Type 1 Diabetes: Management Strategies

 

There is considerable benefit of tight glucose control in patients with type 1 diabetes mellitus. Tight blood glucose control dramatically decreases the incidence of microvascular and macrovascular complications. Although glycemic goals should be individualized, most nonpregnant adults should strive for an A1C level less than 7%. Greater frequency of glucose monitoring and continuous glucose monitoring are both associated with lower A1C levels. The choice to monitor glucose levels via multiple daily capillary blood samples or continuous glucose monitoring is based on cost and patient preference. Intensive insulin treatment is recommended with a combination of multiple mealtime bolus and basal injections or with continuous insulin infusion through an insulin pump. The option to administer insulin with multiple daily injections vs. a pump should be individualized. Adjunctive medical therapy is under investigation but is not currently recommended. All patients with type 1 diabetes should participate in diabetes self-management education and develop individualized premeal insulin bolus plans under the guidance of a dietitian, if possible. Blood pressure and lipid control are important to prevent cardiovascular disease events. Patients with type 1 diabetes should have sick-day plans and be able to identify warning signs of hypoglycemia and diabetic ketoacidosis. Advances in diabetes care, including the bionic pancreas and the closed-loop system of glucose monitoring with an automated insulin pump, may have a significant effect on type 1 diabetes care in the years ahead.

The benefit of tight glucose control in patients with type 1 diabetes mellitus is well established.14 Microvascular complications (e.g., neuropathy, nephropathy, retinopathy) and macrovascular complications (e.g., myocardial infarction, cerebrovascular accident, cardiovascular disease– related deaths) are dramatically decreased when glucose levels are maintained as close to the nondiabetic range as possible.4 The numbers needed to treat with intensive therapy (A1C of approximately 7% vs. 9%) for a 10-year period to prevent progression of retinopathy and clinical neuropathy are 3 and 1.5, respectively.2 Additionally, intensive glycemic control reduces the risk of cardiovascular disease by 42% and severe cardiovascular events (nonfatal myocardial infarction, stroke, or death from cardiovascular disease) by 57% over 11 years among patients with type 1 diabetes.3 Long-term follow-up of the Diabetes Control and Complications Trial shows that the benefit of early, aggressive insulin therapy and intensive glycemic control persists for several decades after initiation of treatment. Although the exact pathophysiologic explanation for prolonged improved outcomes remains unclear, there is a decrease in all-cause mortality.5

WHAT IS NEW ON THIS TOPIC: TYPE 1 DIABETES

Long-term follow-up of the Diabetes Control and Complications Trial shows that the benefit of early, aggressive insulin therapy and intensive glycemic control persists for several decades after treatment and is associated with a decrease in all-cause mortality.

A well-designed double-blind randomized controlled trial of adults with type 1 diabetes who were taking metformin did not show significant improvement in glycemic control. The potential cardiovascular disease benefit remains under investigation.

In September 2016, the U.S. Food and Drug Administration approved the first combination glucose monitoring and automated insulin delivery device, a hybrid closed-loop system.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In persons with type 1 diabetes mellitus, self-monitoring blood glucose levels more frequently is recommended because it leads to improved A1C levels.

C

8

Basal-bolus insulin regimens are recommended for most persons with type 1 diabetes.

C

14

The decision to administer insulin via multiple daily injections or insulin pump can be individualized in persons with type 1 diabetes; neither method appears to be universally more effective.

C

16

In persons with type 1 diabetes, adjunctive treatment with metformin for improved glycemic control is not advised.

C

25

Regular education regarding sick day management and hypoglycemia should be provided to all persons with type 1 diabetes.

C

35, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In persons with type 1 diabetes mellitus, self-monitoring blood glucose levels more frequently is recommended because it leads to improved A1C levels.

C

8

Basal-bolus insulin regimens are recommended

The Authors

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ANDREW SMITH, MD, is a faculty member at the Lawrence Family Medicine Residency Program, Lawrence, Mass., and an assistant professor of Family Medicine at the Tufts University School of Medicine, Boston, Mass....

CHELSEA HARRIS, MD, is a fourth-year resident at Lawrence Family Medicine Residency Program.

Address correspondence to Andrew Smith, MD, Lawrence Family Health Center, 34 Haverhill St., Lawrence, MA 01841. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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