Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
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