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2034 Care Volume 37, July 2014

Jane L. Chiang,1 M. Sue Kirkman,2 Type1DiabetesThroughtheLife Lori M.B. Laffel,3 and Anne L. Peters,4 on behalf of the Sourcebook Span: A Position Statement of the Authors* American Diabetes Association Diabetes Care 2014;37:2034–2054 | DOI: 10.2337/dc14-1140

Type 1 diabetes is characterized by an immune-mediated depletion of b-cells that results in lifelong dependence on exogenous . While both type 1 and result in , the and etiology of the are distinct and require us to consider each type of diabetes independently. As such, this position statement summarizes available data specific to the comprehensive care of individuals with type 1 diabetes. The goal is to enhance our ability to recognize and manage type 1 diabetes, to prevent its associated complications, and to eventually and prevent this .

INCIDENCE AND PREVALENCE OF TYPE 1 DIABETES The exact number of individuals with type 1 diabetes around the world is not known, but in the U.S., there are estimated to be up to 3 million (1). Although it has long been called “juvenile diabetes” due to the more frequent and relatively POSITION STATEMENT straightforward diagnosis in children, the majority of individuals with type 1 di- abetes are adults. Most children are referred and treated in tertiary centers, where clinical data are more readily captured. The SEARCH for Diabetes in Youth study estimated that, in 2009, 18,436 U.S. youth were newly diagnosed with type 1 diabetes (12,945 non- Hispanic white, 3,098 Hispanic, 2,070 non-Hispanic black, 276 Asian-Pacific Islander, and 47 American Indian) (2). Worldwide, ;78,000 youth are diagnosed with type 1 diabetes annually. Incidence varies tremendously among countries: East Asians and American Indians have the lowest incidence rates (0.1–8 per 100,000/year) as compared with the Finnish who have the highest rates (.64.2 per 100,000/year) (3). In the U.S., the number of youth with type 1 diabetes was estimated to be 166,984 (4). The precise incidence of new-onset type 1 diabetes in those over 20 years of age is unknown. This may be due to the prolonged phase of onset and the subtleties in distinguishing the different types of diabetes. In one European study of adults aged 30–70 years, ;9% tested positive for GAD antibodies (GADA) within 5 years of a 1 diabetes diagnosis, consistent with other studies (5). American Diabetes Association, Alexandria, VA 2Department of , University of North Adults with type 1 diabetes often receive care in settings rather than Carolina at Chapel Hill, Chapel Hill, NC with an endocrinologist. Unlike the consolidated care seen in pediatric diabetes man- 3Pediatric, Adolescent and Young Adult Section, agement, the lack of consolidated care in adults makes incidence and prevalence rates ; Department of Pediat- difficult to characterize, and therefore they are often underestimated. The number of rics, Harvard Medical School, Boston, MA 4 adults living with type 1 diabetes is increasing due to two factors: 1) the rising number Division of , Keck School of Med- icine of the University of Southern California, Los of new-onset cases of type 1 diabetes in adults, including those diagnosed with latent Angeles, CA autoimmune diabetes in adults (LADA), and 2) individuals with childhood-onset di- Corresponding author: Jane L. Chiang, jchiang@ abetes are living longer (6,7). diabetes.org. The position statement was reviewed and ap- CLASSIFICATION AND DIAGNOSIS proved by the Professional Practice Committee Type 1 diabetes has traditionally been diagnosed based on clinical catabolic symp- in April 2014 and approved by the Executive toms suggestive of insulin deficiency: , , , and marked Committee of the Board of Directors in April 2014. hyperglycemia that is nonresponsive to oral agents. It is classified as an autoimmune disease with progressive b-cell destruction, resulting in a physiological dependence *A list of authors of the American Diabetes As- sociation/JDRF Type 1 Diabetes Sourcebook can on exogenous insulin. Recent studies have broadened our understanding of the be found in the ACKNOWLEDGMENTS. disease, but have made diagnosis more complex. © 2014 by the American Diabetes Association. There is tremendous variability in the initial presentation of type 1 diabetes in See http://creativecommons.org/licenses/by- both youth and adults. Children often present acutely, with severe symptoms of polyuria, nc-nd/3.0/ for details. care.diabetesjournals.org Chiang and Associates 2035

Figure 1—The percentage of antibody-positive subjects is affected by the duration of type 1 diabetes for GADA (A)andIA2A(B).Givenanincreaseinthe scatter (due to lower numbers of subjects), the x-axis is truncated at a duration of 30 years. Reproduced with permission from Tridgell et al. (16). polydipsia, and ketonemia. However, in more likely to be diagnosed as having the empiric risk of being affected is ;5% adults, type 1 diabetes presents with a type 1 diabetes, the potential for type 1 (17,18), representing a 15-fold increase more gradual onset, with a clinical pre- diabetes exists in those who phenotypi- among family members. Studies evaluat- sentation that may initially appear consis- cally appear to have type 2 diabetes. If ing children at risk for developing type 1 tent with type 2 diabetes. Distinguishing hyperglycemia persists after treatment diabetes have shown that the presence of betweentype1andtype2diabetes with noninsulin agents, which is unusual more than two was asso- presents diagnostic challenges. Tradition- in the treatment of newly diagnosed type ciated with a nearly 70% risk for disease ally, progressive b-cell destruction has 2 diabetes, then type 1 diabetes should development within 10 years and 84% been the hallmark of type 1 diabetes, be considered. within 15 years (19). Evaluating at-risk in- but residual C-peptide (a surrogate marker dividuals in the clinical setting is not yet for insulin secretion) may be detected over Pancreatic Autoantibodies recommended due to limited clinical in- 40 years after initial diagnosis, regardless Pancreatic autoantibodies are charac- terventions; however, ongoing research of whether the initial diagnosis was made teristic of type 1 diabetes. Highly sensi- studies are identifying at-risk individuals in childhood or in adulthood (8). tive laboratory measurements capture through genetic testing in both the lower- ;98% of individuals with autoantibod- risk general population and in the higher- Clinical Clues ies at diagnosis (10). Unfortunately, risk population of relatives of people with Much of the diagnosis will depend on most commercial laboratories do not type 1 diabetes. clinical clues, but the rising incidence have reliably sensitive or specific assays Recommendations of / has also con- that measure all five autoantibodies: founded the diagnosis of type 1 diabetes. Diagnosis GADA, islet cell antibodies (ICA), insulin c The American Diabetes Association’s A lean individual presenting with clinical autoantibodies (IAA), protein tyro- (ADA’s) diagnostic criteria for type 1 symptoms without a first-degree relative sine phosphatase antibodies (ICA512 and type 2 diabetes are the same with diabetes (but often with a history of or IA2A), and zinc transporter protein (Table 1). (A) distant relatives with type 1 diabetes or (ZnT8). Thus, it may be inappropriate c Consider measurement of pancreatic other autoimmune disease) is generally to report a patient as neg- autoantibodies to confirm the diag- suggestive of type 1 diabetes. An over- “ ” ative. Another of false-negative nosis of type 1 diabetes. (B) weight individual (of any age) with meta- autoantibodies is testing far out from bolic syndrome and a strong family history diagnosis as antibody titers diminish Identification of At-Risk Relatives of type 2 diabetes may be assessed only over time (Fig. 1). It appears that there c Inform type 1 diabetic patients of the for the development of type 2 diabetes, is an increased incidence of type 1 di- opportunity to have their relatives even though type 1 diabetes is on the abetes in ethnic populations where au- tested for type 1 diabetes risk in the differential diagnosis. Obesity does not toantibody markers may be of variable setting of a clinical research study. (B) preclude that and hyper- utility, such as in Asians where autoanti- glycemia will occur even amid the rela- bodies are often negative (11–15). INITIAL EVALUATION AND tively higher levels of endogenous insulin FOLLOW-UP secretion observed in obesity. In young Family History General Considerations patients aged 10–17 years with pheno- Type 1 diabetes has a genetic predilection All patients with type 1 diabetes typic type 2 diabetes, 10% have evidence and, in some cases, can be predicted in need age-appropriate care, with an of islet autoimmunity suggesting that family members. The overall prevalence understanding of their specific needs type 1 diabetes was the likely diagnosis of type 1 diabetes in the U.S. is ;0.3%, and limitations. Infants and toddlers (9). Thus, although leaner individuals are but if a first-degree relative has diabetes, are approached quite differently from 2036 Position Statement Diabetes Care Volume 37, July 2014

