New Type 1 Treatment Guidelines for All Ages
In a world where around 90 percent of diabetes is the “other” kind, people with type 1 may occasionally feel left out. While type 1 and type 2 diabetes are often considered together, the two conditions are distinct. Each type requires a specialized approach to diagnosis and ongoing health care. Recognizing these differences, the American Diabetes Association (ADA) has published a position statement that focuses on those aspects of diabetes that are specific to type 1.
A position statement is the voice of the ADA, containing the organization’s official recommendations. It’s based on the current scientific and medical literature. Health care providers refer to these documents when considering the best treatment for a person with diabetes, and insurance companies may use position statements to decide which insulin delivery devices and how many test strips they’ll cover. Overall, the type 1 position statement may prompt providers to focus on all aspects of a person’s health—including self-management skills and mental well-being—and consider individual characteristics, such as age and general health, when making decisions about a person’s care.
“It’s the first time that the ADA (or any diabetes organization that I know of) has really looked at type 1 diabetes across the lifespan and in all settings,” says Sue Kirkman, MD, professor of medicine at the University of North Carolina–Chapel Hill, one of the statement’s authors. “There have been ADA position statements on specific situations related to type 1 diabetes or certain populations, such as children, pregnant women, diabetes and driving, or employment rights. But this statement is much broader.” Here are some highlights from the document, which was published in the July 2014 issue of Diabetes Care:
The Great Divide
Type 1 diabetes is estimated to affect 3 million people in the United States, but experts aren’t particularly confident in that number. The reason, the ADA paper says, is that there is tremendous variability in how type 1 diabetes presents itself in both youth and adults, which can make it difficult to distinguish between type 1 and type 2. Type 1 diabetes used to be called “juvenile diabetes,” but we now know that it can develop in adults as well, complicating efforts to diagnose the disease. Here’s an example to illustrate the challenge: An overweight adult who slowly develops type 1 diabetes in middle age may initially be diagnosed as having type 2 diabetes because type 2 is associated with obesity and type 1 is often thought of as a childhood illness with a rapid onset.
“Medical providers need to remember that most people living with type 1 are adults,” says Kirkman. “Exact numbers are hard to get, but we think that at least half of [all] cases of type 1 come on in adulthood. And, of course, even those whose diabetes was diagnosed in childhood grow up—and continue to have type 1 in middle and old age. But because so many more adults have type 2—25 percent of those over age 65, for example—adult type 1s tend to kind of get lost in the crowds.”
In contrast to type 2, type 1 is an autoimmune disease, characterized by a dysfunctional immune system that damages the cells in the pancreas that produce insulin (beta cells), necessitating that insulin be taken as a medication throughout life. Many people with type 2 diabetes also take insulin, but most still make a significant amount of their own insulin as well. To help with diagnosing the cause of a person’s elevated blood glucose, doctors may look for pancreatic autoantibodies—signs of an immune system attack on the pancreas—to confirm the presence of type 1 diabetes. When a diagnosis of type 1 or type 2 is in question, simple lab tests that look for autoantibodies are readily available. The statement offers the caveat, however, that the levels of pancreatic autoantibodies decline over time, and so autoantibody testing in a person who has had type 1 diabetes for a long time may come up negative despite the presence of type 1.
Getting elevated blood glucose (hyperglycemia) under control lowers a person’s risk for long-term damage to the eyes, kidneys, and nerves. But what does “control” mean? The type 1 position statement recommends that adults aim for an A1C (average blood glucose level over the previous two to three months) under 7 percent, though depending on circumstances, a higher or lower goal may be appropriate. For example, an older adult with a limited life expectancy may benefit from a less-strict goal, while tighter control may work for someone young and ultra-motivated. It’s critical that patient and health care provider work together to come up with a personalized A1C target.
One of the most notable recommendations in the type 1 position statement is a change in the blood glucose target for children and adolescents. The new recommendation, based in part on the recognition that hyperglycemia in youth can contribute to short- and long-term complications, is that people with type 1 diabetes under the age of 18 aim for an A1C of less than 7.5 percent. Previously, the ADA used a stepwise approach based on age—with less stringent goals for younger people—due to the risk of hypoglycemia (low blood glucose) and concerns about possible damage to intelligence, memory, and other elements of cognition.
