For updates on diagnosis and management of coexisting conditions during the pandemic, see our topic 'Management of coexisting conditions in the context of COVID-19'.
In the short term, insulin is life-saving because it prevents diabetic ketoacidosis, a potentially life-threatening condition. The long-term goal of insulin treatment is the prevention of chronic complications by maintaining blood glucose levels as close to normal as possible. Generally, glycosylated haemoglobin (HbA1c) goals determine the aggressiveness of therapy, which is in turn individualised. Current guidelines recommend a target HbA1c of <53 mmol/mol (<7%) for adult patients and many children.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
[35]Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018 Aug 9;41(9):2026-44.
http://care.diabetesjournals.org/content/41/9/2026.long
http://www.ncbi.nlm.nih.gov/pubmed/30093549?tool=bestpractice.com
[43]Chiang JL, Kirkman MS, Laffel LM, et al; Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care. 2014 Jul;37(7):2034-54.
http://care.diabetesjournals.org/content/37/7/2034.long
http://www.ncbi.nlm.nih.gov/pubmed/24935775?tool=bestpractice.com
In the UK, national guidance recommends that patients with type 1 diabetes aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower to minimise the risk of long‑term vascular complications.[44]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Jul 2016 [internet publication].
https://www.nice.org.uk/guidance/ng17
[45]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. Nov 2016 [internet publication].
https://www.nice.org.uk/guidance/ng18
Less stringent goals may be appropriate for very young children, older adults, people with a history of severe hypoglycaemia, and those with limited life expectancies, advanced microvascular or macrovascular complications, or comorbid conditions.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Good glycaemic control in type 1 diabetes requires attention to diet, exercise, and insulin therapy. All three components should be co-ordinated for ideal control. Self-monitoring of blood glucose (SMBG) is a core component of good glycaemic control. Patients on multiple injections daily should consider SMBG before meals, occasionally after meals and at bedtime, and before exercising to assess presence and adequate treatment of hypoglycaemia, and before any task during which hypoglycaemia could have particularly dangerous consequences.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Some patients will need to check their blood glucose 6-10 times daily.[46]Diabetes UK. Self-monitoring of blood glucose levels for adults with type 1 diabetes. March 2017 [internet publication].
https://www.diabetes.org.uk/professionals/position-statements-reports/diagnosis-ongoing-management-monitoring/self-monitoring-of-blood-glucose-levels
As continuous glucose monitoring (CGM) technology continues to improve, the indications for its use are likely to expand.[47]Petrie JR, Peters AL, Bergenstal RM, et al. Improving the clinical value and utility of CGM systems: issues and recommendations: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. 2017 Dec;40(12):1614-21.
http://care.diabetesjournals.org/content/40/12/1614.long
http://www.ncbi.nlm.nih.gov/pubmed/29070577?tool=bestpractice.com
Evidence supports use of CGM for improved glucose control in adults and children.[48]Benkhadra K, Alahdab F, Tamhane SU, et al. Continuous subcutaneous insulin infusion versus multiple daily injections in individuals with type 1 diabetes: a systematic review and meta-analysis. Endocrine. 2016 Aug 1;55(1):77-84.
http://www.ncbi.nlm.nih.gov/pubmed/27477293?tool=bestpractice.com
[49]Šoupal J, Petruželková L, Grunberger G, et al. Glycemic outcomes in adults with T1D are impacted more by continuous glucose monitoring than by insulin delivery method: 3 years of follow-up from the COMISAIR study. Diabetes Care. 2020 Jan;43(1):37-43.
https://www.doi.org/10.2337/dc19-0888
http://www.ncbi.nlm.nih.gov/pubmed/31530663?tool=bestpractice.com
[50]Oliver N, Gimenez M, Calhoun P, et al. Continuous glucose monitoring in people with type 1 diabetes on multiple-dose injection therapy: the relationship between glycemic control and hypoglycemia. Diabetes Care. 2020 Jan;43(1):53-8.
https://www.doi.org/10.2337/dc19-0977
http://www.ncbi.nlm.nih.gov/pubmed/31530662?tool=bestpractice.com
Appropriate use of CGM is when it is targeted at people with type 1 diabetes who have hypoglycaemic unawareness, frequent hypoglycaemia, or continued poor control during intensified insulin therapy, and at those who are willing to use CGM frequently.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
[51]Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ. 2011 Jul 7;343:d3805.
https://www.bmj.com/content/343/bmj.d3805.long
http://www.ncbi.nlm.nih.gov/pubmed/21737469?tool=bestpractice.com
The limiting factor for tight glycaemic control in type 1 diabetes is hypoglycaemia. Well-controlled blood pressure and lipids, and avoidance of smoking are essential components of cardiovascular risk reduction.
