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Diabetes mellitus type 1

Definition
T1DM is an endocrine disorder characterized by T-cell mediated autoimmune destruction of insulin-producing beta cells in the pancreas, resulting in insulin deficiency with resultant hyperglycemia and a predisposition to ketoacidosis.
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Pathophysiology
The cause of T1DM is mostly autoimmune destruction of beta cells of the pancreas (70-90%) and idiopathic (10-30%).
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Epidemiology
The annual incidence of T1DM in the US is 22.9 per 100,000 person-years.
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Disease course
Environmental triggers in genetically predisposed people lead to the production of autoantibodies against insulin-producing islet beta cells of the pancreas resulting in autoimmune destruction of these cells. This leads to insulin insufficiency and overt hyperglycemia, T1DM and its complications, diabetic ketoacidosis, altered mental status, coma, and death.
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Prognosis and risk of recurrence
On average, the life expectancy of a person with T1DM is approximately 12 years less than the general population.
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Key sources
The following summarized guidelines for the evaluation and management of diabetes mellitus type 1 are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024; 2023), the European Society of Cardiology (ESC 2023), the European Society of Hypertension (ESH 2023), the Endocrine Society (ES 2022; 2020; 2016), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022; 2020), the Society for Vascular Medicine (SVM/SVS/APMA 2016), and the American College of Gastroenterology (ACG 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening, type 1 diabetes: monitor patients with preclinical T1DM for disease progression using HbA1c approximately every 6 months and 75-g OGTT (fasting and 2-hour blood glucose) annually, modifying the frequency of monitoring based on individual risk assessment based on age, number, and type of autoantibodies, and glycemic metrics.
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  • Indications for screening (neonatal diabetes)

  • Indications for screening (MODY)

2.Classification and risk stratification

CVD risk assessment: consider using the Scottish/Swedish risk prediction model to estimate the 10-year CVD risk in patients with T1DM.
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3.Diagnostic investigations

General principles: ensure a person-centered communication style using person-centered, culturally sensitive, and strength-based language and active listening, eliciting individual preferences and beliefs, and assessing literacy, numeracy, and potential barriers to care in order to optimize health outcomes and health-related QoL.
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  • HbA1c

  • Glucose tolerance test

  • Screening for hypertension

  • Screening for CVD

  • Screening for autoimmune thyroid disease

  • Screening for celiac disease

  • Screening for diabetic nephropathy

  • Screening for diabetic retinopathy

  • Screening for diabetic neuropathy

  • Screening for diabetic foot

  • Screening for anxiety

  • Screening for depression

  • Screening for sleep disorders

  • Screening for cognitive impairment

  • Screening for serious mental illness

  • Screening for disordered eating behavior

  • Screening for gastroparesis

4.Medical management

Glycemic targets: set an HbA1c goal of < 7% (53 mmol/mol) without significant hypoglycemia in many nonpregnant adult patients with diabetes.
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  • Insulin therapy (indications)

  • Insulin therapy (delivery systems)

  • Monoclonal antibodies

  • Management of hypoglycemia

  • Management of diabetic nephropathy (general principles)

  • Management of diabetic neuropathy

  • Management of diabetic foot

  • Management of hypertension (BP targets)

  • Management of hypertension (lifestyle modifications)

  • Management of hypertension (pharmacotherapy)

  • Management of CVD (general principles)

  • Management of CVD (antihypertensives)

  • Management of CVD (antiplatelets)

  • Management of CVD (revascularization)

  • Management of dyslipidemia (lifestyle modifications)

  • Management of dyslipidemia (statin therapy)

  • Management of dyslipidemia (non-statin lipid-lowering therapy)

  • Management of dyslipidemia (lipid profile monitoring)

  • Management of dyslipidemia (hypertriglyceridemia)

  • Management of diabetic nephropathy (smoking cessation)

  • Management of diabetic nephropathy (RAAS blockade)

  • Management of diabetic nephropathy (kidney transplantation)

  • Management of diabetic retinopathy

5.Inpatient care

Management of hospitalized patients, general principles, ADA: consult with a specialized diabetes or glucose management team, when possible, when caring for hospitalized patients with diabetes.
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  • Management of hospitalized patients (HbA1C testing)

  • Management of hospitalized patients (glucose monitoring)

  • Management of hospitalized patients (insulin therapy)

  • Management of hospitalized patients (treatment targets)

  • Management of hospitalized patients (prevention of hypoglycemia)

  • Management of hospitalized patients (oral carbohydrate fluids)

6.Nonpharmacologic interventions

Smoking cessation: advise all patients to abstain from using cigarettes and other tobacco products or e-cigarettes.
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  • Physical activity

  • Dietary modifications (general principles)

  • Dietary modifications (eating patterns)

  • Dietary modifications (carbohydrates)

  • Dietary modifications (fat)

  • Dietary modifications (nonnutritive sweeteners)

  • Dietary modifications (sodium)

  • Dietary modifications (micronutrients and supplements)

  • Dietary modifications (alcohol)

  • Psychosocial care

7.Specific circumstances

Elderly patients, screening for comorbidities: consider assessing medical, psychological, functional (self-management abilities), and social domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management.
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  • Elderly patients (screening for hypoglycemia)

  • Elderly patients (treatment goals)

  • Elderly patients (lifestyle modifications)

  • Elderly patients (pharmacotherapy)

  • Elderly patients (residing in nursing facilities)

  • Elderly patients (end-of-life care)

  • Pregnant patients (preconception counseling and care)

  • Pregnant patients (nutrition)

  • Pregnant patients (glycemic targets)

  • Pregnant patients (management of preexisting diabetes)

  • Pregnant patients (management of gestational diabetes)

  • Pregnant patients (BP targets)

  • Pregnant patients (prevention of preeclampsia)

  • Pregnant patients (postpartum care)

  • Pediatric patients (screening for hypertension)

  • Pediatric patients (screening for dyslipidemia)

  • Pediatric patients (screening for autoimmune thyroid disease)

  • Pediatric patients (screening for celiac disease)

  • Pediatric patients (screening for disordered eating behavior)

  • Pediatric patients (screening for diabetic nephropathy)

  • Pediatric patients (screening for diabetic retinopathy)

  • Pediatric patients (screening for diabetic foot)

  • Pediatric patients (glycemic targets)

  • Pediatric patients (glucose monitoring)

  • Pediatric patients (insulin delivery devices)

  • Pediatric patients (dietary modifications)

  • Pediatric patients (physical activity)

  • Pediatric patients (smoking cessation)

  • Pediatric patients (psychosocial care)

  • Pediatric patients (self-management counseling)

  • Pediatric patients (preconception counseling)

  • Pediatric patients (management of hypertension)

  • Pediatric patients (management of dyslipidemia)

  • Pediatric patients (management of diabetic nephropathy)

  • Pediatric patients (transition to adult care)

  • Patients with COVID-19 infection

8.Patient education

Self-management counseling: offer all patients with diabetes participation in self-management education and support to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care.
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9.Preventative measures

Routine immunizations: provide routine immunizations in pediatric and adult patients with diabetes as indicated by age.
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10.Follow-up and surveillance

Treatment monitoring: include most components of the initial comprehensive medical evaluation in the follow-up visit.
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  • Continuous glucose monitoring

  • Monitoring of glycemic status

11.Quality improvement

Health promotion: ensure that treatment decisions are timely, rely on evidence-based guidelines, include social community support, and are made collaboratively with patients based on individual preferences, prognoses, comorbidities, and informed financial considerations.
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  • Use of diabetes technology