Table 1—Criteria for the diagnosis of diabetes frequency in patients with type 1 diabetes (1–16% of individuals compared with A1C $6.5%. The test should be performed in a laboratory using a method that is NGSP 0.3–1% in the general population) fi certi ed and standardized to the DCCT assay.* (21,22). Symptoms of celiac disease in- OR clude diarrhea, weight loss or poor weight $ fi FPG 126 mg/dL (7.0 mmol/L). Fasting is de ned as no caloric intake for at least 8 h.* gain, abdominal , bloating, chronic OR , malnutrition due to malabsorp- Two-hour plasma $200 mg/dL (11.1 mmol/L) during an oral . tion, and unexplained or The test should be performed as described by the World Health Organization, using erratic glucose levels. Screening a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* for celiac disease with serum levels of tis- OR sue transglutaminase or antiendomysial In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma antibodies should be considered soon glucose $200 mg/dL (11.1 mmol/L). after the diagnosis of diabetes and/or if *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. symptoms develop. Individuals who test positive should be referred to a gastroen- adolescents; the needs of young adults two providers), psychosocial issues (e.g., terologist for possible small-bowel biopsy may vary from middle-aged or older ), and other issues identified to confirm the diagnosis, although this is adults. Regardless of age, the patient’s by the family/youth. pro- not necessary in all cases. Symptomatic needs are the same: an individualized viders, family, and youth should agree to children with strongly positive antibodies care plan with ongoing education and an achievable plan and supportive genetic or HLA testing support, ongoing assessment for acute and provide resources for unanticipated may not require a biopsy, but asymptom- and chronic complications, and access issues. We refer the reader to the ADA’s atic at-risk children should have a biopsy to medical providers with type 1 diabe- position statement on diabetes care for (23). In symptomatic individuals with type tes expertise. Just as patients change, emerging adults (20). 1 diabetes and confirmed celiac disease, a the therapeutic approach should change Table 2 provides the childhood devel- -free reduces symptoms and and should be evaluated at each visit and opmental phases and needs. Tables 3, 4, decreases rates of hypoglycemia (24). modified as needed. and 5 provide detailed elements of the Thyroid Disease Type 1 diabetes care must be an iter- initial and follow-up evaluation in indi- About one-quarter of children with type ative process, adapted as the needs of viduals with type 1 diabetes. 1 diabetes have thyroid autoantibodies the individual evolve. Clinical assess- Assessing the history of acute compli- (thyroid peroxidase antibodies or antithy- ments for type 1 diabetes in children and cations (e.g., severe hypoglycemia/ roglobulin antibodies) at the time of di- adults should incorporate age-appropriate hyperglycemia and diabetic ketoacido- agnosis (25,26). The presence of thyroid and -focused evaluations, sis [DKA]) is important. Providers should autoantibodies is predictive of thyroid based on the likelihood that an abnormal- provide continuing education for the dysfunction, generally ity will be present. For example, a young patient/family to prevent ongoing re- and less commonly (27). adult with low currence. For example, it is important Thyroid dysfunction is more common in (CVD) risk and no complications may to review management to re- adults with type 1 diabetes, although the need more of an assessment of lifestyle duce hypoglycemia risk and discuss sick- exact prevalence is unknown. Women adjustment as opposed to an older adult day management to reduce DKA risk. are more commonly affected than men. with longer duration of the disease who (e.g., cardiovascular) evalu- Subclinical hypothyroidism, hyperthy- may need more evaluation of vascular and ation for prevention and screening for roidism, or coexistent Addison disease neurological issues. early evidence of micro- and macrovascu- (adrenal insufficiency) may also deterio- lar complications for early intervention rate metabolic control with increased risk Transition of Care From Pediatric to should be implemented starting in ado- of symptomatic hypoglycemia (28) and Adult Providers lescence and continue through adult- may reduce linear growth in children (29). As youth transition into emerging adult- hood. For children, risk factors should be hood, the supportive infrastructure of- assessed shortly after diagnosis based on Additional Considerations for ten abruptly disappears and glycemic family history and initial screening labo- Pediatrics control tends to deteriorate. The ADA ratory test results. Providers should man- All children require some level of adult recognizes that this is a challenging age risk factors, considering age-specific supervision in managing their diabe- time and recommends a strong, practi- goals and targets (e.g., , tes. Assessments of pediatric patients cal transition plan to anticipate the up- lipid, depression, and BMI assessment should address issues specific to infants/ coming changes. A successful transition and management). The frequency of on- preschoolers, school-aged children, ado- plan should be initiated early (e.g., early going screening for complications should lescents, and emerging adults (Table 2). teenage years) and include ongoing di- be based on age and disease duration. Health care providers should do a thor- alogue between the family and youth. ough assessment of the developmental The discussion should include finances, Coexistent Autoimmunity needs of the youth (and caregiver), fo- insurance, obtainment of supplies, iden- Celiac Disease cusing on physical and emotional devel- tification of an adult care provider (ide- Celiac disease is an immune-mediated opment, family issues, and psychosocial ally with communication between the disorder that occurs with increased needs. The diabetes treatment plan care.diabetesjournals.org Chiang and Associates 2037

Table 2—Major developmental issues and their effect on diabetes in children and adolescents Type 1 diabetes Family issues in type 1 Developmental stages (ages) Normal developmental tasks management priorities diabetes management Infancy (0–12 months) Developing a trusting relationship Preventing and treating Coping with or bond with primary caregiver(s) hypoglycemia Sharing the burden of care to avoid Avoiding extreme fluctuations in parent burnout blood glucose levels Toddler (13–26 months) Developing a sense of mastery Preventing hypoglycemia Establishing a schedule and autonomy Avoiding extreme fluctuations in Managing the picky eater blood glucose levels due to Limit-setting and coping with irregular intake toddler’s lack of cooperation with regimen Sharing the burden of care Preschooler and early Developing initiative in activities Preventing hypoglycemia Reassuring child that diabetes is no elementary school and confidence in self Coping with unpredictable one’sfault (3–7 years) appetite and activity Educating other caregivers about Positively reinforcing cooperation diabetes management with regimen Trusting other caregivers with diabetes management Older elementary school Developing skills in athletic, Making diabetes regimen flexible Maintaining parental involvement (8–11 years) cognitive, artistic, and to allow for participation in in insulin and blood glucose social areas school or peer activities management tasks while Consolidating self-esteem with Child learning short- and long-term allowing for independent self- respect to the peer group benefits of optimal control care for special occasions Continuing to educate school and other caregivers Early adolescence Managing body changes Increasing insulin requirements Renegotiating parent and (12–15 years) Developing a strong sense during puberty teenager’s roles in diabetes of self-identity Diabetes management and blood management to be acceptable glucose control becoming to both more difficult Learning coping skills to enhance Weight and body image concerns ability to self-manage Preventing and intervening in diabetes-related family conflict for signs of depression, eating disorders, and risky behaviors Later adolescence Establishing a sense of identity Starting an ongoing discussion of Supporting the transition to (16–19 years) after high school (decisions transition to a new diabetes independence about location, social issues, team (discussion may begin Learning coping skills to enhance work, and education) in earlier adolescent years) ability to self-manage Integrating diabetes into Preventing and intervening with new lifestyle diabetes-related family conflict Monitoring for signs of depression, eating disorders, and risky behaviors should be individualized and tailored using the appropriate size cuff and of puberty or after 5–10 years of diabetes to the needs of individual patients with the child seated and relaxed. Hyper- (30). As screening recommendations are and their families. Efforts to achieve tension should be confirmed on at least 3 based on recent evidence, these periodi- targetbloodglucoseandA1Clevels separate days. Normal blood pressure cally change. Therefore, we refer the should be balanced with preservation levels for age, sex, and height and appro- reader to the ADA Standards of Care for of quality of life and protect against priate methods for determinations are the current screening recommendations excessive hypoglycemia. available online at www.nhlbi.nih.gov/ for children. It is recommended that those Heightandweightshouldbemeasured health/prof//hbp/hbp_ped.pdf. with expertise in diabetes management at each visit and tracked via appropriate should conduct the assessments. For ex- height and weight growth charts. An age- Chronic Complications in Children ample, ophthalmologic exams should be adjusted BMI can be calculated starting at , nephropathy, and neurop- performed by those skilled in diabetic ret- age 2 years. These tools can be found for athy rarely have been reported in pre- inopathy management and experienced children and teens at http://apps.nccd pubertal children and children with in counseling pediatric patients and pa- .cdc.gov/dnpabmi. Blood pressure mea- diabetes duration of only 1–2years; rents on the importance of early preven- surements should be determined correctly, however, they may occur after the onset tion/intervention. Another example, 2038 Position Statement Diabetes Care Volume 37, July 2014

Table 3—Medical history measurement of blood pressure and weight (and height in children), Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) foot exam, inspection of injection/ Eating patterns, physical activity habits, nutritional status, and weight history insertion sites, and discussion of psycho- Whether or not patient wears medical alert identification social and educational needs (Tables 4 Diabetes education history; health literacy assessment and 5). (E) Review of previous insulin treatment regimens and response to therapy (A1C records), c Providers should routinely document treatment preferences, and prior difficulty with therapies the patient’s age and disease duration. Current treatment of diabetes, including and , meal plan, When clinically indicated, laboratory physical activity patterns, and readiness for behavior change measures such as lipids, renal function Use of insulin, insulin pumps, carbohydrate ratios, and corrections; knowledge of sick-day measurements, and antibodies for as- rules; testing; pump troubleshooting (if applicable) sociated autoimmune disease (thyroid ’ Results of glucose monitoring, including SMBG and CGM and patient s use of data or celiac disease) should be docu- DKA frequency, severity, and cause mented. (E) Hypoglycemic episodes c Parent/guardian involvement in care Hypoglycemia unawareness is required throughout childhood, Any severe hypoglycemia: frequency and cause Whether or not patient has available and someone to administer it with a gradual shift in responsibility -related complications of care from the parent/guardian to Microvascular: retinopathy, nephropathy, and neuropathy (sensory, including history of the youth. (E) foot lesions; autonomic, including and ) c Health care for adults should be fo- Macrovascular: coronary heart disease, , and peripheral cused on the needs of the individual disease throughout the various stages of their Other: dental disease life, with age-appropriate evaluation Psychosocial issues, including current or past history of depression, , eating disorders, and treatment. (E) and others; assess support systems and need for assistance c Evaluation and treatment of CVD risk History of and any diabetes-related complications; desire for future should be individualized. (E) Contraception (if a woman is of childbearing age) c Immunizations should be given as recommended by the Centers for Dis- Alcohol use, abuse, and impact on blood glucose levels ease Control and Prevention (CDC) for Illicit drug use children/adults in general and people Driving with diabetes specifically. (C) c Consider screening for celiac disease by measuring IgA antitissue transgluta- minase or antiendomysial antibodies, nephrologists with experience with dia- Recommendations with documentation of normal total betic nephropathy would be aware that See 2014 ADA Standards of Medical Care serum IgA levels, soon after the diag- intermittent elevations in urinary albu- for detailed screening information for nosis of diabetes and/or if symptoms min excretion are common in pediatric CVD, nephropathy, retinopathy, neurop- develop. Refer the patient to a gastro- patients, particularly in association with athy, and foot care. enterologist if the test is positive. (E) exercise. c Consider screening for thyroid peroxi- c Access to health care should include dase and thyroglobulin antibodies soon Additional Considerations for Adults clinicians with expertise in type 1 after diagnosis. (E) Adults with type 1 diabetes now span a diabetes management, including c Screen for thyroid dysfunction by mea- very large age spectrumdfrom 18 to (but not limited to) an endocrinolo- suring thyroid-stimulating 100 years of age and beyond. Unlike gist (or other health care provider (TSH) concentrations soon after type 1 the well-characterized developmental with expertise in type 1 diabetes diabetes diagnosis (and after stable stages of children, the life stages tra- management), a registered , metabolic control). If normal, consider versed through adulthood are often a diabetes educator, a rechecking every 1–2 years or more fre- less well documented and underappre- professional, an exercise specialist/ quently if the patient develops unusual ciated. However, an understanding of physiologist, and specialists required glycemic variation or symptoms of thy- each individual’s circumstances is vital. to treat diabetes complications. (E) roid dysfunction or thyromegaly. (E) This is true for aging in general, but par- c Routine follow-up (generally quar- c Assess for the presence of additional ticularly true for those with significant terly) should include review of autoimmune conditions at diagnosis due to long-standing self-monitoring of blood glucose and if symptoms develop. (E) type 1 diabetes. Thus, it is important to (SMBG), continuous glucose monitor- c Ongoing and diabetes self- assess the clinical needs of the patient, ing (CGM) and pump data (if applica- management education (DSME) and setting specific goals and expectations ble), A1C measurement, evidence for support (DSMS) areneededtoad- that may differ significantly between a acute and/or chronic complications of dress changes in food preferences, healthy 26-year-old and a frail 84-year- diabetes (particularly episodes of DKA access to food, daily schedules, activ- old with CVD and retinopathy. and mild and/or severe hypoglycemia), ity patterns, and potential barriers to care.diabetesjournals.org Chiang and Associates 2039