Including technology-based methods, along with individual and group settings are recommended for the delivery of effective diabetes self-management education and support.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
This approach can be used for adults,[52]Chatterjee S, Davies MJ, Heller S, et al. Diabetes structured self-management education programmes: a narrative review and current innovations. Lancet Diabetes Endocrinol. 2018 Feb;6(2):130-42. as well as children and adolescents.[53]Christie D, Thompson R, Sawtell M, et al. Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study. Health Technol Assess. 2014 Mar;18(20):1-202.
https://www.journalslibrary.nihr.ac.uk/hta/hta18200/#/full-report
http://www.ncbi.nlm.nih.gov/pubmed/24690402?tool=bestpractice.com
Diet and exercise
There is no standardised dietary advice that is suitable for all individuals with diabetes.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Individualised nutrition advice should be based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, and willingness and ability to make behavioural changes. It should also address barriers to change. All patients with diabetes should receive individualised medical nutrition therapy, preferably provided by a registered dietitian who is experienced in providing this type of therapy to diabetes patients.[54]Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care. 2019 May;42(5):731-54.
https://www.doi.org/10.2337/dci19-0014
http://www.ncbi.nlm.nih.gov/pubmed/31000505?tool=bestpractice.com
Carbohydrate counting or consistent carbohydrate intake with respect to time and amount may improve glycaemic control. Rapid-acting insulins may make timing of meals less crucial than in the past, but regular meals are still important.
Adults with diabetes are recommended to engage in 150 minutes/week of moderate-intensity aerobic exercise (to 50% to 70% of max heart rate) spread over at least 3 days per week, with no more than 2 consecutive days without exercise.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Children and adolescents with diabetes should aim for 60 minutes of moderate- to vigorous-intensity aerobic activity daily and vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week.[35]Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018 Aug 9;41(9):2026-44.
http://care.diabetesjournals.org/content/41/9/2026.long
http://www.ncbi.nlm.nih.gov/pubmed/30093549?tool=bestpractice.com
Patients with type 1 diabetes can safely exercise and manage their glucose levels.[35]Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018 Aug 9;41(9):2026-44.
http://care.diabetesjournals.org/content/41/9/2026.long
http://www.ncbi.nlm.nih.gov/pubmed/30093549?tool=bestpractice.com
[55]Riddell MC, Gallen IW, Smart CE, et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol. 2017 May;5(5):377-90.
http://www.ncbi.nlm.nih.gov/pubmed/28126459?tool=bestpractice.com
Pre-exercise carbohydrate intake and insulin doses can be effectively modified to avoid hypoglycaemia during exercise and sport.[56]Aronson R, Brown RE, Li A, et al. Optimal insulin correction factor in post-high-intensity exercise hyperglycemia in adults with type 1 diabetes: the FIT Study. Diabetes Care. 2018 Nov 19;42(1):10-6.
http://www.ncbi.nlm.nih.gov/pubmed/30455336?tool=bestpractice.com
[57]Miculis CP, Mascarenhas LP, Boguszewski MC, et al. Physical activity in children with type 1 diabetes [in Portuguese]. J Pediatr (Rio J). 2010 Jul-Aug;86(4):271-8.
http://www.ncbi.nlm.nih.gov/pubmed/20711549?tool=bestpractice.com
Hypoglycaemia can occur up to 24 hours after exercise and may require reducing insulin dosage on days of planned exercise. A carbohydrate snack should be given at the start of exercise if the blood sugar is <5.6 mmol/L (<100 mg/dL).
Clinical judgement should be used in determining whether to screen asymptomatic individuals for coronary artery disease prior to recommending an exercise programme.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
The following should be assessed prior to starting an exercise programme: age; physical condition; blood pressure; and presence or absence of autonomic neuropathy or peripheral neuropathy, preproliferative or proliferative retinopathy, or macular oedema. Vigorous exercise may be contraindicated with proliferative or severe preproliferative diabetic retinopathy. Non-weight-bearing exercise may be advisable in patients with severe peripheral neuropathy.
