What is the primary treatment for Type 1 diabetes?

Primary Treatment for Type 1 Diabetes

Intensive insulin therapy is the primary treatment for Type 1 diabetes, delivered through either multiple daily injections (MDI) of prandial and basal insulin or continuous subcutaneous insulin infusion (CSII) via insulin pump. 1, 2

Insulin Therapy Approaches

Multiple Daily Injections (MDI)

• Requires 3-4 injections per day 1, 2
• Components:
  • Basal insulin (long-acting) to control blood glucose between meals
  • Prandial insulin (rapid-acting) before meals to control post-meal glucose excursions
• Rapid-acting insulin analogs are preferred over regular human insulin to reduce hypoglycemia risk 1

Continuous Subcutaneous Insulin Infusion (CSII/Insulin Pump)

• Delivers continuous basal insulin with patient-activated boluses for meals 2
• Slight advantage over MDI in HbA1c reduction (-0.30% difference) 1, 2
• Associated with reduced rates of severe hypoglycemia 1
• Advanced options include:
  • Sensor-augmented pumps with low glucose suspend features
  • Hybrid closed-loop systems that automatically adjust basal rates based on glucose values

Insulin Dosing Guidelines

• Initial dosing for metabolically stable patients: 0.5 units/kg/day (range: 0.4-1.0 units/kg/day) 1, 2
• Higher doses may be required during:
  • Puberty
  • Pregnancy
  • Medical illness 1, 2
• Typically split as:
  • 50% basal insulin
  • 50% prandial insulin 1

Insulin Types

1. Basal insulins:

   • Long-acting analogs (glargine, detemir, degludec)
   • Provide stable background insulin levels

2. Prandial insulins:

   • Rapid-acting analogs (aspart, lispro, glulisine)
   • Faster onset and shorter duration than regular human insulin
   • Should be administered 0-15 minutes before meals 3

Key Management Strategies

1. Carbohydrate counting: Patients should match prandial insulin doses to carbohydrate intake 1, 2
2. Pre-meal glucose adjustment: Modify insulin doses based on blood glucose readings 1, 2
3. Activity adjustment: Adjust insulin doses based on anticipated physical activity 1, 2
4. Regular monitoring: Use blood glucose monitoring to guide insulin adjustments 2

Treatment Goals

• Target HbA1c < 7% for most adults 1, 4
• Target HbA1c < 7.5% for children with T1DM 3
• Minimize glycemic variability and hypoglycemia risk

Common Pitfalls to Avoid

• Hypoglycemia risk: Use rapid-acting insulin analogs instead of regular human insulin to reduce this risk 1
• Lipohypertrophy: Rotate injection sites to prevent poor insulin absorption 3
• Intramuscular injections: Avoid these, especially with long-acting insulins, as severe hypoglycemia may result 3
• Sliding-scale insulin: Avoid using this as the sole treatment strategy 2

Adjunctive Therapies

While insulin is the mainstay of treatment, other therapies may be considered:

• Pramlintide: An injectable amylin analog that can be used as an adjunct to mealtime insulin 1
• Metformin: May be considered in overweight/obese patients to reduce insulin requirements 2
• GLP-1 receptor agonists: Not FDA-approved for T1DM but being studied 2

The DCCT (Diabetes Control and Complications Trial) clearly demonstrated that intensive insulin therapy significantly improves long-term outcomes in type 1 diabetes, with reduced microvascular and macrovascular complications 1.