Table 4—Children and adolescents* Clinical evaluation Initial Annual Quarterly follow-up Height X X X Weight X X† X† BMI percentile X X X Blood pressure X X X General physical exam X X Thyroid exam X X X Injection/infusion sites X (if already on insulin) X X Comprehensive foot exam‡ If needed, based on age Beginning with older teens with diabetes since childhood Visual foot exam X If needed, based on high-risk characteristics Retinal exam by eye care specialist X§ In some cases, may be done every 2 years (see ADA Standards of Care) Depression screen X X X Hypoglycemia assessment X X X Diabetes self-management skills X X X Physical activity assessment X X X Assess clinically relevant issues X As needed for teens As needed for teens (e.g., alcohol, drug, and tobacco use; use of contraception; driving) Nutritional knowledge X X As needed Query for evidence of other X As needed As needed autoimmune disease Immunizations as recommended by CDC X X As needed

Laboratory assessments Initial Annual Follow-up A1C X X Every 3 months Creatinine clearance/estimated XX glomerular filtration rate Lipid panel|| Once glycemia is stable X As needed based on treatment TSH X X As needed based on Frequency of testing varies treatment based on clinical symptoms, presence of antibodies, and/or if on treatment Antithyroid antibodies X Repeat as clinically indicated (antithyroid peroxidase and Frequency of testing is unknown; antithyroglobulin antibodies) test if symptoms are present or for periodic screening Celiac antibody panel X Repeat as clinically indicated Frequency of testing is unknown; test if symptoms are present or for periodic screening albumin-to-creatinine ratio Starting 5 years after diagnosis X As needed based on treatment Islet cell antibodies: X GADA/IA2A/IAA/ZnT8 May be needed in new-onset patients to establish diagnosis C-peptide levels X Occasionally needed to establish type 1 diabetes in a patient on insulin or to verify type 1 diabetes for insurance purposesdalways measure a simultaneous blood glucose level *Assumes a patient has a health care provider to manage the nondiabetes-related health assessments and to perform annual evaluations. †Patient may opt out of measurement if psychologically distressing. ‡Foot inspection should be done at each visit and self-exams taught if high-risk characteristics are present. Comprehensive foot exam includes inspection, palpation of dorsalis pedis and posterior tibial pulses, presence or absence of patellar and Achilles reflexes, and determination of proprioception, vibration, and monofilament sensation. §Within 5 years after diagnosis. ||If triglycerides are elevated in a nonfasting specimen, measure a direct LDL level. 2040 Position Statement Diabetes Care Volume 37, July 2014

Table 5—Adults* Clinical evaluation Initial Annual Follow-up Height X Weight X X† X† BMI X X Blood pressure X X X General physical exam X Thyroid exam X If indicated Injection/infusion sites X X X Comprehensive foot exam‡ XX Visual foot exam As neededdat each visit, if high-risk foot Retinal exam by eye care Starting 5 years after diagnosis; In some individuals, screening specialist§ earlier if visual symptoms and/or may be done every 2 years (see true date of diagnosis is unknown ADA Standards of Medical Care) Depression screen X X Hypoglycemia assessment X X X Diabetes self-management skills X X X Physical activity assessment X X X Assess clinically relevant issues X As needed As needed (e.g., alcohol, drug, and tobacco use; use of contraception; driving) Nutritional knowledge X X As needed Query for evidence of other X As needed based on As needed based on autoimmune disease clinical scenario clinical scenario Immunizations as recommended X X As needed by CDC

Laboratory assessments Initial Annual Follow-up A1C X X Every 3 months Creatinine clearance/estimated XX glomerular filtration rate Fasting lipid panel|| X X As needed based on treatment TSH X X As needed based on Frequency of testing varies based treatment on clinical symptoms, presence of antibodies, or if on treatment Antithyroid antibodies X Frequency of testing is unknown; test if symptoms are present or for periodic screening Celiac antibody panel X Frequency of testing is unknown; test if symptoms are present or for periodic screening Urine albumin-to-creatinine ratio X X GADA X May be needed in new-onset patients to establish diagnosis C-peptide levels X Occasionally needed to establish type 1 diabetes in a patient on insulin or to verify type 1 diabetes for insurance purposesdalways measure a simultaneous blood glucose level *Assumes a patient has a health care provider to manage the nondiabetes-related health assessments and to perform annual evaluations. †Patient may opt out of measurement if psychologically distressing. ‡Foot inspection should be done at each visit and self-exams taught if high-risk characteristics are present. Comprehensive foot exam includes inspection, palpation of dorsalis pedis and posterior tibial pulses, determination of presence or absence of patellar and Achilles reflexes, and determination of proprioception, vibration, and monofilament sensation. §In some instances, the test may not need to be done yearly. ||If a patient is unable to undertake a fasting test due to hypoglycemia, measure a direct LDL cholesterol level. care.diabetesjournals.org Chiang and Associates 2041

self-care, including the risk of an eat- Table 6—DSME content based on life stages ing disorder. (E) – c Assess psychosocial status annually Infancy (birth 18 months) Period of trust versus mistrust and more often as needed; treat Providing warmth and comfort measures after invasive procedures is important and/or refer to a mental health pro- Feeding and sleeping or nap routines fessional as indicated. (E) Vigilance for hypoglycemia age (3–5 years) DSME AND DSMS Reassurance that body is intact, use of Band-Aids and kisses after procedures Identification of hypoglycemic (temper tantrums and nightmares are common) DSME and DSMS are the ongoing pro- Include child in choosing injection and finger-prick sites cesses of facilitating the knowledge, Positive reinforcement for cooperation skill, and ability necessary for diabetes Begin process for teaching child awareness of hypoglycemia self-care. These processes incorporate School age (6–12 years) the needs, goals, and life experiences Integrate child into educational experience Determine skill level ofthepersonwithdiabetes.Theoverall Identify self-care skills objectives of DSME and DSMS are to Determine roles and responsibilities support informed decision making, Communication with peers and school staffdwho and when to tell about diabetes self-care behaviors, problem solving, Adolescence (12–18 years) and active collaboration with the Begin transition care planning Personal meaning of diabetes health care team to improve clinical Determine roles and responsibilities in care outcomes, health status, and quality Social situations and dating of life in a cost-effective manner (31). Who or when to tell about diabetes Because changes in both treatment Driving Sex and preconception counseling and life circumstances occur across Alcohol and drugs the life span, DSME and DSMS must be College and career planning a continuous process adapted through- Young adults out the life of the person with type 1 Personal meaning of diabetes diabetes so that self-management can Roles and responsibilities in care Social situations and dating be sustained. Who or when to tell about diabetes No matter how sound the medical Genetic risks, conception, and preconception regimen, it can only be as successful as Travel the ability of the individual and/or fam- Choosing or pursuing a career ily to implement it. Family involvement Workplace rights Health or life insurance remains an important component of Involving friends and significant others in diabetes care optimal diabetes management through- Safety out childhood and adolescence. Health Creating a support network care providers who care for children and Establishing or maintaining independence adolescents must, therefore, be capable Middle-aged adults Personal meaning of diabetes of evaluating the educational, behav- Roles and responsibilities in care ioral, emotional, and psychosocial fac- Involving spouse or significant other in care tors that impact implementation of a Sexual functioning treatment plan and must assist the in- Developing a support network Travel dividual and family to overcome bar- Pursuing a career riers or redefine goals as appropriate Workplace rights (Table 6). Diabetes education should Health or life insurance occur at diagnosis and upon transition Talking with children or other family members about diabetes to adult diabetes care and should be an Balancing other responsibilities with diabetes care Safety ongoing process. The information needs Facing complications to be individualized and continually Older adults adaptedtothepatient’sneeds. Personal meaning of diabetes Roles and responsibilities in care Recommendations Maintaining independence c Individuals with type 1 diabetes and Obtaining assistance with diabetes care tasks parents/caregivers (for individuals Involving spouse or significant other in care , Travel aged 19 years) should receive cul- Talking with adult children or other family members about diabetes turally sensitive and developmentally Safety appropriate individualized DSME Assessing for declines in ability to perform self-care/activities of daily living and DSMS according to national Caring for diabetes along with other chronic illnesses or comorbidities standards for DSME and DSMS when Obtaining health care when living in multiple locations Community resources their diabetes is diagnosed and rou- Care of type 1 diabetes in long-term or other care facilities tinely thereafter. (B) 2042 Position Statement Diabetes Care Volume 37, July 2014