Prolonged sitting should be interrupted every 30 minutes with short bouts of physical activity.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Initiating insulin
Intensive therapy with insulin should be started as soon as possible after diagnosis.[58]Fullerton B, Jeitler K, Seitz M, et al. Intensive glucose control versus conventional glucose control for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2014 Feb 14;(2):CD009122.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009122.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/24526393?tool=bestpractice.com
Unlike older regimens that used non-physiological insulin dosing, intensive therapy aims to mimic physiological insulin release by combining basal insulin with bolus dosing at mealtimes. Both continuous infusion with an insulin pump and a regimen of multiple daily injections (MDI) can provide intensive therapy.[59]Misso ML, Egberts KJ, Page M, et al. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005103.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005103.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/20091571?tool=bestpractice.com
[
]
In people with type 1 diabetes mellitus, how does continuous subcutaneous insulin infusion compare with multiple insulin injections at improving outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.19/fullShow me the answer
The choice between pump and MDI is based on patient interest and self-management skills, as well as physician preference, as outcomes are generally similar.[60]Beck RW, Buckingham B, Miller K, et al; Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Factors predictive of use and of benefit from continuous glucose monitoring in type 1 diabetes. Diabetes Care. 2009 Nov;32(11):1947-53.
http://care.diabetesjournals.org/content/32/11/1947.long
http://www.ncbi.nlm.nih.gov/pubmed/19675206?tool=bestpractice.com
The insulin pump uses regular or rapid-acting insulin, and provides a basal rate of insulin and delivers mealtime bolus dosing. However, the patient or parent must still measure blood glucose frequently in order to adjust the pump to deliver the appropriate amount of insulin. Insulin pumps may reduce hypoglycaemia, especially when combined with continuous glucose monitoring systems (CGMS) and threshold suspend features,[61]Ly TT, Nicholas JA, Retterath A, et al. Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trial. JAMA. 2013 Sep 25;310(12):1240-7.
http://jamanetwork.com/journals/jama/fullarticle/1741822
http://www.ncbi.nlm.nih.gov/pubmed/24065010?tool=bestpractice.com
and improve HbA1c, while providing greater flexibility.[62]Monami M, Lamanna C, Marchionni N, et al. Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 1 diabetes: a meta-analysis. Acta Diabetol. 2010 Dec;47(suppl 1):77-81.
http://www.ncbi.nlm.nih.gov/pubmed/19504039?tool=bestpractice.com
[63]Li XL. Multiple daily injections versus insulin pump therapy in patients with type 1 diabetes mellitus: a meta analysis. J Clin Rehabil Tissue Eng Res. 2010;14(46):8722-5.[64]Cummins E, Royle P, Snaith A, et al. Clinical effectiveness and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes: systematic review and economic evaluation. Health Technol Assess. 2010 Feb;14(11):iii-iv;xi-xvi;1-181.
https://www.journalslibrary.nihr.ac.uk/hta/hta14110#/full-report
http://www.ncbi.nlm.nih.gov/pubmed/20223123?tool=bestpractice.com
Use of a pump requires a motivated patient with strong family support (for children) and access to practitioners trained in pump therapy.[65]Kordonouri O, Hartmann R, Danne T. Treatment of type 1 diabetes in children and adolescents using modern insulin pumps. Diabetes Res Clin Pract. 2011 Aug;93(suppl 1):S118-24.
