Guía de Atención de la Diabetes Tipo I

Objectives

The guide establishes an integrated care framework for people with type 1 diabetes affiliated with Colombia’s contributory and subsidised health regimes. Its core purpose is to secure timely, high-quality diagnosis, treatment and follow-up, reduce complications, sequelae and deaths, and sustain metabolic stability and quality of life through continuous, individualised care centred on the person and their family.[1][2]

• Detect type 1 diabetes promptly and distinguish it from other conditions, including selected forms of alcohol intoxication.[1][3]
• Achieve strict metabolic control to support multisystem functioning, minimise secondary complications, and maintain age- and sex-appropriate growth and development.[4]
• Enable people with diabetes and their families to acquire the knowledge and skills needed for self-care, prevention of acute and chronic complications, and the best achievable quality of life.[4][5]
• Identify chronic complications early through annual review, particularly for children who have reached puberty and people living with diabetes for more than five years.[5]
• Provide continuing diabetes education for people and families, with 12 to 24 hours annually in addition to education delivered at diagnosis.[6]
• Support appropriate insulin treatment by balancing metabolic-control needs with hypoglycaemia risk, meal and schedule flexibility, patient capability, and clinical circumstances.[6][7]

Implementation

Implementation is organised as a clinical pathway spanning diagnosis, differential diagnosis, emergency and hospital management, outpatient stabilisation, long-term follow-up, self-monitoring, education and insulin adjustment. Care is intended to be continuous and individualised, involving the person with diabetes and their family, with general practitioners, specialist and multidisciplinary diabetes-care teams, and referral services contributing according to clinical need.[8][1][3]

• Diagnose diabetes in people with classic symptoms and casual plasma glucose of at least 200 mg/dL, or in slower-onset presentations through fasting plasma glucose of at least 126 mg/dL or a two-hour oral glucose-tolerance result of at least 200 mg/dL.[2]
• Assess consciousness, hydration, clinical stability, glucose, ketones, osmolality and acid-base status to determine the need for intravenous fluids and hospital care.[3]
• Hospitalise people with diabetic ketoacidosis or clinical instability, while managing clinically stable adults as outpatients only where they and their families can collaborate and an interdisciplinary diabetes team is available; hospitalise all paediatric patients to avoid deterioration.[3]
• Manage diabetic ketoacidosis with insulin, parenteral hydration and potassium administration, using electrocardiography to identify hypokalaemia and monitor potassium treatment.[9][10]
• Conduct the first outpatient consultation through a suitably trained general practitioner, covering clinical history, pharmacological treatment, metabolic control, self-monitoring, nutrition, weight, physical activity, acute decompensation, hypoglycaemia and education needs.[10]
• Undertake comprehensive clinical assessment, including relevant family and medication histories, growth, vital signs, oral health, eye examination, thyroid, cardiovascular, skin, neurological and vascular status; use laboratory investigations such as glycaemia, glycated haemoglobin, lipid profile, creatinine, urine testing, proteinuria or microalbuminuria, and thyroid function.[11][4]
• Develop an individual nutrition plan, adjust insulin according to glycaemic responses to food and exercise, and establish a personalised monitoring plan.[4]
• Provide monthly medical consultations during outpatient stabilisation, then extend intervals to no more than three months once the person has stable control and has met educational targets.[4][5]
• Use consultations every 30 to 90 days to review clinical and laboratory results, diet, exercise, intercurrent events, medicines, severe hypoglycaemia, insulin therapy and self-monitoring, and agree revised priorities with the patient.[5]
• Provide an ideal quarterly specialist review, annual multidisciplinary assessment, and annual diabetes education; permit trained general practitioners to undertake annual review for clinically compensated patients.[10][5]
• Refer people as needed to education, nutrition, dentistry, podiatry and ophthalmology services.[5]
• Use annual review to assess intercurrent illness and chronic complications, including blood pressure, puberty where relevant, retinal health, foot status, peripheral neuropathy and pulses, ischaemia, orthopaedic deformities and injection sites.[12]
• Select insulin regimens from once- or twice-daily neutral protamine Hagedorn insulin through mixed regimens to multiple daily injections, recognising that intensive regimens may improve flexibility and control but require frequent self-monitoring, treatment understanding, motivation and tolerance of a greater injection and hypoglycaemia burden.[6][7]
• Equip people for capillary glucose self-monitoring with an automated device and test strips, generally measuring before meals and bedtime, increasing frequency during insulin changes or destabilising events, and recording results for review and dose adjustment.[13][14]
• Adjust the relevant insulin dose when readings remain outside the agreed range on two successive days, generally by one or two units according to age and the size of the deviation.[14]

Clinical monitoring includes glucose, glycated haemoglobin, lipid levels, growth and development, hypoglycaemia, acute decompensation and self-monitoring records. The guide gives ideal targets for fasting glucose, post-prandial glucose, bedtime glucose, glycated haemoglobin and lipid measures, but does not specify formal programme-level reporting, surveillance, audit or accountability arrangements.[11][4][14]

