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Need Exists for Specific Type 1 Diabetes Guidelines and Interventions

Authors

Eileen Koutnik-Fotopoulos

San Francisco—Type 1 diabetes occurs when the body cannot produce enough insulin to convert food into energy. Although it is most commonly thought of as a disease diagnosed in childhood, the majority of people living with type 1 diabetes are adults. The management of type 1 diabetes differs from that of type 2 diabetes. A panel of experts explored guideline recommendations during a symposium at the ADA meeting. This study was supported by a grant from The Leona M. and Harry B. Helmsley Charitable Trust.

Glycemic Targets
It is important to discuss targets because new data released in June from the Centers for Disease Control and Prevention found more Americans have type 1 and type 2 diabetes. The data show that 29.1 million people, or 9.3% of the US population, have diabetes, according to Lori M. Laffel, MD, MPH, chief, pediatric, adolescent, and young adult section, Joslin Diabetes Center, associate professor of pediatrics, Harvard Medical School. Research reported from the SEARCH for Diabetes in Youth Study in Journal of the American Medical Association in 2014 documented the rise in and occurrence of type 1 and type 2 diabetes. Dr. Laffel highlighted the 21% increase in type 1 diabetes during the short period of 2001 to 2009.

Dr. Laffel said, “It is timely that we have a talk about specific guidelines related to type 1 diabetes because we are having more patients with diabetes. As healthcare providers working with so many patients dealing with type 1 diabetes, we need to avoid blaming the person with diabetes who may not or should never be the target.”

Dr. Laffel reviewed why glycemic targets are necessary. Blood glucose control reduces the risk of developing eye, nerve, and kidney complications of diabetes. Also, older patients with type 1 and type 2 diabetes and children with type 1 diabetes are at a particularly high risk for adverse outcomes associated with hypoglycemia.

In type 1 diabetes, glycemic targets for hemoglobin A1c (HbA1c) vary across healthcare associations. However, in June the ADA published a new position statement regarding HbA1c in type 1 diabetes through the lifespan (Sidebar).

Several factors served as the rationale for lowering HbA1c in children. Separate HbA1c targets according to age have been abolished in youth. ADA glycemic targets are now harmonized with other international groups, according to Dr. Laffel.

Lipid Management
Type 1 diabetes is associated with cardiovascular disease (CVD); however, guidelines lack specific lipid management recommendations in treating type 1 diabetes, according to Trevor J. Orchard, MD, University of Pittsburgh.

Currently, there is limited trial evidence to guide lipid management in type 1 diabetes. “While the Diabetes Control and Complications trial and the Epidemiology of Diabetes Interventions and Complications trial data is impressive and clearly shows the benefit of intensive therapy initiated early in the course of type 1 diabetes in youth and young adults, this does not help guide lipid management, especially in adults with longstanding childhood-onset type 1 diabetes,” said Dr. Orchard. He noted the Heart Protection Study is the only lipid intervention trial with CVD outcomes that included almost 6000 individuals with type 1 diabetes.

He reviewed the 2014 ADA Standards of Medical Care recommendations for lipid management published in Diabetes Care. The recommendations call for adding statin therapy regardless of baseline low-density lipoprotein (LDL) cholesterol if the individual has CVD or is >40 years of age with an additional risk factor. Clinicians should consider statin therapy if LDL cholesterol is >100 mg/dL for lower risk individuals. While these recommendations provide target goals, Dr. Orchard said a drawback is that the recommendation does not strongly suggest intervention for triglycerides and high-density lipoprotein (HDL) cholesterol.

Dr. Orchard also highlighted issues with the new ADA Position Statement for lipid recommendations. The statement recognizes that adults with a >20-year duration of diabetes have a coronary artery disease risk approaching 1%, thus meriting high-intensity statin therapy according to the 2013 American College of Cardiology/American Heart Association guidelines (≥7.5% 10-year risk), even if the patient is not 40 years of age. However, the recommendations do not specify this. “They only suggest consideration of intervention on an individual basis for those <40 years of age with <20 years duration or >75 years of age. Furthermore, there is no guidance for HDL cholesterol or triglyceride management,” he said.