http://www.ncbi.nlm.nih.gov/pubmed/21864743?tool=bestpractice.com
Using a combination of long- (insulins glargine, detemir, or degludec) or intermediate-acting (NPH) insulin for basal dosing, and rapid- (insulins lispro, aspart, or glulisine) or short- (regular-) acting insulin for bolus dosing, MDI regimens can be designed based on physician and patient preference and modified based on finger-prick data. There is no consensus as to whether insulin analogues are superior to conventional insulins for glycaemic control or reductions in complications.[66]Laranjeira FO, de Andrade KR, Figueiredo AC, et al. Long-acting insulin analogues for type 1 diabetes: an overview of systematic reviews and meta-analysis of randomized controlled trials. PLoS One. 2018 Apr 12;13(4):e0194801.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194801
http://www.ncbi.nlm.nih.gov/pubmed/29649221?tool=bestpractice.com
[67]Fullerton B, Siebenhofer A, Jeitler K, et al. Short-acting insulin analogues versus regular human insulin for adults with type 1 diabetes mellitus. Cochrane Database Syst Rev. 2016 Jun 30;(6):CD012161.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012161/full
http://www.ncbi.nlm.nih.gov/pubmed/27362975?tool=bestpractice.com
[
]
How do short-acting insulin analogs compare with regular human insulin in adults with type 1 diabetes mellitus?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1466/fullShow me the answer
In the past, many patients were managed with twice-daily injections of a mixture of rapid-acting and intermediate-acting insulin. This regimen may be used if patients are unable to comply with MDI, but it is no longer a first-line recommendation for management because of its lack of flexibility.
Designing a regimen
An initial total daily dose of insulin in adults can be 0.2 to 0.4 units/kg/day. In children, an initial daily dose will be 0.5 to 1.0 units/kg/day, and during puberty the requirements may increase to as much as 1.5 units/kg/day. Often, when first started on insulin, patients with type 1 diabetes will experience a honeymoon period, during which they may require only 10 or 15 units/day. One half of the total dose is given as basal insulin and one half as bolus dosing.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
The bolus dosing is divided and given before meals. Patients need to self-monitor their blood glucose levels. The insulin doses can be adjusted every 2-3 days to maintain target blood glucose. To achieve an HbA1c <53 mmol/mol (<7%), the pre-meal blood glucose goal is 4.4 to 7.2 mmol/L (80-130 mg/dL) and the post-meal blood glucose goal (1-2 hours after starting the meal) is <10.0 mmol/L (180 mg/dL).
The simplest approach to covering mealtime insulin requirements is to suggest a range of doses, such as 4 units for a small meal, 6 units for a medium-sized meal, and 8 units for a larger meal. For greater flexibility of carbohydrate content of meals, pre-meal insulin can be calculated based on the estimated amount of carbohydrate in the meal and the patient's individual insulin-to-carbohydrate ratio. A simple beginning approach is to use 1 unit of mealtime insulin for every 15 g of carbohydrate in the meal. Patients can use the carbohydrate content per serving listed on food packaging to assess the number of grams in their anticipated meal, but carbohydrate counting is best learned with the help of a nutritionist. Using a food diary and 2-hour postprandial blood glucose measurements, the insulin-to-carbohydrate ratio can be adjusted.
A correction dose may be added to the bolus insulin based on the pre-meal blood glucose level. Correction dosing may be calculated as follows when the patient's total daily dose of insulin (TDD) and food intake is stable: 1800/TDD = the predicted point drop in blood glucose per unit of rapid acting insulin. For example, if the TDD is 40 units of insulin, 1800/40 = 45 point drop per unit of insulin.
Example of correction dosing based on pre-meal glucose and above calculation:
2.2 to 4.9 mmol/L (45-90 mg/dL): subtract 1 unit from mealtime insulin
5.0 to 7.4 mmol/L (91-135 mg/dL): add 0 units of correction insulin
7.5 to 9.9 mmol/L (136-180 mg/dL): add 1 unit of correction insulin
9.9 to 12.4 mmol/L (181-225 mg/dL): add 2 units of correction insulin
12.4 to 14.5 mmol/L (226-270 mg/dL): add 3 units of correction insulin
14.5 to 17.3 mmol/L (271-315 mg/dL): add 4 units of correction insulin
17.4 to 19.8 mmol/L (316-360 mg/dL): add 5 units of correction insulin
19.8 to 22.3 mmol/L (361-405 mg/dL): add 6 units of correction insulin
>22.3 mmol/L (>405 mg/dL): add 7 units of correction insulin; seek medical assistance.
The number used to calculate the correction dose may be as low as 1500 or as high as 2200. There are no specific guidelines to determine this number. In general, a lower number should be used for obese, insulin-resistant patients, and a higher number should be used for lean, insulin-sensitive patients.
This correction dose can be added to the patient's mealtime insulin requirement (whether based on general meal size or carbohydrate counting) and given as the total bolus dose.
