Diabetes Mellitus, Type 1 Author: Maureen D. Passaro, MD; Robert E. Ratner, MD
Editorial changes - 2009-10-30
Author information and module status
Prevention
Screening
Diagnosis
Consultation for Diagnosis
Hospitalization
Non-drug Therapy
Drug Therapy
Patient Education
Consultation for Management
Follow-up
Tables
Figures
References
Glossary
What's New
Patient Information
Additional Resources
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Quality Measures Quality Measures
Drug Therapy
  • Set a target for glycemic control based on the patient's risk of hypoglycemia and underlying medical conditions.
  • Recognize the importance of insulin therapy in achieving glycemic targets to prevent complications.
  • Use insulin-adjustment algorithms and delivery systems individualized for each patient.
  • Take measures to avoid severe hypoglycemia.
  • Consider aspirin therapy for primary and secondary prevention of cardiovascular diseases.
  • Aggressively manage blood pressure.
  • Aggressively manage serum lipid levels.
  • Treat diabetic nephropathy with ACE inhibitors and dietary protein restriction.
  • Treat painful peripheral neuropathy and foot ulcerations.
  • Aggressively maintain blood glucose control in patients with acute cardiac and CNS ischemia.
  • Consider treatment of autonomic neuropathy in the overall management of type 1 diabetes.
  • Take measures to avoid severe hypoglycemia.

Set a target for glycemic control based on the patient's risk of hypoglycemia and underlying medical conditions. B

  • Note that unless contraindicated, the primary treatment goal is to achieve HbA1c <7%.
  • Intervene and consider changing therapy if HbA1c >8%.
  • Consider the following conditions as contraindications to tight control:
    • History of unconcious reactions
    • Hypoglycemic unawareness
    • Seizure disorder
    • Clinically apparent cardiovascular or cerebrovascular disease
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Recognize the importance of insulin therapy in achieving glycemic targets to prevent complications. A

  • Use insulin to aim for normoglycemia.
  • Recognize that to achieve adequate glucose control, most patients require multiple daily insulin injections.
  • Consider combination therapy with long- and short-acting insulin analogs.
  • See table Drug Treatment for Diabetes Mellitus, Type 1.
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Use insulin-adjustment algorithms and delivery systems individualized for each patient. BC

  • Use programmed standing doses of long- and short-acting insulin with adjustments instead of sliding-scale insulin regimens.
  • Consider the various approved insulin delivery devices:
    • Traditional syringe is most commonly used in the U.S. and allows mixing of different types of insulin. Insulin pens may increase convenience but allow use of only a single type of insulin or premixed (e.g., 70/30, 50/50, 75/25) insulin.
    • Insulin pumps allow constant basal infusion but generally require the supervision of a diabetologist.
  • See figure Insulin Adjustment When Testing Blood Sugar Before and After Meals.
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Take measures to avoid severe hypoglycemia. BC

  • Routinely assess all patients for their glycemic threshold and presenting symptoms for hypoglycemia.
  • To prevent, recognize, and correct mild hypoglycemia:
    • Understand that the treatment of type 1 diabetes commonly results in mild hypoglycemia.
    • Look for common etiologic factors (e.g, excessive insulin administration, increased exercise, delay in a scheduled meal, reduction in expected caloric intake) and make appropriate modification in insulin dose.
    • Instruct patients about how to recognize the symptoms and the appropriate amount of carbohydrates necessary to ameliorate the condition without causing excessive hyperglycemia or weight gain.
  • To prevent, recognize, and correct severe hypoglycemia:
    • Individualize the goals of glycemic control based on the risk of severe hypoglycemia.
    • Instruct patients to monitor for hypoglycemia and treat it early with rapid-acting carbohydrates.
    • Instruct family members to recognize severe hypoglycemia and to treat it with glucagon therapy.
    • Target glucose levels specifically to avoid activation of counter-regulatory hormone responses for individuals with a history of severe hypoglycemia or with hypoglycemia unawareness.
Background | Back to top


Consider aspirin therapy for primary and secondary prevention of cardiovascular diseases. BC

  • Consider enteric-coated aspirin (75-162 mg/d) for primary prevention in high-risk patients with:
    • Family history of heart disease
    • Smokers
    • Hypertension
    • Albuminuria
    • LDL >100 mg/dL
    • Age >40 years
    • Obesity
  • Use enteric-coated aspirin as secondary prevention in those with established macrovascular disease.
  • Avoid aspirin in patients aged <18 years or with other contraindications.
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Aggressively manage blood pressure. A

