Type 1 Diabetes Mellitus Guidelines

Updated: May 03, 2018
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Guidelines

Guidelines Summary

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” [158] :

  • 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 [147, 148] :

  • 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
  • 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
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