Show 2 more Pediatric patients (screening for disordered eating behavior): screen young patients with T1DM for disordered eating starting at 10-12 years of age. Refer to a qualified mental health professional for further assessment and treatment if indicated. B Pediatric patients (screening for diabetic nephropathy): consider obtaining annual screening for albuminuria with a random (morning sample preferred to avoid effects of https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 12/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway exercise) spot urine sample for albumin-to-creatinine ratio at puberty or at age > 10 years, whichever is earlier, once the patient has had diabetes for 5 years. C Pediatric patients (screening for diabetic retinopathy): obtain an initial dilated and comprehensive eye examination once the patient has had T1DM for 3-5 years, provided the patient is aged 11 years or puberty has started, whichever is earlier. B Show 2 more Pediatric patients (screening for diabetic foot): consider obtaining an annual comprehensive foot examination (including inspection, assessment of foot pulses, pinprick, and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests) at the start of puberty or at age 10 years, whichever is earlier, once the patient has had T1DM for 5 years. C Pediatric patients (glycemic targets): individualize HbA1c goals and reassess over time, recognizing that an HbA1c level of < 7% (53 mmol/mol) is appropriate for many pediatric and adolescent patients. B Show 3 more Pediatric patients (glucose monitoring): advise all young patients with T1DM to monitor glucose levels multiple times daily (up to 6-10 times/day by blood glucose meter or continuous glucose monitoring), including before meals and snacks, at bedtime, and as needed for safety in specific situations, such as exercise, driving, or the presence of symptoms of hypoglycemia. B Show 3 more Pediatric patients (insulin delivery devices): offer automated insulin delivery systems for diabetes management in young patients with T1DM capable of using the device safely (either by themselves or with caregivers). Decide on the choice of the device based on the patient's and family's circumstances, desires, and needs. A Show 2 more Landmark trials: Insulin-Only Bionic Pancreas In participants 6 years of age with T1DM, bionic pancreas were superior to standard care with respect to glycated Hgb level at week 13. Bionic Pancreas Research Group et al. N Engl J Med. 2022 Sep 29. Pediatric patients (dietary modifications): offer individualized medical nutrition therapy as an essential component of the overall treatment plan in young patients with T1DM. A Show 2 more Pediatric patients (physical activity): advise physical activity in all young patients with T1DM with the goal of 60 minutes of moderate- to vigorous-intensity aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week. B Show 3 more Pediatric patients (smoking cessation): Elicit a smoking history at initial and follow-up diabetes visits. Discourage smoking in non- smokers and encourage smoking cessation in smokers. A https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 13/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Discourage the use of electronic cigarettes. A Pediatric patients (psychosocial care): screen for psychosocial issues and family stresses (likely to impact diabetes management) at diagnosis and during routine follow-up care and refer to trained mental health professionals, preferably experienced in childhood diabetes. B Show 6 more Pediatric patients (self-management counseling): provide culturally sensitive and developmentally appropriate individualized diabetes self-management education and support to young patients with T1DM and their parents/caregivers, according to national standards at diagnosis and routinely thereafter. B Pediatric patients (preconception counseling): incorporate preconception counseling starting at puberty into routine diabetes care for all female patients of childbearing potential. A Pediatric patients (management of hypertension): offer lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management for the treatment of elevated BP (defined as the 90-95th percentile for age, gender, and height or, in adolescents aged 13 years, 120-129/< 80 mmHg). B Show 2 more Pediatric patients (management of dyslipidemia): optimize glycemia and offer medical nutrition therapy to limit the number of calories from fat to 25-30% and saturated fat to < 7%, limit cholesterol to < 200 mg/day, avoid trans fats and aim for 10% calories from monounsaturated fats, as initial therapy if lipids are abnormal. A Show 3 more Pediatric patients (management of diabetic nephropathy): Consider initiating an ACEI or an ARB, titrated to normalization