnancy

🛡️ Safeguarding: Recurrent unexplained DKA in young woman → T1DE / insulin omission · Child in repeated DKA → parental neglect · Insulin as self-harm method · Partner withholding insulin · Financial barrier to CGM access

🎔

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow — with Domain Scoring

0–2 min

Open & ICE

"I can see from the nurse's note your blood sugar was 22 this morning. Before I explain anything — can you tell me, in your own words, how this all started and what has been going through your mind?"

"What has been your biggest worry since the symptoms started?"

Explore: fear of injections, family history of diabetes, fear of losing licence/job, concerns about pregnancy/fertility.

Relating to OthersGlobal Skills

✖ Re-asking glucose already in nurse note · Starting with SOCRATES · Not exploring fear before clinical agenda

2–5 min

Safety Screen

"Before I go any further — are you feeling sick or have you been vomiting? Any tummy pain? Are you breathing more heavily than usual? I want to check a ketone level right now."

Name DKA signs aloud: Kussmaul breathing, vomiting, abdominal pain, drowsiness, fruity breath.

Ketone result drives urgency: ≥3.0 = 999 now; 1.5–3.0 = urgent; <0.6 = can plan together.

TasksGlobal Skills

✖ Going straight to "I'll refer you" without ketone screen · Not verbalising DKA symptoms aloud · Missing the urgency threshold

5–7 min

Context & Classification

Psychosocial: work (driving, shifts), mood and eating behaviour, finances, relationships, pregnancy plans

Classification axis: young, lean, rapid onset, FH, autoimmune history → T1DM vs T2DM vs MODY

Drug/alcohol/steroid history; check other autoimmune conditions (thyroid, coeliac)

TasksRelating to Others

✖ Not asking about eating behaviour (T1DE risk) · Missing driving question · Missing pregnancy plans in women of reproductive age

7–10 min

Explain & Plan

"Insulin is like a key that lets sugar from your food enter the cells of your body. In Type 1 diabetes the body has stopped making the key entirely — so we need to replace it. This is very different from your dad's diabetes."

Address "can't I just have tablets?" directly: T1 vs T2 distinction in lay language

Phone specialist team now, in the consultation. Explain what will happen today.

TasksRelating to Others

✖ T1 explained as "worse version of T2" · Not distinguishing from tablet-managed T2DM · Sending home with OPD letter

10–12 min

Plan & Close

"If you start vomiting, feel very drowsy, or your ketone meter reads 3 or above — call 999 immediately. Never stop your background insulin even if you are not eating. I will personally call you tomorrow."

DVLA: explain Group 1 rules (CBG ≥5 to drive, must test, glucose in car). Document this.

Sick-day rules + hypo 15–15 rule + glucagon kit + CGM prescription + "anything else?"

TasksRelating to OthersGlobal Skills

✖ Vague safety-net · No DVLA mention · No sick-day rules · No glucagon kit discussion · No closing question

🔴🅐🟢 RAG Scoring — All 3 Domains

Tasks Domain

🟢

Ketones checked and interpreted · DKA screen named aloud · T1 vs T2 classification verbalised · Specialist contacted same-day (phone, not letter) · Sick-day rules + hypo protocol given · DVLA counselled · CGM prescribed · Annual 9 processes initiated

🅐

Ketones mentioned but not acted on · T1/T2 distinction mentioned but not explained · Referral suggested but not phoned · Safety-net present but DKA symptoms not specific

🔴

No ketone check · No DKA screen · Explains as "tablet diabetes" · Sends home with OPD letter · No sick-day rules · No safety-net · DVLA not mentioned

Relating to Others

🟢

Family history fear explored and addressed in plan · T1 vs T2 in lay language (insulin-as-key analogy) · Needle fear validated then practically addressed · ICE woven into plan · "Not your fault" framing · Driving/pregnancy/work raised proactively · "Anything else?"

🅐

ICE asked but not explored deeply · Fear acknowledged but not addressed in plan · Tablet question answered but T1 vs T2 not fully explained · Driving mentioned but rules not explained

🔴

Jumps to management without ICE · Needle fear not acknowledged · T1 vs T2 conflated · Lectures without shared discussion · No DVLA/work/pregnancy explored

Global Skills

🟢

Used nurse's note before asking · Open Q first · Data gathering complete by 6–7 min · Clear lay language throughout · Responsive to fear and distress cues · Efficient progression through all domains within 12 min

🅐

Re-asks some documented information · Some jargon · Data gathering slightly overruns · Misses one key cue (needle fear or driving)

🔴

Re-asks everything · Rigid disease-focused agenda · Jargon throughout · Misses cues · Data gathering not complete before management

💬 Key Phrases — ICE, Diagnosis & Plan

💡 Ideas

"What do you think might be causing all of this — the thirst, the weight loss, the exhaustion? Had you had any ideas before coming in today?"

😟 Concerns — fear of needles / job

"I can hear that the idea of injections is frightening — that is one of the most common fears people have, and I want to address it properly. Modern insulin pens are very fine and most people say they are far less painful than they imagined."

🎯 Expectations

"Were you hoping this might be managed with tablets — like your dad's diabetes? That is a completely understandable expectation. Can I explain why this type is different, and then we decide together how we move forward?"

🗣️ Lay diagnosis — insulin as key

"Insulin is like a key that lets sugar from your food enter your body's cells to be used for energy. In Type 1 diabetes, the immune system has accidentally destroyed the cells that make this key — so sugar builds up in the blood and the body starts breaking fat for fuel instead. That is why you have lost weight and feel exhausted. None of this is your fault."

