What is the recommended monitoring and management plan for Type 1 diabetes?

Type 1 Diabetes Monitoring and Management

All adults with type 1 diabetes should use continuous glucose monitoring (CGM) from diagnosis, combined with either continuous subcutaneous insulin infusion (insulin pump) or multiple daily injections of insulin analogs, with automated insulin delivery systems strongly preferred for optimal glycemic control and reduced hypoglycemia risk. 1

Glucose Monitoring Strategy

Continuous glucose monitoring is the standard of care and should be initiated early after diagnosis to improve glycemic outcomes, quality of life, and minimize hypoglycemia. 1 CGM is superior to self-monitoring of blood glucose (SMBG), particularly in individuals with HbA1c >64 mmol/mol (>8%), where it reduces HbA1c by approximately 4.67 mmol/mol (0.43%). 2

• For patients using CGM: Monitor glucose trends continuously, with particular attention before, during, and after meals and physical activity 1
• For patients without CGM access: Perform capillary blood glucose testing at least 3 times daily, including before meals, at bedtime, and when hypoglycemia is suspected 1, 3
• Frequency increases to 6-10 times daily when using multiple daily injections without CGM to adequately guide insulin dosing 3

Insulin Delivery and Dosing

Automated insulin delivery systems (closed-loop systems) should be considered for all adults as they provide superior glycemic control with reduced hypoglycemia compared to other methods. 1

Initial Insulin Regimen

• Start with 0.5 units/kg/day total daily insulin in metabolically stable patients 4
• Split approximately 50% as basal insulin and 50% as prandial insulin 4
• Use rapid-acting insulin analogs (aspart, lispro, or glulisine) rather than regular human insulin to minimize hypoglycemia risk 1, 4

Insulin Adjustment

• Total daily requirements typically range 0.4-1.0 units/kg/day, with higher doses needed during puberty, pregnancy, or acute illness 4
• Administer prandial insulin before meals, with timing based on premeal glucose and carbohydrate content 4
• Reevaluate insulin regimen every 3-6 months and adjust based on glycemic patterns 1

Laboratory Monitoring

Measure HbA1c at least twice yearly in patients meeting glycemic targets, and quarterly in those not meeting targets or with treatment changes. 1

• Target HbA1c <7% (53 mmol/mol) for most nonpregnant adults 1, 3
• Preprandial plasma glucose goal: 90-130 mg/dL (5.0-7.2 mmol/L) 1
• Peak postprandial glucose goal: <180 mg/dL (10.0 mmol/L) 1

Important caveat: HbA1c has limitations for individual patient assessment and should be interpreted alongside CGM data when available. 5

Patient Education Requirements

All patients must receive comprehensive education on carbohydrate counting and insulin dose adjustment at diagnosis and ongoing. 1

Core Education Components

• Match mealtime insulin to carbohydrate intake using carbohydrate counting or experience-based estimation 1, 4
• Adjust for fat and protein content in meals, as high-fat and high-protein meals impact postprandial glucose excursions 1
• Calculate correction doses based on current glucose, glycemic trends, and anticipated activity 1
• Sick-day management protocols including when to check ketones and adjust insulin 1, 3

Exercise Management

• Ensure pre-exercise glucose 90-250 mg/dL (5-13 mmol/L) before engaging in activity 1
• Reduce prandial insulin by 25-50% for the meal preceding exercise 1
• Monitor glucose before, during, and after exercise to prevent hypoglycemia that can occur up to 24 hours post-exercise 1
• Increase carbohydrate intake or reduce basal insulin for prolonged or intense activity 1

Hypoglycemia Prevention and Management

Prescribe glucagon for all patients taking insulin, with non-reconstitution formulations preferred for ease of emergency use. 1

• Educate family members, caregivers, and school personnel on glucagon administration 1
• Patients should always carry rapid-acting carbohydrates (15-20g glucose tablets or equivalent) 1
• Teach recognition of hypoglycemia symptoms including tremor, palpitations, sweating, confusion 1, 3

Cardiovascular Risk Factor Monitoring

Monitor blood pressure and lipids regularly as cardiovascular disease prevention is critical. 1

• Target blood pressure <130/80 mmHg 1
• Target LDL cholesterol <100 mg/dL (2.6 mmol/L) 1
• Consider daily aspirin for cardiovascular risk reduction in appropriate patients 1

Complication Screening

Perform dilated eye examination annually starting 3-5 years after type 1 diabetes diagnosis. 1

Screen for microalbuminuria annually to detect early nephropathy. 1

Ketone Monitoring

Check blood or urine ketones when glucose >250 mg/dL (13.9 mmol/L), during illness, or with symptoms of diabetic ketoacidosis (nausea, vomiting, abdominal pain). 3, 6

• Blood β-hydroxybutyrate >0.6 mmol/L requires caution; >1.5 mmol/L requires immediate medical attention 1
• Postpone intense exercise with glucose ≥350 mg/dL (19.4 mmol/L) and moderate-to-large ketones 1

Nutrition Therapy

Comprehensive nutrition assessment by a registered dietitian nutritionist at diagnosis and annually is essential. 1

• Emphasize nonstarchy vegetables, whole fruits, legumes, fish, lean protein, whole grains, and low-fat dairy 1
• Minimize red meat, sugar-sweetened beverages, sweets, refined grains, and processed foods 1
• Limit saturated fat to <7% of calories and sodium to <1,500 mg/day for cardiovascular protection 1