|Criteria for Type 1 Diabetes Diagnosis: 4 Options
Perform in lab using NGSP-certified method and standardized to DCCT assay
FPG ≥126 mg/dL (7.0 mmol/L)*
Fasting defined as no caloric intake for ≥8 hrs
2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)*
Random PG ≥200 mg/dL (11.1 mmol/L)
In persons with symptoms of hyperglycemia or hyperglycemic crisis
- Consider measurement of pancreatic autoantibodies to confirm diagnosis.
- Recommend relatives be tested for type 1 risk.
*In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing
Clinical Clues for Type 1 Diabetes Diagnosis
- Leaner individuals are more likely to be diagnosed with type 1 diabetes
- The potential for type 1 diabetes exists in individuals who phenotypically appear to have type 2 diabetes
- If hyperglycemia persists after treatment with noninsulin agents, consider type 1 diabetes
|A1C Testing & Targets
A1C reflects average glycemia over 2 to 3 months and strongly predicts diabetes complications
- Perform quarterly A1C test in most patients with type 1—more frequently as clinically indicated (eg, pregnancy)
- Point-of-care A1C testing using a DCCT standardized assay may be helpful in making timely treatment adjustments
DCCT=Diabetes Complications and Control Trial
|A1C Targets for Nonpregnant Individuals
|Youth (age <18 yrs)
Healthy (long life expectancy, no comorbidities)
Very complex/poor health
Glycemic targets should be individualized according to:
- Diabetes duration
- Age/life expectancy
- Known cardiovascular disease or advanced microvascular complications
- Hypoglycemia unawareness
- Individual patient considerations
|A1C Targets for Pregnant Women
Labor and delivery
60-99 mg/dL (3.3-5.5 mmol/L)
100-129 mg/dL (5.5-7.2 mmol/L)
<100 mg/dL (5.5 mmol/L)
80-110 mg/dL (mean <100 mg/dL)
mean <5.5 mmol/L)
Insulin drips + D10 50 cc/h
||Preconception: <7.0% and as close to normal as possible without hypoglycemia During pregnancy: <6.0%
- Begin preconception counseling starting at puberty and incorporate it into routine visits for all adolescents and women of child-bearing potential
- Discuss birth control techniques with women who do not desire pregnancy
- Potential risks and benefits of medications contraindicated in pregnancy should be considered (statins, ACE inhibitors, ARBs, most noninsulin therapies contraindicated in pregnancy)
- Prenatal vitamins with folate should be initiated with preconception planning to reduce the risk for birth defects
- All pregnant women with type 1 should be screened for thyroid disease
- Evaluate and/or treat (if indicated) women with type 1 who are contemplating pregnancy for diabetic retinopathy, nephropathy, neuropathy, and cardiovascular disease
- Encourage an A1C level as close to normal as possible prior to conception attempt: <7.0%
- Optimize nutritional intake as part of preconception planning
|Glycemic Goals & Monitoring
|Glycemic Goals for Adults
Lowering A1C to ≤7.0% has been shown to reduce microvascular complications. It has also been associated with long-term macrovascular disease reduction if achieved soon after diagnosis.
- More stringent goals (eg, <6.5%) may be considered for select patients only if the goal can be achieved without significant hypoglycemia or other adverse effects. Candidates include subjects with short diabetes duration, long life expectancy, hypoglycemia awareness, and no cardiovascular disease.
- Less stringent goals (eg, <8.5%) may be considered for select patients with a history of severe hypoglycemia, hypoglycemia unawareness, short life expectancy, advanced microvascular or macrovascular complications, and comorbidities.
Glycemic control should be assessed based on self-monitored blood glucose levels and A1C.
Self-monitoring of blood glucose (SMBG) should be performed prior to meals and snacks at a minimum. Other times to consider:
- Postprandially to assess insulin-to-carb ratios
- At bedtime
- Prior to, during, and after exercise
- When low blood glucose is suspected
- After treating low blood glucose until normoglycemia
- When correcting high blood glucose levels
- Prior to driving
- Frequently during illness
Individuals with type 1 diabetes require access to test strips to test glucose at all times; some may require 10 or more strips per day.
Continuous glucose monitoring (CGM) is useful to reduce A1C in adults without increasing hypoglycemia and can reduce glycemic excursions in children.
Most patients with type 1 diabetes should be treated with multiple daily insulin injections
- ≥3 injections/day prandial insulin or CSII
- 1-2 injections/day basal insulin or CSII
Type 1 patients should be educated on matching prandial insulin dose to carbohydrate intake, premeal glucose, and anticipated activity. Insulin analogs are preferable to reduce hypoglycemia risk.
