What are the primary recommendations for managing type 1 diabetes?

Type 1 Diabetes Management

All adults with type 1 diabetes should be treated with either continuous subcutaneous insulin infusion (insulin pump) or multiple daily injections of basal and prandial insulin, using insulin analogs rather than human insulin to minimize hypoglycemia risk. 1

Insulin Therapy Framework

Insulin Regimen Selection

• Initiate with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) as the standard of care for all patients with type 1 diabetes 1, 2
• Automated insulin delivery systems should be considered for all adults with type 1 diabetes, as they provide superior glycemic control with reduced hypoglycemia risk 1, 2
• Total daily insulin requirements typically range from 0.5 to 1.0 units/kg/day, with approximately 50% as basal insulin and 50% as prandial insulin 2, 3

Insulin Type Selection

• Use rapid-acting insulin analogs (aspart, lispro, or glulisine) for prandial coverage rather than regular human insulin 1, 2
• Insulin analogs are strongly preferred over injectable human insulins to minimize hypoglycemia risk 1, 4
• Long-acting basal insulin analogs (glargine, detemir) are preferred over NPH insulin due to reduced peak effect and lower nocturnal hypoglycemia risk 5, 6

The 2024 American Diabetes Association guidelines provide Level A evidence for these recommendations, representing the highest quality data from large multicenter trials 1. The preference for analogs over human insulin is based on consistent evidence showing reduced hypoglycemia rates, particularly nocturnal episodes 4, 5.

Glucose Monitoring

Continuous Glucose Monitoring (CGM)

• Early use of continuous glucose monitoring is recommended for all adults with type 1 diabetes to improve glycemic outcomes, quality of life, and minimize hypoglycemia 1
• CGM should be implemented particularly in patients with hypoglycemia unawareness or frequent hypoglycemic episodes 2, 3

Self-Monitoring Blood Glucose

• Patients on intensive insulin regimens should check blood glucose before meals and snacks, at bedtime, when suspecting low blood glucose, after treating hypoglycemia, and before exercise or critical tasks like driving 1
• Minimum frequency should be 4-6 times daily for patients not using CGM 3

Patient Education Requirements

Insulin Dosing Education

• All patients must receive comprehensive education on matching mealtime insulin doses to carbohydrate intake, with additional consideration for fat and protein content 1, 2
• Teach correction dose calculation based on concurrent glycemia, glycemic trends, sick-day management, and anticipated physical activity 1, 2
• Carbohydrate counting forms the foundation of prandial insulin dosing, and patients who master this should advance to fat and protein gram estimation 2, 3

Hypoglycemia Management

• Glucagon must be prescribed for all individuals taking insulin, with family members, caregivers, and school personnel educated on its location and administration 1, 2
• Glucagon preparations that do not require reconstitution are preferred for ease of emergency use 1, 2
• Patients should carry at least 15 grams of fast-acting carbohydrates at all times 3

The American Diabetes Association assigns a Level B recommendation to education on insulin dose matching, reflecting strong evidence from cohort studies demonstrating improved glycemic outcomes and quality of life 1.

Treatment Monitoring and Adjustment

Regular Reassessment

• Insulin treatment plans and insulin-taking behavior should be reevaluated every 3-6 months and adjusted to incorporate specific patient needs 1, 2
• For patients with A1C >15%, start with total daily insulin doses of 0.5-1.0 units/kg/day, using higher doses (closer to 1.0 units/kg/day) for severe hyperglycemia 3
• Increase basal insulin by 2-4 units every 3-7 days until fasting blood glucose reaches target levels of 60-130 mg/dL 3

Glycemic Targets

• Target A1C <7% for most nonpregnant adults 3, 7
• Target premeal glucose 60-130 mg/dL and postprandial glucose <180 mg/dL 3

Medication Safety Considerations

Hypoglycemia Risk Factors

• Hypoglycemia is the most common adverse reaction of all insulins, with risk highest when glucose-lowering effect is maximal 8
• Risk increases with changes in meal patterns, physical activity level, or concomitant medications 8
• Patients with renal or hepatic impairment are at higher risk and require more frequent monitoring 8

Medication Error Prevention

• Always check the insulin label before each injection to avoid accidental mix-ups between insulin products 8
• Never share insulin pens between patients, even if the needle is changed, due to risk of blood-borne pathogen transmission 8

Injection Site Management

• Avoid repeated injections into areas of lipodystrophy or localized cutaneous amyloidosis, as this can result in hyperglycemia 8
• A sudden change in injection site to an unaffected area can result in hypoglycemia, requiring close monitoring 8

Adjunctive Therapies

FDA-Approved Options

• Pramlintide is the only FDA-approved adjunctive therapy for type 1 diabetes, functioning as an amylin analog that delays gastric emptying and blunts glucagon secretion 4, 9
• When using pramlintide, reduce prandial insulin dosing to minimize hypoglycemia risk 4

Investigational Therapies

• SGLT-2 inhibitors provide insulin-independent glucose lowering but increase risk of euglycemic diabetic ketoacidosis and should be used with extreme caution 4
• GLP-1 receptor agonists show modest A1C reductions but increase hypoglycemia and ketosis risk 4
• Metformin may reduce insulin requirements but does not significantly improve HbA1c 4

Common Pitfall: Avoid abruptly discontinuing oral medications when starting insulin therapy due to risk of rebound hyperglycemia 7. However, given that insulin is the cornerstone of type 1 diabetes management and most patients do not require oral agents, this primarily applies to patients transitioning from misdiagnosed type 2 diabetes.

Lifestyle Modifications

Dietary Recommendations

• Follow a heart-healthy diet with daily fat intake ≤30% of calories, with <7% from saturated fat 1
• Limit sodium intake to ≤1,500 mg per day 1
• Consume at least 3 oz of whole grains, 2 cups of fruit, and 3 cups of vegetables daily 1

Cardiovascular Risk Management

• Maintain LDL cholesterol <100 mg/dL, with therapeutic option of <70 mg/dL for high-risk patients 1
• Target blood pressure <130/80 mm Hg 1
• Daily aspirin regimen lowers coronary heart disease risk by 20-25% 1