ADA-EASD Consensus Report 2021

Methods

17 sections were identified.
A draft was presented at the ADA Scientific Sessions in June.
Public consultation was followed by final amendment before approval by the EASD and ADA.

Other types of diabetes can be misdiagnosed as T1D, such as type 2 diabetes and monogenic diabetes
Islet autoantibodies testing is recommended in all adults with suspected T1D.
Beyond 3 years after diagnosis, where there is uncertainty about diabetes type, a random C-peptide measurement (with concurrent glucose) in people receiving insulin treatment is recommended.
If the results is ≥600 pmol/L the circumstances of testing do not matter.
If the result is <600 pmol/L and concurrent glucose of <4 mmol/L or the person may have been fasting consider repeating the test.
Very low levels do not need to be repeated.
Do not test C-peptide within 2 weeks of a hyperglycaemic emergency.

Shared decision making should be used, while setting attainable, realistic goals.
Parameters such as behaviour (diet and nutrition, physical activity, smoking cessation) and glycaemia (HbA_1c, time in range, hyperglycaemia) should be taken into account.
The treatment plan should be revised as needed.

Four critical times should be considered for DSMES in T1D: diagnosis, when complication develop, annually and/or when not meeting treatment targets and when transitions in life and care occur.
The key areas include physical activity, medication usage, monitoring and using patient-generated health data, preventing and treating acute and chronic complications, healthy coping with psychosocial issues and problem solving.
Nutrition therapy along with screening for excess alcohol/drug use is recommended, along with promoting smoking cessation, adequate physical activity and the importance of sleep hygiene.

While widely employed, HbA_1c does not inform about glycaemic variability and hypoglycaemia, and is therefore inappropriate as the only method of glucose evaluation.
The optimal number of blood glucose measurements is uncertain and may depend on the individual’s lifestyle.
Continuous glucose monitoring (CGM) is the standard for glucose monitoring in adults with T1D, and the choice of device can be based on the individual’s preferences and which devices are available or reimbursed.

Ideal insulin replacement maintains blood glucose in a near-normal state and allows flexibility in terms of mealtimes and activity.
This is best achieved with multiple daily injections or pump therapy.
Insulin replacement is enhanced by CGM and automation, and improves glycaemic parameters; the greatest benefits are seen with algorithm-driven automated basal insulin delivery.
Adverse effects of insulin therapy include hypoglycaemia and skin reactions to subcutaneous insulin therapy.
Several insulin regimens are available that can closely mimic insulin secretion.

Hypoglycaemia is the main limiting factor in the glycaemic management of T1D.
Several conditions such as longer duration of T1D, older age, physical exercise, impaired awareness of hypoglycaemia and chronic kidney disease can promote hypoglycaemia.
It is important to control for impaired awareness of hypoglycaemia through proactive detection during consultations, and appropriate blood glucose awareness training is provided.

Psychosocial care should be included in management since T1D is psychologically challenging, cognitive and emotional factors are critical determinants of daily self-care and emotional health is an important outcome of diabetes care.
Several screening and monitoring recommendations are provided.
These include periodic evaluation of psychological health and social barriers to self-management, integration of a core set of screeners in routine practice, know the right questions to ask patients and implement organisational improvements such as clear referral pathways.
All members of the diabetes care team have responsibility when it comes to offering psychosocial support, which includes informal coaching, psychological counselling and psychiatric treatment by a clinical psychologists or medical social worker.

DKA is a life-threatening but preventable complication of T1D.
Non-modifiable risk factors include young adult age and female sex; modifiable risk factors include previous episode of DKA, high HbA_1c, low self-management skills, infections, alcohol and drug abuse, and SGLT2 inhibitor treatment.
Several treatment guidelines for DKA are available, all with the general principles of management of fluids, insulin and potassium.
The cause needs to be identified to prevent future episodes

Both pancreas and islet cell transplantation have the potential to provide lifelong restoration of normoglycaemia, both methods require chronic systemic immunosuppression.
The main indication of pancreas transplantation is frequent, acute and severe metabolic complications and problems with exogenous insulin therapy
Islet cell transplantation is less invasive and allows for inclusion of older people and those with coronary artery disease; the main indication is excessive glycaemic liability and frequent severe hypoglycaemia despite optimal medical therapy.
Both these methods need to be balanced with surgical risk, metabolic needs and choice of the individual with diabetes.

Few adjunctive therapies are approved for T1D due to safety or concerns and/or lack of data.
Metformin and GLP-1 receptor agonists are not approved in T1D.
Pramlintide is approved in the US, while SGLT2 inhibitors are approved in the EU at a low dose when BMI is ≥27 mg/m².

T1D is of special concern in some populations, such as in older people and in pregnancy.
Diabetes technologies should not be discontinued because of older age, although insulin management should be simplified in those with complications or functional/cognitive impairment.
The management of pregnancy in women with T1D should begin before conception and is best managed by a multidisciplinary team.
In-patient management of T1D also presents specific issues in terms of glycaemic targets: A dedicated in-patient diabetes service should be consulted when available and CGM can be used in selected situations.