Additional Considerations for should be pursued through treatment weight at all ages. Specifically, with re- Pediatrics that may include referral to a mental gards to individuals with type 1 diabetes, c Education should be provided to ap- health specialist. (E) topics such as carbohydrate counting and propriate school personnel as a signif- meal composition should be addressed. ’ icant portion of a child s day is spent Additional Considerations for For selected individuals who have mas- in school. (E) Pediatrics tered carbohydrate counting, education c The developing teenager must be edu- c Ensure that there is developmentally on the impact of protein and on gly- cated about the transition to adult appropriate parent/family involve- cemic excursions should be incorporated health care, beginning in early to mid- ment in the management of the into diabetes management (32). Those adolescence, with increasing efforts to child’s/adolescent’sdiabetescare who are overweight or obese may benefit establish self-reliance in diabetes care tasks, avoiding a premature transfer from weight reduction counseling. beginning at least 1 year prior to the of sole responsibility for diabetes transition. Even after the transition to management to the developing child/ Recommendations adult care is made, support and rein- teenager. (B) c Individualized medical nutrition therapy forcement are recommended. (E) c Directly ask about diabetes-related is recommended for all people with fl Additional Considerations for Adults family con ict and stress and negoti- type 1 diabetes as an effective compo- c Adult learning theory can be used to ate an acceptable resolution with the nent of the overall treatment plan. (A) tailor DSME and DSMS to the age, life child/adolescent and parent(s). How- c Monitoring carbohydrate intake, stage, culture, literacy/numeracy, ever, if family conflict is extremely en- whether by carbohydrate counting knowledge, experience, and cognitive trenched and cannot be resolved by the or experience-based estimation, ability of the patient. (C) diabetes team, referral should be made remains a key strategy in achieving to a mental health specialist who is glycemic control. (B) PSYCHOSOCIAL: ASSESSMENT AND knowledgeable about type 1 diabetes c If adults with type 1 diabetes choose TREATMENT OF PSYCHOSOCIAL in youth and family functioning. (C) to drink alcohol, they should be ad- ISSUES visedtodosoinmoderation(one Assessment and appropriate manage- Additional Considerations for Adults drink per day or less for adult women c ’ ment of psychosocial issues are important Ongoing evaluation of patients gen- and two drinks per day or less for throughout the life span of individuals eral and diabetes-related quality of adult men). Discussion with a health with type 1 diabetes. In pediatrics, health life, emotional well-being, distress, care provider is advised to explore po- care providers should assess the individ- depression, and resources is war- tential interactions with medications. ual child and the child’s family for their ranted, preferably by a team that Adults should be advised that alcohol ability to function and behave appropri- includes a mental health specialist if can lower blood glucose levels and that ately regarding safe and responsible dia- such resources are available. (C) driving after alcohol is contra- c betes care. For adults, the individual is Health care providers should promptly indicated. (E) the focus of care. However, family involve- address issues related to self-care ca- PHYSICAL ACTIVITY AND EXERCISE ment should be strongly encouraged pacity, mobility, and autonomy. (E) when appropriate. Exercise has many positive health NUTRITION THERAPY Depression screening and discussion and psychological benefits including about psychosocial issues are important Nutrition therapy is an important com- physical fitness, , components of the diabetes visit. Special ponent of the treatment plan for all in- and enhanced insulin sensitivity. It also attentionshouldbepaidtodiabetes- dividuals with type 1 diabetes. Each provides opportunities for social inter- related distress, fear of hypoglycemia patient should have an individualized actions and builds self-esteem. How- (and hyperglycemia), eating disorders, in- food plan based on food preferences, ever, exercise creates challenges for sulin omission, subclinical depression, schedule, and physical activity. Nutrition people with type 1 diabetes due to the and clinical depression. These factors therapy aims to ensure that the patient increased risk for both hypoglycemia are significantly associated with poor di- and family understand the impact food and hyperglycemia. During exercise, abetes self-management, a lower quality has on blood glucose, how food interacts multiple (insulin, glucagon, of life, and higher rates of diabetes com- with exercise and insulin to prevent hypo- catecholamines, , and plications. As individuals age, health care and hyperglycemia and to achieve glu- cortisol) control fuel and providers should evaluate issues related cose goals, and how to implement the create a balance between glucose up- to self-care capacity, mobility, and food plan in a variety of situations. The take by exercising muscles and hepatic autonomy. Such factors are to be food plan takes into consideration the pa- glucose production (33,34). The equilib- promptly addressed, as they make the tient’s numeracy, literacy, engagement, rium between insulin secretion and the management of type 1 diabetes ever and ability to adjust insulin. counterregulatory hormones varies ac- more problematic. General diabetes nutrition principles, cording to the exercise type, intensity, as defined in the ADA Standards of Care, and duration (35). Recommendations apply to people with type 1 diabetes, Hyperglycemia results from counter- c Make age-appropriate screenings for particularly in reference to normal regulatory hormone excess with insuffi- psychosocial issues a component of growth and development in youth and cient insulin, leading to excessive most diabetes visits. Any concerns the maintenance of a healthy body hepatic glucose production and limiting care.diabetesjournals.org Chiang and Associates 2043

increased glucose uptake into skeletal amount (60–75 min/week) of vigorous- demonstrated that achieving an A1C of muscle. Hyperglycemia can occur be- intensity activity (40,41). Exercise ,7% reduced the incidence of microvascu- fore, during, and after various types of should also include resistance and flexi- lar complications of type 1 diabetes com- exercise. If the patient feels well, with bility training. pared with standard control, which negative or minimal urine and/or blood Individuals, particularly adults, should achieved an A1C of ;9% during the pe- , and there is a clear reason for be assessed for cardiovascular risk and riod of the randomized trial. The Epide- the elevated blood glucose level, such as the presence of complications that miology of Diabetes Interventions and underdosing insulin at the preceding might limit exercise as discussed more Complications (EDIC) study (44,45) meal, it is not necessary to postpone fully in the ADA Standards of Medical was a follow-up of the DCCT cohorts. exercise based solely on hyperglycemia. Care in Diabetes (42). The EDIC study remarkably demon- However, when people with type 1 diabe- strated persistent microvascular and car- tes are deprived of insulin for 12–48 h and Recommendations diovascular benefits in subjects who had are ketotic, exercise can worsen hypergly- c Exercise should be a standard recom- previously received intensive treatment, cemia and ketosis. Therefore, vigorous mendation as it is for individuals without even though their glycemic control had activity should be avoided in the presence diabetes; however, recommendations deteriorated over time. of severe hyperglycemia and ketosis, es- may need modifications due to the While A1C and blood glucose targets pecially with known insulin omission. presence of macro- and microvascular are needed, the ADA emphasizes that Physical activity increases hypoglyce- diabetes complications. (E) glycemic targets should be individual- mia risk during and immediately follow- c Patients of all ages (or caregivers of ized with the goal of achieving the best ing exercise, and, again, about 7–11 h children) should be educated about possible control while minimizing the postexercise. This delayed susceptibility the prevention and management of risk of severe hyperglycemia and hypo- to hypoglycemia is referred to as the hypoglycemia that may occur during glycemia (Table 7). Goals should be in- “lag effect” of exercise (36,37) and is or after exercise. (E) dividualized based on duration of caused by muscles replenishing glyco- c Patients should be advised about safe diabetes, age/life expectancy, comorbid gen stores postexercise. Hypoglycemia preexercise blood glucose levels (typ- conditions, known CVD or advanced and fear of hypoglycemia can limit par- ically 100 mg/dL or higher depending microvascular complications, hypogly- ticipation in exercise. on the individual and type of physical cemia unawareness, and individual pa- Strategies should be developed to activity). (E) tient considerations. More or less prevent and treat hypoglycemia readily. c Reducing the prandial insulin dose for stringent glycemic goals may be appro- Individualization is necessary, but clini- the meal/snack preceding exercise priate for individual patients. Postpran- cal experience suggests that it is safest and/or increasing food intake can be dial glucose may be targeted if A1C goals for most patients to have a blood glu- used to help raise the preexercise are not met despite reaching preprandial cose level of 100 mg/dL (5.6 mmol/L) or blood glucose level and reduce hypo- glucose goals. higher prior to starting exercise. This glycemia. (E) may be achieved by reducing the pran- c A reduction in overnight basal insulin Recommendation dial insulin dose for the meal/snack the night following exercise may re- c Lifestyle, psychosocial, and medical preceding exercise and/or increasing duce the risk for delayed exercise- circumstances should be considered food intake. Some patients can avoid induced hypoglycemia. (C) when recommending glycemic goals hypoglycemia by reducing insulin c SMBG should be performed as fre- for all age-groups. (E) (such as by lowering pump basal rates) quently as needed (before, during, (38) or by consuming additional carbo- and after exercise) in order to pre- Glycemic Control Goals in Pediatrics hydrates during prolonged physical vent, detect, and treat hypoglycemia As the DCCT only included pediatric pa- $ activity. One study in children on and hyperglycemia. (E) tients aged 13 years (195 adolescents – pumps suggested that a reduction in c Source(s) of simple carbohydrate aged 13 17 years at entry), treatment overnight basal insulin the night follow- should be readily available before, guidelines for pediatric patients have ing exercise may reduce the risk of delayed during, and after exercise to prevent been based nearly exclusively on profes- exercise-induced hypoglycemia (39). Fre- and treat hypoglycemia. (E) sional, expert advice. Furthermore, quent SMBG and/or CGM use are key to exercising safely, as is ready access to car- TREATMENT TARGETS Table 7—Summary of A1C bohydrates. General Considerations recommendations for nonpregnant Basic recommendations for physical Hyperglycemia defines diabetes and is people with diabetes* activity are the same as those for all directly related to the incidence of com- Youth (,18 years) ,7.5% children and adults, independent of plications. Therefore, glycemic control is Adults ,7.0% the diagnosis of diabetes: children fundamental to diabetes management. Older adults should be encouraged to engage in at The Diabetes Control and Complications Healthy† ,7.5% least 60 min of physical activity daily, Trial (DCCT) (43) was a prospective ran- Complex/intermediate ,8.0% , and adults should be advised to perform domized controlled study comparing Very complex/poor health 8.5% at least 150 min/week of moderate- intensive versus standard glycemic con- *Targets must be individualized based on intensity aerobic physical activity (50– trol in patients diagnosed with type 1 apatient’scircumstances.†No comorbidities, long life expectancy. 70% of maximum heart rate) or a lesser diabetes relatively recently. The DCCT 2044 Position Statement Diabetes Care Volume 37, July 2014

