Several members of the international writing group that drafted the first-ever ADA/European Association for the Study of Diabetes (EASD) Consensus Report on the management of adults with type 1 diabetes came together on Monday, June 28, to highlight key topics addressed in the report and to solicit input before it is finalized.
“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,” said Anne L. Peters, MD, Professor of Medicine, Keck School of Medicine, University of Southern California (USC), and Director of the USC Clinical Diabetes Programs.
As co-chair of the writing group that developed the new consensus report, Dr. Peters acknowledged the influence of the ADA/EASD consensus report on the management of type 2 diabetes.
“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 recognized 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 Management of Type 1 Diabetes in Adults—2021 Draft ADA/EASD Consensus Report.
That session can be viewed by registered meeting attendees at ADA2021.org through 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 were encouraged to provide feedback on the report, which can be read here, in early July. The writing group will review and address comments before the final version of the report is presented at the EASD annual meeting this fall.
“This is your report as well as ours,” said co-chair Richard I.G. Holt, PhD, FRCP, Professor in Diabetes and Endocrinology, Human Development and Health, Faculty of Medicine, University of Southampton, The Institute of Developmental Sciences, United Kingdom.
The consensus report includes a new diagnostic algorithm for type 1 diabetes that begins with measuring islet autoantibodies. Islet cell antibody (ICA) measurement is no longer recommended, said J. Hans DeVries, MD, PhD, Professor of Internal Medicine, University of Amsterdam, the Netherlands, and Medical Director, Institute for Metabolic Research, Germany.
Ruth S. Weinstock, MD, PhD, ADA President, Medicine & Science, outlined the recommended schedule of care for new onset type 1 diabetes and existing type 1 diabetes in adults.
“The unifying concept is personalized 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,” said Dr. Weinstock, SUNY Distinguished Service Professor and Chief of Endocrinology, Diabetes and Metabolism, State University of New York Upstate Medical University.
To achieve individualized care, a needs assessment should precede diabetes self-management education and support (DSMES) from the health care team, said Amy Hess Fischl, MS, RDN, LDN, BC-ADM, CDCES, Sections of Adult and Pediatric Endocrinology, 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 behavior considerations such as alcohol and tobacco use, sleep, sick day management, driving, employment, physical activity, and nutrition.
“There is no one eating pattern recommended,” Fischl said. “It is all based on the individual sitting in front of us.”
Irl B. Hirsch, MD, Professor of Medicine, 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. “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.
Sue Kirkman, MD, Professor of Medicine, Division of Endocrinology and Metabolism, and Medical Director of the Clinical Trial Unit, Diabetes Care Center, University of North Carolina School of Medicine, explained considerations related to insulin therapy. 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, she said.
Eric Renard, MD, PhD, Head of the Department of Endocrinology, Diabetes, and Nutrition, Montpellier University Hospital, and Professor and Chair in Endocrinology, Diabetes and Metabolism, University of Montpellier, France, 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.
Frank J. Snoek, PhD, Professor of Medical Psychology, Vrije Universiteit, Amsterdam University Medical Centers, The Netherlands, 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.
“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,” he said.
Kirsten Nørgaard, MD, DMSc, MHPE, Professor of Clinical Endocrinology, University of Copenhagen, and Head of Diabetes Technology Research, Steno Diabetes Center, Demark, reviewed the recommendations for diabetic ketoacidosis (DKA). Several guidelines are available for DKA, she said, and fluid, insulin, and potassium remain the principles of treatment. Dr. Nørgaard listed one more step: “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, she added.
Barbara Ludwig, MD, PhD, Professor of Medicine, Head of Islet Transplantation, Medical Clinic III, Department of Endocrinology and Diabetes, and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany, discussed the consensus report’s section on pancreas and islet cell transplantation, each considered a “functional cure” for diabetes.
“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,” she said.
Jeremy Pettus, MD, Associate Professor, University of California, San Diego, and Type 1 Diabetes Director, Taking Control of Your Diabetes, reviewed commonly used compounds in adjunctive therapy for type 1 diabetes.
“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,” Dr. Pettus said. “Type 1s, even with good glycemic control, are still at high risk for cardiovascular disease.”
Tomasz Klupa, MD, PhD, Professor in Diabetology, Head of the Unit on Advanced Technologies in Diabetes, Department of Metabolic Diseases, Jagiellonian University Medical College, Poland, highlighted considerations for special populations such as pregnant women and older adults with type 1 diabetes.
“Diabetes management in older adults should be individualized with safety a key priority,” he said. “Glycemic targets should be based on functional-status life expectancy rather than chronological age.”
Jay S. Skyler, MD, MACP, FRCP, Professor of Medicine, Pediatrics, and Psychology, University of Miami Leonard M. Miller School of Medicine, and Deputy Director for Clinical Research and Academic Programs at the Diabetes Research Institute, 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, he said.
Dr. Holt concluded the session by addressing key knowledge gaps and evolving areas in the management of type 1 diabetes.
“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,” he said.