Diabète de type 1

Objectives

Provide evidence-informed guidance for health professionals on care pathways for children, adolescents and adults with uncomplicated long-term type 1 diabetes, classified as ALD 9, covering diagnosis, treatment, education, follow-up, complications and pregnancy-related care.[1][2][3]The guidance draws on recommendations from the International Society for Pediatric and Adolescent Diabetes, the French National Authority for Health and the American Diabetes Association, while focusing on the essential organisation of care rather than every comorbidity or clinical scenario.[3]

• Prevent life-threatening hyperglycaemia, ketosis and diabetic ketoacidosis through uninterrupted insulin replacement and timely urgent care.[4][5]
• Reproduce physiological insulin secretion as closely as possible through individualised basal-bolus treatment, adapted to age, diet, lifestyle, motivation, socioeconomic circumstances, complications and intercurrent illness.[6]
• Reduce long-term microvascular, neurological, renal, retinal, foot and cardiovascular complications through sustained metabolic control, early detection and dynamic treatment adjustment.[4][7][8][9]
• Strengthen patient and family capacity for self-management through progressive therapeutic education on insulin use, glucose monitoring, nutrition, hypoglycaemia, illness, foot care, physical activity, psychological adjustment and emergency responses.[10][11]
• Promote adequate and balanced nutrition, reduced glycaemic fluctuation and control of vascular risk factors through dietary care tailored to dietary patterns, glycaemic profile, therapeutic objectives and existing knowledge.[12][13]
• Support safe regular physical activity through treatment and dietary adjustment, hydration, foot care, glucose monitoring and rapid management of hypoglycaemia.[14]
• Address psychological, behavioural and social effects of diabetes through regular assessment and support for patients and families, including referral where specialist mental-health treatment is needed.[14][7]
• Tailor care for children and adolescents by monitoring growth, puberty and menstrual disorders, and by screening higher-risk patients for autoimmune disease, microangiopathic complications, dyslipidaemia and eating disorders.[15][16]
• Achieve strict glycaemic control before conception and throughout pregnancy through planned, multidisciplinary care and close clinical follow-up.[17]

Implementation

Organise care through a multidisciplinary, specialist-supported model that combines diagnosis and referral, insulin treatment, hospital care when required, therapeutic education, self-monitoring and regular complication screening.[18][4][7]General practitioners establish diagnosis and refer patients, while endocrinologists lead initial consultation, insulin initiation and adjustment, follow-up and complication management; qualified paediatricians may support follow-up where endocrinology services are unavailable.[18]

• Initiate insulin therapy and therapeutic education in hospital, and provide urgent admission for diagnosis with ketosis or ketoacidosis, including comprehensive clinical and biological monitoring.[4][5]
• Use subcutaneous rapid-, intermediate- and long-acting insulin for routine treatment, reserve intramuscular or intravenous rapid-acting insulin for emergencies, and prioritise insulin pens to support adherence and effectiveness.[5][6]
• Deliver basal-bolus regimens using long-acting basal insulin and at least three pre-meal rapid-acting boluses; consider external pumps for selected patients and establish specialised services for pump management.[6]
• Provide self-monitoring of blood glucose for all patients, with an average of four capillary tests daily, including pre-meal and post-meal checks, to guide insulin-dose adjustment.[6]
• Test urine ketones during illness, stress, pregnancy, marked hyperglycaemia or symptoms of ketoacidosis, and urgently refer patients with evidence of ketosis or ketoacidosis.[6]
• Deliver education progressively, beginning with immediately useful information at diagnosis and expanding during subsequent weeks and months, with regular reinforcement and review.[10][14]
• Engage nurses, diabetes educators, dietitians and psychologists alongside medical specialists; involve families and wider support networks where possible in negotiated dietary care and self-management education.[12][10][7]
• Assess psychological status and provide psychological or psychotherapeutic support; refer patients with severe depression, anxiety, dependence, adaptation disorders or cognitive dysfunction to psychiatry.[7]
• Coordinate ongoing care through the treating physician, with consultation frequency determined by glycaemic control, disease progression, education and self-monitoring capacity, and with at least one consultation every three months.[7][19]
• Monitor weight, blood pressure, symptoms, hypoglycaemic and ketotic events, infections and glycaemic control at consultations; assess glycated haemoglobin every three months, with an HbA1c target below 7% subject to individual clinical judgement and risk.[19]
• Screen annually and according to risk for retinopathy, nephropathy, neuropathy, foot disease and cardiovascular risk, increasing assessment frequency where abnormalities or elevated foot risk are identified.[8][9]
• Implement pregnancy care through endocrinology, nursing, dietetics, obstetrics, midwifery and paediatrics, with planned conception, intensive insulin therapy, frequent glucose checks and urine acetone testing.[16][17]