Pump therapy utilises a similar concept as basal and bolus dosing and does not require multiple injections of insulin. However, patients still need to monitor their blood glucose from 4-7 times daily. There is some evidence that insulin pump therapy may be associated with improved glycaemic control and lower risk of hypoglycaemia,[68]Fatourechi M, Kudva Y, Murad MH, et al. Clinical review: hypoglycemia with intensive insulin therapy: a systematic review and meta-analysis of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. J Clin Endocrinol Metab. 2009 Mar;94(3):729-40.
https://academic.oup.com/jcem/article/94/3/729/2596271
http://www.ncbi.nlm.nih.gov/pubmed/19088167?tool=bestpractice.com
including in children, adolescents, and young adults.[69]Karges B, Schwandt A, Heidtmann B, et al. Association of insulin pump therapy vs insulin injection therapy with severe hypoglycemia, ketoacidosis, and glycemic control among children, adolescents, and young adults with type 1 diabetes. JAMA. 2017 Oct 10;318(14):1358-66.
http://www.ncbi.nlm.nih.gov/pubmed/29049584?tool=bestpractice.com
Because of the monitoring and dose adjustment required, patients selected for pump therapy must be skilled in diabetes self-management and able to manage and troubleshoot the various pump components.[70]REPOSE Study Group. Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE). BMJ. 2017 Mar 30;356:j1285.
https://www.bmj.com/content/356/bmj.j1285.long
http://www.ncbi.nlm.nih.gov/pubmed/28360027?tool=bestpractice.com
The insulin pump uses a subcutaneous insulin injection port. The port is changed every 3 days and may reduce anxiety and help achieve better glycaemic control in selected patients.[71]Burdick P, Cooper S, Horner B, et al. Use of a subcutaneous injection port to improve glycemia control in children with type 1 diabetes. Pediatr Diabetes. 2009 Apr;10(2):116-9.
http://www.ncbi.nlm.nih.gov/pubmed/19175512?tool=bestpractice.com
[72]Kaiserman K, Rodriguez H, Stephenson A, et al. Continuous subcutaneous infusion of insulin lispro in children and adolescents with type 1 diabetes mellitus. Endocr Pract. 2012 May-Jun;18(3):418-24.
http://www.ncbi.nlm.nih.gov/pubmed/22297055?tool=bestpractice.com
CGMS measure subcutaneous interstitial fluid glucose every 5 minutes. CGMS may be indicated in selected patients with widely fluctuating glucose levels or hypoglycaemia unawareness. A 3-day glucose monitoring system using a CGMS may help the physician adjust insulin doses. Real-time CGMS, worn by a patient on a regular basis, may help improve glycaemic control.[73]Yeh HC, Brown TT, Maruthur N, et al. Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis. Ann Intern Med. 2012 Sep 4;157(5):336-47.
https://annals.org/aim/fullarticle/1355700/comparative-effectiveness-safety-methods-insulin-delivery-glucose-monitoring-diabetes-mellitus
http://www.ncbi.nlm.nih.gov/pubmed/22777524?tool=bestpractice.com
[74]Langendam M, Luijf YM, Hooft L, et al. Continuous glucose monitoring systems for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2012 Jan 18;(1):CD008101.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008101.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/22258980?tool=bestpractice.com
[75]Beck RW, Riddlesworth T, Ruedy K, et al; DIAMOND Study Group. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. JAMA. 2017 Jan 24;317(4):371-8.
https://jamanetwork.com/journals/jama/fullarticle/2598770
http://www.ncbi.nlm.nih.gov/pubmed/28118453?tool=bestpractice.com
[76]Benkhadra K, Alahdab F, Tamhane S, et al. Real-time continuous glucose monitoring in type 1 diabetes: a systematic review and individual patient data meta-analysis. Clin Endocrinol (Oxf). 2017 Mar;86(3):354-60.
http://www.ncbi.nlm.nih.gov/pubmed/27978595?tool=bestpractice.com
The glucose sensors used in CGMS are not reliable at lower ranges of glucose, and thus do not eliminate the need for fingersticks. Development of these systems is ongoing.[47]Petrie JR, Peters AL, Bergenstal RM, et al. Improving the clinical value and utility of CGM systems: issues and recommendations: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. 2017 Dec;40(12):1614-21.
