Type 1 Diabetes Mellitus Guidelines

Updated: Oct 22, 2018
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Guidelines

Guidelines Summary

ADA: Position statement on type 1 diabetes in children and adolescents

In August 2018, the American Diabetes Association released a position statement on type 1 diabetes in children and adolescents, which included the following guidelines [153, 154] :

  • Consult a pediatric endocrinologist before diagnosing type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in patients with acute illness in the absence of classic symptoms
  • Differentiating type 1 diabetes, type 2 diabetes, monogenic diabetes, and other forms of diabetes is based on patient history and characteristics, as well as on laboratory tests, such as an islet autoantibody panel
  • The majority of children with type 1 diabetes should be treated with intensive insulin regimens using multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
  • A 1C should be measured every 3 months
  • Blood glucose levels should be monitored up to 6-10 times daily
  • Continuous glucose monitors (CGM) should be considered in all children and adolescents with type 1 diabetes; the benefits of CGM correlate with adherence to ongoing use of the device
  • Blood or urine ketone levels should be monitored in children with type 1 diabetes in the presence of prolonged/severe hyperglycemia or acute illness
  • Individualized medical nutrition therapy is recommended for children and adolescents
  • Exercise is recommended, with a goal of 60 minutes a day of moderate to vigorous aerobic activity, along with vigorous muscle-strengthening and bone-strengthening activities at least 3 days a week
  • It is important to frequently monitor glucose before, during, and after exercise (with or without CGM use) to prevent, detect, and treat hypoglycemia and hyperglycemia
  • All individuals with type 1 diabetes should have access to an uninterrupted supply of insulin; lack of access and insulin omissions are major causes of diabetic ketoacidosis
  • Glucagon should be prescribed for all individuals with type 1 diabetes, and caregivers or family members should be instructed regarding administration
  • Once the child has had diabetes for 5 years, annual screening for albuminuria, using a random spot urine sample (morning sample preferred to avoid effects of exercise) to assess the albumin-to-creatinine ratio, should be considered at puberty or at age greater than 10 years, whichever occurs earlier
  • Once the youth has had diabetes for 3-5 years, an initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, and an annual routine follow-up is generally recommended
  • For adolescents who have had type 1 diabetes for 5 years, consider an annual comprehensive foot exam at the start of puberty or at age 10 years, whichever is earlier
  • Blood pressure should be measured at each routine visit; children who have high-normal blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP] at 90th percentile for age, sex, and height) or hypertension (SBP or DBP at 95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days
  • Initial treatment of high-normal blood pressure (SBP or DBP consistently at the 90th percentile for age, sex, and height) includes dietary modification and increased exercise for weight control; if target blood pressure is not reached within 3-6 months after lifestyle intervention, consider pharmacologic treatment
  • Because of their potential teratogenic effects, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be considered for initial pharmacologic treatment of hypertension after reproductive counseling
  • The blood pressure treatment goal is consistently less than the 90th percentile for age, sex, and height
  • If low-density lipoprotein (LDL) cholesterol is within an acceptable risk level (< 100 mg/dL [2.6 mmol/L]), a lipid profile every 3-5 years is reasonable
  • If lipid levels are abnormal, initial therapy should consist of optimizing glucose control and initiating a Step 2 American Heart Association diet (restricting saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day)
  • After age 10 years, consider adding a statin if, despite 6 months of medical nutrition therapy and lifestyle changes, LDL cholesterol remains greater than 160 mg/dL (4.1 mmol/L) or LDL cholesterol remains greater than 130 mg/dL (3.4 mmol/L) with one or more cardiovascular disease (CVD) risk factors present (after reproductive counseling because of the potential teratogenic effects of statins)
  • The LDL therapy goal is less than 100 mg/dL (2.6 mmol/L)
  • In children with type 1 diabetes, consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis
  • In children and adolescents with type 1 diabetes, an A 1C target of less than 7.5% should be considered but individualized
  • Glucose (15 g) is preferred treatment for conscious individuals with hypoglycemia (blood glucose < 70 mg/dL [3.9 mmol/L]), but any form of carbohydrate may be used; treatment should be repeated if self-monitoring blood glucose (SMBG) 15 minutes after treatment shows hypoglycemia is still present; when blood glucose concentration returns to normal, consider a meal or snack and/or reduce insulin to prevent recurrence of hypoglycemia
  • In patients with classic symptoms, blood glucose measurement is sufficient to diagnose diabetes (symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [11.1 mmol/L])
  • Measure thyroid-stimulating hormone concentrations when the patient is clinically stable or once glycemic control has been established; if normal, suggest rechecking every 1-2 years (or sooner if the patient develops symptoms or signs that suggest thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability)
  • Screen children for celiac disease by measuring IgA tissue transglutaminase antibodies
  • Criteria for diagnosis of diabetes is fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
  • In asymptomatic children and adolescents at high risk for diabetes, if FPG ≥126 mg/dL (7 mmol/L), if 2-hr PG ≥200 mg/dL (11.1 mmol/L), or if A 1C ≥6.5%, testing should be repeated on a separate day to confirm the diagnosis

