A new consensus report, The Management of Type 1 Diabetes in Adults, was recently published.1,2 The report, crafted by 14 experts, was completed and published under the auspices of American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).1,2

The focus is on adults (18 years and older) with T1D* vs. children because, as stated in the report, “[T1D] accounts for approximately 5–10% of all cases of diabetes. Although the incidence peaks in puberty and early adulthood, new-onset [T1D] occurs in all age-groups and people with T1D [now] live for many decades after onset, such that the overall prevalence of [T1D] is higher in adults than in children.”

This 37-page publication is comprehensive and covers an array of topics, many of which are covered in this article. According to the report, “The writing group aimed to highlight major areas that health care professionals (HCPs) should consider when managing adults with T1D,” as well as to factor in “the rapid development of new treatments and technologies.”

Here we broadly summarize the report and focus on topics of greatest interest to our community.

Overarching goal of diabetes care:

“To support people with T1D to live a long and healthy life. Providing approaches, treatments, and devices that minimize the psychosocial burden of living with T1D and, consequently, diabetes-related distress, while promoting psychological well-being,” states the report.

According to a co-author, Ruth S. Weinstock, MD, PhD, “The unifying concept in this report is personalized care—meeting the needs of the person with T1D—including replacing insulin as physiologically and as safely as possible, and setting individualized goals, taking into account and addressing personal preferences, related medical problems, capabilities, health status, and psychological, social and other circumstances.” Weinstock is Distinguished Service Professor and Division Chief, Endocrinology, Diabetes and Metabolism at SUNY Upstate Medical University in Syracuse NY, Principal Investigator for Upstate Medical University in the T1D Exchange Quality Improvement Collaborative and 2021 American Diabetes Association President, Medical and Science.

Missed Diagnosis of T1D in Adults:

Adults with T1D are often, due to their age of diagnosis and presentation, initially misdiagnosed with Type 2 Diabetes (T2D). Misdiagnosis can be confusing and can delay appropriate management as well as disease acceptance.

In people diagnosed under 35 years of age, T1D is the most likely diagnosis, especially if there’s no signs or symptoms of T2D. In people over 35 years of age, T2D is more likely. “The report presents a new algorithm for the diagnosis of T1D in adults that begins with measuring pancreatic islet autoantibodies,” said Weinstock.

The use of the term latent autoimmune diabetes of adulthood (LADA) to describe T1D in adulthood remains up for debate. Experts can’t yet verify if LADA is a discrete diabetes subtype, a milder form of T1D, or a mixture of some people with T1D and others with T2D.

Metabolic targets:

Glycemic targets:

The report recognizes that despite significant progress made with glucose-lowering medications and diabetes technologies over the last 100 years, many people with T1D still do not achieve and maintain recommended glycemic targets regularly enough to prevent or slow the progression of diabetes complications.

The report states, “An A1c goal for most adults is <7.0% without significant hypoglycemia is appropriate.” The report encourages individualized glycemic goals based on factors such as: duration of diabetes, other medical conditions and challenges, impaired hypoglycemia awareness.

Glycemic goals should be reviewed and revised during various ages and stages of life. According to the report, they should be, “achieved in conjunction with an understanding of the person’s psychosocial needs and reduction in diabetes distress if elevated.” Authors call attention to the “significant benefit” of “any A1c reduction even if/when the goal A1c is not met.”

Blood pressure and lipid (blood fat) targets:

The report calls attention to the importance of careful management of blood pressure and lipids with medications, if and when needed to prevent long-term complications, particularly cardiovascular disease.

Diabetes Self-Management Education and Support (DSMES):

DSMES provides people (and their caregivers, if applicable) with the knowledge, skills, and confidence to successfully self-manage diabetes and reduce the risks of acute and long-term complications while maintaining quality of life. An emphasis should be placed on shared decision-making and active collaboration with one’s HCPs.

“DSMES has been proven to reduce A1c, decrease risk of long-term complications, reduce hypoglycemia and improve quality of life. It should not be considered a once and done service. The four critical times for DSMES shows it is needed throughout the lifespan and at certain stages including: 1) at diagnosis, 2) when not meeting targets, 3) when transitions occur, and 4) when complications develop. Working with a Certified Diabetes Care and Education Specialist (CDCES) who is proficient in T1D management makes it a valuable collaboration,” said Amy Hess-Fischl, MS, RDN, LDN, BC-ADM, CDCES, co-author of the consensus statement and program coordinator at the Kovler Diabetes Center, University of Chicago.

“It is important for adults with T1D to receive the DSMES they need to help them meet personalized treatment goals and optimize quality of life,” added Weinstock.

Though DSMES is, as noted in this report, “…an essential component of T1D care that allows all other interventions to work optimally,” most adults with T1D do not receive sufficient initial or regular DSMES.

“T1Ds can advocate to receive DSMES by requesting a referral from their primary HCP. Coverage of DSMES by a health plan is always the question. In my experience, after communicating with a person’s health plan, they are usually covered for at least two hours of service per year,” said Hess Fischl. She suggests that people check with their health plan for details noting, “an appeal usually increases the chances of ongoing coverage.”

Nutrition Therapy and Weight Management:

The report states that people with T1D should be referred for individualized Medical Nutrition Therapy (the legal term for nutrition therapy) provided by a registered dietitian (RD)/registered dietitian nutritionist (RDN) knowledgeable and skilled in providing diabetes-specific nutrition advice with diabetes technology integration.

The topic of excess weight and weight management in people with T1D has begun to attract attention and does so in this report. It notes, the weight of adults with T1D is rising at a faster rate than the general population.

