S90 Diabetes Care Volume 42, Supplement 1, January 2019 9. Pharmacologic Approaches to American Diabetes Association Glycemic Treatment: Standards of Medical Care in Diabetesd2019 Diabetes Care 2019;42(Suppl. 1):S90–S102 | https://doi.org/10.2337/dc19-S009 The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. PHARMACOLOGIC THERAPY FOR TYPE 1 DIABETES Recommendations 9.1 Most people with type 1 diabetes should be treated with multiple daily 9. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. A 9.2 Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. A 9.3 Consider educating individuals with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity. E 9.4 Individuals with type 1 diabetes who have been successfully using continuous subcutaneous insulin infusion should have continued access to this therapy after they turn 65 years of age. E Insulin Therapy Because the hallmark of type 1 diabetes is absent or near-absent b-cell function, in- sulin treatment is essential for individuals with type 1 diabetes. Insufficient provision Suggested citation: American Diabetes Associa- of insulin causes not only hyperglycemia but also systematic metabolic disturbances tion. 9. Pharmacologic approaches to glyc- like hypertriglyceridemia and ketoacidosis, as well as tissue catabolism. Over the past emic treatment: Standards of Medical Care in three decades, evidence has accumulated supporting multiple daily injections of Diabetesd2019. Diabetes Care 2019;42(Suppl. insulin or continuous subcutaneous administration through an insulin pump as 1):S90–S102 providing the best combination of effectiveness and safety for people with type 1 © 2018 by the American Diabetes Association. diabetes. Readers may use this article as long as the work is properly cited, the use is educational and not for Generally, insulin requirements can be estimated based on weight, with typical profit, and the work is not altered. More infor- doses ranging from 0.4 to 1.0 units/kg/day. Higher amounts are required during mation is available at http://www.diabetesjournals puberty, pregnancy, and medical illness. The American Diabetes Association/JDRF .org/content/license. care.diabetesjournals.org Pharmacologic Approaches to Glycemic Treatment S91 Type 1 Diabetes Sourcebook notes 0.5 the literature in adolescents and adults complications, and avoidance of intra- units/kg/day as a typical starting dose in with type 1 diabetes (10,11). Intensive muscular (IM) insulin delivery. patients with type 1 diabetes who are diabetes management using CSII and Exogenous-delivered insulin should metabolically stable, with half adminis- continuous glucose monitoring should be injected into subcutaneous tissue, not tered as prandial insulin given to control be considered in selected patients. See intramuscularly. Recommended sites for blood glucose after meals and the other Section 7 “Diabetes Technology” for a full insulin injection include the abdomen, half as basal insulin to control glycemia discussion of insulin delivery devices. thigh, buttock, and upper arm (21). Be- in the periods between meal absorp- The Diabetes Control and Complica- cause insulin absorption from IM sites tion (1); this guideline provides detailed tions Trial (DCCT) demonstrated that differs according to the activity of the information on intensification of ther- intensive therapy with multiple daily muscle, inadvertent IM injection can apy to meet individualized needs. In injections or CSII reduced A1C and was lead to unpredictable insulin absorp- addition, the American Diabetes Associ- associated with improved long-term out- tion and variable effects on glucose, ation position statement “Type 1 Diabe- comes (12–14). The study was carried with IM injection being associated tes Management Through the Life Span” out with short-acting and intermediate- with frequent and unexplained hypo- provides a thorough overview of type 1 acting human insulins. Despite better glycemia in several reports (21–23). diabetes treatment (2). microvascular, macrovascular, and all- Risk for IM insulin delivery is increased in Physiologic insulin secretion varies cause mortality outcomes, intensive ther- younger and lean patients when injecting with glycemia, meal size, and tissue apy was associated with a higher rate into the limbs rather than truncal sites demands for glucose. To approach this of severe hypoglycemia (61 episodes (abdomen and buttocks) and when using variability in people using insulin treat- per 100 patient-years of therapy). Since longer needles (24). Recent evidence ment, strategies have evolved to adjust the DCCT, rapid-acting and long-acting supports the use of short needles prandial doses based on predicted needs. insulin analogs have been developed. (e.g., 4-mm pen needles) as effective and Thus, education of patients on how to These analogs are associated with less well tolerated when compared to longer adjust prandial insulin to account for hypoglycemia, less weight gain, and needles (25,26), including a study per- carbohydrate intake, premeal glucose lower A1C than human insulins in people formed in obese adults (27). Injection levels, and anticipated activity can be with type 1 diabetes (15–17). Longer- site rotation is additionally necessary to effective and should be considered. acting basal analogs (U-300 glargine or avoid lipohypertrophy and lipoatrophy Newly available information suggests degludec) may convey a lower hypogly- (21). Lipohypertrophy can contribute that individuals in whom carbohydrate cemia risk compared with U-100 glargine to erratic insulin absorption, increased counting is effective can incorporate es- in patients with type 1 diabetes (18,19). glycemic variability, and unexplained timates of meal fat and protein content Rapid-acting inhaled insulin to be used hypoglycemic episodes (28). Patients into their prandial dosing for added before meals is now available and may and/or caregivers should receive educa- benefit(3–5). reduce rates of hypoglycemia in patients tion about proper injection site rotation Most studies comparing multiple daily with type 1 diabetes (20). and to recognize and avoid areas of injections with continuous subcutane- Postprandial glucose excursions may lipohypertrophy (21). As noted in ous insulin infusion (CSII) have been be better controlled by adjusting the tim- Table 4.1, examination of insulin injec- relatively small and of short duration. ing of prandial insulin dose administration. tion sites for the presence of lipohyper- However, a recent systematic review The optimal time to administer prandial trophy, as well as assessment of injection and meta-analysis concluded that pump insulin varies, based on the type of insulin device use and injection technique, are therapy has modest advantages for used (regular, rapid-acting analog, in- key components of a comprehensive di- lowering A1C (–0.30% [95% CI –0.58 to haled, etc.), measured blood glucose level, abetes medical evaluation and treatment –0.02]) and for reducing severe hypo- timing of meals, and carbohydrate con- plan. As referenced above, there are now glycemia rates in children and adults sumption. Recommendations for prandial numerous evidence-based insulin delivery (6). There is no consensus to guide insulin dose administration should there- recommendations that have been pub- choosing which form of insulin adminis- fore be individualized. lished. Proper insulin injection technique tration is best for a given patient, and may lead to more effective use of this research to guide this decision making is Insulin Injection Technique therapy and, as such, holds the potential needed (7). The arrival of continuous Ensuring that patients and/or caregivers for improved clinical outcomes. glucose monitors to clinical practice understand correct insulin injection tech- has proven beneficial in specific circum- nique is important to optimize glucose Noninsulin Treatments for Type 1 stances. Reduction of nocturnal hypogly- control and insulin use safety. Thus, it is Diabetes cemia in people with type 1 diabetes important that insulin be delivered into Injectable and oral glucose-lowering drugs using insulin pumps with glucose sensors the proper tissue in the right way. Rec- have been studied for their efficacy as is improved by automatic suspension of ommendations have been published adjuncts to insulin treatment of type 1 insulin delivery at a preset glucose level elsewhere outlining best practices for diabetes. Pramlintide is based on the (7–9). The U.S. Food and Drug Adminis- insulin injection (21). Proper insulin naturally occurring b-cell peptide amylin tration (FDA) has also approved the