The new goal may be a challenge for young children, who might not always eat what’s on their plate and can go through sudden growth spurts. “It is my view, especially with the young children, that we not add further pressure to already stressed caregivers,” says Fran Cogen, MD, CDE, professor of pediatrics at the Children’s National Health System. Rather, she says, providers should support incremental improvements as the child with diabetes moves toward the stated goal of 7.5 percent without significant hypoglycemia. At the same time, Cogen emphasizes how important it is to get rid of false beliefs that lows take a toll on brain function and instead provide encouragement and support for tighter glycemic goals. “There was some earlier literature noting possible cognitive defects from hypoglycemia in children; however, these have not borne out in recent evidenced-based literature,” says Cogen.
Evidence suggests that blood glucose control also helps protect the heart and blood vessels of people with type 1, but heart attack and stroke are still common in this group. And much of the research on heart health and diabetes has focused on type 2. “We know a lot about this in type 2 diabetes because there have been so many studies in adults with that more common form of diabetes,” says Kirkman, “but we can’t just take type 2 evidence and apply it to type 1s.” As the statement suggests, treatment with statins, medications that lower levels of LDL (“bad”) cholesterol, may benefit individuals with type 1 diabetes between the ages of 40 and 75, or younger, if indicated, though individualized treatment is key.
Insulin and Beyond
Everyone with type 1 diabetes needs insulin, and the statement says most will require multiple daily injections or an insulin pump. “Type 1 diabetes requires intensive insulin management that differs from how type 2 is managed,” says study author Anne Peters, MD, FACP, a professor of medicine at the Keck School of Medicine of the University of Southern California. “People with type 1 require more supplies and must monitor their blood glucose levels more often. This is not a one-size-fits-all disease, and it’s important that we recognize that.”
Aside from insulin, the only other approved medication for type 1 diabetes is pramlintide (Symlin), an injectable drug that may help lower weight and post-meal blood glucose. The statement says the medication may be considered in cases where a person is not reaching glycemic goals. Some medications for type 2 diabetes, such as metformin, are being studied as potential add-on therapies for people with type 1. These approaches may be able to lower insulin doses or improve blood glucose control for people with type 1, but additional clinical research is needed.
There is no cure for type 1 diabetes, but studies are ongoing that aim to prevent the disease, preserve beta cells, and replace damaged beta cells. A pancreas transplant, done with or without a kidney transplant, can restore insulin production, but the procedure has drawbacks, such as the need to take immunosuppressant medications to prevent organ rejection. (For more on transplants, check out “Gift of Life”.) Focused on a less-invasive approach, scientists are developing methods to transplant islets—clusters of cells that include insulin-producing beta cells—into people with type 1 diabetes. While scientists continue to work on these potential cures, the position statement on type 1 may serve to clearly define what is and isn’t known about the best way to treat people with diabetes. At the very least, it provides a source of information exclusively for those with type 1, giving much-needed recognition of the differences between the diabetes types.
Blood Glucose Tests
The type 1 diabetes position statement provides some guidelines for keeping blood glucose levels in a healthy range. These specifics may help ensure people get unimpeded access to the medications and supplies they need to take care of their diabetes.
- Frequently checking blood glucose with a meter is an essential part of achieving A1C targets. Regardless of age, people with type 1 diabetes may require 10 or more strips daily to monitor for hypoglycemia, assess insulin needs prior to eating, and determine if their blood glucose level is safe enough for sleeping.
- Continuous glucose monitors (CGMs), which test glucose every couple of minutes, may help people with type 1 reach targets.
- Getting A1C checks four times a year can help keep people with diabetes on track.
- Frequent blood glucose checks and a ready supply of fast-acting carbohydrates and glucagon can help prevent and treat hypoglycemia (low blood glucose).
A Lifetime of Individualized Care
Diabetes care across the lifespan means tracking the disease from multiple angles and updating people’s individualized care as their needs change over time. Here are some guidelines from the type 1 diabetes position statement:
- Ideal care is individualized to the person and life stage.
- Diabetes education and support from knowledgeable health care providers is essential.
- Education and support should be adjusted as a child transitions from a reliance on parents/guardians for care to self-management.
- Women with type 1 diabetes who are or are planning to become pregnant need extra attention from their providers to ensure their babies come into this world healthy.