http://care.diabetesjournals.org/content/40/12/1614.long
http://www.ncbi.nlm.nih.gov/pubmed/29070577?tool=bestpractice.com
CGMS are also less accurate than traditional capillary blood glucose-monitoring methods. However, they provide information on glucose trends, provide alarms to alert patients to impending hypo- or hyperglycaemia, and reduce episodes of hypoglycaemia.[61]Ly TT, Nicholas JA, Retterath A, et al. Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trial. JAMA. 2013 Sep 25;310(12):1240-7.
http://jamanetwork.com/journals/jama/fullarticle/1741822
http://www.ncbi.nlm.nih.gov/pubmed/24065010?tool=bestpractice.com
[77]Hirsch IB. Clinical review: realistic expectations and practical use of continuous glucose monitoring for the endocrinologist. J Clin Endocrinol Metab. 2009 Jul;94(7):2232-8.
https://academic.oup.com/jcem/article/94/7/2232/2596341
http://www.ncbi.nlm.nih.gov/pubmed/19383778?tool=bestpractice.com
Insulin pumps with glucose sensors integrated into the same unit are called sensor-augmented insulin pumps. Functionality between sensor and pump has been integrated in one available device: a 'closed loop' system. The insulin delivery can be determined automatically based on sensed glucose levels. These integrated devices use a computerised control algorithm to create the closed loop insulin delivery system, which functions as an artificial pancreas.[35]Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018 Aug 9;41(9):2026-44.
http://care.diabetesjournals.org/content/41/9/2026.long
http://www.ncbi.nlm.nih.gov/pubmed/30093549?tool=bestpractice.com
[78]Weisman A, Bai JW, Cardinez M, et al. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinol. 2017 May 19;5(7):501-12.
http://www.ncbi.nlm.nih.gov/pubmed/28533136?tool=bestpractice.com
In clinical trials, such systems have been shown to reduce the risk of nocturnal hypoglycaemia and to improve glucose control, including in children.[48]Benkhadra K, Alahdab F, Tamhane SU, et al. Continuous subcutaneous insulin infusion versus multiple daily injections in individuals with type 1 diabetes: a systematic review and meta-analysis. Endocrine. 2016 Aug 1;55(1):77-84.
http://www.ncbi.nlm.nih.gov/pubmed/27477293?tool=bestpractice.com
[79]Bergenstal RM, Tamborlane WV, Ahmann A, et al. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010 Jul 22;363(4):311-20.
https://www.nejm.org/doi/full/10.1056/NEJMoa1002853
http://www.ncbi.nlm.nih.gov/pubmed/20587585?tool=bestpractice.com
[80]Brown SA, Kovatchev BP, Raghinaru D, et al. Six-month randomized, multicenter trial of closed-loop control in type 1 diabetes. N Engl J Med. 2019 Oct 31;381(18):1707-17.
https://www.doi.org/10.1056/NEJMoa1907863
http://www.ncbi.nlm.nih.gov/pubmed/31618560?tool=bestpractice.com
Some models come with smartphone apps that can be used to monitor glucose and insulin dosing. Use of sensors and sensor-augmented pumps is increasing and is increasingly reimbursed by insurance providers in the US.
Hypoglycaemia is the most common and potentially most serious side effect of insulin therapy, as it can lead to decreased quality of life, confusion, seizures, and coma. Episodes of hypoglycaemia should be sought at each visit, and efforts made to determine contributing factors, and the ability of the patient to recognise and treat it appropriately.
Goal not met
If glycaemic control is not adequate as measured by the HbA1c or by episodes of hypoglycaemia, the patient's nutrition, exercise, and insulin regimen must be re-examined. Children and adolescents may have erratic eating patterns or snack frequently. Consultation with a nutritionist is an invaluable part of the treatment approach, as patients can learn how to count carbohydrates and adjust their pre-meal insulin to allow for flexibility in meal content and activity. Consistent hyperglycaemia may require an increase in basal insulin. Pre-prandial and postprandial hyperglycaemia may be due to inadequate insulin coverage for the most recent meal, and may be addressed by considering carbohydrate content of meals, the patient's assessment of their carbohydrate intake, and subsequent pre-meal insulin dosing. If a patient is getting regular insulin, replacing it with rapid-acting insulin may reduce postprandial glucose excursions.
