What is the recommended management for autoimmune diabetes?

Management of Autoimmune Diabetes

The recommended management for autoimmune diabetes (type 1 diabetes) includes intensive insulin therapy with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII/insulin pump), along with comprehensive monitoring and screening for associated autoimmune conditions. 1

Insulin Therapy

• Most people with type 1 diabetes should be treated with intensive insulin regimens, either via multiple daily injections (3-4 injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII) therapy 1
• Patients should be educated on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated activity 1
• Insulin analogs are preferred over human insulin for most patients, especially those with hypoglycemia, as they are associated with less postprandial hyperglycemia and delayed hypoglycemia 2
• For patients with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness, sensor-augmented insulin pump therapy with low glucose suspend threshold may be considered 1
• Automated insulin delivery systems improve glycemic control and reduce hypoglycemia in adolescents and should be considered 1

Glycemic Targets

• The target HbA1c for children and adolescents with type 1 diabetes is <7.5% (58 mmol/mol) 1
• For adults with type 1 diabetes, target HbA1c is generally <7.0%, but should be adjusted based on hypoglycemia risk 3
• Blood glucose targets before meals: 90-130 mg/dL (5.0-7.2 mmol/L) 1
• Blood glucose targets at bedtime/overnight: 90-150 mg/dL (5.0-8.3 mmol/L) 1
• Postprandial glucose values <180 mg/dL may help lower A1C 1

Monitoring

• All patients with type 1 diabetes should self-monitor blood glucose levels multiple times daily, including premeal, prebedtime, and as needed for safety in specific situations such as exercise, driving, or symptoms of hypoglycemia 1
• Continuous glucose monitoring (CGM) should be considered as an additional tool to help improve glycemic control, with benefits correlating with adherence to ongoing use 1, 4
• For patients using insulin pumps, CGM can provide additional benefits in reducing hypoglycemia risk and improving overall glycemic control 4, 5

Screening for Associated Autoimmune Conditions

• Screen for additional autoimmune conditions soon after diagnosis of type 1 diabetes and if symptoms develop 1
• Test for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis, as thyroid autoimmunity occurs in 17-30% of patients with type 1 diabetes 1
• Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or after optimizing glycemia; if normal, recheck every 1-2 years or sooner if symptoms develop 1
• Screen for celiac disease by measuring IgA tissue transglutaminase antibodies with documentation of normal total serum IgA levels soon after diagnosis 1
• Repeat celiac disease screening within 2 years of diagnosis and then again after 5 years 1
• Consider screening for other less common autoimmune conditions such as Addison disease, autoimmune hepatitis, and pernicious anemia if clinically indicated 6

Nutritional Management

• Patients should learn carbohydrate counting or use another meal planning approach to quantify carbohydrate intake for insulin dosing 1
• For patients on insulin pumps or multiple daily injections, take mealtime insulin before eating 1
• For patients on fixed insulin plans, eat similar amounts of carbohydrates each day to match set insulin doses 1
• Referral to a registered dietitian for medical nutrition therapy is recommended 6
• For patients with confirmed celiac disease, a gluten-free diet should be implemented with consultation from a dietitian experienced in managing both diabetes and celiac disease 1

Special Considerations

For Children and Adolescents

• The majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens 1
• Lower HbA1c goals (<7.0%) may be reasonable if achievable without excessive hypoglycemia 1
• Special consideration should be given to hypoglycemia risk in young children (<6 years) who often cannot recognize or manage hypoglycemia 1

For Insulin Pump Users

• Insulin pump therapy offers advantages including reduced number of needle insertions, greater flexibility in insulin delivery, and more accurate dosing 7
• During surgery or hospitalization, continued insulin pump therapy may be appropriate with proper monitoring and management 1
• Patients should be prepared for situations requiring switching back to multiple daily injections if needed 7

Common Pitfalls to Avoid

• Delaying insulin initiation in patients with severely elevated blood glucose 6
• Overlooking screening for associated autoimmune conditions 6
• Failing to adjust insulin doses for exercise, which may result in hypoglycemia 1
• Inadequate monitoring of blood glucose levels, which is essential for effective insulin therapy 8
• Not recognizing that symptoms of hypoglycemia may be different or less pronounced in patients with long duration of diabetes or diabetic neuropathy 8

By implementing comprehensive management strategies that address insulin therapy, monitoring, screening for associated conditions, and nutritional management, patients with autoimmune diabetes can achieve optimal glycemic control and reduce the risk of complications.