What are the guidelines for managing type 1 diabetes?

Management of Type 1 Diabetes: Guidelines and Best Practices

Most individuals with type 1 diabetes should be treated with continuous subcutaneous insulin infusion or multiple daily doses of prandial (injected or inhaled) and basal insulin, with insulin analogs preferred over human insulins to minimize hypoglycemia risk. 1

Core Insulin Therapy Recommendations

• Multiple daily injections (MDI) of prandial and basal insulin or continuous subcutaneous insulin infusion (CSII) via insulin pump are the standard of care for type 1 diabetes management 1
• Rapid-acting insulin analogs should be used over regular human insulin to reduce hypoglycemia risk 1
• Automated insulin delivery systems should be considered for all adults with type 1 diabetes to improve glycemic control 1
• Early use of continuous glucose monitoring is recommended to improve glycemic outcomes and quality of life while minimizing hypoglycemia 1

Insulin Administration and Dosing

• Total daily insulin requirements typically range from 0.4 to 1.0 units/kg/day, with approximately 30-50% as basal insulin and the remainder as prandial insulin 1
• Prandial insulin should be administered before meals, with timing based on the specific insulin formulation's pharmacokinetics, premeal blood glucose, and carbohydrate content 1
• Insulin aspart and other rapid-acting analogs should be injected subcutaneously within 5-10 minutes before meals, typically into the abdominal area, thigh, buttocks, or upper arm 2
• Injection sites should be rotated within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis 2

Patient Education Requirements

• Patients should receive comprehensive education on matching mealtime insulin doses to:
  • Carbohydrate intake
  • Fat and protein content of meals
  • Premeal blood glucose levels
  • Anticipated physical activity 1
• Education should include correction dose calculation based on concurrent glycemia, glycemic trends (if available), and sick-day management 1
• All patients should be prescribed glucagon, with family members and caregivers educated on its administration for hypoglycemia management 1
• Patients should be taught to recognize and manage both hyperglycemia and hypoglycemia 3

Monitoring and Adjustment

• Regular blood glucose monitoring is essential for effective insulin therapy, with fasting plasma glucose values used to titrate basal insulin and both fasting and postprandial glucose values used to titrate mealtime insulin 4
• Periodic measurement of HbA1c is recommended for monitoring long-term glycemic control, with a target of <7% appropriate for most non-pregnant adults 5
• Insulin treatment plans should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed 1
• Continuous glucose monitoring should be considered for all patients, particularly those with hypoglycemia unawareness or frequent hypoglycemic episodes 1, 5

Advanced Insulin Delivery Options

• Continuous subcutaneous insulin infusion (insulin pump therapy) offers advantages including:
  • More physiologic insulin delivery
  • Reduced hypoglycemia risk
  • Greater flexibility with meal timing and content 5, 6
• Automated insulin delivery systems that combine continuous glucose monitoring with insulin pumps provide superior glycemic control with reduced hypoglycemia risk 1
• For patients using multiple daily injections, long-acting insulin analogs (insulin glargine, insulin detemir, insulin degludec) provide more stable basal coverage with less hypoglycemia compared to NPH insulin 7, 3

Hypoglycemia Prevention and Management

• Insulin analogs are associated with lower risk of hypoglycemia compared to human insulins 1
• Patients should be educated about early warning symptoms of hypoglycemia, which may be different or less pronounced in certain conditions (long duration of diabetes, neuropathy, use of beta-blockers) 3
• Glucagon should be prescribed for all individuals taking insulin, with proper education for family and caregivers on administration techniques 1
• Glucagon preparations that do not require reconstitution are preferred for ease of use in emergency situations 1

Special Considerations

• Insulin requirements may increase during puberty, menses, and medical illness 1
• Insulin dosage may need adjustment during intercurrent conditions such as illness, emotional disturbances, or other stresses 3
• Patients with renal or hepatic impairment may require adjusted insulin dosing 3
• Numerous medications can affect glucose metabolism and may require insulin dose adjustments, including corticosteroids, diuretics, beta-blockers, and oral contraceptives 3