New Guidelines for Type 1 Diabetes in Adults: An Overview
Let me tell you the story of how these guidelines began. Dr Richard Holt, who's in the UK, decided that we need a set of guidelines for the management of T1D because, frankly, it was always under the shadow of the treatment of people with type 2 diabetes (T2D). Also in part because the guidelines for the treatment of T2D have been really well established and accepted around the world.
He decided to set forth an ADA/EASD committee. He chose 14 people from around the United States and Europe — seven from the US and seven from Europe. The first meeting was the EASD group alone, and they met in January 2020; the first combined group was in March 2020. We all had visions of European meetings and everything else, but of course that didn't happen. Instead, we marched along through the COVID pandemic to make these recommendations.
What Do the Guidelines Cover? An Overview
The first thing we did was narrow what we wanted to discuss. We don't discuss the management of the complications of diabetes because it's the same in people with T1D and T2D, and we wanted these guidelines to be very type 1–focused.
The first thing that's important is: How do we diagnose T1D? I'm going to go through that algorithm in a bit more detail because it's different from what we're used to. The next section talks about aims and goals. One of the things we talk about is not only using metrics that come from CGM data (such as time in range) as a goal, but we also say that in certain individuals, a target A1c of perhaps even < 6.5 makes some sense. For most people we recommend a target of < 7.0, but there may be benefit to being even lower than that as long as it occurs without an unacceptable risk for side effects, particularly hypoglycemia. We recognize now that, with some of the newer technologies, people can do better than ever.
We provide a schedule of care and talk about diabetes self-management, education, and support. We talk about monitoring and the fact that almost everybody with T1D should be on a continuous glucose monitor, with rare exceptions.
We talk about insulin therapy. Importantly, we talk a lot about the use of analogue therapy and insulin pumps, but we also talk about the use of non-analogue therapy, because around the world, not everybody has access to insulin analogues, and they are also much more expensive.
We talk about hypoglycemia and a whole host of behavioral considerations: nutrition, alcohol, drugs, smoking, sleep, physical activity, sick-day rules, driving, employment, and travel. We talk about diabetic ketoacidosis — not in great detail, but we do discuss it. We talk about psychosocial care, which is very important.
Throughout the guideline, we bring it back to What does the patient want? What's important to the patient? We talk about social determinants of health, pancreas and islet cell transplantation, and adjunctive therapies. We talk about special populations (pregnancy, older individuals, and people living with late complications) and inpatient management. Finally, in the end, we talk about emergent and future perspectives.
We don't exactly tell you what to do, but we do tell you what needs to be done and what needs to be considered in the management of patients with T1D. Hopefully, this is the kind of guideline that can be refined over time to become more and more specific.
Diagnosing T1D in Adults
We provide a fairly complicated flowchart for the diagnosis of T1D in adults, but let me simplify it for you.
You basically have an adult who you think might have T1D, so you test for islet autoantibodies. In most people who have T1D, those antibodies will be positive, so you diagnose them with adult-onset T1D. For the 5%-10% who are negative for antibodies but you still think might have T1D, we suggest that you think about them based on age. If they're younger, you probably want to rule out monogenic diabetes; if they're older, they may well have T2D. We give you a suggested pathway that looks at measurement of C peptide and other features to try to determine between those two.
The bottom line, of course, is that it's always clinical. It's always based on what the patient needs to control their diabetes. Do they need insulin? Do they need other agents? But we really try to give you a framework for diagnosing T1D in adulthood.
Next, we give you a flow for the general management principles of patients with T1D. The first question we always ask is, Are glycemic targets being met?And we stress the need for individualization of targets.
When you're having this conversation with a patient, you want to see if they're at their target. Are they comfortable at their target? Do they need anything else? Do they want to see a nutritionist or a diabetes educator? Do they have psychosocial issues that require them to see a mental health professional? Do they want change? Somebody may be doing well on their regimen but perhaps they want to change. They may want to go on a continuous glucose monitor or a hybrid closed-loop pump system.
If glycemic targets are not being met, we want to figure out why. And that's obviously going to require a conversation with the patient. There are many reasons that patients aren't reaching their targets. Some have to do with lack of education and lack of support. Some have to do with psychosocial issues and social determinants of health. Others have to do with the fact that they need different insulin, newer insulins, or perhaps other technology.
You really need to delve into why that patient isn't meeting glycemic targets. We stress that it's the patient's choice; they need to feel good about what they're doing and the technology and treatments they're using. We need to help facilitate that.
We also talk about the fact that people can go back and forth. A patient may be on multiple daily insulin injections and want to try a hybrid closed-loop pump system. They try that for a while, but then they want to switch back. That's fine. People can switch back and forth. Our goal as providers is not to force patients to do any one thing but to provide them with alternatives as well as our advice about what seems to be the best for them at any given time.
Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts, and three books, on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.
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The Management of Type 1 Diabetes in Adults — A Consensus Report by the ADA and EASD
Type 1 diabetes is a condition caused by autoimmune damage of the insulin-producing β cells of the pancreatic islets, usually leading to severe endogenous insulin deficiency. Type 1 diabetes accounts for approximately 5-10% of all cases of diabetes. Although the incidence peaks in puberty and early adulthood, type 1 diabetes affects all age groups. The American Diabetes Association and the European Association for the Study of Diabetes convened a writing group to develop a consensus report on the management of type 1 diabetes in adults. The group has developed a draft consensus report, which was presented at ADA’s 2021 Scientific Sessions, providing an opportunity for the greater diabetes professional community to provide critical feedback on this important work in progress.
Read the draft of The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).(link is external)
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