As for future recommendations, Dr. Orchard outlined several areas for improvement, citing the need for a better understanding of the role of HDL metabolism in type 1 diabetes and the differing effects for fatal versus nonfatal events before and after controlling for triglycerides.

Blood Pressure (BP) Targets
Bruce A. Perkins, MD, MPH, division of endocrinology, University of Toronto, also noted gaps with BP targets in type 1 diabetes, acknowledging that organizations have varying target recommendations based on the same body of evidence. “We have data from type 2 diabetes primarily, and there is a discord between type 1 diabetes and type 2 diabetes research,” he said. “The type 1 diabetes observational research implies that very low systolic BP is protective, but type 2 diabetes shows an opposite picture.”

Guidelines are exclusively based on an older type 2 diabetes population with other CVD risk factors. The type 2 diabetes data is controversial and does not provide a universal approach. “The guidelines do not guide the clinician with respect to risk-stratification and targets based on patient-specific risk-benefit profiles,” he added.

Dr. Perkins concluded by outlining a 3-pronged call to action for BP  targets in type 1 diabetes.
Step 1 is to evaluate safety in observational trials. Step 2 is to implement a randomized, controlled trial. Step 3 is to fight the hypertension epidemic with novel pharmacologic approaches in type 1 diabetes.

Overcoming Barriers
In the final presentation, Barbara J. Anderson, PhD, professor of pediatrics, Baylor College of Medicine, discussed overcoming barriers to type 1 diabetes patient care. “In type 1 diabetes, unrecognized and untreated mental and behavioral comorbidities are barriers to optimal self-care and healthcare,” she said. “This is an extensive and expensive problem.”

Short, evidence-based tools to screen for major depressive disorder and diabetes-related depression are available and practical to implement in clinical settings, according to Dr. Anderson.

“I think finding the minimal intervention needed could become a new rallying cry in behavioral research,” said Dr. Anderson, noting that low-intensity, cost-effective, clinic-based interventions can improve glycemic control and quality of life outcomes. Randomized, controlled trials are needed to train fellows and certified diabetes educators to screen for comorbidities of type 1 diabetes, especially for diabetes distress.

Finally, a need exists to “design low-intensity, low-expense interventions, in which the clinical encounter routinely validates that diabetes distress and quality of life are impacted by this difficult chronic disease,” she said. “It would go a long way in changing the culture of diabetes care.”—Eileen Koutnik-Fotopoulos

 


A new position statement from the ADA specifically addresses hemoglobin A1c (HbA1c) target levels for children with type 1 diabetes. “Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association” was released during a press briefing at the ADA meeting and simultaneously published in Diabetes Care.

A new pediatric glycemic control target of HbA1c <7.5% across all ages replaces previous ADA guidelines that outlined different targets by age: <8.5% for children <6 years of age, <8% for children 6 to 12 years of age, and <7.5% for children 13 to 19 years of age. The adult target remains at <7%, with individualized lower or higher targets based on patient needs. The authors emphasized that the guidelines are suggestions based on evidence, but they are not
requirements.

“These pediatric targets are going to have a very important impact moving forward,” said Jane Chiang, MD, lead author of the position statement. She noted that providers have followed the <7.5% HbA1c goal for children for the past several years. Other organizations had already set the target at <7.5%, including the International Society for Pediatric and Adolescent Diabetes and the Pediatric Endocrine Society.

Although type 1 diabetes is thought of as a disease mostly affecting children, it is estimated that 1 to 2 million adults suffer from the disease, according Anne Peters, MD, FACP, coauthor of the paper. Of the new cases of type 1 diabetes each year, between one-third to one-half are diagnosed in patients >18 years of age.

“Type 1 diabetes spans the entire age spectrum,” added Sue Kirkman, MD, coauthor of the paper. “Plenty of patients in geriatric care and on Medicare have type 1 diabetes. It is unique, novel, and exciting that ADA is taking type 1 diabetes through the lifespan.”

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