What is the recommended management for Type 1 Diabetes Mellitus (DM Type 1)?

Management of Type 1 Diabetes Mellitus

Most adults 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, 2

Core Insulin Therapy

• Insulin treatment is essential for individuals with type 1 diabetes due to absent or near-absent β-cell function 1
• Multiple daily injections (MDI) should include prandial insulin before meals and basal insulin for background coverage 2, 3
• Insulin analogs are strongly preferred over human insulins due to their lower risk of hypoglycemia 1, 4
• Automated insulin delivery systems (combining continuous glucose monitoring with insulin pumps) should be considered for all adults with type 1 diabetes 1, 2
• Total daily insulin requirements typically range from 0.4 to 1.0 units/kg/day, with approximately 30-50% as basal insulin 2

Monitoring and Technology

• Early use of continuous glucose monitoring (CGM) is recommended to improve glycemic outcomes, quality of life, and minimize hypoglycemia 1, 2
• Insulin treatment plans should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed 1, 2
• Automated insulin delivery systems provide superior glycemic control with reduced hypoglycemia risk 2
• Frequent blood glucose measurements are essential for proper insulin dosing 5

Patient Education Requirements

• Patients must 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, 2
• Education should include correction dose calculation based on concurrent glycemia, glycemic trends, and sick-day management 1, 2
• Carbohydrate counting is a critical skill for patients with type 1 diabetes 5

Hypoglycemia Prevention and Management

• Glucagon should be prescribed for all individuals taking insulin 1, 2
• Family members, caregivers, and school personnel should be educated on glucagon administration 1, 2
• Glucagon preparations that don't require reconstitution are preferred for ease of use in emergency situations 1, 2
• Insulin analogs significantly reduce the risk of nocturnal hypoglycemia compared to human insulins 5, 6

Insulin Types and Administration

• For basal insulin coverage, long-acting insulin analogs (like glargine) are preferred due to their flat, peakless action profile 2, 7
• For prandial coverage, rapid-acting insulin analogs should be administered before meals 2, 5
• Continuous subcutaneous insulin infusion via insulin pump is considered the gold standard of basal insulin replacement 7
• The shortest needles (4-mm pen and 6-mm syringe needles) are safest, most effective, and least painful 8
• Injection site rotation is important to prevent lipohypertrophy, which can distort insulin absorption 8

Adjunctive Therapies

• Pramlintide is the only FDA-approved non-insulin adjunctive therapy for type 1 diabetes 3, 4
• When using pramlintide, prandial insulin dosing should be reduced to minimize hypoglycemia risk 4
• Metformin may reduce insulin requirements but does not significantly improve HbA1c in type 1 diabetes patients 3, 4
• GLP-1 receptor agonists and SGLT-2 inhibitors show some promise but are not FDA-approved for type 1 diabetes and may increase risk of diabetic ketoacidosis 3, 4

Glycemic Targets

• A glycemic target of HbA1c <7% is appropriate for most nonpregnant adults with type 1 diabetes 5
• For children with T1DM, including preschool children, the target HbA1c is <7.5% 8
• Both fasting plasma glucose and postprandial glucose values should be used to guide insulin therapy 8