📋 Specialist plan + DVLA

"I am going to phone the specialist diabetes team right now, while you are with me. They will arrange to start you on insulin today with a nurse walking you through every step. About driving — you can still drive, but you will need to check your blood sugar before each journey once you are on insulin, and keep glucose in the car. I will give you the DVLA form."

✅ Closing + safety net

"Vomiting, very drowsy, breathing heavily, or a ketone reading of 3 or more — call 999. Never stop your background insulin even if you are not eating. I will personally call you tomorrow. Is there anything else on your mind today?"

🚫 9 Danger Zones — Instant Deductions

✖

Not measuring ketones in a hyperglycaemic symptomatic patient
→ Always measure ketones when glucose >11 + symptoms. ≥3.0 = 999. Never skip this step.

✖

Explaining T1DM as "just like your dad's diabetes"
→ T1 = no insulin at all. T2 = some insulin, not working well. Tablets cannot treat T1. Explain this specifically.

✖

Sending home with a routine outpatient diabetes referral letter
→ Suspected new T1DM = same-day specialist phone call during the consultation. Not a letter. Not next week.

✖

Starting insulin in primary care without specialist input
→ NICE NG17: insulin initiation in adults via specialist team. NICE NG18: all children via paediatric diabetes team.

✖

Not addressing needle fear when the patient raises it
→ Acknowledge it specifically. Reassure with modern pen devices. DSN will train them step-by-step. Fear is the consultation's central cue.

✖

Not raising DVLA / driving safety
→ DVLA notification and CBG ≥5 rule before driving must be documented. Failure to document = medico-legal risk.

✖

Generic sick-day advice ("rest and drink plenty")
→ "Never stop insulin during illness." "Check ketones if glucose >13." "Ketones ≥3 = 999." These specific thresholds prevent avoidable DKA.

✖

Not prescribing or arranging CGM
→ NG17: CGM offered to all adults with T1DM. Asking about CGM access and prescribing Libre 2/3 = Tasks domain mark.

✖

Not asking about eating behaviour / T1DE risk in a young woman
→ Recurrent DKA + young female + weight/body-image concerns = T1DE. Ask directly, non-judgementally. Refer jointly to ED service + diabetes psychology.

💊 Insulin Quick-Pick

Standard new adult T1DM

→

MDI: degludec + aspart + Libre 2

Specialist initiates

Pregnancy (established T1DM)

→

Detemir basal + aspart bolus + Dexcom

5mg folic acid

Shift worker / variable schedule

→

Tresiba (ultra-long flexible) + CGM alarms

DSN specialist plan

Hypo unawareness / HbA1c ≥58 on MDI

→

Hybrid closed-loop pump (NICE TA943)

Specialist only

Cannot manage 4 injections

→

Premixed BD (NovoMix 30) after MDI discussed

Fixed routine needed

Pump failure + hyperglycaemia

→

Revert to MDI + check ketones + phone pump team

Check ketones every 2h

✖ Never start insulin alone · ✖ Never stop basal during illness · ✖ No SGLT2i in T1DM in primary care · ✖ No premixed in pregnancy · ✖ Pump failure = revert MDI + ketones

Type 1 Diabetes & Insulin Therapy · GP Clinical Reasoning Framework v2 · NICE NG17 (2015, updated 2024) · NICE NG18 (children and young people) · NICE TA943 (hybrid closed-loop 2023) · DVLA INF294/2 · Diabetes UK · GMC Good Medical Practice

v3: Dual tailored summaries (Clinic + SCA) with visual algorithms · v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial impact (Step 1E + Step 7G) · Lay language DDx (Step 5) · Safeguarding including T1DE (Step 1) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC · Clinical judgement takes precedence over any framework

Type 1 Diabetes

Red Flags — act before continuing history

Safeguarding Considerations — Consider in Every Consultation

🏠 Domestic Abuse / Intimate Partner Violence

👴 Older Adults / Carer-related Concern

🧒 Children in the Household

💊 Self-Harm / Medication Misuse Risk

🧠 Mental Health & Diabetes Distress

🍽️ Eating Behaviour & T1DE Risk

💰 Financial & Practical Barriers

💑 Family & Relationships

🏢 Work · Shift Patterns · Driving

🌐 Health Beliefs & Cultural Context

999 or Same-Day Hospital

Same-Day GP / Urgent Referral

Manage in Primary Care

New-Onset Type 1 Diabetes

LADA (Latent Autoimmune Diabetes in Adults)

MODY (Maturity-Onset Diabetes of the Young)

Type 2 Diabetes (atypical presentation)

Diabetic Ketoacidosis (DKA)

Severe Hypoglycaemia with Impaired Consciousness

Hyperosmolar Hyperglycaemic State (HHS) — rare in T1DM

Validate — name their expectation

Explain — share your clinical reasoning

Negotiate — offer something today

Select patient characteristics — Insulin regimen recommendation appears below

Driving — DVLA Legal Duties

Work & Occupation

Relationships, Sex & Pregnancy

Travel & Time Zones

Insurance & Financial

Mental Health, Burnout & Identity

Same day — specialist diabetes team contact

Within 1 week — GP review + DSN call

2–4 weeks — first dose adjustment review

3-monthly — structured HbA1c-driven review

Annual — 9 care processes (QOF + NG17)

Memory rule

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked directly

Lifestyle + bonus details