What is the recommended management plan for Type 1 diabetes?

Management of Type 1 Diabetes

For most adults with type 1 diabetes, treatment should consist of continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) of prandial and basal insulin, with insulin analogs preferred over human insulins to minimize hypoglycemia risk. 1, 2

Core Insulin Therapy

• Most patients with type 1 diabetes require a basal insulin to suppress hepatic glucose production in the fasting state and prandial insulin to cover glycemic excursions after meals 2, 1
• 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 2
• Higher insulin amounts may be required during puberty, menses, and medical illness 2
• Insulin analogs or inhaled insulin are preferred over injectable human insulins to minimize hypoglycemia risk 2
• Automated insulin delivery systems should be considered for all adults with type 1 diabetes to improve glycemic control 2, 1

Insulin Administration

• Prandial insulin should be administered before meals, with timing based on the specific insulin formulation's pharmacokinetics, premeal blood glucose, and carbohydrate content 2, 3
• Inject insulin subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks, or upper arm 3
• Rotate injection sites within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis 3
• Never share insulin pens, needles, or syringes between patients, even if the needle is changed, due to risk of blood-borne pathogen transmission 3

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, and anticipated physical activity 2, 1
• Education should include correction dose calculation based on concurrent glycemia, glycemic trends, and sick-day management 1
• All patients should be prescribed glucagon, with family members and caregivers educated on its administration for hypoglycemia management 2, 1
• Glucagon preparations that do not require reconstitution are preferred for ease of use in emergency situations 2

Monitoring and Technology

• Early use of continuous glucose monitoring is recommended to improve glycemic outcomes and quality of life and minimize hypoglycemia 2, 1
• Insulin treatment plans should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed 2, 1
• Continuous subcutaneous insulin infusion via pump therapy has modest advantages for lowering A1C and reducing severe hypoglycemia rates in children and adults 2, 4
• Automated insulin delivery systems that combine continuous glucose monitoring with insulin pumps provide superior glycemic control with reduced hypoglycemia risk 1

Hypoglycemia Prevention and Management

• Hypoglycemia is the most common adverse effect of insulin therapy 3, 5
• Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes, diabetic nerve disease, or use of medications like beta-blockers 5
• Insulin analogs are associated with lower risk of hypoglycemia compared to human insulins 1, 6
• Frequent blood glucose monitoring is essential for prevention and management of hypoglycemia 3

Adjunctive Therapies

• Pramlintide is the only FDA-approved non-insulin adjunctive therapy for type 1 diabetes, functioning as an amylin analog that delays gastric emptying, blunts glucagon secretion, and enhances satiety 7
• When using pramlintide, reduce prandial insulin dosing to minimize hypoglycemia risk 7
• Other agents like metformin, GLP-1 receptor agonists, and SGLT-2 inhibitors have been studied but are not FDA-approved for type 1 diabetes and may increase risks of hypoglycemia and ketosis 7, 8

Special Considerations

• Insulin requirements may need to be adjusted in patients with renal or hepatic impairment 5
• Patients with type 1 diabetes should be monitored for injection site reactions including lipodystrophy, which may affect insulin absorption 3, 5
• Systemic allergic reactions to insulin, though rare, can be serious and potentially life-threatening 3, 5
• Intercurrent conditions such as illness, emotional disturbances, or other stresses may alter insulin requirements 5