No astounding news compared to 2019. The main novelty is the efficacy of closed-loop CSII systems. Here the original.
Main recommendations are:
- Most individuals with T1DM must be treated with multiple daily insulin injections (prandial and basal) or continual subcutaneous insulin infusion (CSII)
- Most individuals with T1DM must use rapid-acting analogs to reduce hypoglycemia
- People with T1DM should be trained (C) to adjust prandial insulin dose to carbo counting, glycemic levels, and physical activity
Historically, three landmarks may be distinguished in type 1 diabetes treatment:
- Conventional insulin treatment with 1 or 2 daily insulin inyections preserve life and prevent acute metabolic complications in type 1 diabetes.
- DCCT trial showed that intensive insulin treatment, including: 1.- CSII or MDII with short-acting regular and intermediate-acting NPH insulin; 2.- SMBG (self-monitoring of blood glucose) and 3.-DSMES (diabetes self-management education and support) reduce microvascular disease.
- New rapid-acting and long-acting analogs have proved reducing A1c, hypoglycemia or body weight.
CSII may be modestly superior to MDI in terms of A1c or hypoglycemia. Benefits of recent clinical implementation of CGM are still not established. CSII with closed-loop systems have proven superiority to sensor-enhanced pumps in terms of A1c and hypos in some recent trials.
Basal and prandial insulin are typically 50% of total daily dose (0.4-1 IU/Kg, more in prgnant, teenagers or acute ilness). Starting dose is about 0.5 IU/Kg. Basal insulin, usually once-a-day bedtime, is adjusted using pre-breakfast glycemia. Prandial insulin is given before every meal and must be individualized and adjusted to carbo count, physical activity and glycemia, but in some individuals fat and protein counting may be appropriate.
Insulin must be applied in SC fat. Proper sites are abdomen, buttocks, tighs and upper arm. IM deposit must be avoided because of hypoglycemia risk. Factors for IM deposit are leaner and younger patients, limb injection and long needles. Short needles of 4 mm are suitable even for obese people.
Lipohypertrophy increase glucose variability. Rotation of inyection sites avoids it, and regular education and advice about this topic is part of good clinical practice.
OTHER DRUGS APART FROM INSULIN
- Pramlintide, an amylin analogue, modestly reduces A1c 0-0.3% and weight 1-2 Kg.
- Metformin modestly reduce weight and lipids, but not A1c.
- GLP-1RAs very modestly reduce A1c <0.2% and weight 3 Kg
- SGLT2-i improve A1c and weight but raise DKA 2-4 fold.
SURGICAL TREATMENT
- Pancreas transplantation needs life-long immunosuppression and is only indicated associated to simultaneous or previous renal transplant.
- Other indications, like recurrent DKA and hypoglucemia, must be careful avaluated in view of new closed-loop systems.