  • Maintain blood pressure below 130/80 mm Hg to achieve optimal risk benefit unless otherwise contraindicated.
  • Institute lifestyle modifications, including exercise, weight loss, sodium restriction, and decreased alcohol intake.
  • Individualize drug therapy on the basis of response to treatment and the presence of complications and comorbid diseases.
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Aggressively manage serum lipid levels. A

  • Maintain serum LDL cholesterol levels at <=100 mg/dL.
  • Aggressively treat patients, using dietary intervention, exercise, and pharmacologic therapy:
    • Reduce total and saturated dietary fat
    • Prescribe HMG CoA-reductase inhibitors as first-line drug treatment for increased LDL cholesterol
    • Control blood glucose level as first-line treatment for an increased triglyceride level
    • Use fibric acid derivatives if blood sugar control does not reduce triglyceride levels
    • Use niacin therapy cautiously because niacin can increase serum glucose
  • Consider statin therapy in patients over age 40 with total cholesterol >=135 mg/dL, regardless of baseline LDL cholesterol levels, to decrease these levels by 30%.
  • See the Drug Therapy section in the module Lipid Disorders.
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Treat diabetic nephropathy with ACE inhibitors and dietary protein restriction. A

  • Use ACE inhibitors and other agents as needed to control BP aggressively.
  • Consider consulting a dietitian for dietary assessment and instruction about decreasing animal protein intake.
  • See the module Essential Hypertension.
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Treat painful peripheral neuropathy and foot ulcerations. BC

  • Consider TCAs, carbamazepine, sodium valproate, gabapentin, pregabalin, capsaicin, and opioids for painful peripheral neuropathy.
  • Maintain a low threshold for using broad-spectrum antibiotics in potentially infected foot ulcers, in addition to local wound care.
  • See table Drug Treatment for Diabetes Mellitus, Type 1.
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Aggressively maintain blood glucose control in patients with acute cardiac and CNS ischemia. A

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Consider treatment of autonomic neuropathy in the overall management of type 1 diabetes. B

  • Adjust glycemic goals of therapy to minimize the risk of hypoglycemia and to initiate hypoglycemia awareness training in patients with an impaired threshold for signs and symptoms of hypoglycemia.
  • Avoid drugs that exacerbate QT abnormalities, and adjust sodium intake and antihypertensive agents to minimize orthostatic change.
  • Use dopaminergic antagonists (e.g., metoclopramide, bethanecol [a parasympathetic agonist], erythromycin [a prokinetic agent]) to improve symptoms and to stabilize glucose levels.
  • Treat other diabetes-related bowel motility disorders, such as diarrhea, symptomatically after excluding other causes.
  • Consider pharmacologic treatment of erectile dysfunction (see module Erectile Dysfunction).
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Take measures to avoid severe hypoglycemia. BC

  • Routinely assess all patients for their glycemic threshold and presenting symptoms for hypoglycemia.
    • To prevent, recognize, and correct mild hypoglycemia:
      • Understand that the treatment of type 1 diabetes commonly results in mild hypoglycemia.
      • Look for common etiologic factors (e.g, excessive insulin administration, increased exercise, delay in a scheduled meal, reduction in expected caloric intake) and make appropriate modification in insulin dose.
      • Instruct patients about how to recognize the symptoms and the appropriate amount of carbohydrates necessary to ameliorate the condition without causing excessive hyperglycemia or weight gain.
    • To prevent, recognize, and correct severe hypoglycemia:
      • Individualize the goals of glycemic control based on the risk of severe hypoglycemia.
      • Instruct patients to monitor for hypoglycemia and treat it early with rapid-acting carbohydrates.
      • Instruct family members to recognize severe hypoglycemia and to treat it with glucagon therapy.
      • Target glucose levels specifically to avoid activation of counter-regulatory hormone responses for individuals with a history of severe hypoglycemia or with hypoglycemia unawareness.
Background | Back to top

FAQs
Abd Tahrani, MD, editorial consultant, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Maureen D. Passaro, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Robert E. Ratner, MD, is a consultant for Amylin Pharmaceuticals, AstraZeneca, GlaxoSmithKline, Lifescan, Inc., NovoNordisk, Sanofi-Aventis, Takeda, owns stocks in Merck, Johnson & Johnson, Abbott, received grants from Amylin, AstraZeneca, Bayhill Therapeutics, Boehringer Ingelheim, Conjuchem, Inc., Eil Lilly, GlaxoSmithKline, Merck, NovoNordisk, Pfizer, Sanofi-Aventis, Takeda.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott.

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