The guideline was prepared and reviewed by multidisciplinary specialists across endocrinology, paediatrics, nephrology, podiatry, obstetrics and gynaecology, psychiatry, nutrition, family medicine, cardiology, ophthalmology, biology, psychology, dentistry and neurology.[18][20]It envisages updating guidance every two to three years as new evidence is validated.[3]The source does not specify programme budgets, financing arrangements, formal performance indicators, reporting systems or accountability mechanisms beyond clinical monitoring and follow-up.[3][21][22]

Monitoring & Evaluation

Monitoring centres on structured clinical follow-up, patient self-monitoring, metabolic control, early detection of complications, and periodic review of therapeutic education. The guidance proposes updates every two to three years as new evidence is validated, but does not establish a formal programme evaluation, reporting, surveillance-governance, audit, or accountability framework.[3][21][11][22]

• Conduct diabetes follow-up at a frequency tailored to glycaemic control, disease progression, education needs, self-monitoring capacity and particular circumstances, with at least one consultation every three months.[7][19]
• Assess body weight, blood pressure, functional symptoms, hypoglycaemic and ketotic events, infections, and glycaemic control at each consultation.[19]
• Measure glycated haemoglobin every three months, using a target below 7% subject to individual clinical judgement and risk.[19]
• Review capillary glucose readings, urine tests, observations and patient monitoring diaries to support insulin-dose adjustment and reinforce therapeutic education.[10][19]
• Support blood-glucose self-monitoring for all people with type 1 diabetes, with an average of four capillary tests daily, including pre-meal and 1.5-to-two-hour post-meal checks.[6]
• Test urine ketones during stress, infection, glucose above 2.5 grams per litre, pregnancy, or symptoms of ketoacidosis, and urgently seek medical management where ketosis or ketoacidosis is indicated.[6]
• Assess dietary and glycaemic patterns, therapeutic objectives and existing patient knowledge when planning dietary support; regularly reinforce and evaluate education after initial and follow-up phases.[12][10]
• Evaluate psychological status regularly, including potential denial, depression and anxiety, and provide psychological or psychiatric support according to assessed need.[14][7]
• Measure triglycerides, total cholesterol and high-density lipoprotein cholesterol annually when normal and at each consultation when abnormal; calculate low-density lipoprotein cholesterol using the Friedewald formula where applicable.[19]
• Screen annually and according to clinical risk for retinal, renal, neurological, foot and cardiovascular complications. Ophthalmic monitoring includes fundus examination, visual acuity and ocular-tonus assessment, with retinal angiography where needed.[8][9]
• Screen for nephropathy through annual microalbuminuria testing after five years of diabetes and after puberty, with repeat testing at each consultation where results are pathological; measure creatinine annually. Pathological microalbuminuria is defined as 30 to 300 milligrams per 24 hours, while creatinine clearance below 60 millilitres per minute warrants specialist nephrology advice.[8]
• Apply foot-risk categories to set examination intervals, ranging from annual assessment where sensation is intact to every one to three months after ulceration or amputation, and arrange rapid specialist referral for people at high risk.[8][9]
• Monitor growth, weight, pubertal progression and menstrual regularity in children and adolescents; screen annually for thyroid dysfunction and test for coeliac-disease antibodies.[15]
• Monitor diabetic pregnancy with strict fasting and post-prandial glucose targets, at least six capillary glucose checks daily, and urine acetone testing at least each morning.[17]
• Undertake pregnancy follow-up through regular consultations, weight and blood-pressure measurement, urine protein and acetone testing, glycated haemoglobin and uricaemia testing every two months, and retinal review according to retinopathy status. During labour, monitor glycaemia hourly to guide intravenous insulin and glucose administration.[21]
• Use additional biological and technical assessments where indicated, including venous glucose, lipid measures, microalbuminuria, creatinine clearance, thyroid-stimulating hormone, selected antibodies, dilated retinal examination or photography, electrocardiography, and vascular Doppler assessment for specified higher-risk groups.[11][22]

Costing & Financing

No budgets, unit costs, cost estimates, funding allocations, financing sources, resource-mobilisation plans, funding gaps, or economic assumptions are specified in the supplied material.[3][5][14][8][15][20]

• Identify resource-dependent components of care, including insulin and other medicines, glucagon, injection equipment, blood-glucose monitoring materials, urine-testing strips, laboratory assessments, specialist consultations and hospital care for insulin initiation or acute metabolic complications; however, no monetary values or funding arrangements are assigned.[4][21][22]
• Require multidisciplinary clinical capacity involving diabetes specialists, nurses, dietitians, psychological or psychiatric professionals, obstetric staff, paediatricians and complication-specific specialists, without specifying workforce costs or financing responsibilities.[18][7][17]
• Provide specialised units for selected people using external insulin pumps, but do not specify capital, operating, procurement, reimbursement or maintenance costs.[6]