despite the overall A1C goal of ,7% for and active ongoing research have dispelled However, as mentioned previously, it adults with type 1 diabetes, pediatric concerns regarding hypoglycemia and must be emphasized that the ADA patients, aged 13–19 years, had an A1C neurocognitive dysfunction (49,50). strongly believes that blood glucose target of ,7.5%. This slightly higher Studies assessing neurocognitive and A1C targets should be individualized A1C target for adolescents with type 1 function have failed to identify adverse with the goal of achieving the best pos- diabetes was based on expert recom- effects of a past history of hypoglycemia sible control while minimizing the risk of mendations and the clinical reality in the young child; however, as always, severe hyperglycemia and hypoglycemia that optimizing glycemic control in ado- further research needs to be conducted. and maintaining normal growth and lescent patients with type 1 diabetes is There are also questions regarding development. especially challenging, given the physio- the premise that the years prior to pu- logical and behavioral challenges that berty do not impact the future risk of Recommendation confront this age-group. complications (51). Many investigators c An A1C goal of ,7.5% is recommended The ADA’s blood glucose and A1C and clinicians believe in the importance across all pediatric age-groups. (E) goals traditionally have been develop- of controlling blood glucose and A1C mentally or age based in the pediatric levels prior to puberty to reduce risk Glycemic Control Goals in Adults population, but it is now time to alter for both micro- and macrovascular Similar to in children, the care of older the traditional goals based on recent complications. Additionally, there is adults with diabetes is complicated data. The traditional recommendations burgeoning evidence that elevated by their clinical and functional hetero- are an A1C goal of ,8.5% for youth un- blood glucose levels and glycemic vari- geneity. Unlike the large older adult pop- der the age of 6 years, ,8% for those ability in the very young child with di- ulation with type 2 diabetes, which 6–12 years old, and ,7.5% for those abetes may produce adverse outcomes includes patients with both long-standing 13–19 years old. Lower blood glucose in the short term on neurocognitive and new-onset diabetes, most older levels and lower A1C targets should function and the central adults with type 1 diabetes have long- be pursued as long as patients can avoid (52,53). These recent articles suggest that standing disease. Even so, there is a severe, recurrent hypoglycemia. Thus, hyperglycemia and glycemic variability wide spectrum of health across older the overall recommendation has in- are associated with changes in the cen- individuals. They may have advanced cluded the goal to achieve as close to tral nervous system white matter, as complications, or they may have lived normal blood glucose and A1C levels as observedinMRIscans. with diabetes for many years without ispossiblewithouttheoccurrenceof Taking into account the combination the development of complications. severe, recurrent hypoglycemia. of spotty past evidence related to the Some older patients have multiple co- Historically, the ADA recommended adverse effects of hypoglycemia on the morbid conditions and/or impairments higher A1C targets for young children. developing brain and increasing evi- of physical or cognitive functioning, This recommendation arose from a dence from more recent investigations while others have little combination of two lines of unsubstan- focused on the potential risks of hyper- and high functional status. Life expec- tiated evidence. First, an older body of glycemia and glucose variability on the tancy is highly variable and is defined , reflecting therapy in the pre- , the ADA has de- by comorbidity and functional status modern era, devoid of insulin analogs, cided to alter the recommendations for more than it is by age. easy-to-use blood glucose monitors, glycemic targets in pediatric patients Health care providers caring for older “smart pumps,” and CGM devices, indi- with type 1 diabetes and harmonize with adults with diabetes must take this het- cated that severe recurrent hypoglycemia other organizations. The International erogeneity into consideration when set- with and/or coma in young chil- Society for Pediatric and Adolescent Di- ting and prioritizing treatment goals. dren was associated with neurocognitive abetes (ISPAD) uses a single A1C goal of The benefits of interventions such as compromise (46). The second line of evi- ,7.5% across all pediatric age-groups. stringent glycemic control may not ap- dence arose from literature that ques- This recommendation is based on clini- ply to those with advanced complica- tioned what, if any, impact blood cal studies and expert opinion, as rigor- tions of diabetes or to those with a life glucose and A1C levels prior to puberty ous evidence does not currently exist. expectancy of less than the anticipated have on the risk for the development of Specifically, the recommendation is de- time frame of benefit. Conversely, the future long-term complications of diabe- rived from a combination of clinical ex- risks of interventions such as tight gly- tes (47,48). With the combination of these perience and intensive management cemic control (hypoglycemia, treatment two independent lines of reports, it is not strategies that provide opportunities burden) may be greater in older pa- surprising that earlier recommendations to achieve as near-normal glycemic con- tients. Although individualization is crit- regarding glycemic targets focused on trol as possible without the occurrence ical, in general, older patients with long the avoidance of severe hypoglycemia in of severe hypoglycemia. life expectancy and little comorbidity order to reduce risk of neurocognitive In light of the above evidence, the should have treatment targets similar dysfunction, especially in young children ADA will harmonize its glycemic goals to those of middle-aged or younger and even school-aged children. with those of ISPAD (as well as the Pe- adults. In more frail patients, treatment Currently, treatment strategies for diatric Endocrine Society and the Inter- targets might reasonably be relaxed, children recommend physiological insulin national Diabetes Federation) by using a while symptomatic hyperglycemia or replacement with modern strategies and single A1C goal of <7.5% across all pedi- the risk of DKA should still be avoided treatment tools. More recent investigation atric age-groups. (54). care.diabetesjournals.org Chiang and Associates 2045

Recommendations to adjust therapy (insulin and/or food). However, these younger patients did c Lowering A1C to below or around 7% Furthermore, SMBG results should be not use CGM consistently. The greatest has been shown to reduce microvas- downloaded and reviewed at each visit. predictor of A1C lowering for all age- cular complications of diabetes, and, SMBG is especially important for pa- groups was frequency of sensor use, if achieved soon after the diagnosis of tients with type 1 diabetes to monitor which was lowest in 15- to 24-year-old diabetes, is associated with long-term for and prevent asymptomatic hypogly- subjects. There was no significant differ- reduction in . cemia and hyperglycemia. Type 1 dia- ence in hypoglycemia in any age-group. Therefore, a reasonable A1C goal for betic patients should perform SMBG In a smaller randomized controlled trial many nonpregnant adults with type 1 prior to, and sometimes after, meals and of 129 adults and children with baseline diabetes is ,7%. (B) snacks, at bedtime, before and after exer- A1C ,7.0%, outcomes combining A1C c Providers might reasonably suggest cise, when they suspect low blood glucose, and hypoglycemia favored the group us- more stringent A1C goals (such as after treating low blood glucose until they ing CGM, suggesting that CGM is benefi- ,6.5%) for select individual pa- are normoglycemic, and prior to critical cial for pediatric patients and adults tients, if this can be achieved with- tasks such as driving. For many patients, with type 1 diabetes who have already out significant hypoglycemia or this will require testing 6–10 times daily, achieved excellent control (58). other adverse effects of treatment. although individual needs may vary. For Overall, meta-analyses suggest that, Appropriate patients might include example, sick children may require up to compared with SMBG, CGM use is asso- those with a short duration of 10 SMBG tests per day or more. ciated with A1C lowering by ;0.26% diabetes, a long life expectancy, hy- A study of children and adolescents (59) without an increase in hypoglyce- poglycemia awareness, and no sig- with type 1 diabetes showed that, mia, although existing studies have nificant CVD. (C) after adjustment for multiple con- small sample sizes and are of relatively c Less stringent A1C goals (such as founders, increased SMBG frequency short duration. The technology may be ,8.5%) may be appropriate for pa- was significantly associated with lower particularly useful in those with hypo- tients with a history of severe hypogly- A1C. In the range of 0–5testsper glycemia unawareness and/or frequent cemia, hypoglycemia unawareness, day, A1C decreased by 0.46% per addi- hypoglycemic episodes, although stud- limited life expectancy, advanced tional test per day. Increased testing ies have not consistently shown signifi- microvascular/macrovascular compli- wasassociatedwithsignificantly less cant reductions in the occurrence of cations, or extensive comorbid condi- DKA and (probably due to reverse cau- severe hypoglycemia. A CGM device tions. (B) sality) significantly more hypoglycemia equipped with an automatic low thresh- c Glycemic control for those of any age (55,56). old suspend feature was approved by the with type 1 diabetes should be as- SMBG accuracy is dependent on both U.S. Food and Drug Administration (FDA) sessed based on frequent SMBG lev- theinstrumentandtheuser(57),soitis in 2013. The Automation to Simulate els (and CGM data, if available) in important to evaluate each patient’s Pancreatic Insulin Response (ASPIRE) trial addition to A1C in order to direct monitoring technique, both initially of 247 patients showed that sensor- changes in therapy. (B) and at regular intervals thereafter. Op- augmented therapy with a timal use of SMBG requires a proper re- low glucose suspend feature significantly MONITORING view and interpretation of the data by reduced nocturnal hypoglycemia without SMBG both the patient and the provider. increasing A1C levels for those .16 years The DCCT demonstrated the benefits of of age (60). These devices may offer the intensive glycemic control on diabetes CGM opportunity to reduce severe hypoglyce- complications with SMBG as part of a Real-time CGM through the measure- mia for those with a history of nocturnal multifactorial intervention, suggesting ment of interstitial glucose (which cor- hypoglycemia, although more clinical tri- that SMBG is a crucial component of ef- relates well with plasma glucose) is als are needed. fective therapy. SMBG allows patients available. These sensors require calibra- to evaluate their individual response to tion with SMBG, and CGM users still re- Recommendations therapy and assess whether glycemic quire SMBG for making acute treatment c Patients with type 1 diabetes should targets are being achieved. SMBG results decisions. CGM devices have alarms for perform SMBG prior to meals and are useful in preventing hypoglycemia, ad- hypo- and hyperglycemic excursions snacks, at a minimum, and at other justing medications (particularly prandial that include absolute level and rate-of- times, including postprandially to assess insulin doses), and understanding the im- change alerts. A 26-week randomized insulin-to-carbohydrate ratios; at bed- pact of appropriate nutrition therapy and trial of 322 type 1 diabetic patients time; midsleep; prior to, during, and/or physical activity. More frequent SMBG is showed that adults aged $25 years us- after exercise; when they suspect low correlated to lower A1C levels (55,56). ing intensive insulin therapy and CGM blood glucose; after treating low blood SMBG frequency and timing should experienced a 0.5% reduction in A1C glucose until they have restored normo- be dictated by the patient’sspecific (from ;7.6% to 7.1%) compared with glycemia; when correcting a high blood needs and goals. When prescribing usual intensive insulin therapy with glucose level; prior to critical tasks such SMBG, providers must ensure that pa- SMBG (58). Participants aged ,25 years as driving; and at more frequent inter- tients receive ongoing instruction and (children, teenagers, and young adults) vals during illness or stress. (B) regular evaluation of their SMBG tech- randomized to sensor use did not c Individuals with type 1 diabetes need nique and their ability to use SMBG data achieve a significant A1C reduction. to have unimpeded access to glucose 2046 Position Statement Diabetes Care Volume 37, July 2014