ADA: Standards of Medical Care in Diabetes

The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 include the following A-grade recommendations, ie, recommendations based on “[c]lear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered” [75] :

  • Align approaches to diabetes management with the Chronic Care Model, emphasizing productive interactions between a prepared, proactive care team and an informed, activated patient
  • Providers should assess social factors that can affect patients with diabetes, such as potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions
  • Provide patients with self-management support from lay health coaches, navigators, or community health workers, when available
  • Effective diabetes self-management education and support should be patient centered, may be given in group or individual settings or using technology, and should help guide clinical decisions
  • Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goal of optimizing health outcomes and health-related quality of life
  • A reasonable A 1C goal for many nonpregnant adults is below 7% (53 mmol/mol)
  • Insulin-treated patients with hypoglycemia unawareness or an episode of clinically significant hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes
  • Most people with type 1 diabetes should be treated with a multiple daily injection regimen of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
  • Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk
  • Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of less than 140 mmHg and a diastolic blood pressure goal of under 90 mmHg
  • Patients with a confirmed office-based blood pressure of 140/90 mmHg or above should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals
  • Patients with a confirmed office-based blood pressure of 160/100 mmHg or above should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
  • Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], thiazide-like diuretics, or dihydropyridine calcium channel blockers)
  • Multiple-drug therapy is generally required to achieve blood pressure targets; however, combinations of ACE inhibitors and ARBs and combinations of ACE inhibitors or ARBs with direct renin inhibitors should not be used
  • Lifestyle modifications focusing on weight loss (if indicated); the reduction of saturated fat, trans fat, and cholesterol intake; an increase in dietary omega-3 fatty acids, viscous fiber, and plant stanol/sterol intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes
  • High-intensity statin therapy should be added to lifestyle therapy for patients of all ages with diabetes and atherosclerotic cardiovascular disease (ASCVD)
  • For patients aged 40-75 years who have diabetes but do not have ASCVD, use moderate-intensity statin treatment in addition to lifestyle therapy
  • For patients with diabetes and ASCVD, if the low-density lipoprotein (LDL) cholesterol level is 70 mg/dL (3.9 mmol/L) or above on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or a proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitor) after evaluating the potential for further ASCVD risk reduction, drug-specific adverse effects, and patient preferences; ezetimibe may be preferred due to lower cost
  • Combination therapy (statin/fibrate) has not been shown to improve ASCVD outcomes and is generally not recommended
  • Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended
  • Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in patients with diabetes and a history of ASCVD
  • In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated
  • Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease
  • Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease
  • Patients should be referred for evaluation for renal replacement treatment if they have an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m 2
  • Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy
  • Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy
  • Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy
  • The traditional standard treatment, panretinal laser photocoagulation therapy, is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy
  • Intravitreous injections of the vascular endothelial growth factor inhibitor ranibizumab are not inferior to traditional panretinal laser photocoagulation and are also indicated to reduce the risk of vision loss in patients with proliferative diabetic retinopathy
  • Intravitreous injections of vascular endothelial growth factor inhibitor are indicated for central-involved diabetic macular edema, which occurs beneath the foveal center and may threaten reading vision
  • The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage
  • Either pregabalin or duloxetine is recommended as initial pharmacologic treatment for neuropathic pain in diabetes

ADA: hypertension guidelines

Guidelines published in 2017 by the American Diabetes Association on managing hypertension in patients with diabetes state the following [155, 156] :

  • Blood pressure should be measured at every routine clinical care visit; patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension
  • All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension
  • Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed
  • Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg
  • Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk for cardiovascular disease if they can be achieved without undue treatment burden
  • For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if the patients are overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)–style dietary pattern, including reduced sodium and increased potassium intake, increased fruit and vegetable consumption, moderation of alcohol intake, and increased physical activity
  • Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals
  • Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
  • Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers; multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACE inhibitors and ARBs)
  • An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and a urine albumin-to-creatinine ratio of ≥300 mg/g creatinine or 30–299 mg/g creatinine; if one class is not tolerated, the other should be substituted
  • For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored
  • Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy
  • In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120-160/80-105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth

ISPAD: Diabetic vascular complications in children and adolescents

In August 2018, the International Society for Pediatric and Adolescent Diabetes (ISPAD) released clinical practice consensus guidelines on diabetic microvascular and macrovascular complications in children and adolescents. These include the following [157] :

