The following is an outline of practice guidelines for management of type 1 diabetes mellitus. A detailed management plan and accompanying DecisionPaths can be found in the original guidelines.
Diagnosis
Majority younger than 30 years old and not obese
Plasma Blood Glucose
Casual >200 mg/dL plus symptoms, fasting >126 mg/dL, or oral glucose tolerance test (OGTT) 2 hour glucose value >200 mg/dL; if acute metabolic decompensation (positive ketones), make diagnosis immediately; in the absence of acute metabolic decompensation, confirm with casual or fasting plasma glucose within 24 hours.
Symptoms
Common: Increased urination, thirst, and appetite; nocturia; weight loss
Occasional: Blurred vision, urinary tract infection, yeast infection, fatigue, acute abdominal pain, flu-like symptoms
Urine Ketones
Usually positive, with or without diabetic ketoacidosis
Treatment Options
Insulin Stages 2, 3A, 4A, 3B, or pump synchronized with food plan and exercise program (see Type 1: Master DecisionPath in the original guideline document.) These patients require insulin therapy and should not be treated with an oral agent.
Targets
Blood Pressure
Less than 130/80 mmHg
Lipids
Low-density lipoprotein (LDL) less than 100 mg/dL, high-density lipoprotein (HDL) >40 mg/dL, Triglyceride less than 150 g/dL
Self-Monitored Blood Glucose
- More than 50% of self-monitored blood glucose values should be within target range
- Age younger than 6 years: 100 to 200 mg/dL pre-meal and bedtime
- Age 6 to 12 years: 80 to 180 mg/dL pre-meal and bedtime
- Age older than 12 years: 80 to 140 mg/dL pre-meal; <160 mg/dL 2 hours after start of meal; 100 to 160 mg/dL at bedtime
- No severe (assisted) or nocturnal hypoglycemia
Adjust pre-meal target upwards if hypoglycemia unawareness or repeated severe hypoglycemia occurs.
Hemoglobin A1c (HbA1c)
- Age younger than 6 years: Within 2.5% points of upper limit of normal (e.g., normal 6%; target <8.5%)
- Age 6 to 12 years: Within 2% points of upper limit of normal (e.g., normal 6%; target <8.0%)
- Age older than 12 years: Within 1.0% points of upper limit of normal (e.g., normal 6%; target <7.0%)
- Use hemoglobin A1c to verify self-monitored blood glucose data or to adjust therapy when data unavailable
Monitoring
Hemoglobin A1c (HbA1c)
Frequency: every 3 to 4 months
Self-Monitored Blood Glucose
Minimum 4 times per day (before meals, 2 hours after start of meal, and bedtime) Check 3 a.m. as needed (AM hyperglycemia, nocturnal hypoglycemia)
Method
Meter and log book
Urine Ketones
Check if unexplained blood glucose >240 mg/dL on 2 consecutive occasions, or if any illness or infection present
Growth and Development
Normal, as determined using anthropometric scales/growth charts
Follow-Up
Weekly
During Start and early Adjust Phase
Monthly
Office visit during Adjust Phase (weekly phone contact may be necessary)
Every 3 Months
Hypoglycemia, medications, weight, height, growth rate, food plan and exercise, blood pressure, self-monitored blood glucose data (download and check meter), hemoglobin A1c, eye screen, foot screen, diabetes/nutrition continuing education, preconception planning for women with child bearing potential, smoking cessation counseling, aspirin therapy
Yearly
In addition to the 3 month follow-up, complete the following: history and physical, dental examination, fasting lipid profile within 6 months of diagnosis.
In patients older than age 12 with diabetes for 5 years, complete the following: albuminuria/proteinuria screen, dilated eye examination, neurologic assessment, complete foot examination (pulses, nerves, and inspection), patient satisfaction evaluation.
Complications Surveillance
Cardiovascular, renal, retinal, neurological, foot, oral, and dermatological