test strips for blood glucose testing. glycemic control or correlate well with active patient/family participation en- Regardless of age, individuals may re- SMBG testing results. In such conditions, hancing successful outcomes (67–69). quire 10 or more strips daily to mon- may be considered as a sub- itor for hypoglycemia, assess insulin stitute measure of long-term (average Recommendations needs prior to eating, and determine over 2 weeks) glycemic control. c Most individuals with type 1 diabetes if their blood glucose level is safe should be treated with multiple daily enough for overnight sleeping. (B) Recommendations insulin injections (three or more in- c CGM is a useful tool to reduce A1C c Perform the A1C test quarterly in jections per day of prandial insulin levels in adults without increasing hy- most patients with type 1 diabetes and one to two injections of basal in- poglycemia and can reduce glycemic and more frequently as clinically in- sulin) or CSII. (A) excursions in children. Glycemic im- dicated (i.e., pregnancy). (A) c Most individuals with type 1 diabetes provements are correlated with fre- c Point-of-care A1C testing, using a should be educated in how to match quency of CGM use across all ages. (A) DCCT standardized assay, may pro- prandial insulin dose to carbohydrate vide an opportunity for more timely intake, premeal blood glucose, and Additional Considerations for treatment changes. (E) anticipated activity. (E) Pediatrics c Most individuals with type 1 diabetes c Children should have additional INSULIN THERAPY should use insulin analogs to reduce blood glucose checks if the parent/ The DCCT clearly showed that intensive hypoglycemia risk. (A) caregiver is concerned that the child’s insulin therapy, defined as three or c All individuals with type 1 diabetes behavior may be due to low/high more injections per day of insulin or con- should be taught how to manage blood blood glucose levels. (E) tinuous subcutaneous insulin infusion glucose levels under varying circum- c School employees and caregivers (CSII) (or insulin pump therapy), was a stances, such as when ill or receiving should be knowledgeable about key part of improved glycemia and better or for those on pumps, SMBG and equipped with all neces- outcomes (43,63). The study was carried when pump problems arise. (E) sary supplies. (E) out with short- and intermediate-acting c Child caregivers and school personnel c Capable children should be permitted to human . Despite better microvas- should be taught how to administer self-manage their diabetes at school. (E) cular outcomes, intensive insulin ther- insulin based on provider orders apy was associated with a high rate of when a child cannot self-manage A1C TESTING severe hypoglycemia (62 episodes per and is out of the care and control of A1C reflects average glycemia over 2–3 100 patient-years of therapy). Since the his or her parent/guardian. (E) months (57) and strongly predicts dia- completion of the DCCT, a number of betes complications (43,61). Thus, A1C rapid-acting and long-acting insulin INTERDICTION testing should be performed routinely in analogs have been developed. These Therapy trials to prevent type 1 diabetes all patients with diabetes at initial as- analogs are associated with less hypogly- development (prevention), to preserve sessment and as part of continuing cemia than human insulin while offering remaining b-cells (preservation), and to care. A1C is a convenient method to thesameamountofA1Cloweringin replace b-cells (transplantation) are on- track diabetes control; however, there people with type 1 diabetes (64,65). going. Although means are available to are disadvantages. rates, and TheSensor-AugmentedPumpTher- screen and predict family members at thus A1C levels, may vary with patients’ apy for A1C Reduction (STAR 3) study risk for developing type 1 diabetes, ef- race/ethnicity. However, this is contro- was a large (n 5 485) randomized clini- forts to delay or prevent disease onset versial. Additionally, anemias, hemoglo- cal trial comparing insulin pump therapy have been largely disappointing. A vari- binopathies, and situations of abnormal and CGM with insulin injections in youth ety of different immunomodulatory and red cell turnover affect A1C (42). and adults with type 1 diabetes. The two immune-suppressive agents have been A1C measurements approximately study groups started with the same evaluated in patients with recent-onset every 3 months determine whether a baseline A1C of 8.3%. After 1 year, the type 1 diabetes, and the effects have patient’s glycemic targets have been group using insulin pump therapy and been modest at best: for the subset of reached and maintained. For any indi- CGM had lower A1C levels (7.5% vs. drugs that appear to have an effect, not vidual patient, the frequency of A1C 8.1%, P , 0.001) without significant all patients respond; for those who do, testing should be dependent on the clin- nocturnal hypoglycemia compared the effects are generally transient. ical situation, the treatment regimen with the insulin injection cohort (66). Many of the agents tested to date are used, and the clinician’s judgment. Un- Recently, a large randomized trial in pa- FDA approved for other indications, but stable or highly intensively managed pa- tients with type 1 diabetes and noctur- given the observations to date and po- tients (e.g., pregnant type 1 diabetic nal hypoglycemia reported that the tential toxicities, the recommendation is women) may require more frequent use of sensor-augmented insulin pump that patients should only receive these testing than every 3 months (62). In pa- therapy with the threshold-suspend fea- drugs after being enrolled in clinical tients with hemoglobinopathies that in- ture reduced nocturnal hypoglycemia research protocols with appropriate terfere with the A1C assay or with without increasing glycated follow-up. Long-term safety and efficacy hemolytic anemia or other conditions values (60). In general, intensive man- data are scarce, especially in children. In- that shorten the red blood cell life agement using pump therapy/CGM vestigators continue to evaluate prom- span, the A1C may not accurately reflect should be strongly encouraged, with ising new agents and combinations of care.diabetesjournals.org Chiang and Associates 2047

drugs or cell-based therapies in an effort over the past decade such that normo- in patients with type 1 diabetes and to safely and effectively modulate the glycemia without insulin is now main- debilitating complications of diabetes autoimmune response (70). tained for an average of 3 years in who are interested in research possi- specialized protocols (74). Even when bilities and fit the criteria for the re- b -CELL REPLACEMENT THERAPY insulin treatment is reinstituted, resid- search protocol. (E) b-Cell replacement may be achieved ual insulin secretion can help recipients through or islet transplantation maintain good control with less hypo- ADJUNCTIVE THERAPIES in select candidates. Pancreas transplants glycemia and a less complicated regi- are now accepted as a proven therapy, men for several more years. Pramlintide, an analog, is an while islet transplants, though signifi- At the present time, few islet trans- agent that delays gastric emptying, cantly improving, are still mostly done plants are being performed and most blunts pancreatic secretion of glucagon, on an experimental basis. are experimental. However, they can and enhances satiety. It is an FDA- be considered as a treatment option Pancreas Transplants approved therapy for use in type 1 di- for those who are poor candidates for Pancreas transplants are most often abetic patients and has been shown to whole-organ transplants. Importantly, performed in combination with reduce A1C, induce weight loss, and their current success has established a transplantation, either as a simulta- lower insulin dose. However, it is only proof of principle for cellular transplanta- neous pancreas-kidney (SPK) transplant indicated for adults. Two 52-week trials tion. Great progress is being made in or as a pancreas-after-kidney (PAK) of pramlintide (n 5 1,131; age .18 finding an abundant source of healthy transplant (71). SPK and PAK transplants years) showed A1C reductions of insulin-producing cells and in developing may be considered for individuals ;0.3–0.4% (77,78). In both studies, a better ways to protect transplanted cells with late-stage because greater proportion of participants from immune destruction (75,76). Poten- the transplants can normalize glucose achieved an A1C target of ,7% with tial solutions for the shortage of islets in- levels, which will prevent hypogly- the therapy than without the therapy. clude embryonic stem cells, induced cemia and provide some protection for There are a few small, short-term stud- pluripotent stem cells, xenogeneic tissue, the transplanted kidney (72), and provide ies of pramlintide use in children with and various other potential sourcesdall other benefits, including an improvement type 1 diabetes, with outcomes similar the focus of ongoing research efforts. An- in quality of life (71). These recipients will to those in the adult studies. Clearly, other possible way to replenish the b-cell already require immunosuppression for larger, long-term studies are needed deficiency of diabetes is through regener- their renal transplants, which means the in pediatrics. ation of the endocrine pancreas; this too major additional risk is the operative pro- is being worked on intensively. cedure. SPK transplants function for an Incretin-Based Therapies average of 9 years, compared with 6 years Injectable glucagon-like peptide-1 (GLP-1) for PAK transplants (71). Recommendations agonists and oral dipeptidyl peptidase-4 c Consider solid organ pancreas trans- There has been debate about pan- (DPP-4) inhibitors are increasingly being plantation simultaneously with kidney creas transplant alone (PTA) in the ab- studied in the type 1 diabetic population, transplantation in patients with type 1 sence of an indication for kidney but are not approved by the FDA for diabetes who have an indication for transplantation because of the risks of this indication. GLP-1 agonists delay and are poorly mortality, morbidity, and immunosup- gastric emptying, suppress the postpran- controlled with large glycemic excur- pression. Outcomes have gradually im- dial rise in glucagon secretion, and may sions. (B) proved (73), such that the procedure increase satiety. Preliminary studies in- c Consider solid organ pancreas trans- can be cautiously considered for indi- dicate that these agents may also facili- plantation after kidney transplanta- viduals without renal failure who have tate weight loss. Further long-term tion in adult patients with type 1 unstable glucose control and hypogly- clinical trials in type 1 diabetic patients diabetes who have already received a cemia unawareness. Because of the are needed. kidney transplant. (C) risks of com- c Judiciously consider solid organ pan- pared with traditional methods for Sodium-Glucose 2 creas transplantation alone in adults controlling blood glucose levels, all Inhibitors with type 1 diabetes, unstable glucose Sodium-glucose cotransporter 2 (SGLT2) available efforts to use exogenous insu- control, hypoglycemia unawareness, inhibitors work by inhibiting glucose re- lin combined with technology, educa- and an increased risk of diabetes- absorption in the kidney and are also tion, and glucose follow-up should be related mortality, who have attempted being tested in individuals with type 1 exhausted before PTA is performed. all of the more traditional approaches diabetes. These agents provide insulin- The durability of function averages 6 to glycemic control and have re- independent glucose lowering by years, which is much better than islet mained unsuccessful, yet are judged blocking glucose reabsorption in the transplantation but about the same as responsible enough to manage the an- proximal renal tubule, leading to weight PAK and not as good as SPK (73). tirejection medication regimen, risks, loss and A1C reduction in individuals Islet Transplantation and follow-up required with an organ with type 2 diabetes. However, insuffi- A major appeal of islet transplantation is transplant. (C) cient data exist to recommend clinical that it does not require major surgery. c Consider referral to research centers for use of these agents in type 1 diabetes at Moreover, outcomes have improved protocolized islet cell transplantation this time. 2048 Position Statement Diabetes Care Volume 37, July 2014