Patients should be taught how to manage glucose levels under various circumstances, for instance, during illness.
Child caregivers and school personnel should be taught how to inject insulin if the child cannot self-manage or his/her parent or guardian is not available.
Pramlinitid, an amylin analog, may be considered as an adjunct to insulin in type 1 adults who have not achieved glycemic goals.
Adding metformin to insulin may reduce insulin requirements and improve metabolic control in overweight/obese subjects and adolescents with poorly controlled glycemia.
SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors may be potential therapy options.
Beta-Cell Replacement Therapies
Consider solid organ pancreas transplantation
|Simultaneously with kidney transplantation for patients who have an indication for kidney transplantation but whose glucose is poorly controlled
After kidney transplantation in adults who have already received a kidney transplant
- Only after they have tried all of the traditional approaches to glycemic control without success, and can manage medication regimen, risks, and follow-up post-transplantation
|Referral to research centers for protocolized islet cell transplantation in patients with type 1 diabetes and incapacitating complications
Metformin, SLGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors are not FDA approved for the treatment of type 1 diabetes in the United States.
CSII=continuous subcutaneous insulin infusion; DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like receptor-1; SGLT2=sodium glucose co-transporter 2
|Inpatient Glycemic Targets
|Inpatient Glycemic Targets
Inpatient glycemic targets for type 1 diabetes are the same as for type 2 diabetes or hospital-related hyperglycemia.
Inpatient and Outpatient Management Procedures
|Critically ill patients
- Initiate insulin starting at ≤180 mg/dL (≤10.0 mmol/L)
- Once insulin started, 140-180 mg/dL (7.8-10.0 mmol/L) recommended glucose range for most patients
More stringent targets may be appropriate for certain patients providing no increased hypoglycemia risk
IV insulin protocol with demonstrated efficacy, safety in achieving targets with no increased hypoglycemia risk
|Non-critically ill patients
||No clear evidence for specific glucose targets
Insulin-treated: premeal target <140 mg/dL (<7.8 mmol/L) with random blood glucose <180 mg/dL (<10.0 mmol/L)
More or less stringent targets may be appropriate:
- More stringent: stable patients with previous tight glycemic control
- Less stringent: severe comorbidities
Preferred method for achieving/maintaining glucose control: scheduled subcutaneous insulin with basal, nutritional, and correction components
- All patients with type 1 diabetes who are admitted to the hospital should have their type 1 diabetes clearly documented in their medical record.
- Self-monitoring of blood glucose (SMBG) should be ordered to fit the patient’s typical insulin regimen with necessary modifications.
- A plan for preventing and treating hypoglycemia must be established
- Insulin dosing adjustments should be made in the perioperative period and inpatient setting. Consider changes in oral intake, recent glucose trends, and the need for uninterrupted basal insulin to prevent hyperglycemia and ketoacidosis. Adjustment of long-acting insulin or basal insulin requirement should be made to reflect true basal requirements.
Management of Hypoglycemia
- Ask individuals with type 1 diabetes (or caregivers) about symptomatic and asymptomatic hypoglycemia at each visit
- Glucose is the preferred treatment (15-20 g) for conscious individuals, although any form of carbohydrate may be used. If hypoglycemia persists 15 mins after carb intake, repeat glucose treatment; eat a meal or snack when normoglycemia achieved to avoid hypoglycemia occurrence.
- Prescribe glucagon for all individuals with type 1 diabetes
- Hypoglycemia unawareness or multiple episodes of hypoglycemia warrant treatment reevaluation
- Raise glycemic targets in insulin-treated patients with hypoglycemia unawareness or severe hypoglycemia episode
Management of Diabetic Ketoacidosis
All patients with type 1 diabetes and caregivers should receive education and a yearly reminder about the prevention of diabetic ketoacidosis (DKA), including sick-day rules, and the importance of administering insulin and monitoring glucose and ketone levels. Insulin omission is a major cause of DKA. It is critical that individuals with type 1 diabetes have unfettered access to insulin. These patients and their families also need 24/7 access to medical advice and support to help with sick-day management.
|Diet & Exercise
Medical Nutrition Therapy
Individualized medical nutrition therapy is recommended for all patients with type 1 diabetes. The patient and his/her family should understand:
- The impact of food on glucose
- The interaction of food with exercise and insulin to prevent hyper- and hypoglycemia
Carbohydrate intake should be monitored—it is a key strategy toward achieving glycemic control. It is also important to stress moderate alcohol consumption for adults. Alcohol can lower blood glucose levels, and many medications interact with alcohol.
