What is the primary recommendation for managing Type 1 Diabetes?

Management of Type 1 Diabetes: Insulin Therapy as the Primary Recommendation

The primary recommendation for managing Type 1 Diabetes is intensive insulin therapy using either multiple daily injections (MDI) of both basal and prandial insulin or continuous subcutaneous insulin infusion (CSII), with most patients benefiting from insulin analogs to reduce hypoglycemia risk. 1

Insulin Therapy Framework

Types of Insulin Regimens

1. Multiple Daily Injections (MDI)

   • Three to four injections per day
   • Combination of basal insulin (once or twice daily) and prandial insulin before meals
   • Typically requires 50% of daily insulin as basal and 50% as prandial 1

2. Continuous Subcutaneous Insulin Infusion (CSII/Insulin Pump)

   • Alternative to MDI with similar efficacy
   • May be preferred for patients with frequent hypoglycemia
   • Sensor-augmented pumps with threshold suspend features can reduce nocturnal hypoglycemia 1

Insulin Selection

• Basal insulin options:

  • Long-acting analogs (glargine, detemir, degludec)
  • NPH insulin (less physiologic profile)
  • Degludec has longer duration of action and less hypoglycemia compared to glargine and detemir 1

• Prandial insulin options:

  • Rapid-acting analogs (aspart, lispro, glulisine)
  • Regular human insulin (slower onset, longer duration)

Dosing Guidelines

• Initial total daily insulin: 0.4-1.0 units/kg/day (typically starting at 0.5 units/kg for metabolically stable patients) 1
• Higher doses often required during puberty, pregnancy, and medical illness
• Proper injection technique is crucial for optimal glucose control and safety 1

Glycemic Targets and Monitoring

Glycemic Goals

• Primary target: HbA1c ≤7% for most patients 1
• Individualized targets:
  • More stringent (HbA1c <6.5%) for selected patients if achievable without significant hypoglycemia
  • Less stringent (HbA1c <8%) for patients with history of severe hypoglycemia, limited life expectancy, or advanced complications 1

Monitoring Requirements

• Frequent blood glucose testing, especially at critical times (before meals, bedtime, before/after exercise) 1
• Continuous glucose monitoring (CGM) should be encouraged for intensive management 1

Patient Education Components

Essential Skills to Teach

1. Insulin dose adjustment based on:

   • Carbohydrate intake (carbohydrate counting)
   • Pre-meal blood glucose levels
   • Anticipated physical activity 1

2. Hypoglycemia management:

   • Recognition of symptoms
   • Treatment with 15-20g of glucose
   • Carrying quick-acting carbohydrates at all times 1
   • Glucagon availability at home

3. Sick day management and ketone testing

Evidence for Intensive Insulin Therapy

The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive insulin therapy significantly reduces:

• Risk of retinopathy progression (4.7 vs 1.2 per 100 patient-years)
• Clinical neuropathy (9.8 vs 3.1 per 100 patient-years)
• Cardiovascular events (0.38 vs 0.80 events per 100 patient-years) in long-term follow-up 1

However, intensive therapy was associated with higher risk of severe hypoglycemia (16.3 vs 5.4 per 100 patient-years) 1

Cardiovascular Risk Reduction

In addition to glycemic control, management should include:

• Maintaining LDL cholesterol <100 mg/dL (<70 mg/dL for high-risk patients) 1
• Blood pressure control <130/80 mmHg 1
• Daily aspirin for appropriate patients (reduces coronary heart disease risk by 20-25%) 1
• Smoking cessation 1

Common Pitfalls to Avoid

• Delayed insulin initiation: Type 1 diabetes requires immediate insulin therapy at diagnosis
• Inadequate monitoring: Insufficient blood glucose testing leads to suboptimal control
• Fear of hypoglycemia: May lead to maintaining higher glucose levels than recommended
• Improper injection technique: Can result in variable insulin absorption and unpredictable effects
• Ignoring carbohydrate counting: Essential for matching prandial insulin to meals
• Focusing solely on glucose control: Neglecting other cardiovascular risk factors

Special Considerations

• Exercise: May require insulin dose adjustments to prevent hypoglycemia
• Alcohol consumption: Should be limited and consumed with food to prevent hypoglycemia 1
• Stress: Can affect blood glucose levels and may require insulin dose adjustments

By implementing intensive insulin therapy with appropriate education and support, patients with Type 1 diabetes can achieve optimal glycemic control and reduce the risk of both acute and chronic complications.