Other conditions contributing to unstable diabetes and that co-exist most commonly with diabetes include coeliac disease, thyroid disease, Addison's disease, and psychosocial distress. Coeliac disease, thyroid disease, and psychosocial distress should be screened for at diagnosis and on a regular basis, while increased clinical suspicion should prompt screening for Addison's disease and pernicious anaemia.
Episodes of hypoglycaemia occur with different frequency among patients. Patients should check a 3 a.m. blood glucose if there is concern about risk of nocturnal hypoglycaemia. Nocturnal hypoglycaemia may result in rebound hyperglycaemia in the morning. The dose of basal insulin should be decreased to prevent nocturnal hypoglycaemia. A bedtime snack is not an effective way of decreasing the risk of nocturnal hypoglycaemia.[81]Raju B, Arbelaez AM, Breckenridge SM, et al. Nocturnal hypoglycemia in type 1 diabetes: an assessment of preventive bedtime treatments. J Clin Endocrinol Metab. 2006 Jun;91(6):2087-92.
https://academic.oup.com/jcem/article/91/6/2087/2843397
http://www.ncbi.nlm.nih.gov/pubmed/16492699?tool=bestpractice.com
Alcohol may cause acute hypoglycaemia, but both alcohol and exercise can cause delayed hypoglycaemia (by up to 24 hours).
Non-insulin treatments
Pramlintide is indicated as adjunctive treatment in patients with postprandial hyperglycaemia that cannot be controlled with pre-meal insulin alone. For example, it may be useful in a patient with high postprandial glucose, but who develops late hypoglycaemia when pre-meal insulin is increased.
The therapy of people with type 1 diabetes also involves regular eye examinations, foot care, treatment of dyslipidaemia, and blood pressure control.
Adults with type 1 diabetes are at three times the risk of clinical depression compared with those without type 1 diabetes.[82]Barnard KD, Skinner TC, Peveler R. The prevalence of co-morbid depression in adults with type 1 diabetes: systematic literature review. Diabet Med. 2006 Apr;23(4):445-8.
http://www.ncbi.nlm.nih.gov/pubmed/16620276?tool=bestpractice.com
The prevalence of depression in diabetes is higher in women (28%) compared with men (18%).[83]Anderson RJ, Freedland KE, Clouse RE, et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78.
http://care.diabetesjournals.org/content/24/6/1069.long
http://www.ncbi.nlm.nih.gov/pubmed/11375373?tool=bestpractice.com
The risk may also be higher in adolescents, at diagnosis, or when there is a change in disease status.[84]American Diabetes Association. Psychosocial factors affecting adherence, quality of life, and well-being: helping patients cope. In: Kaufman FR, ed. Medical management of type 1 diabetes. 5th ed. Alexandria, VA: American Diabetes Association; 2008:173-93. Psychosocial screening and support can help to ameliorate distress and improve the individual’s and family's capacity for self-care.
Pregnancy
Infants of women with diabetes are at high risk of major congenital malformations and miscarriage.[85]Ludvigsson JF, Neovius M, Söderling J, et al. Periconception glycaemic control in women with type 1 diabetes and risk of major birth defects: population based cohort study in Sweden. BMJ. 2018 Jul 5;362:k2638.
https://www.bmj.com/content/362/bmj.k2638.long
http://www.ncbi.nlm.nih.gov/pubmed/29976596?tool=bestpractice.com
Pre-conception diabetes care reduces this risk.[86]Kitzmiller JL, Block JM, Brown FM, et al. Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care. 2008 May;31(5):1060-79.
http://care.diabetesjournals.org/content/31/5/1060.long
http://www.ncbi.nlm.nih.gov/pubmed/18445730?tool=bestpractice.com
Pre-conception counselling should, therefore, be incorporated in the routine diabetes clinic visit for all women of childbearing potential. Women with type 1 diabetes should use an effective method of contraception until they plan pregnancy. The American Diabetes Association (ADA) recommends that HbA1c should be <48 mmol/mol (<6.5%) before conception if this can be achieved without hypoglycaemia.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Women should also be evaluated before pregnancy for retinopathy, nephropathy, neuropathy, and possible cardiovascular disease, which may worsen during or complicate pregnancy.
