Can a patient with type 1 diabetes (T1D) receive long-term management according to the latest International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines?

Long-Term Management of Type 1 Diabetes According to Latest Guidelines

Yes, patients with type 1 diabetes can and should receive comprehensive long-term management following current evidence-based guidelines, with multiple daily injections or insulin pump therapy as the cornerstone of treatment. 1, 2

Core Insulin Regimen

Most individuals with type 1 diabetes should be treated with either multiple daily injections (MDI) of prandial and basal insulin, or continuous subcutaneous insulin infusion (CSII) via pump therapy. 1, 2

• MDI consists of rapid-acting insulin analogs before each meal combined with once or twice-daily long-acting basal insulin 2
• CSII offers a modest additional benefit over MDI, with approximately 0.3 percentage point lower HbA1c and reduced severe hypoglycemia rates 1, 2
• Rapid-acting insulin analogs (aspart, lispro, or glulisine) should be used rather than regular human insulin to reduce hypoglycemia risk while achieving equivalent HbA1c control 1, 2

The landmark Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with these regimens reduced A1C and led to approximately 50% reductions in microvascular complications over 6 years, with continued benefits showing fewer macrovascular complications in long-term follow-up. 1

Insulin Dosing Education

Patients must receive comprehensive education on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, fat and protein content, and anticipated physical activity. 1

• Monitoring carbohydrate intake through carbohydrate counting or experience-based estimation is key to achieving optimal glycemic control 1
• A typical starting regimen consists of 50% of total daily dose as basal insulin and 50% as bolus insulin 3

Glycemic Targets

Target HbA1c should be <7.5% for children and adolescents, and <7% for adults, when achievable without problematic hypoglycemia. 2

• HbA1c should be measured every 3 months to assess overall glycemic control 2
• Continuous glucose monitoring (CGM) metrics should be integrated beyond HbA1c, including time in target range and frequency of hypoglycemia 2

Glucose Monitoring

CGM is associated with lower mean A1C in youth for both insulin pump users and patients using multiple daily injection regimens. 1

• Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted 4
• Fasting plasma glucose values should be used to titrate basal insulin, whereas both fasting and postprandial glucose values should be used to titrate mealtime insulin 4

Lifestyle Management

Individualized medical nutrition therapy is essential as a component of the overall treatment plan. 1

• Comprehensive nutrition education at diagnosis with annual updates by an experienced registered dietitian is required 1
• Carbohydrate intake should come from vegetables, fruits, legumes, whole grains, and dairy products, with emphasis on foods higher in fiber and lower in glycemic load 1
• Medical nutrition therapy has been shown to lower A1C by up to 1.9% in patients with type 1 diabetes 3

Adjunctive Therapies

Pramlintide (injectable amylin analog) can be considered as adjunct to mealtime insulin for patients not achieving glucose goals despite optimized insulin therapy, with prandial insulin doses reduced by 50% when initiating to minimize severe hypoglycemia risk. 2

• There is currently insufficient evidence to support routine use of other adjunctive medical therapies (metformin, GLP-1 receptor agonists, SGLT2 inhibitors) in children with type 1 diabetes 1
• SGLT2 inhibitor use in type 1 diabetes has been associated with increased rates of diabetic ketoacidosis 1

Screening for Associated Conditions

Screen for thyroid autoantibodies at diabetes diagnosis, then measure TSH after metabolic control is established and recheck every 1-2 years. 2

• Screen for other autoimmune conditions common in type 1 diabetes, including celiac disease 2
• Regular screening for hypertension and other complications should be performed 3

Common Pitfalls to Avoid

Distinguish type 1 from type 2 diabetes by measuring islet autoantibodies and C-peptide in overweight/obese adolescents, as 10% of apparent type 2 cases have islet autoimmunity. 2

• Consider monogenic diabetes (MODY) in antibody-negative youth, as 1.2-4% of pediatric diabetes is monogenic and frequently misdiagnosed as type 1 diabetes 2
• The shortest needles (4-mm pen and 6-mm syringe needles) should be first-line choice in all patient categories to avoid intramuscular injections, which can cause severe hypoglycemia especially with long-acting insulins 4
• Correct injection site rotation is essential to prevent lipohypertrophy, which distorts insulin absorption 4