of albumin excretion, when elevated urinary albumin-to-creatinine ratio (> 30 mg/g) is documented (2 of 3 urine samples obtained over a 6-month interval following efforts to improve glycemic control and normalize BP). C Provide reproductive counseling and avoid using ACEIs and ARBs in individuals of childbearing age not using reliable contraception, due to the potential teratogenic effects. B Pediatric patients (transition to adult care): Begin to prepare young patients for transition to adult healthcare in early adolescence and, at the latest, at least 1 year before the transition. B Provide support and resources for transitioning young adults by both pediatric and adult diabetes care providers. B Patients with COVID-19 infection: support patients with diabetes to achieve individualized targeted glycemic control to reduce the risk of macrovascular and microvascular risk as well as reduce the risk of COVID-19 and its complications. B Show 8 more 7. Patient education Self-management counseling: offer all patients with diabetes participation in self- management education and support to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care. A https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 14/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Show 9 more 8. Preventative measures Routine immunizations: provide routine immunizations in pediatric and adult patients with diabetes as indicated by age. A 9. Follow-up and surveillance Treatment monitoring: include most components of the initial comprehensive medical evaluation in the follow-up visit. A Show 3 more Continuous glucose monitoring: As per ES 2022 guidelines: Obtain continuous glucose monitoring rather than self-monitoring of blood glucose by fingerstick in patients with T1DM receiving multiple daily injections. B Consider obtaining real-time continuous glucose monitoring and algorithm-driven insulin pumps rather than multiple daily injections with self-monitoring of blood glucose TID in adult and pediatric patients with T1DM. C As per ES 2016 guidelines, obtain real-time continuous glucose monitoring in adult patients with T1DM with HbA1c levels above target and are willing and able to use these devices on a nearly daily basis. A Show 2 more Continous glucose monitoring: as per ADA 2023 guidelines, obtain real-time continuous glucose monitoring A or intermittently scanned continuous glucose monitoring B in adult patients with diabetes on multiple daily injections or continuous subcutaneous insulin infusion capable of using the devices safely, either by themselves or with a caregiver. Decide on the choice of the device based on the patient's circumstances, preferences, and needs. A Show 12 more Monitoring of glycemic status: assess glycemic status (HbA1c or other glycemic measurements, such as time in range or glucose management indicator) at least two times a year in patients meeting treatment goals (and having stable glycemic control). B Show 3 more Landmark trials: FLASH-UK In adult participants with T1DM and glycated Hgb levels between 7.5-11.0%, flash glucose monitoring was superior to self-monitoring of blood glucose with respect to glycated Hgb level at 24 weeks. Lalantha Leelarathna et al. N Engl J Med. 2022 Oct 20. https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 15/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway 10. Quality improvement Health promotion: ensure that treatment decisions are timely, rely on evidence-based guidelines, include social community support, and are made collaboratively with patients based on individual preferences, prognoses, comorbidities, and informed financial considerations. B Show 5 more Use of diabetes technology: individualize the type and selection of devices based on the patient's specific needs, preferences, and skill level. Include the caregiver's skills and preferences in the decision-making process in the setting of a patient with diabetes partially or wholly managed by someone else (such as a young child or a person with cognitive impairment or dexterity, psychosocial, and/or physical limitations). B Show 5 more Clinical findings Symptoms Past medical history Abdominal pain Addison's disease Confusion CKD Fatigue Celiac disease Headache Diabetic foot Increased appetite Diabetic nephropathy Itching Diabetic neuropathy Nocturia Diabetic retinopathy Polydipsia Dyslipidemia Polyuria Graves' disease Urinary incontinence Hashimoto's disease Vomiting Pernicious anemia Weight loss Vitiligo Neurological exam Integument exam Lethargy Dehydration Skin dryness Lab findings Serological findings Diabetic ketoacidosis Hyperglycemia anti-glutamic acid decarboxylase autoantibodies Metabolic acidosis anti-insulin autoantibodies serum HbA1c anti-islet cell autoantibodies urine glucose anti-zinc transporter 8 autoantibodies C-peptide insulinoma-associated-2 autoantibodies Imaging findings Cerebral edema Diagnostic procedures https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 16/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Abnormal oral glucose tolerance Studies 2022 FLASH-UK In adult participants with T1DM and glycated Hgb levels between 7.5-11.0%, flash glucose monitoring was superior to self-monitoring of blood glucose with respect to glycated Hgb level at 24 weeks. Lalantha Leelarathna et al. N Engl J Med. 2022 Oct 20. 