Management of Type 1 Diabetes

Insulin Regimens

The American Diabetes Association recommends insulin therapy as the cornerstone of type 1 diabetes management, with most patients requiring multiple daily injections (MDI) of basal and prandial insulin or continuous subcutaneous insulin infusion (CSII) via pump therapy to achieve optimal glycemic control and reduce long-term complications 1, 2
MDI typically consists of basal insulin (once or twice daily) plus prandial insulin before meals and correction insulin as needed, with basal insulin options including long-acting insulin analogs (glargine, degludec) and NPH insulin 3, 4
Prandial insulin options include rapid-acting analogs (aspart, lispro, glulisine), ultra-rapid-acting analogs (faster-acting aspart, faster lispro), and inhaled human insulin, with rapid-acting analogs preferred over regular human insulin due to quicker onset and better postprandial glucose control 1

CSII delivers rapid-acting insulin continuously with programmable basal rates and bolus doses, and has been shown to have modest advantages for lowering A1C (0.30% reduction) and reducing rates of severe hypoglycemia 1, 3, 5
The American Diabetes Association recommends considering CSII for patients not meeting glycemic targets, experiencing frequent/severe hypoglycemia, or with pronounced dawn phenomenon, although this should be individualized based on patient preferences and self-management capabilities 1, 3

Hybrid closed-loop systems combine insulin pumps with continuous glucose monitors (CGM) to automatically adjust insulin delivery, and have been shown to be superior to sensor-augmented pump therapy for increasing time in range and reducing hypoglycemia 1
The American Diabetes Association recommends considering AID systems for individuals capable of using the device safely, although cost and accessibility may be prohibitive for some patients 1, 3

The American College of Physicians recommends targeting HbA1c <7% for most nonpregnant adults, with intensive insulin therapy (targeting near-normal glycemia) reducing microvascular complications by 50% and macrovascular complications (long-term follow-up showed 57% reduction in cardiovascular events) 2, 3, 4
Intensive insulin therapy also reduces all-cause mortality, although it increases the risk of severe hypoglycemia (62 vs 19 episodes per 100 patient-years with conventional therapy) 2, 3

The American Diabetes Association recommends starting total daily insulin dose at 0.4-1.0 units/kg/day (typically 0.5 units/kg for metabolically stable patients), with distribution of approximately 30-50% as basal insulin and the remainder as prandial insulin 1, 2
Higher doses may be needed during puberty or when presenting with diabetic ketoacidosis, and patient preferences, cost, insulin type, dosing regimen, and self-management capabilities should all be considered when choosing between insulin delivery systems 1, 2, 3

The American Diabetes Association recommends education on matching prandial insulin doses to carbohydrate intake (carbohydrate counting), pre-meal blood glucose levels, and anticipated physical activity, as well as advanced education on fat and protein gram estimation for patients who have mastered carbohydrate counting 2, 5
Regular reassessment of insulin-taking behavior and treatment plans is recommended every 3-6 months, with consideration of patient preferences, cost, and self-management capabilities 1, 3

The American Diabetes Association recommends continuous glucose monitoring (CGM) as standard of care for most people with type 1 diabetes, with benefits including improved glycemic control regardless of insulin delivery method and reduced nocturnal hypoglycemia 1, 3
CGM with alerts/alarms helps identify and prevent hypoglycemic episodes, and should be considered for individuals at high risk of hypoglycemia or with a history of severe hypoglycemic episodes 3

The American Diabetes Association recommends using insulin analogs rather than human insulins to reduce hypoglycemia risk, as well as newer longer-acting basal analogs (U-300 glargine, degludec) which confer lower hypoglycemia risk compared to U-100 glargine 1, 3
CGM with alerts/alarms helps identify and prevent hypoglycemic episodes, and should be considered for individuals at high risk of hypoglycemia or with a history of severe hypoglycemic episodes 3

The American Society of Anesthesiologists recommends that patients on insulin pump therapy can often continue therapy with appropriate monitoring during elective surgery, although insulin pump therapy should be discontinued and replaced with alternative insulin regimens during emergency surgery 6, 7, 8
Hospitals should develop clear protocols for managing patients on insulin pump therapy during hospitalization, with consideration of patient preferences, cost, and self-management capabilities 6