Metformin reduced sympathoadrenal response to associated with new-onset type 1 diabe- is a that decreases hypoglycemia; it can occur in the setting tes, insulin omission, and increased levels hepatic and is used as of recurrent hypoglycemia or autonomic of counterregulatory hormones/cytokines first-line therapy in type 2 diabetes. It failure and can be reversed by scru- associated with stress, such as an infection. has been shown to have some benefit pulous avoidance of hypoglycemia. Pa- Mild cases can be safely and effectively in reducing insulin doses and weight in tients should be screened to determine treated in an acute care setting with ap- small studies in patients with type 1 di- the threshold at which hypoglycemia propriate resources and may not require abetes (79) and is now being evaluated symptoms occur; if the threshold is sug- hospitalization. Education must be pro- more fully for use in patients with type 1 gestive of hypoglycemia unawareness, vided to individuals with type 1 diabetes diabetes. Two randomized controlled the treatment goals and regimen should in order to help prevent DKA, which can trials are currently under way evaluating be revisited and counseling regarding ap- have serious sequelae, particularly in chil- metformin in type 1 diabetic patients. The propriate self-monitoring before critical dren under 5 years of age. Although DKA first study is in adults and is using carotid tasks should be reinforced (82). and hyperglycemic hyperosmolar state intima-medial thickness as an outcome Oral carbohydrate is the treatment of (HHS) may overlap, especially when dehy- measure (ClinicalTrials.gov identifier: choice for self-treatment or for the dration is severe, DKA must be distin- NCT01483560). The second study is focus- treatment of hypoglycemic adults and guished from HHS (serum glucose .600 ing on overweight or obese youths be- children who are alert and able to eat. mg/dL, serum osmolality .330 mOsm/kg, tweentheagesof12and19yearswho Glucagon is used for severe hypoglyce- and no significant ketosis and ) require $0.85 units/kg/day of insulin (Clin- mia. In children, small studies have led because patients with HHS typically are icalTrials.gov identifier: NCT01808690). to the concept of using age-based mini- severely dehydrated and require more Results are currently pending. dose glucagon if the child is alert but not aggressive fluid management. There are able to eat (83). multiple guidelines available for the Recommendations management of DKA (84). c Pramlintide may be considered for Recommendations use as adjunctive therapy to pran- c Individuals with type 1 diabetes, or their Recommendations dial insulin in adults with type 1 di- caregivers, should be asked about c Individuals and caregivers of individ- abetes failing to achieve glycemic symptomatic and asymptomatic hypo- uals with type 1 diabetes should be goals. (B) glycemia at each encounter. (E) educated and reminded annually c Evidence suggests that adding met- c Glucose (15–20 g) is the preferred how to prevent DKA, including a re- formin to insulin therapy may reduce treatment for the conscious individ- view of sick-day rules and the critical insulin requirements and improve ual with hypoglycemia, although any importance of always administering metabolic control in overweight/ form of carbohydrate may be used. insulin and monitoring both glucose obese patients and poorly controlled If the SMBG result 15 min after treat- and ketone levels. (B) adolescents with type 1 diabetes, but ment shows continued hypoglycemia, c Insulin omission is the major cause of evidence from larger longitudinal the treatment should be repeated. DKA; therefore, individuals with type studies is required. (C) Once blood glucose concentration re- 1 diabetes must have access to an un- c Current type 2 diabetes medications turns to normal, the individual should interrupted supply of insulin. (E) (GLP-1 agonists, DPP-4 inhibitors, and consume a meal or snack to prevent c Patients with type 1 diabetes and their SGLT2 inhibitors) may be potential recurrence of hypoglycemia. (E) families should have around-the-clock therapies for type 1 diabetic patients, c Glucagon should be prescribed for all access to medical advice and support to but require large clinical trials before individuals with type 1 diabetes. assist with sick-day management. (C) use in type 1 diabetic patients. (E) Caregivers or family members of c Standard protocols for DKA treat- these individuals should be instructed ment should be available in emer- HYPOGLYCEMIA in its administration. (E) gency departments and hospitals. (E) c Hypoglycemia unawareness or one or Hypoglycemia risk is the limiting step in more episodes of severe hypoglyce- the treatment of type 1 diabetes at any CVD SCREENING AND TREATMENT mia should trigger reevaluation of age. Because current methods of blood Much of the existing data on the risk of the treatment regimen. (E) glucose detection and insulin replace- CVD in individuals with diabetes is based c Insulin-treated patients with hypogly- ment are imperfect (though improved on people with type 2 diabetes who often cemia unawareness or an episode from prior eras), hypoglycemia risk is have additional CVD risk factors, such as of severe hypoglycemia should be ad- invariably present. Patient education , , and vised to raise their glycemic targets to (80), frequent SMBG, and CGM can . How much is applicable to strictly avoid further hypoglycemia for help detect hypoglycemia and allow people with type 1 diabetes is unknown. at least several weeks to partially re- for adjustments in insulin dosing and However, people with type 1 diabetes are verse hypoglycemia unawareness and carbohydrate intake. Severe hypoglycemia at increased risk for CVD, particularly reduce the risk of future episodes. (B) rates increase with antecedent episodes those with additional risk factors. of hypoglycemia, age, and duration of In type 1 diabetes, standard risk factors diabetes; thus, this is an issue that DKA apply, such as , hyperten- must be reassessed frequently (81). Hy- DKA (see ref. 70 for definition) is an acute sion, age, family history, smoking, weight, poglycemia unawareness is related to a complication of diabetes that can be and presence of . As such, care.diabetesjournals.org Chiang and Associates 2049

these should be considered when deter- counseling and care are critical. Precon- health care providers must be vigilant mining the need for evaluation and treat- ception care with tight glycemic control and frequently adjust insulin dosing ment for CVD. However, even in the improves outcomes including lower ce- throughout gestation. absence of classic risk factors, there may sarean rates (88), decreased perinatal In a pregnancy complicated by dia- be high CVD risk. An adult with childhood- mortality (89–91), and decreased congen- betes and chronic hypertension, target onset type 1 diabetes of 20-year duration ital malformations (89–97). Although blood pressure goals of systolic blood has a substantially increased risk of coro- there is some evidence that childbearing pressure 110–129 mmHg and diastolic nary artery disease of 1% per year (83), may be reduced (98–100), in general, fer- blood pressure 65–79 mmHg are reason- thus meriting high-intensity ther- tility should be assumed to be normal, able. Lower blood pressure levels may be apy according to the new joint American and all young women with type 1 diabe- associated with impaired fetal growth College of /American Heart As- tes should receive preconception coun- (Table 8). ACE inhibitors and angiotensin sociation guidelines ($7.5% 10-year risk) seling covering diabetes and general blockers are contraindicated (85). In some cases, measurement of cor- topics, including use of prenatal vitamin, during pregnancy because they may onary artery calcification may be a help- discontinuation of potentially teratogenic have adverse effects on the fetus. Antihy- ful method for determining CVD risk medications, and the importance of gly- pertensive drugs known to be effective (86). Here, as with all management is- cemic control to reduce the risk of con- and safe in pregnancy include methyl- sues for people with type 1 diabetes, genital malformations. dopa, labetalol, diltiazem, clonidine, and providers need to individualize assess- prazosin. ment and treatment options. Pregnancy Eye examinations should occur in the With regard to treatment, statin ther- Type 1 diabetes affects approximately first trimester with close follow-up apy is the preferred treatment for lipid 0.1–0.2% of all pregnancies (101). Dur- throughout pregnancy and for 1 year lowering/CVD risk reduction (85). The ing pregnancy, there are substantial postpartum because of the risk of rapid Heart Protection Study (HPS) did include changes in maternal insulin sensitivity retinopathy progression during preg- type 1 diabetic participants who ap- that may cause profound changes in in- nancy. Those with progressive retino- peared to experience the same degree sulin requirements. Whereas insulin re- pathy should have more frequent of benefit from as others in the sistance increases markedly during the screening by an ophthalmologist expe- study, though the finding was not statis- second and third trimesters, a greater rienced in retinopathy management. tically significant due to low numbers proportion of total daily insulin dose See the American Diabetes Association/ (87). Unfortunately, there are no blood must be given prandially and a lower JDRF Type 1 Diabetes Sourcebook (70) pressure intervention trials with CVD proportion used to cover basal meta- for a summary of pregnancy recommen- end points in type 1 diabetes and only bolic requirements (102). Pregnant dations. The prevalence of Hashimoto one LDL cholesterol–lowering trial (85). women with type 1 diabetes require thyroiditis may be as high as 31% in Statin and therapy (if not contra- meticulous glycemic management by womenwithtype1diabetes(105). indicated) should be considered and used experts trained in , endocri- Therefore, all pregnant women with as is individually indicated. nology, and maternal-fetal medicine. type 1 diabetes should be screened for Women who are planning pregnancy thyroid disease early in pregnancy. Recommendations or who are pregnant may need to test c Therapy for those under age 40 years blood glucose levels frequently (often Recommendations with less than a 20-year diabetes dura- 10 or more times daily) to reach and c Starting at puberty, preconception tion (or over age 75 years) should be maintain a near-normal A1C level with- counseling should be incorporated considered on an individual basis, out excessive hypoglycemia. into routine diabetes clinic visits for though, depending on overall risk, an Severe hypoglycemia may occur early all adolescents and women of child- LDL cholesterol ,100 mg/dL has been during pregnancy (102). This is followed bearing potential, and appropriate suggested as an appropriate goal with by periods of and sub- birth control techniques should be statin intervention for those with LDL sequent hyperglycemia if the increased discussed with women who do not cholesterol levels of 130–160 mg/dL. (E) insulin needs are not met. Therefore, desire pregnancy. (C) c Individuals with type 1 diabetes aged 40– 75 years may benefit from moderate- to-intensive statin therapy with consid- Table 8—ADA Standards of Care optimal targets in pregnancy* eration of diabetes duration and CVD Target maternal glucose† risk factors. If 10-year risk is estimated Fasting 60–99 mg/dL to be $7.5%, then intensive statin Peak postprandial 100–129 mg/dL therapy should be considered. (B) Mean ,100 mg/dL Labor and delivery 80–110 mg/dL (mean ,100) Insulin drips 1 D10 50 cc/h SPECIFIC SETTINGS AND A1C Preconception ,7% and as close to normal as possible POPULATIONS without significant hypoglycemia , Pregnancy During pregnancy 6% Preconception Counseling and Care *See refs. 70, 103, and 104. †These represent the mean 12 SD for normal. They are targets, but To minimize risks associated with preg- not everyone can achieve them. There is certainly marked variability, which explains why there is greater incidence of large-for-gestational-age infants in patients with type 1 diabetes. nancy and type 1 diabetes, preconception 2050 Position Statement Diabetes Care Volume 37, July 2014