  • Commence screening for microvascular complications at age 11 years
  • Screening for microvascular disease should be performed preconception and during each trimester of pregnancy
  • Intensive education and treatment should be provided to children and adolescents to prevent or delay the onset and progression of vascular complications
  • Achievement of target glycemic control will reduce the risk for onset and progression of diabetic vascular complications
  • Prevention or cessation of smoking will reduce progression of albuminuria and cardiovascular disease
  • Screening for diabetic retinopathy should start at age 11 years with 2 to 5 years’ diabetes duration
  • Screening for diabetic retinopathy should be performed by an ophthalmologist or optometrist or a trained, experienced observer, through dilated pupils, with assessment carried out via biomicroscopic examination or fundal photography
  • Laser treatment and intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents reduce the rate of vision loss for individuals in vision-threatening stages of retinopathy (severe nonproliferative retinopathy or worse and/or diabetic macular edema)
  • Screen for renal disease using first morning albumin/creatinine ratio as the preferred method.
  • Blood pressure (BP) should be measured at least annually; hypertension is defined as average systolic BP (SBP) and/or diastolic BP (DBP) that is at or above the 95th percentile for gender, age, and height on three or more occasions
  • Angiotensin-converting enzyme (ACE) inhibitors are recommended for use in children with diabetes and hypertension; they have been effective and safe in children in short-term studies but are not safe during pregnancy
  • Screen for lipid abnormalities in the nonfasting state
  • With regard to macrovascular disease, screening of BP and lipids is recommended, as above; the benefit of routine screening for other markers of macrovascular complications outside the research setting is unclear

ISPAD: Glycemic control targets and glucose monitoring in children, adolescents, and young adults

In July 2018, the ISPAD released clinical practice consensus guidelines on glycemic control targets and glucose monitoring in children, adolescents, and young adults with diabetes. These include the following [158] :

  • Glycemic control of children and adolescents must be assessed by both quarterly hemoglobin A1c (HbA1c) measurements and by regular home glucose monitoring; these permit achievement of optimal health in the following ways: (1) by determining with accuracy and precision an individual's glycemic control, including through assessment of each individual's glycemic determinants; (2) by reducing the risks of acute and chronic disease complications; and (3) by minimizing the effects of hypoglycemia and hyperglycemia on brain development, cognitive function, and mood
  • Regular self-monitoring of glucose (using accurate finger-stick blood glucose [BG] measurements, with or without continuous glucose monitoring [CGM] or intermittently scanned CGM [isCGM]), is essential for diabetes management for all children and adolescents with diabetes
  • Each child should have access to technology and materials for self-monitoring of glucose measurements to provide for enough testing for optimized diabetes care
  • When finger-stick BG measurements are used, testing may need to be performed 6-10 times per day to optimize intensive control; regular review of these BG values should be performed with adjustments to medication/nutritional therapies to optimize control
  • Real-time CGM data particularly benefit children who cannot articulate symptoms of hypoglycemia or hyperglycemia and those with hypoglycemic unawareness
  • Intermittently scanned CGM can complement finger-stick BG assessments. Although isCGM provides some benefits similar to those of CGM, it does not alert users to hypoglycemia or hyperglycemia in real time, nor does it permit calibration. Without robust pediatric use efficacy data, it cannot fully replace BG monitoring
  • For children, adolescents, and young adults aged 25 years or younger, ISPAD recommends individualized targets, aiming for the lowest achievable HbA1c without undue exposure to severe hypoglycemia, balanced with quality of life and burden of care
  • For children, adolescents, and young adults aged 25 years or younger who have access to comprehensive care, a target HbA1c of less than 53 mmol/mol (7.0%) is recommended
  • A higher HbA1c goal (in most cases below 58 mmol/mol [7.5%]) is appropriate in the following contexts: (1) inability to articulate symptoms of hypoglycemia; (2) hypoglycemia unawareness/history of severe hypoglycemia; (3) lack of access to analog insulins, advanced insulin delivery technology, and CGM, and lack of ability to regularly check BG; and (4) individuals who are “high glycators,” in whom an at-target HbA1c would reflect a significantly lower mean glucose level than 8.6 mmoL/L (155 mg/dL)
  • A lower goal (6.5%) or 47.5 mmol/mol may be appropriate if achievable without excessive hypoglycemia, impairment of quality of life, and undue burden of care
  • A lower goal may be appropriate during the honeymoon phase of type 1 diabetes
  • For patients who have elevated HbA1c, a stepwise approach to improve glycemic control is advised, including individualized attention to the following: (1) dose adjustments, (2) personal factors limiting achievement of the target, (3) assessment of the psychological effect of goal setting on the individual, and (4) incorporation of available technology to improve glucose monitoring and insulin delivery modalities
  • HbA1c measurement should be available in all centers caring for persons with diabetes
  • HbA1c measurements should be performed at least every 3 months
  • Examining variations in HbA1c between centers can assist in evaluating the care provided by health-care centers, including compliance with agreed-to standards to improve therapies and delivery of pediatric diabetes care