Consensus on Managing Type 1 Diabetes in Adults

Last summer, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a consensus report on the management of type 1 diabetes (T1D) in adults. This was the first time that recommendations specific to adults with T1D were ever published. A similar consensus report had been published on type 2 diabetes (T2D), and it now forms the basis for current recommendations for that population.

The consensus, developed by a panel of diabetes experts, addresses many aspects, including: diagnosis; aims and goals of blood sugar management; schedule of care (visits with the healthcare team, screening for complications, etc.); education and self-management; lifestyle (diet, physical activity, smoking, etc.); monitoring of blood glucose levels (capillary blood sugar measurements or continuous glucose monitoring); insulin therapy (injections, pumps and, more recently, artificial pancreases); hypoglycemia (prevention, frequency, treatment); psychosocial care (acceptance support, mental health issues, etc.); diabetic ketoacidosis (prevention, frequency, treatment); special populations (pregnant women, seniors, hospitalized patients); and emergent prevention and treatment solutions. 

Here are some of the highlights of this consensus report.

A diagnostic algorithm

The section on diagnosis is one of the strong points of this consensus report. It highlights frequent diagnostic errors, in particular when the onset of T1D occurs later in life, stating that more than 40% of adults who develop T1D after age 30 are initially diagnosed with T2D and treated as such without insulin. This form of late-onset diabetes is called LADA (latent autoimmune diabetes of adulthood). More than 10% of patients who have signed up for the BETTER registry report having this type of diabetes which develops later in life and often more progressively.

It’s often difficult for a family physician or for emergency room staff to distinguish between T2D and late-onset T1D. One of the reasons that can make this diagnosis challenging is the fact that people with LADA can sometimes be overweight or obese. In addition, since the decline in insulin production is often a lot more progressive than in early-onset forms, a patient may initially respond well to T2D treatments.

To avoid these kinds of diagnostic errors and decide on the best treatment, the consensus report suggests that, when in doubt, healthcare teams should request an assessment of autoantibodies (markers in the blood that indicate an attack against the pancreas). In Quebec, it’s possible to measure GAD65 autoantibodies, whose presence indicates a strong likelihood of T1D. As needed, this assessment of antibodies is complemented with a C-peptide count, which reflects the amount of insulin that the pancreas is able to produce. This assessment will indicate whether or not a patient needs to start taking insulin. 

Strategies for living longer and healthier

One of the goals of the consensus report is to help people with T1D live longer and healthier. Among the strategies mentioned in the report, the panel highlights four aspects:

• the choice and administration of insulin, and the method for measuring blood sugar levels to maintain them as close as possible to target values and prevent chronic complications (affecting the eyes, kidneys, nerves and heart) while minimizing hypoglycemia, especially severe hypoglycemia, and diabetic ketoacidosis;
• the management of cardiovascular risk factors (e.g., high blood pressure or cholesterol);
• the alleviation of the psychosocial burden;
• the promotion of psychological well-being.

The consensus report states that healthcare teams should provide approaches, treatments and tools to achieve these goals while taking steps to minimize the burden associated with T1D in order to promote psychological well-being.

A personalized approach for the schedule of care

The frequency and type of appointments should be established based on each person’s unique situation. There should be one in-person visit at least once a year when everything is going well, and more frequent visits (e.g., every three months) when blood sugar targets are not met, when one or several complications arise or worsen, or after a change in treatments.

Telemedicine could be integrated to follow-up mechanisms and even promoted, but its use should be based on each person’s needs and computer literacy. Some studies suggest that telemedicine has the potential to improve outcomes (e.g., HbA1c), quality of life and self-management; increase access to care and reduce costs; and lead to improved treatment satisfaction. To benefit from telemedicine, a patient should receive clear instructions from the healthcare team on the expectations for the televisit and how to prepare for it (e.g., weighing, uploading data from glucose monitors or insulin pumps). 

Treatment and technology recommendations

The rapid development of new treatments and technologies in recent years is progressively changing how T1D is being managed. However, the report highlights that access to these new options is often complex.

The consensus takes these new options into consideration and provides recommendations on them. It states that whenever possible, glucose monitoring should be performed using a continuous glucose monitoring (CGM) system or flash device (e.g., Dexcom, FreeStyle Libre), considering the benefits of those devices for blood sugar management (improved HbA1C, reduced frequency and duration of hypoglycemia) and treatment satisfaction.

With regard to insulin, the consensus report states that insulin analogs (Novorapid, Humalog, Admelog, Apidra, Fiasp, Lantus, Basaglar, Toujeo, Tresiba, etc.) should be favoured due to a lower risk of hypoglycemia compared to human insulin (Humulin N, Novolin NPH, Toronto, etc.). This insulin can be administered using an insulin pump or through multiple daily injections, and the choice between these two methods depends on multiple factors. However, the administration method that provides the most benefits is the hybrid closed loop system, or artificial pancreas, a new type of insulin pump (which combines a continuous glucose monitor, a pump and an algorithm to adjust insulin based on blood sugar levels). This system is more effective (fewer hyperglycemia episodes), safer (fewer hypoglycemia episodes) and simpler in many respects (automated management of a good amount of insulin). 

The consensus report also mentions homemade artificial pancreases, also known as “DIY” or “do-it-yourself” systems, used by many people with T1D. Even though the consensus report is not in favour of actively recommending these systems (because they are not approved), it notes that healthcare teams should respect the choice of each patient and continue to provide user support. The BETTER team is currently leading a study to compare commercially available versions (Medtronic 670/770G and Tandem control IQ) with homemade artificial pancreases (Milestone study).

An underestimated psychological and social impact

According to the consensus report, between 20% and 40% of people with T1D suffer from diabetes-related emotional distress, including 15% who suffer from depression. These psychological issues often develop upon diagnosis and, of course, when complications appear.

As a result, the consensus report recommends conducting more periodic monitoring and screening using validated screening tools. Healthcare teams should ask more questions and should not hesitate to use validated screening questionnaires on mental health, psychological needs and social issues to explore problems and identify possible solutions. 

“We are aware of the many and rapid advances in the diagnosis and treatment of type 1 diabetes… However, despite these advances, there is also a growing recognition of the psychosocial burden of living with type 1 diabetes,” said writing group co-chair Richard I.G. Holt, MB BChir, PhD, professor of diabetes and endocrinology at the University of Southampton, UK.