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New (2018) ADA Position Statement for Type 1 Diabetes

Nov 3, 2018
 

Author: Steve Freed, R.PH., CDE


Recommendations place special emphasis on youth newly diagnosed with diabetes.

The ADA position statement was recently released. Updates include the following:

  • Consult a pediatric endocrinologist before diagnosing type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in patients with acute illness in the absence of classic symptoms.
  • Differentiating type 1 diabetes, type 2 diabetes, monogenic diabetes, and other forms is based on patient history and characteristics and laboratory tests, such as islet autoantibody panel.

Key recommendations include:

  • The majority of children with type 1 diabetes should be treated with intensive insulin regimens using multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion.
  • A1C should be measured every 3 months.
  • Glucose levels should be monitored up to 6 to 10 times a day.
  • Continuous glucose monitors (CGM) should be considered in all children and adolescents with type 1 diabetes. The benefits of CGM correlate with adherence to ongoing use of the device.
  • Blood or urine ketone levels should be monitored in children with type 1 diabetes in the presence of prolonged/severe hyperglycemia or acute illness.
  • Individualized medical nutrition therapy is recommended for children and adolescents.
  • Exercise is recommended with a goal of 60 minutes a day of moderate to vigorous aerobic activity, along with vigorous muscle-strengthening and bone-strengthening activities at least 3 days a week.
  • It is important to frequently monitor glucose before, during, and after exercise (with or without CGM use) to prevent, detect, and treat hypoglycemia and hyperglycemia.
  • All individuals with type 1 diabetes should have access to an uninterrupted supply of insulin. The lack of access and insulin omissions are major causes of diabetic ketoacidosis.
  • Glucagon should be prescribed for all individuals with type 1 diabetes, and caregivers or family members should be instructed regarding administration. Expiration dates need to be checked.
  • Once the child has had diabetes for 5 years, annual screening for albuminuria with a random spot urine sample (morning sample preferred to avoid effects of exercise) for an albumin-to-creatinine ratio should be considered at puberty or at greater than 10 years of age, whichever occurs earlier.
  • Once the youth has had diabetes for 3 to 5 years, an initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, and an annual routine follow-up is generally recommended.
  • For adolescents who have had type 1 diabetes for 5 years, consider an annual comprehensive foot exam at the start of puberty or at age 10 years, whichever is earlier.
  • Blood pressure should be measured at each routine visit. Children who have high-normal blood pressure (SBP or DBP at 90th percentile for age, sex, and height) or hypertension (SBP or DBP at 95th percentile for age, sex, and height) should have BP confirmed on 3 separate days.
  • Initial treatment of high-normal blood pressure (SBP or DBP consistently at the 90th percentile for age, sex, and height) includes dietary modification and increased exercise for weight control. If target blood pressure is not reached within 3 to 6 months after lifestyle intervention, consider pharmacologic treatment.
  • ACE inhibitors or ARBs should be considered for initial pharmacologic treatment of hypertension after reproductive counseling because of potential teratogenic effects.
  • BP treatment goal is consistently less than 90th percentile for age, sex, and height.
  • If LDL cholesterol is within acceptable risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile every 3 to 5 years is reasonable.
  • If lipid levels are abnormal, initial therapy should consist of optimizing glucose control and initiating a Step 2 American Heart Association diet (restricting saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day).
  • After 10 years of age, consider adding a statin if after 6 months, despite medical nutrition therapy and lifestyle changes, LDL cholesterol remains greater than 160 mg/dL (4.1 mmol/L) or LDL cholesterol remains greater than 130 mg/dL (3.4 mmol/L) with one or more CVD risk factors (after reproductive counseling because of potential teratogenic effects of statins). LDL therapy goal is less than 100 mg/dL (2.6 mmol/L).
  • In children with type 1 diabetes, consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis.
  • In children and adolescents with type 1 diabetes, A1C target of less than 7.5% should be considered but individualized.
  • Glucose (15 g) is preferred treatment for conscious individuals with hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]), but any form of carbohydrate may be used. Treatment should be repeated if self-monitoring blood glucose (SMBG) 15 min. after treatment shows hypoglycemia is still present. When blood glucose concentration returns to normal, consider a meal or snack and/or reduce insulin to prevent recurrence of hypoglycemia.
  • In patients with classic symptoms, blood glucose measurement is sufficient to diagnose diabetes (symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [11.1 mmol/L]), a fasting plasma glucose over 99 mg/dL. or an A1c result of higher than 6.4%. Criteria for diagnosis of diabetes is fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L).
  • In asymptomatic children and adolescents at high risk for diabetes, if FPG ≥126 mg/dL (7 mmol/L), if 2-hr PG ≥200 mg/dL (11.1 mmol/L), or if A1C ≥6.5%, test should be repeated on a separate day to confirm diagnosis.
  • Measure thyroid-stimulating hormone concentrations when patient is clinically stable or once glycemic control has been established. If normal, suggest rechecking every 1 to 2 years or sooner if the patient develops symptoms or signs that suggest thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability.
  • Screen children for celiac disease by measuring IgA tissue transglutaminase antibodies.

Reference:

Chiang JL, Maahs DM, Garvey KC, et al. Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes Care. 2018 Aug 9. http://care.diabetesjournals.org/content/41/9/2026