In addition to the complications noted above, infants of mothers with hyperglycaemic diabetes are at risk of macrosomia and neonatal distress. Pre-eclampsia is also more common in diabetic pregnancies. Euglycaemia or near-euglycaemia reduces the risk of complications. During pregnancy women should be cared for by a multidisciplinary team including a nutritionist, a nurse educator, an endocrinologist, and an obstetrician. All pregnant women require a dilated eye examination soon before or early in pregnancy. Women with diabetes have an increased risk of having infants with neural tube defects compared with the general population,[87]Becerra JE, Khoury MJ, Cordero JF, et al. Diabetes mellitus during pregnancy and the risk for specific birth defects: a population-based case-control study. Pediatrics. 1990 Jan;85(1):1-9.
http://www.ncbi.nlm.nih.gov/pubmed/2404255?tool=bestpractice.com
and should take a folic acid supplement prior to and during pregnancy. Statins, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers should be discontinued pre-conception. Intensive insulin treatment with MDI or insulin pump should be started. Commonly used insulins during pregnancy include NPH, detemir, regular, lispro, and aspart.[88]Mathiesen ER, Hod M, Ivanisevic M, et al; Detemir in Pregnancy Study Group. Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes. Diabetes Care. 2012 Oct;35(10):2012-7.
http://care.diabetesjournals.org/content/35/10/2012.long
http://www.ncbi.nlm.nih.gov/pubmed/22851598?tool=bestpractice.com
Use of CGM during pregnancy may help in improving glycaemic control and neonatal outcomes.[89]Feig DS, Donovan LE, Corcoy R, et al; CONCEPTT Collaborative Group. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet. 2017 Nov 25;390(10110):2347-59. [Erratum in: Lancet. 2017 Nov 25;390(10110):2346.]
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32400-5/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/28923465?tool=bestpractice.com
There are no large randomised trials supporting the safety of insulin glargine in pregnant patients with diabetes. However, insulin glargine has been safely used in many patients during pregnancy. It can be considered second-line to NPH or insulin detemir for basal insulin dosing during pregnancy because there are fewer long-term safety monitoring data. There are few data comparing outcomes for continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes.[90]Farrar D, Tuffnell DJ, West J, et al. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Cochrane Database Syst Rev. 2016 Jun 7;(6):CD005542.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005542.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/27272351?tool=bestpractice.com
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Is there randomized controlled trial evidence to support the use of continuous subcutaneous insulin infusion instead of multiple daily injections of insulin in pregnant women with diabetes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1386/fullShow me the answer However, one randomised controlled trial reports better glycaemic outcomes with use of multiple daily injection therapy versus insulin pump therapy.[91]Feig DS, Corcoy R, Donovan LE, et al. Pumps or multiple daily injections in pregnancy involving type 1 diabetes: a prespecified analysis of the CONCEPTT randomized trial. Diabetes Care. 2018 Oct 16;41(12):2471-9.
http://care.diabetesjournals.org/content/41/12/2471.long
http://www.ncbi.nlm.nih.gov/pubmed/30327362?tool=bestpractice.com
ADA guidelines recommend the following blood glucose targets in pregnant women with pre-existing type 1 diabetes (the same as for gestational diabetes): <5.3 mmol/L (<95 mg/dL) fasting, and either <7.8 mmol/L (<140 mg/dL) 1 hour postprandially or <6.7 mmol/L (<120 mg/dL) 2 hours postprandially, with HbA1c goal individualised <42 mmol/mol (<6%) or up to <53 mmol/mol (<7%) as necessary to prevent hypoglycaemia.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
The ADA recommends that all pregnant women with pre-existing type 1 diabetes should consider daily low-dose aspirin starting at the end of the first trimester in order to reduce the risk of pre-eclampsia.[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1
Ongoing comprehensive medical evaluation
Includes assessment of diabetic complications, a psychosocial assessment, and management of comorbid conditions (e.g., autoimmune diseases).[1]American Diabetes Association. Standards of medical care in diabetes - 2020. Diabetes Care. 2020;43(suppl 1):S1-212.
https://care.diabetesjournals.org/content/43/Supplement_1