What is the management of new onset Type 1 Diabetes Mellitus (T1DM) in a 13-year-old female?

From the Guidelines

Management of new onset type 1 diabetes in a 13-year-old female requires immediate initiation of insulin therapy along with comprehensive education and support, with a recommended A1C goal of <7.5% and consideration of intensive insulin regimens, such as multiple daily injections or continuous subcutaneous insulin infusion, as stated in the 2021 standards of medical care in diabetes 1.

Key Components of Management

• Insulin therapy: The cornerstone of treatment is a multiple daily injection (MDI) insulin regimen consisting of a long-acting basal insulin and rapid-acting insulin, with a total daily insulin dose typically starting at 0.5-0.8 units/kg/day.
• Blood glucose monitoring: Should occur 4-6 times daily, including before meals, at bedtime, and occasionally at night to detect hypoglycemia.
• Education and support: The patient and family need education on carbohydrate counting, with insulin doses adjusted using an insulin-to-carbohydrate ratio and correction factor.
• Essential supplies: Include glucose meter, test strips, lancets, insulin pens or syringes, ketone testing supplies, and glucagon for emergency hypoglycemia.

Importance of Individualized Care

• A1C goals must be individualized and reassessed over time, with consideration of factors such as hypoglycemia unawareness, limited life expectancy, and nonglycemic factors that increase A1C 1.
• The use of continuous glucose monitoring (CGM) metrics, such as time in ranges, can be useful in conjunction with A1C to assess glycemic control 1.

Role of Family and Caregivers

• Family involvement is a vital component of optimal diabetes management throughout childhood and adolescence, with a need for culturally sensitive and developmentally appropriate individualized diabetes self-management education and support 1.
• The pediatric diabetes care team must be capable of evaluating the educational, behavioral, emotional, and physical needs of the patient and family, and providing support and guidance as needed.

From the FDA Drug Label

In a randomized, controlled clinical study (Study D), pediatric patients (age range 6 to 15 years) with type 1 diabetes (n=349) were treated for 28 weeks with a basal-bolus insulin regimen where regular human insulin was used before each meal. Insulin Glargine was administered once daily at bedtime and NPH insulin was administered once or twice daily.

The management of new onset type 1 diabetes in a 13-year-old female may involve the use of insulin glargine as part of a basal-bolus insulin regimen, with regular human insulin administered before each meal.

• The dosage of insulin glargine should be adjusted to achieve adequate glycemic control, with careful monitoring of blood glucose levels and HbA1c.
• It is essential to educate the patient and her family on the proper administration of insulin, injection techniques, and hypoglycemia management.
• Regular follow-up with a healthcare provider is necessary to adjust the insulin regimen as needed and to monitor for potential adverse reactions, such as hypoglycemia and injection site reactions 2.

From the Research

Management of New Onset Type 1 Diabetes in a 13-Year-Old Female

• The primary goal of treatment for type 1 diabetes mellitus (T1DM) in children and adolescents is to maintain near-normoglycemia through intensive insulin therapy, avoid acute complications, and prevent long-term microvascular and macrovascular complications 3.
• Effective insulin therapy must be provided on the basis of the needs, preferences, and resources of the individual and the family for optimal management of T1DM 3.
• Basal-bolus therapy, either with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII), is the best therapeutic option for patients with T1DM to achieve target glycemic control 3, 4.

Insulin Therapy Options

• MDI treatment involves basal insulin requirements given as an injection of long- or intermediate-acting insulin analogs, while meal-related glucose excursions are controlled with bolus injections of rapid-acting insulin analogs 3.
• CSII provides a 24-h preselected but adjustable basal rate of rapid-acting insulin, along with patient-activated mealtime bolus doses, eliminating the need for periodic injections 3.
• A twice-daily insulin regimen using a mixture of NPH insulin and rapid-acting insulin analogue at breakfast and separate injections of rapid-acting insulin analogue and insulin detemir at dinner can be an effective initial treatment for young patients with new-onset T1DM 5.

Glycemic Control and Monitoring

• The safety and success of a prescribed insulin regimen is dependent on self-monitoring of blood glucose and/or a continuous glucose monitoring system to avoid critical hypoglycemia and glucose variability 3.
• A glycemic target of glycated hemoglobin <7% (53 mmol/mol) is appropriate for most nonpregnant adults, but may need to be adjusted for pediatric patients 6.
• Frequent blood glucose measurements along with patient education on insulin dosing based on carbohydrate counting, premeal blood glucose, and anticipated physical activity is paramount 6.

Newer Insulin Analogues

• Second-generation rapid-acting insulin analogues, such as faster insulin aspart and ultrarapid-acting lispro, have shown to be safe, efficient, and superior in controlling postprandial plasma glucose levels without an increase in hypoglycemia 7.
• The newest basal insulin analogues, insulin glargine U300 and degludec, have proven to be efficient in reducing hypoglycemic events due to a more stable action profile 7.