What is the recommended outpatient management for diabetes type 1?

Outpatient Management of Type 1 Diabetes

The recommended outpatient management for type 1 diabetes should include multiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII/insulin pump) as the cornerstone of treatment, along with continuous glucose monitoring to improve glycemic outcomes and minimize hypoglycemia risk. 1, 2

Insulin Therapy Framework

Insulin Regimen Options

• First-line therapy options:
  • Multiple daily injections (MDI): 3-4 injections per day of basal and prandial insulin 1, 3
  • Continuous subcutaneous insulin infusion (CSII/insulin pump) 1, 3
  • Automated insulin delivery systems should be considered for all adults with T1DM 1

Insulin Selection

• Basal insulin: Insulin analogs are preferred over human insulins to minimize hypoglycemia risk 1, 2
• Prandial insulin: Rapid-acting analogs (aspart, glulisine, lispro) or faster-acting insulin aspart are preferred over regular human insulin 1, 3
• Insulin distribution: Typically 50% basal insulin and 50% bolus insulin of total daily dose 4

Glucose Monitoring

• Early implementation of continuous glucose monitoring (CGM) is strongly recommended 1, 2
• For patients without CGM, frequent self-monitoring of blood glucose is essential 5
• Target HbA1c <7% for most nonpregnant adults 3
• For children with T1DM, target HbA1c <7.5% 5

Patient Education Requirements

• Carbohydrate counting for meal insulin dosing 1
• Matching mealtime insulin to carbohydrate intake, and additionally to fat and protein intake 1
• Modifying insulin doses based on:
  • Pre-meal blood glucose levels
  • Glycemic trends (if CGM available)
  • Anticipated physical activity
  • Sick day management 1

Nutritional Management

• Medical nutrition therapy can lower HbA1c by up to 1.9% 4
• For patients on MDI or insulin pump:
  • Take mealtime insulin before eating
  • Meals can be consumed at different times
  • Adjust insulin dose if physical activity is performed within 1-2 hours of mealtime insulin 1

Hypoglycemia Prevention and Management

• Prescribe glucagon for all individuals taking insulin 1
• Educate family members, caregivers, and school personnel on glucagon administration 1
• Prefer glucagon preparations that don't require reconstitution 1
• For hypoglycemia treatment, use 15-20g of glucose (glucose tablets preferred) 1
• Recheck blood glucose after 15-20 minutes and repeat treatment if hypoglycemia persists 1

Monitoring and Follow-up

• Reevaluate insulin treatment plan every 3-6 months 1
• Screen regularly for associated conditions:
  • Thyroid dysfunction
  • Vitamin B12 deficiency
  • Celiac disease 1
  • Hypertension and other diabetes complications 4

Special Considerations

• Avoid sliding-scale insulin as the sole treatment strategy 1
• For patients with frequent nocturnal hypoglycemia or hypoglycemia unawareness, consider sensor-augmented low glucose suspend threshold pump 1
• For physical activity:
  • Carry carbohydrate source to prevent hypoglycemia
  • Consider reducing insulin dose if activity occurs within 1-2 hours of insulin injection 1

By implementing this comprehensive approach to type 1 diabetes management with appropriate insulin therapy, glucose monitoring, patient education, and regular follow-up, patients can achieve optimal glycemic control while minimizing the risk of hypoglycemia and other complications.