Frequency of Type 1 Diabetes Patients on Intensive Insulin Therapy in Outpatient Clinics
The vast majority of type 1 diabetes patients attending outpatient clinics should be on multiple daily injections (3-4 injections per day) or insulin pump therapy, as this represents the standard of care for essentially all type 1 diabetes patients—not a select subgroup. 1, 2
Standard of Care, Not Exception
The premise that patients requiring three or more insulin injections daily represent a special subset is fundamentally incorrect:
The American Diabetes Association explicitly states that "most individuals with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion"—this is a Grade A recommendation applying to nearly all type 1 diabetes patients. 1
This intensive insulin regimen (MDI or pump) is the foundational treatment approach for type 1 diabetes, not an exception. 2 The ADA reinforces that this level of insulin intensity is universally required unless contraindicated. 2
In real-world outpatient diabetes clinics, the expectation is that the overwhelming majority of type 1 diabetes patients are already on or should be transitioned to intensive insulin therapy. 3, 4 A 2022 Chinese study of 362 type 1 diabetes patients from outpatient clinics found that 83% (301/362) were on MDI therapy defined as 4 or more injections per day, with an additional 17% on insulin pumps. 3
Clinical Reality vs. Ideal Practice
While guidelines establish MDI as standard care, implementation gaps exist:
Approximately 50% of type 1 diabetes patients fail to achieve HbA1c targets below 7.5%, often due to psychological barriers, treatment non-adherence, or inadequate physician prescribing patterns rather than lack of indication for intensive therapy. 5
Physicians sometimes contribute to suboptimal outcomes by maintaining patients on only two daily injections with premixed insulin when intensive therapy is indicated. 5
CGM Indication Beyond Injection Frequency
The suggestion that CGM is "primarily beneficial" only for patients on intensive insulin therapy misrepresents current evidence:
The ADA recommends early adoption of continuous glucose monitoring for all adults with type 1 diabetes to improve glycemic outcomes, quality of life, and reduce hypoglycemia—independent of injection frequency. 2
Automated insulin delivery systems should be offered to all adults with type 1 diabetes, extending CGM utility beyond simple injection counting. 2
CGM can be beneficial as a supplemental tool even for patients on less intensive insulin regimens. 2
HbA1c Remains the Gold Standard
Your assertion about HbA1c is correct—it remains the primary target for glycemic control, correlating with long-term microvascular and macrovascular outcomes in both type 1 and type 2 diabetes. 2 The DCCT demonstrated that lower HbA1c with intensive control (7%) led to 50% reductions in microvascular complications, with sustained benefits for macrovascular complications over 20+ years of follow-up. 1
Bottom Line
If your outpatient clinic is not seeing the majority of type 1 diabetes patients on intensive insulin therapy (≥3 injections daily or pump), this represents a care gap rather than an unusual patient population. The clinical question should not be "how often do we see these patients?" but rather "why aren't all our type 1 diabetes patients on this standard regimen?"