All individuals with type 1 diabetes should be educated about prevention and management of hypoglycemia. It is important to note that hypoglycemia may occur during or after exercise.
Safe pre-exercise glucose level: ≥100 mg/dL (5.5 mmol/) depending on the individual and type of activity.
The prandial insulin dose for the meal/snack preceding physical activity can be reduced to help raise pre-exercise glucose and prevent hyperglycemia. Reducing overnight basal insulin the night prior to exercise may reduce the risk for delayed exercise-induced hypoglycemia.
Patients should be encouraged to perform self-monitoring of blood glucose (SMBG) frequently as needed to prevent and treat hypoglycemia. Sources of simply carbohydrate should be readily accessible before, during, and after exercise.
|Follow-Up & DSME
Management & Follow-Up
Follow-up visits should include the following:
- Review of self-monitoring of blood glucose (SMBG), continuous glucose monitoring (CGM), and pump data
- Evidence of complications
- Blood pressure and weight measurement
- Foot exam
Diabetes Self-Management Education and Support
All individuals with type 1 diabetes (and caregivers for children aged <19 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education (DSME) and diabetes self-management support (DSMS) at diagnosis and routinely thereafter. Education should also be offered to appropriate school personnel.
Developing teens should receive education about transition to adult care. Self-reliance should be established starting ≥1 year prior to transition. Support and reinforcement are important post-transition.
|Transitioning Care from Youth to Adult
A strong, practical transition plan should be initiated early. The plan should include ongoing dialogue between the youth and family, touching on finances, insurance, ability to obtain supplies, identification of an adult care provider, and psychosocial issues (eg, depression)
Providers, family, and youth are encouraged to set an achievable diabetes management plan, making provisions for resources to address unanticipated issues.
The patient’s history of acute complications should be addressed, and risk factors for prevention and screening for early micro- and macrovascular complications evaluated; in children, assess risk factors shortly after diagnosis.
Considerations for Children and Adolescents
Conduct a thorough assessment of developmental needs of youth focusing on:
- Physical and emotional development
- Family issues
- Psychosocial needs
Create an individualized diabetes treatment plan tailored to the needs of patients and their families. Achievement of target glucose and A1C must be balanced with quality of life and protection against hypoglycemia
- Measure height & weight at each visit
- Calculate age-adjusted BMI beginning at age 2 years
- Measure BP using appropriate size cuff with child seated and relaxed; confirm hypertension on 3 separate days
- Increased frequency in type 1 diabetes
- Symptoms include diarrhea, weight loss/poor weight gain, abdominal pain, bloating, chronic fatigue, malnutrition, unexplained hypoglycemia
- Screen for celiac disease shortly after type 1 diabetes diagnosis and refer to a gastroenterologist to confirm diagnosis
- 25% of children with type 1 diabetes have thyroid autoimmunities
- These immunities are predictive of thyroid dysfunction, hypothyroidism, and hyperthyroidism
- Subclinical hypo- and hyperthyroidism or concomitant adrenal insufficiency (Addison disease) may deteriorate metabolic control and increase hypoglycemia risk
|Age-appropriate screening for psychosocial issues is recommended at most visits. Any concerns that arise may require referral to a mental health specialist.
|Developmentally appropriate parent/family involvement in management of child’s care and tasks
||Ongoing evaluation of the patient’s quality of life, emotional well-being, distress, depression, and resources
|Ask about diabetes-related family conflict and stress, and negotiate a resolution with the child and parents
||Promptly address issues of self-care capacity, mobility, and autonomy
|If conflict cannot be resolved by diabetes team, refer to a mental health specialist
|Cardiovascular Disease Screening and Treatment
Statins are the preferred treatment for lipid-lowering and cardiovascular disease (CVD) risk reduction.
|Age <40 yrs with <20-yr diabetes duration or age >75 yrs
||Consider therapy on an individual basis
Depending on overall risk, LDL-C <100 mg/dL is an appropriate goal among individuals with
LDL-C 130-160 mg/dL
|Age 40-75 yrs
||May benefit from moderate-to-intensive statin therapy with consideration of diabetes duration and CVD risk factors
If 10-yr risk ≥7.5%, consider intensive statin therapy
Risk factors contributing to CVD risk include hyperlipidemia, hypertension, age, family history, smoking, weight, and albuminuria presence.
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|Cardiovascular Disease Screening and Treatment
For more information about statin therapy in individuals with diabetes, click here to view an interactive summary of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.
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