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ADA/EASD Draft Guidance Aims to Bring Adults With Type 1 Diabetes Out of Shadows

A new draft consensus statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) addresses diagnosis and management of type 1 diabetes in adults.  

The impetus for the document comes from the “highly influential” EASD-ADA consensus report on the management of type 2 diabetes, which led to the realization that a comparable document was needed for adults with type 1 diabetes, said writing panel cochair Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine, University of Southern California, Los Angeles.

“In recent years, there have been rapid advances in the treatment of type 1 diabetes together with a growing recognition of the psychosocial burden of living with [it],” Peters said.

She noted that although there is already some guidance available for the management of type 1 diabetes in adults, “this gets admixed into broader guidelines, and many of those are mostly derived from data in people with type 2 diabetes.”  

The new draft document was coauthored by 14 content experts in type 1 diabetes, with equal numbers from the United States and Europe.

We Want to Be Helpful to Clinicians; Feedback Welcome Until July 8

Topics covered include diagnosis of type 1 diabetes, goals of therapy and glycemic targets, schedule of care, diabetes self-management education and additional behavioral considerations, glucose monitoring, insulin therapy, hypoglycemia, psychosocial care, diabetic ketoacidosis, pancreas and islet cell transplantation, adjunctive therapies, special populations (including pregnant women, older adults, and inpatient management), and emergent/future perspectives, including beta-cell replacement and immunotherapy.

At the end of the document are tables of glycemic targets for adults with type 1 diabetes, schedule of care, nonglycemic factors that alter A1c levels, standardized continuous glucose meter (CGM) metrics for clinical care, examples of subcutaneous insulin regimens, and the various properties of approved and nonapproved adjunctive therapies for type 1 diabetes, including metformin, pramlintide, GLP-1 agonists, and SGLT2 inhibitors.  

Several colorful flowcharts are also provided, including algorithms for diagnosing and managing type 1 diabetes in adults.

Document coauthor M. Sue Kirkman, MD, of the Diabetes Care Center’s Clinical Trials Unit at the University of North Carolina, Chapel Hill, told Medscape Medical News: “We want it to be helpful to clinicians who are diagnosing type 1 diabetes in adults or caring for adults with type 1 diabetes, whether diagnosed in childhood or adulthood…We really do want feedback.”

The authors presented an overview of the document in a symposium on June 28 at the virtual ADA 81st Scientific Sessions. The final version will be presented October 1 at the EASD 2021 Annual Meeting.

The draft document and video of the ADA meeting presentation are both available on the ADA website. The associations encourage interested individuals to submit comments to from now through to July 8, 2021.

New Algorithm to Reduce Misdiagnosis of Type 1 Diabetes in Adults

Misdiagnosis of adult-onset type 1 diabetes is common, occurring in up to 40% of those who develop the condition after age 30 years, said J. Hans de Vries, MD, PhD, medical director, Profil Institute for Metabolic Research, Neuss, Germany.

There are multiple reasons for this, including the fact that obesity and type 2 diabetes are becoming more prevalent at younger ages, C-peptide levels may still be relatively high at the time of clinical type 1 diabetes onset, and islet autoantibodies don’t have 100% positive predictive value.

“No single feature confirms type 1 diabetes in isolation,” de Vries noted.

The document provides a detailed diagnostic algorithm specifically for adults in whom type 1 diabetes is suspected, starting with autoantibody measurement. If the diagnosis isn’t confirmed that way, the algorithm advises investigating for monogenic diabetes, including use of a maturity-onset diabetes of the young (MODY) calculator and subsequent C-peptide measurement.

Measurement of C-peptide is also recommended if the diabetes type is still uncertain more than 3 years after diabetes onset in those treated with insulin, because by that point it is likely to be < 200 pmol/L in people with type 1 diabetes.  

Clear Statements on Diabetes Technology, Preferred Insulins

The draft document clearly states that physiologic insulin replacement using a pump or multiple daily injections, CGM, and analog rather than human insulin are standards of care for adults with type 1 diabetes. Use of hybrid closed-loop insulin delivery systems is advised when available, as they offer the “greatest benefits.”

However, the document also notes that in cases of cost barriers, subcutaneous regimens of human regular and NPH insulin may be used. It cautions, though, that these may result in higher glucose variability, higher risk of hypoglycemia, and less lifestyle flexibility.

Kirkman told Medscape Medical News: “Using human insulins such as NPH and Regular in type 1 diabetes is definitely not preferred, but sometimes due to people’s inability to afford analogs we have to use them. People need to know how to use them safely.”

As for the do-it-yourself insulin delivery systems that many with type 1 diabetes now use with open-source software algorithms that reverse-engineer older pumps, the document advises that healthcare providers shouldn’t actively recommend them as they’re not approved by regulatory authorities, but should also “respect the individual’s right to make informed choices and continue to offer support,” Kirkman said when presenting the insulin therapy section.

Psychosocial Aspects of Type 1 Diabetes Underappreciated

Special emphasis is placed on psychosocial support, which may be overlooked in adults, Kirkman noted.

“Clinicians probably underappreciate what people with type 1 diabetes go through on a daily basis. A lot of the evidence out there regarding psychosocial issues is in children and families of children with type 1 diabetes, or in adults with type 2 diabetes…Maximizing quality of life needs to be at the forefront of care, not just focusing on glycemic goals.”

Indeed, between 20% and 40% of people with type 1 diabetes experience diabetes-related emotional distress — including 15% with depression — particularly at the time of diagnosis and when complications develop, noted Frank J. Snoek, PhD, professor of medical psychology at Amsterdam University Medical Center, the Netherlands.

To address this, the draft advises that “self-management difficulties, psychological, and social problems” be screened periodically and monitored using validated screening tools.

“Healthcare providers should be proficient at asking questions about and discussing emotional health, psychological needs, and social challenges as part of the consultation,” Snoek said.

Panel Seeks Feedback, Particularly in Certain Areas  

Richard I.G. Holt, MB BChir, PhD, panel cochair and professor in diabetes and endocrinology human development and health, faculty of medicine, University of Southampton, UK, said the writing panel welcomes feedback on any aspect of the document, but they are particularly seeking comments on the following:

  • The new algorithm for diagnosing type 1 diabetes in adults

  • Care and follow-up recommendations

  • The advice regarding insulin use in various settings, including analog and nonanalog formulations

  • The strong recommendations for use of diabetes technologies including CGM and hybrid closed-loop systems

  • Use of adjunctive therapies in type 1 diabetes

  • The emphasis on psychosocial issues and need for context and understanding of social determinants of health

“We’d love to receive your comments, whether they be small or large,” Holt said, “because the more feedback we can have, the better the final report…will be.”

Peters has reported being an advisor for, a consultant for, and/or receiving research support from Abbott Diabetes Care, AstraZeneca, Lilly, Medscape, Novo Nordisk, Vertex, and Zealand, and holding stock options in Omada and Teledoc. Holt has reported receiving research support from Novo Nordisk and being a speaker for Novo Nordisk, Abbott, Eli Lilly, Otsuka, and Roche. Kirkman has reported receiving research support from Novo Nordisk and Bayer. de Vries has reported being an advisor to, consultant for, speaker for, and/or research support recipient from Adocia, Novo Nordisk, Zealand, Eli Lilly, and Afon. Snoek has reported being an advisor to, consultant for, speaker for, and/or research support recipient from Roche Diabetes, Novo Nordisk, Sanofi, and Eli Lilly.

ADA 81st Scientific Sessions. Presented June 28, 2021.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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