What is the management of type 1 diabetes?

Management of Type 1 Diabetes

Insulin therapy is the cornerstone of type 1 diabetes management, with most patients requiring multiple daily injections (MDI) of basal and prandial insulin or continuous subcutaneous insulin infusion (CSII) via pump therapy to achieve optimal glycemic control and reduce long-term complications. 1

Insulin Regimens

Multiple Daily Injections (MDI)

• MDI typically consists of basal insulin (once or twice daily) plus prandial insulin before meals and correction insulin as needed 1
• Basal insulin options include:
  • Long-acting insulin analogs (glargine, degludec) - preferred due to flatter action profiles, less hypoglycemia risk, and longer duration of action compared to NPH insulin 1, 2
  • NPH insulin - more variable absorption and shorter duration of action (10-15 hours), with higher hypoglycemia risk 3
• Prandial insulin options include:
  • Rapid-acting analogs (aspart, lispro, glulisine) - preferred over regular human insulin due to quicker onset, better postprandial glucose control, and reduced hypoglycemia risk 1, 4
  • Ultra-rapid-acting analogs (faster-acting aspart, faster lispro) - even quicker onset for better postprandial control 1
  • Inhaled human insulin - rapid peak and shortened duration of action 1

Continuous Subcutaneous Insulin Infusion (CSII/Pump Therapy)

• Delivers rapid-acting insulin continuously with programmable basal rates and bolus doses 1
• Benefits compared to MDI include:
  • Modest advantages for lowering A1C (0.30% reduction) 1
  • Reduced rates of severe hypoglycemia 1
  • More flexibility for lifestyle variations 1
• Consider CSII for patients not meeting glycemic targets, experiencing frequent/severe hypoglycemia, or with pronounced dawn phenomenon 5

Automated Insulin Delivery (AID) Systems

• Hybrid closed-loop systems combine insulin pumps with continuous glucose monitors (CGM) to automatically adjust insulin delivery 1
• Superior to sensor-augmented pump therapy for increasing time in range and reducing hypoglycemia 1
• Should be considered for individuals capable of using the device safely 1

Glycemic Targets

• Target HbA1c <7% for most nonpregnant adults 1
• Intensive insulin therapy (targeting near-normal glycemia) reduces:
  • Microvascular complications by 50% 1
  • Macrovascular complications (long-term follow-up showed 57% reduction in cardiovascular events) 1
  • All-cause mortality 1

Insulin Dosing Considerations

• Starting total daily insulin dose: 0.4-1.0 units/kg/day (typically 0.5 units/kg for metabolically stable patients) 1
• Distribution: Approximately 30-50% as basal insulin, remainder as prandial insulin 1
• Higher doses may be needed during puberty or when presenting with diabetic ketoacidosis 1

Patient Education and Self-Management

• Education on matching prandial insulin doses to:
  • Carbohydrate intake (carbohydrate counting)
  • Pre-meal blood glucose levels
  • Anticipated physical activity 1
• Advanced education on fat and protein gram estimation for patients who have mastered carbohydrate counting 1

Glucose Monitoring

• Continuous glucose monitoring (CGM) is now considered standard of care for most people with type 1 diabetes 1
• Benefits include:
  • Improved glycemic control regardless of insulin delivery method 1
  • Reduced nocturnal hypoglycemia, especially when paired with insulin pumps with automatic suspension features 1

Hypoglycemia Prevention

• Use of insulin analogs rather than human insulins reduces hypoglycemia risk 1
• Newer longer-acting basal analogs (U-300 glargine, degludec) confer lower hypoglycemia risk compared to U-100 glargine 1
• CGM with alerts/alarms helps identify and prevent hypoglycemic episodes 1

Perioperative Management

• For elective surgery, patients can often continue insulin pump therapy with appropriate monitoring 1
• For emergency surgery, insulin pump therapy should be discontinued and replaced with alternative insulin regimens 1
• Hospitals should develop clear protocols for managing patients on insulin pump therapy during hospitalization 1

Emerging Therapies

• Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and GLP-1 receptor agonists may provide additional benefits 6
• Islet cell transplantation and stem cell-derived islet cell therapies are being developed as potential future treatments 7

Common Pitfalls and Caveats

• Intensive insulin therapy increases risk of severe hypoglycemia (62 vs 19 episodes per 100 patient-years with conventional therapy) 1
• Cost and accessibility of insulin analogs and advanced technologies may be prohibitive for some patients 1
• Patient preferences, cost, insulin type, dosing regimen, and self-management capabilities should all be considered when choosing between insulin delivery systems 1
• Regular reassessment of insulin-taking behavior and treatment plans is recommended every 3-6 months 1