2022 Insulin-Only Bionic Pancreas In participants 6 years of age with T1DM, bionic pancreas were superior to standard care with respect to glycated Hgb level at week 13. Bionic Pancreas Research Group et al. N Engl J Med. 2022 Sep 29. Show 4 more References 1. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 2. Mary T Korytkowski, Ranganath Muniyappa, Kellie Antinori-Lent et al. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022 Jun 12;dgac278. Open 3. Anthony L McCall, David C Lieb, Roma Gianchandani et al. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022 Dec 7;dgac596. Open 4. Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022 Nov;102 5S S1 S127. Open 5. Anil Hingorani, Glenn M LaMuraglia, Peter Henke et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016 Feb;63 2 Suppl):3S 21S. Open 6. Jennifer S Lawton, Jacqueline E Tamis-Holland, Sripal Bangalore et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145 3):e18-e114. Open 7. Anne L Peters, Andrew J Ahmann, Tadej Battelino et al. Diabetes Technology-Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016 Nov;101 11 3922 3937. Open 8. Camilleri M, Parkman HP, Shafi MA et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108 1 18 37. Open https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 17/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway 9. Steven J Chadban, Curie Ahn, David A Axelrod et al. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104 4S1 Suppl 1 S11 S103. Open 10. Connie B Newman, Michael J Blaha, Jeffrey B Boord et al. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2020 Dec 1;105 12):dgaa674. Open 11. Kahanovitz L, Sluss PM, Russell SJ. Type 1 Diabetes A Clinical Perspective. Point Care. 2017 Mar;16 1 37 40. Open 12. Rogers MAM, Kim C, Banerjee T et al. Fluctuations in the incidence of type 1 diabetes in the United States from 2001 to 2015 a longitudinal study. BMC Med. 2017 Nov 8;15 1 199. Open 13. Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet. 2014 Jan 4;383 9911 69 82. Open 14. Kimber M Simmons, Aaron W Michels. Type 1 diabetes: A predictable disease. World J Diabetes. 2015 Apr 15;6 3 380 90. Open 15. Copenhaver M, Hoffman RP. Type 1 diabetes: where are we in 2017?. Transl Pediatr. 2017 Oct;6 4 359 364. Open 16. Jeff A Simerville, William C Maxted, John J Pahira. Urinalysis: a comprehensive review. Am Fam Physician. 2005 Mar 15;71 6 1153 62. Open 17. ADA. Executive summary: Standards of medical care in diabetes 2013. Diabetes Care. 2013 Jan;36 Suppl 1 S4 10. Open 18. American Diabetes Association. Standards of Medical Care in Diabetes-2017 Abridged for Primary Care Providers. Clin Diabetes. 2017 Jan;35 1 5 26. Open 19. American Diabetes Association. 10. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018 Jan;41 Suppl 1 S105 S118. Open 20. Diabetes Canada Clinical Practice Guidelines Expert Committee, McFarlane P, Cherney D et al. Chronic Kidney Disease in Diabetes. Can J Diabetes. 2018 Apr;42 Suppl 1 S201 S209. Open 21. Game FL, Attinger C, Hartemann A et al. IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1 75 83. Open 22. American Diabetes Association. Standards of Medical Care in Diabetes-2019 Abridged for Primary Care Providers. Clin Diabetes. 2019 Jan;37 1 11 34. Open 23. American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes 2019. Diabetes Care. 2019 Jan;42 Suppl 1 S124 S138. Open 24. American Diabetes Association Professional Practice Committee, American Diabetes Association Professional Practice Committee:, Draznin B et al. Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45 Supplement_1 S1 S264. Open 25. Bionic Pancreas Research Group, Steven J Russell, Roy W Beck et al. Multicenter, Randomized Trial of a Bionic Pancreas in Type 1 Diabetes. N Engl J Med. 2022 Sep 29;387 13 1161 1172. Open 26. Lalantha Leelarathna, Mark L Evans, Sankalpa Neupane et al. Intermittently Scanned Continuous Glucose Monitoring for Type 1 Diabetes. N Engl J Med. 2022 Oct 20;387 16 1477 1487. Open 27. Diabetes Canada Clinical Practice Guidelines Expert Committee, Jean-Fran ois Yale, Breay Paty et al. Hypoglycemia. Can J Diabetes. 2018 Apr;42 Suppl 1 S104 S108. Open https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 18/18