Resource requirements include glucose-monitoring devices and test strips. Insulin lis-pro is identified as more costly than an alternative regimen, but no prices, budgets, funding sources, financing mechanisms, allocation arrangements or wider economic assumptions are specified.[7][13]

Monitoring & Evaluation

Monitoring centres on continuous clinical review, metabolic control, self-monitoring of blood glucose, laboratory assessment and scheduled specialist or multidisciplinary follow-up. Formal programme-level indicators, reporting systems, surveillance arrangements, audit procedures and accountability mechanisms are not specified in the supplied extracts.[8][2][3][9][10][7][14]

• Monitor diabetic ketoacidosis through clinical assessment and tests for glucose, glucosuria, ketonuria, ketonaemia, bicarbonate and arterial pH; assess electrolytes and use electrocardiography to identify hypokalaemia and monitor potassium treatment.[9][10]
• Review outpatient progress at intervals of 30 to 90 days, using clinical and laboratory parameters to assess achievement of targets and to reset priorities and treatment strategies jointly with the patient.[8][5]
• Provide at least monthly medical consultations during outpatient stabilisation, then extend intervals to no more than three months after stability, education goals and good metabolic control have been achieved.[4][5]
• Undertake an ideal quarterly specialist review and annual multidisciplinary assessment, alongside 24 hours of annual diabetes education in one section of the guidance; another section specifies 12 to 24 annual education hours, excluding education delivered at diagnosis.[10][6]
• Measure fasting, post-prandial and bedtime glucose, glycated haemoglobin, lipid levels, growth and development, hypoglycaemia, and acute decompensation as part of metabolic monitoring.[11][4]
• Apply ideal metabolic targets of fasting glucose 80 to 115 milligrams per decilitre, post-prandial glucose 80 to 145 milligrams per decilitre, bedtime glucose 100 to 120 milligrams per decilitre, glycated haemoglobin below 6.5%, total cholesterol below 200 milligrams per decilitre, low-density lipoprotein cholesterol below 130 milligrams per decilitre, high-density lipoprotein cholesterol above 35 milligrams per decilitre, and triglycerides below 150 milligrams per decilitre.[4]
• Request blood glucose testing, glycated haemoglobin and urinalysis at least for three-monthly reviews.[5]
• Conduct annual reviews to identify intercurrent illness and chronic complications through a complete physical examination, including blood pressure, pubertal development where relevant, eye assessment, optometry, feet, peripheral neuropathy, pulses, ischaemic signs, orthopaedic deformities and insulin-injection-site changes.[12]
• Use dilated-pupil examination or non-mydriatic retinal photography where possible, and refer identified abnormalities for specialist ophthalmological assessment.[12]
• Undertake mandatory annual screening for chronic complications in children who have reached puberty and in people with diabetes duration exceeding five years.[5]
• Monitor thyroid disease where indicated by measuring thyroid-stimulating hormone in people with previously diagnosed and treated hypothyroidism, and repeat anti-thyroid peroxidase antibody testing only after five years when it was performed at the first consultation.[12]
• Establish a self-monitoring plan tailored to the insulin regimen and glycaemic targets, with measurements at least before each meal and at bedtime; increase testing when insulin is changed or destabilising factors occur.[13]
• Use post-prandial testing two hours after meals to assess food and short-acting insulin effects, and measurements at 2 to 3 am to identify nocturnal hypoglycaemia or investigate the dawn phenomenon.[14]
• Record capillary glucose results in a log and review them with the doctor at each visit to support insulin-dose adjustment and patient capability for daily decision-making.[14]
• Adjust the relevant insulin dose when readings remain outside the agreed range for two successive days, generally by one or two units according to age and degree of deviation.[14]
• Use frequent self-monitoring for multiple daily insulin injection regimens and, for intensive therapy, consider daily testing when control is unstable or under assessment; reduce to two or three tests weekly or a staggered schedule only when control is stable.[7][13]

Costing & Financing

Costing and financing information is largely absent. The extracts do not provide budgets, numerical prices, financing sources, allocations, funding gaps, resource-mobilisation measures, or economic assumptions, and they do not set out a costing methodology.[8][2][3][9][10][11][5][12][6][7]

• Identify insulin lis-pro as more costly than an alternative insulin regimen, without providing a price, currency, budget impact, financing source or period.[7]
• Require resources for automated capillary glucose-monitoring devices and glucose test strips, but do not specify their unit costs, procurement arrangements, funding source or affordability implications.[13]
• Imply service-resource requirements through specialist and multidisciplinary assessments, trained general practitioners, diabetes education, laboratory testing, eye assessment, nutrition, dentistry, podiatry and ophthalmology referrals; no associated costs or allocations are specified.[10][5][6]