Updated Type 1 Diabetes Treatment Guidelines

Pubblicato il di

Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Chamberlain JJ et al. Ann Intern Med 2017 Sep 12.

Glycemic monitoring, goals, and pharmacologic therapies endorsed by the American Diabetes Association

Sponsoring Organization: American Diabetes Association (ADA)

Target Audience: All clinicians providing care to patients with type 1 diabetes

Background

The ADA updates their guidelines and care standards for patients with diabetes annually. The full recommendations are available online. They offer evidence-based recommendations, rated on supporting literature (A, large clinical trials or meta-analyses; B, cohort studies; C, uncontrolled observational studies; or E, expert/consensus recommendation).

Key Recommendations

  • Monitoring glycemia

    • Patients with intensive insulin regimens (multiple insulin injections daily or continuous insulin infusions) require frequent blood glucose self-monitoring. Self-monitoring of blood glucose should occur no fewer than 6 to 10 times daily. (B)

    • Continuous glucose monitoring can lower glycosylated hemoglobin (HbA1c) in selected adults. (C)

    • HbA1c level should be monitored twice annually in patients who achieve treatment and glycemic goals and more frequently in those who do not meet glycemic goals. Avoiding hypoglycemia takes precedence over achieving HbA1c targets. (E)

  • Glycemic goals

    • HbA1c goals for nonpregnant adults is <7%, but this target can be liberalized to <8% for patients with histories of severe hypoglycemia or comorbid diseases. (A)

    • HbA1c goal can be more strict (<6.5%) in patients with short duration of diabetes, long life expectancy, and no clinically significant cardiovascular disease. (C)

  • Pharmacologic therapy

    • Insulin therapies require patient education to match dosing to carbohydrate intake, premeal glucose levels, and anticipated physical activity.

    • Intensive glycemic monitoring should be encouraged in active patients with family participation.

    • Rapid-acting inhaled insulin is noninferior to aspart insulin for HbA1c lowering and is less likely to cause hypoglycemia.

    • Although most hypoglycemia is managed with oral glucose or other carbohydrates, patients who are at risk for significant hypoglycemia can be prescribed glucagon for administration by family members, caregivers, or school personnel. (E)

    • Patients with clinically significant hypoglycemia, or severe hypoglycemia with unawareness, should raise their glycemic targets transiently for several weeks both to avoid hypoglycemia and to improve hypoglycemia awareness. (A)

COMMENT

Of note, most authors of this guideline had significant associations with pharmaceutical corporations that manufacture antidiabetes drugs. Nevertheless, these literature-supported recommendations should help guide clinicians who manage patients with type 1 diabetes. Primary care providers should have a low threshold for referring patients with new or uncontrolled type 1 diabetes to endocrinology experts for patient education and care-management strategies.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

  • Disclosures for Daniel D. Dressler, MD, MSc, SFHM, FACP at time of publicationRoyaltiesMcGraw-Hill Editorial boards Journal of Hospital Medicine (Frontline); Principles and Practice of Hospital Medicine (McGraw-Hill)

CITATION(S):

  1. Chamberlain JJ et al. Treatment of type 1 diabetes: Synopsis of the 2017 American Diabetes Association standards of medical care in diabetes. Ann Intern Med 2017 Sep 12; [e-pub]. (http://dx.doi.org/10.7326/M17-1259)