c As most pregnancies are unplanned, and surgeons as well as other specialists care personnel is essential for optimal di- consider the potential risks and ben- who perform procedures, understands abetes management, safety, and maximal efits of medications that are contrain- type 1 diabetes and how it factors into academic opportunities. Child care per- dicated in pregnancy in all adolescents the comprehensive delivery of care. sonnel and school staff should receive and women of childbearing potential From a practical perspective, this means training to provide diabetes care in the and counsel women using such medi- that people with type 1 diabetes will absence of a school nurse or licensed cations accordingly. (E) be at high risk for hypoglycemia during health care professional. Able and willing c Such medications should be evalu- prolonged fasting and are at risk for school staff members should be taught ated prior to conception, as drugs ketosis if insulin is inappropriately with- the principles of diabetes management commonlyusedtotreatdiabetes held. Once under anesthesia, individ- and trained to provide needed care for and its complications may be con- uals with type 1 diabetes must be the child according to the ADA’s Safe at traindicated or not recommended carefully monitored for hypoglycemia School program (see the ADA position in pregnancy, including statins, ACE and hyperglycemia. statement on diabetes care in the school inhibitors, angiotensin receptor For some individuals, once the most and day care setting [106] for further dis- blockers, and most noninsulin ther- acute phase of an illness has resolved cussion). Young children often lack the apies. (B) or improved, patients may be able to motor, cognitive, and communication c Prenatal vitamins with should self-administer their prior multiple- skills and abilities to manage their diabe- be started with preconception plan- dose or CSII insulin regimen under the tes and completely depend on adult care- ning to reduce the risk for birth de- guidance of hospital personnel who are givers. The management priority for fects. (B) knowledgeable in glycemic manage- younger children is the prevention, recog- c All pregnant women with type 1 di- ment. Individuals managed with insulin nition, and treatment of hypoglycemia abetes should be screened for thyroid pumps and/or multiple-dose regimens and marked hyperglycemia. disease early in pregnancy. (B) with carbohydrate counting and cor- Students with diabetes should re- c Women contemplating pregnancy rection dosing may be allowed to man- ceive proper diabetes management should be evaluated and, if indicated, age their own diabetes if this is what in school, with as little disruption to treated for , ne- they desire, once they are capable of the school and child’sroutineaspossi- phropathy, neuropathy, and CVD. (B) doing so. ble. Whenever possible, the student c A1C levels should be as close to nor- should have the opportunity to self- mal as possible (,7%) before concep- Recommendations manage by performing blood glucose tion is attempted. (B) c All patients admitted to the hospital monitoring, using CGM (if utilized), ad- c Nutritional intake should be opti- should have type 1 diabetes clearly ministering insulin, having access to mized and included in preconception identified in the medical record. (E) meals/snacks, managing hypoglycemia planning according to general preg- c SMBG should be ordered to fitthe (with trained personnel prepared nancy guidelines. (E) patient’s usual insulin regimen with to provide glucagon treatment, if re- modifications as needed based on quired) and hyperglycemia, and partici- Inpatient Management and clinical status. (E) pating fully in all school-sponsored Outpatient Procedures c Goals for blood glucose levels are the activities (Table 9). Management of individuals with type 1 same as for people with type 2 diabe- diabetes in the hospital and in prepara- tes or hospital-related hyperglyce- Camps tion for scheduled outpatient pro- mia. (E) A diabetes camp is an ideal place for cedures often differs from that of c A plan for preventing and treating hy- children and youth to have an enjoyable individuals with type 2 diabetes. The poglycemia should be established for camp experience and receive peer sup- challenges include difficulties associ- each patient. (E) port from other children with diabetes ated with fasting, maintaining a con- c Insulin dosing adjustments should be under close medical oversight. The sistent source of carbohydrate, and made in the perioperative period and goals for campers are to learn to cope facilitating inpatient blood glucose man- inpatient setting with consideration more effectively with diabetes, learn agement while modifying scheduled in- of changes in oral intake, recent self-management skills to gain more in- sulin therapy. Outpatient procedures blood glucose trends, and the need dependence, and share experiences should be performed with the aware- for uninterrupted basal insulin to pre- with other young people with diabetes. ness that individuals with type 1 diabe- vent hyperglycemia and ketoacidosis, The camp is respon- tes may have difficulty fasting for long with adjustment of the long-acting in- sible for the diabetes management of periods of time (more than 10 h) prior to sulin or basal insulin requirement to the children. A registered dietitian over- a procedure. Patients with type 1 diabetes reflect true basal requirements, inso- sees dietary planning at camp. Medical should be prepared with a treatment plan far as they may be anticipated. (B) directors and staff should have exper- for insulin dose adjustments and oral glu- tise in managing type 1 diabetes and cose intake prior to any procedure that Child Care and Schools must receive training concerning rou- requires alterations in dietary intake and/ Because a large portion of a child’sday tine diabetes management and treat- or fasting. may be spent in school and/or in the ment of diabetes-related emergencies It is imperative that the entire health child care setting, close communication at camp. Staff must follow universal pre- care team, including anesthesiologists with and cooperation of the school or day cautions including Occupational Safety care.diabetesjournals.org Chiang and Associates 2051

Table 9—Diabetes care tasks for school personnel Diabetes care tasks Signs* Treatment Outcome if not treated Hypoglycemia recognition Catecholamine effect (sweating, Glucose, wait 15 min, recheck, Seizure or coma and treatment jitteriness, tachycardia, and give food if blood glucose is palpitations) or adequate (based on DMMP) (behavior change) Know when and how to give glucagon Know when to contact parents or emergency medical services Have all contact information available on emergency plan Hyperglycemia recognition Polyuria, polydipsia (most common), Rapid- or short-acting insulin Check for ketones. Follow and treatment difficulty concentrating, , Dose and frequency should be directions for ketones if or irritability clearly elucidated on emergency positive to avoid ketoacidosis plan to avoid “insulin stacking” and consequent hypoglycemia (DMMP) Insulin dosing technique (/vial, pens, pumps) Insulin required (DMMP) Ketone checks and when to call parents Correction factor calculations and insulin for hyperglycemia and ketones DMMP, Diabetes Medical Management Plan. *Varies among individuals but consistent within a given child.

and Health Administration (OSHA) regu- Not all older adults are alike: some remains less common in people of non- lations, Clinical Laboratory Improve- may continue a rigorous regimen, with European descent. A better understand- ment Amendments (CLIA) standards, tighter control, while others may re- ing of the unique pathophysiology of and state regulations (107). quire less stringent targets. Along with type 1 diabetes is needed. In addition, age-related conditions, older adults may multidisciplinary diabetes teams should Diabetes in the Workplace develop diabetes-related complications, receive training to properly address the There are practical and legal issues re- which make managing type 1 diabetes diverse cultural needs of these popula- lated to diabetes in the workplace. Em- more challenging. Providers should be tions and to optimize health care deliv- ployers and employees with diabetes aware that insulin dosing errors, meal ery, improve glycemic control, and should work together to find solutions planning, and physical activities must prevent complications. Additionally, and educate themselves about the be properly managed in older adults. there is a need for approaches to reduce rights of individuals with diabetes. Indi- Severe hyperglycemia can lead to symp- health disparities and improve out- viduals with diabetes are responsible for toms of and hyperglycemic comes in racial/ethnic minorities and having all necessary diabetes supplies, crises. While chronic hyperglycemia is in the underserved population with eating properly, and being aware of detrimental, hypoglycemia may be type 1 diabetes (70). safety issues and regulations at work. more of a concern in some older adults. The Americans with Act states Declining cognition may contribute to Developing Countries: The Global that most employers must provide “rea- hypoglycemia unawareness or the in- Epidemic sonable accommodations” to allow an in- ability to safely manage hypoglycemia Type 1 diabetes is an increasing global dividual with diabetes to safely and when it occurs. An individualized ap- burden. The demands of successfully perform a job, unless doing proach that includes the reassessment daily management, chronicity of the dis- so would place an “undue burden” on the of prior targets may be warranted. We re- ease, potential complications, paucity of employer. We refer the reader to ADA fer the reader to the ADA consensus report diabetes specialists, and rising incidence position statement on diabetes and em- “Diabetes in Older Adults” (54). Even are challenging in the U.S., but these ployment for additional information though this report focuses primarily on issues, including the considerable cost (108) and to the relevant section of the the type 2 diabetic population, there is sig- of management, are crippling for those American Diabetes Association/JDRF nificant overlap in the comorbidities and in the developing world. International Type 1 Diabetes Sourcebook (70). complications experienced by the older organizations play a major role in im- type 1 and type 2 diabetic populations. proving care for individuals with type 1 Older Adults diabetes in the developing world, but Older individuals with type 1 diabetes Special Population Groups implementable, cost-saving, and sus- are unique in that they have lived for Although type 1 diabetes is increasing in tainable strategies are needed to make many years with a complex disease. several ethnic and racial groups, it such programs successful (70). 2052 Position Statement Diabetes Care Volume 37, July 2014

6. Miller RG, Secrest AM, Sharma RK, Songer TJ, the American Association of Clinical Endocrinol- Orchard TJ. Improvements in the life expectancy ogists, the American Osteopathic Association, Acknowledgments. The authors thank the following contributors to the American Diabe- of type 1 diabetes: the Pittsburgh Epidemiology the Centers for Disease Control and Prevention, tes Association/JDRF Type 1 Diabetes Source- of Diabetes Complications study cohort. Diabe- Children with Diabetes, The Endocrine Society, – book: Nora Algothani, Pamela Allweiss, tes 2012;61:2987 2992 the International Society for Pediatric and Ado- Barbara J. Anderson, Florence M. Brown, 7. Scottish Diabetes Research Network Epidemiol- lescent Diabetes, Juvenile Diabetes Research H. Peter Chase, William L. Clarke, Sheri R. Colberg, ogy Group. Life expectancy in type 1 diabetes: a Scot- Foundation International, the National Diabetes Kathleen Dungan, Steven Edelman, Martha tish Registry Linkage Study [Internet], 2013. Education Program, and the Pediatric Endocrine M. Funnell, Stephen E. Gitelman, Ann E. Goebel- Available from http://www.easdvirtualmeeting.org/ Society (formerly Lawson Wilkins Pediatric En- – Fabbri, Jeffrey S. Gonzalez, Carla J. Greenbaum, resources/3906. Accessed 9 April 2014 docrine Society). Diabetes Care 2011;34:2477 Michael J. Haller, Kara Hawkins, Laurie A. Higgins, 8. Davis A, Haller MJ, Miller K, et al. Residual 2485 Irl B. Hirsch, William C. Hsu, Heba Ismail, Crystal C-peptide in patients 3-81 years from diagnosis 21. Holmes GK. Coeliac disease and type 1 di- Crismond Jackson, Tamarra James-Todd, of T1D: A T1D Exchange Study. Diabetes 2013; abetes mellitus - the case for screening. Diabet – Georgeanna J. Klingensmith, David C. Klonoff, 62(Suppl. 1):A422 Med 2001;18:169 177 Mary Korytkowski, David Maahs, Hussain Mahmud, 9. Klingensmith GJ, Pyle L, Arslanian S, et al.; 22. Rewers M, Liu E, Simmons J, Redondo MJ, Medha N. Munshi, Trevor Orchard, Bruce TODAY Study Group. The presence of GAD and Hoffenberg EJ. Celiac disease associated with A. Perkins, Jeremy Hodson Pettus, Andrew IA-2 antibodies in youth with a type 2 diabetes type 1 diabetes mellitus. Endocrinol Metab – M. Posselt, Michael C. Riddell, Elizabeth phenotype: results from the TODAY study. Di- Clin North Am 2004;33:197 214 – R. Seaquist, Janet Silverstein, Linda M. Siminerio, abetes Care 2010;33:1970 1975 23. Husby S, Koletzko S, Korponay-SzaboIR,´ Peter Stock, William V. Tamborlane, Guillermo E. 10. Wenzlau JM, Juhl K, Yu L, et al. The cation et al.; ESPGHAN Working Group on Coeliac Dis- fl Umpierrez, Raynard Washington, Joseph I. ef ux transporter ZnT8 (Slc30A8) is a major ease Diagnosis; ESPGHAN Gastroenterology Wolfsdorf, Howard Wolpert, Jennifer Ann autoantigen in human type 1 diabetes. Proc Committee; European Society for Pediatric Gas- Wyckoff, and Mary Ziotas Zacharatos. The au- Natl Acad Sci USA 2007;104:17040–17045 troenterology, Hepatology, and Nutrition. 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Stratton IM, Adler AI, Neil HAW, et al. As- et al. A randomized study and open-label ex- 47. Krolewski AS, Warram JH, Christlieb AR, sociation of glycaemia with macrovascular and tension evaluating the long-term efficacy of Busick EJ, Kahn CR. The changing natural history microvascular complications of type 2 diabetes pramlintide as an adjunct to insulin therapy 2054 Position Statement Diabetes Care Volume 37, July 2014

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