Hess-Fischl adds, “We did not go into great depth about obesity and overweight in T1D since we knew an in-depth review article was in the works.3 Overweight and obesity has become more prevalent in the past two decades for various reasons – intensified treatment modalities, hormonal responses, treatments (containing calories) to manage hypoglycemia; to name a few.”

(Note: T1D Exchange has this topic on our docket for a near-future blog.)

Psychological Well-being:

Greater attention is now being paid to the emotional health of T1D with recognition that the demands of self-care are challenging. This report states, “Cognitive, emotional, and social factors are critical determinants of [the ability to perform] self-care behaviors and, consequently, [achieve] treatment success.”

The report notes, “Due to the high prevalence and impact of psychosocial problems and psychological disorders in diabetes, [regular] screening and monitoring [for these issues] should be integral parts of diabetes care.” The report notes that, when necessary, HCP should refer people to specialized mental health services.

Alcohol and Recreational Drug Use:

Due to the potential risks (e.g., diabetic ketoacidosis, hypoglycemia) of alcohol and recreational drugs people with T1D who choose to use these should become knowledgeable about their safe use with diabetes care.

Communication is critical. People should feel comfortable sharing their use of substances with their HCPs. Conversely, the report states that HCPs have a responsibility to inform people about the effects of these substances or people will get information elsewhere which may not be accurate.

Employment:

Today people with T1D can successfully work in myriad employment settings. Over time barriers to hold certain jobs have been removed, such as being a commercial airline pilot.

The biggest challenge in the workplace is the “prejudice” that remains due specifically to concerns about hypoglycemia or work in situations that don’t allow the person with T1D their supply of effective insulin.

Glucose Monitoring:

The report covers both BGM and CGM, however, Weinstock states, “Continuous glucose monitoring (CGM) is the standard of care for glucose monitoring in T1D adults. CGM can help individuals meet their glycemic goals which should be defined by time in range, time in hypoglycemia and time in hyperglycemia as well as glucose variability and periodic A1c measurements.”

Regarding advancing technologies, the report states, “CGM sensors will increasingly integrate with insulin delivery devices and upload to a cloud to enable greater data sharing and analysis. “People with T1D should be encouraged to review their reports regularly,” follow their progress over time, and share data with their HCPs to progress and change therapy as needed.

But is CGM sufficiently used by T1Ds? A recent publication from the T1D Exchange Quality Improvement Collaborative showed that widespread use of CGM from eight endocrinology clinics in the QIC remains limited.4 Forty-eight percent used CGM and had better glycemic management and lower rates of DKA and severe hypoglycemia, compared to non CGM users. A deeper dive into the data showed less use in Hispanics (38%), Blacks (18%). People with private insurance were more likely to use CGM (57%) vs. public insurance (Medicaid and Medicare) (33%). CGM users had lower median A1c (7.7%) vs. 8.4% in nonusers.

Insulin therapy:

The goal of insulin therapy is to achieve and maintain glucose levels in the normal physiological range as much as possible (see above under glycemic targets) while allowing flexibility in terms of food consumption and activity levels and the timing of both.

Glucose-Lowering Medications Other than Insulin:

Several new glucose-lowering medications have been added to the armamentarium for T2D management. Questions have been raised and studies conducted to seek regulatory approval for several of them, referred to as “adjunctive therapies” for T1D. The goal with these medications is to augment insulin therapy by addressing some of the other metabolic and hormonal disturbances of T1D.

The report advises that before adjunctive therapies are used that a person’s insulin regimen should be reviewed and optimized. Three medications are discussed: Pramlintide, SGLT2 (sodium-glucose cotransporter-2) inhibitors, and Glucagon-like peptide 1 (GLP-1) receptor agonists.

Several of these are approved by FDA for people with T2D, but not to date for T1D. They are being explored for two reasons: 1) to decrease the decline of beta cells at T1D diagnosis, 2) ability to decrease the amount of insulin a person needs.

Medications to prevent or delay the diagnosis of T1D and preserve beta cells:

The report notes, “Many interventions have been tested in clinical trials with the goal of preserving and/or improving beta cell function.” The most promising to date have been Provention Bio’s anti-CD3 monoclonal antibody teplizumab, low-dose antithymocyte globulin (ATG), and the anti-TNF drug, golimumab.

Equity of Diabetes Care:

Research shows that despite many advances in medications and technologies, the costs of these management tools can be a barrier to optimal care for many people with T1D, especially people of color.

Beyond costs, evidence shows that some people with T1D are not offered these newer medications and technologies. The study by DeSalvo et al. makes this point clearly regarding CGMs.4

T1D Exchange is working to address these disparities. One example of this work is the partnership with Medtronic. This report encourages advocacy to ensure better access to the technologies and services for everyone with T1D.

This review broadly summarizes this dense and lengthy consensus report. We encourage you to access the entire publication1,2 and read more about the topics of most interest to you and your T1D diabetes care.

*The report uses type 1 diabetes, abbreviated here as T1D.

References:

  1. Holt, RIG, DeVries, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2021;44(11)2589-2625.
  2. Holt, RIG, DeVries, Hess-Fischl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021; DOI: https://doi.org/10.1007/s00125-021-05568-3).
  3. Van der Schueren B, Ellis D, Faradji R, et al. Obesity in people living with type 1 diabetes. Lancet. 2021;9(11):776-785.
  4. DeSalvo DJ, Noor N. Xie C, et al. Patient Demographics and Clinical Outcomes Among Type 1 Diabetes Patients Using Continuous Glucose Monitors: Data From T1D Exchange Real-World Observational Study. J Diab Sci Technol. (Ahead of print 10/9/21) https://doi.org/10.1177/19322968211049783