New consensus report on adults with type 1 diabetes focuses on individualised care

By Editor
2nd July 2021
Research, Type 1 diabetes

A group of leading academics teamed up earlier this week to identify the key topics addressed in the first-ever ADA European Association for the Study of Diabetes Consensus Report on the management of adults with type 1 diabetes. 

Director of the USC Clinical Diabetes Programs, Dr. Professor Anne L. Peters said: “We know we have guidance for the management of people with type 1 diabetes, but this gets mixed into broader guidelines and many of those broader guidelines are mostly derived from data in people with type 2 diabetes.”

As co-chair of the writing group that developed the new consensus report, Dr. Peters acknowledged the influence of the ADA European Association for the Study of Diabetes (EASD) consensus report on the management of type 2 diabetes.

During the symposium, Management of Type 1 Diabetes in Adults—2021 Draft ADA/EASD Consensus Report, she said: “That’s been a document all of us have referred to many times as we talk about treating people with type 2 diabetes, so the EASD and the ADA recognised that there was a need to develop a comparable consensus report that specifically addresses the needs of people with type 1 diabetes,” she explained during the symposium

That session can be viewed by registered meeting attendees at ADA2021.org until September 29, 2021.

If you haven’t registered for the Virtual 81st Scientific Sessions, register today to access all of the valuable meeting content.

Scientific Sessions attendees also are encouraged to provide feedback on the report, which can be read here.

Comments will be accepted via email at adacomments@diabetes.org until 11:59 p.m. ET July 8, 2021.

The writing group will review and address comments before the final version of the report is presented at the EASD annual meeting this fall.

Co-chair, Dr. Richard I.G. Holt said: “This is your report as well as ours.”

The consensus report includes a new diagnostic algorithm for type 1 diabetes that begins with measuring islet autoantibodies.

ADA President Dr. Ruth S. Weinstock outlined the recommended schedule of care for new onset type 1 diabetes and existing type 1 diabetes in adults.

She said: “The unifying concept is personalised care—meeting the needs of the person with type 1 diabetes—including replacing insulin as physiologically and as safely as possible, and taking into account their preferences, comorbidities, capabilities, health status, and social and other circumstances.”

“To achieve individualised care, a needs assessment should precede diabetes self-management education and support (DSMES) from the health care team,” said Amy Hess Fischl from the University of Chicago.

She shared four critical times for ongoing DSMES identified in the consensus report: at diagnosis, annually and/or when the patient is not meeting treatment targets, when complicating factors develop, and when transitions in life and care occur.

The report also addresses behaviour considerations such as alcohol and tobacco use, sleep, sick day management, driving, employment, physical activity, and nutrition.

Fischl said: “There is no one eating pattern recommended.

“It is all based on the individual sitting in front of us.”

Dr Irl B. Hirsch from the University of Washington School of Medicine, reviewed the report’s recommendations for monitoring blood glucose levels.

“There is a strong correlation between A1C and average glucose during the preceding three months, and this exists where glucose levels are stable,” he said.

He added: “Unfortunately, this biomarker does not inform glycemic variability and hypoglycemia, therefore it’s inappropriate as the only method of glucose evaluation, especially in type 1 diabetes.”

Continuous glucose monitoring (CGM) has become the standard of care for glucose monitoring in adults with type 1 diabetes, although the choice of device is determined by individual patient preferences and needs, he noted.

Dr. Sue Kirkman said: “Insulin replacement regimens in type 1 diabetes aim to mimic normal physiology as closely as possible, which is best achieved through multiple daily injections or an insulin pump.”

Dr. Professor Eric Renard, from Montpellier University Hospital discussed the main limiting factor in the glycemic management of type 1 diabetes: hypoglycemia.

He said: “Structured education, CGM, and automated insulin delivery can lower A1C without increasing the occurrence of hypoglycemia.”

Dr. Professor Frank J. Snoek, PhD, from Amsterdam University Medical Centers outlined the rationale for including psychosocial care in the consensus report.

He said: “20% to 40% of people with type 1 diabetes experience high levels of disease-related emotional distress.

“The consensus report supports periodic patient screening for self-management difficulties and psychological and social problems.”

He added: “Health care professionals should be proficient at asking questions about and discussing emotional health issues, psychological needs, and social challenges as part of the consultation.”

Dr. Professor Kirsten Nørgaard from the University of Copenhagen reviewed the recommendations for diabetic ketoacidosis (DKA).

She said: “Several guidelines are available for DKA and fluid, insulin, and potassium remain the principles of treatment.

“Identify the cause in this specific patient and consider how to prevent further episodes.

“Participation in DSMES programs has been shown to reduce DKA risk”

Dr. Professor Barbara Ludwig from the University Hospital Carl Gustav Carus discussed the consensus report’s section on pancreas and islet cell transplantation, each considered a “functional cure” for diabetes.

She said: However, due to the fact that we work with a foreign tissue, both procedures require lifelong and potent systemic immunosuppression in order to control for alginate immune rejection and, therefore, thorough risk-benefit assessment is essential for a positive overall outcome of these procedures.”

Dr. Professor Jeremy Pettus, from the University of California reviewed commonly used compounds in adjunctive therapy for type 1 diabetes.

He said: “There’s other things wrong in type 1 diabetes physiology that we could potentially address with medications to help the vast majority of type 1s get their blood sugars down to where they need them to be, help lose weight, improve cardiovascular outcomes.

“Type 1s, even with good glycemic control, are still at high risk for cardiovascular disease.”

Dr. Professor Tomasz Klupa highlighted considerations for special populations such as pregnant women and older adults with type 1 diabetes.

He said: “Diabetes management in older adults should be individualised with safety a key priority.

“Glycemic targets should be based on functional-status life expectancy rather than chronological age.”

Dr. Professor Jay S. Skyler from the University of Miami provided perspective on two emergent approaches: beta-cell replacement and immunotherapy.

“One of the challenges of beta-cell replacement is the availability of cells. Possible solutions are xenotransplantation from pig islets or stem cells—either human embryonic stem cells or induced pluripotent stem cells” said Dr. Skyler.

Dr. Holt concluded the session by addressing key knowledge gaps and evolving areas in the management of type 1 diabetes.

He said :”As we learn about other types of diabetes that can also occur in people across the age span, but particularly in younger people, we need to make sure that our diagnoses are as secure as possible, and we need to diagnose as reliably as possible.”

To access the report, click here.

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