Guideline sources The following summarized guidelines for the evaluation and management of diabetes mellitus type 1 are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the Endocrine Society (ES 2022; 2020; 2016), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022; 2020), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the Society for Vascular Medicine (SVM/SVS/APMA 2016), and the American College of Gastroenterology (ACG 2013). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Definition T1DM is an endocrine disorder characterized by T-cell mediated autoimmune destruction of insulin-producing beta cells in the pancreas, resulting in insulin deficiency with resultant hyperglycemia and a predisposition to ketoacidosis. 11 Epidemiology https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 1/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway The cause of T1DM is mostly autoimmune destruction of beta cells of the pancreas (70-90%) and idiopathic (10-30%). 13 Pathophysiology The annual incidence of T1DM in the United States is 22.9 per 100,000 person-years. 12 Disease course Environmental triggers in genetically predisposed people lead to the production of autoantibodies against insulin-producing islet beta cells of the pancreas resulting in autoimmune destruction of these cells. This leads to insulin insufficiency and overt hyperglycemia, T1DM and its complications, diabetic ketoacidosis, altered mental status, coma, and death. 14 Prognosis and risk of recurrence On average, the life expectancy of a person with T1DM is approximately 12 years less than the general population. 15 Guidelines 1. Screening and diagnosis Indications for screening (type 1 diabetes): Consider obtaining autoantibodies to insulin, glutamic acid decarboxylase, islet antigen 2, or zinc transporter 8 to screen for presymptomatic T1DM. C Recognize that multiple confirmed islet autoantibodies is a risk factor for clinical diabetes. Consider testing for dysglycemia to further forecast near-term risk. Consider referring patients with multiple islet autoantibodies to a specialized center for further evaluation and/or consideration of a clinical trial or approved therapy to potentially delay the development of clinical diabetes. B Indications for screening (neonatal diabetes): Obtain immediate genetic testing for neonatal diabetes in all patients diagnosed with diabetes in the first 6 months of life, regardless of the current age. A Consult with a center specializing in diabetes genetics to understand the significance of genetic mutations and how best to approach further evaluation, treatment, and genetic counseling in patients with neonatal diabetes mellitus. B Indications for screening (MODY): Obtain genetic testing for MODY in children and young adults without typical characteristics of T1DM or T2DM and often having a family history of diabetes in successive generations (suggestive of an autosomal dominant pattern of inheritance). A Consult with a center specializing in diabetes genetics to understand the significance of genetic mutations and how best to approach further evaluation, treatment, and genetic counseling in patients with MODY. B 2. Diagnostic investigations https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 2/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway General principles: ensure a person-centered communication style using person-centered, culturally sensitive, and strength-based language and active listening, eliciting individual preferences and beliefs, and assessing literacy, numeracy, and potential barriers to care in order to optimize health outcomes and health-related quality of life. B Show 2 more Hemoglobin A1C: obtain HbA1c testing using a method certified by the National GlycoHgb Standardization Program and standardized to the Diabetes Control and Complications Trial assay, in order to avoid misdiagnosis or missed diagnosis. B Show 3 more Glucose tolerance test: ensure adequate carbohydrate intake (at least 150 g/day) for 3 days before oral glucose tolerance testing as a screen for diabetes. A Screening for hypertension: measure BP at every routine clinical visit. Confirm BP using multiple readings, when possible, in patients found to have elevated BP (systolic BP 120-129 mmHg and diastolic < 80 mmHg), including measurements on a separate day, to diagnose hypertension. Diagnose hypertension in case of a systolic BP 130mmHg or a diastolic BP 80 mmHg based on an average of 2 measurements obtained on 2 occasions. A Show 2 more Screening for cardiovascular diseases: Do not obtain routine screening for coronary artery disease in asymptomatic patients, as it does not improve outcomes as long as ASCVD risk factors are treated. D Consider obtaining investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (such as unexplained dyspnea, chest discomfort) signs or symptoms of associated vascular disease (including carotid bruits, TIA, stroke, claudication, or peripheral arterial disease) ECG abnormalities (such as Q waves). C Screening for autoimmune thyroid disease: screen for autoimmune thyroid disease soon after the diagnosis of T1DM and periodically thereafter. B Screening for celiac disease: screen for celiac disease in adult patients with T1DM in the presence of gastrointestinal symptoms, signs, laboratory manifestations, or clinical suspicion suggestive of celiac disease. B Screening for diabetic nephropathy: Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM regardless of treatment. B Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year depending on the stage of the disease in patients with established diabetic kidney disease. B Screening for diabetic retinopathy: obtain an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of T1DM. B Show 4 more Screening for diabetic neuropathy: screen for diabetic peripheral neuropathy in all patients with T2DM starting 5 years after the diagnosis and at least annually thereafter. B https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 3/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Show 2 more Screening for diabetic foot: As per ADA 2023 guidelines, obtain a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. B Show 4 more As per SVS 2016 guidelines, consider obtaining a probe-to-bone test to aid in the diagnosis of diabetic foot osteomyelitis in patients with diabetic foot infection with an open wound. C Show 5 more Screening for anxiety: Consider screening patients with diabetes for symptoms or diabetes-related worries. Consider discussing diabetes-related worries and referring to a qualified mental health professional for further assessment and treatment if anxiety symptoms indicate interference with diabetes self-management behaviors or quality of life. C Refer patients with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, to a trained professional to receive evidence-based intervention to help re- establish awareness of symptoms of hypoglycemia and reduce fear of hypoglycemia. A Screening for depression: consider obtaining at least annual screening for depressive symptoms in all patients with diabetes, especially in patients with a self-reported history of depression. Use age-appropriate, validated depression screening measures, recognizing that further evaluation will be necessary for patients with a positive screen. C Show 2 more Screening for sleep disorders: consider screening for sleep health in patients with diabetes, including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and worries about sleep. Refer to sleep medicine and/or a qualified behavioral health professional as indicated. C Screening for cognitive impairment: Monitor cognitive capacity throughout the life span in all patients with diabetes, particularly in patients with documented cognitive disabilities, patients experiencing severe hypoglycemia, very young children, and older adults. B Consider referring for a formal assessment if cognitive capacity changes or appears to be suboptimal for patient decision-making and/or behavioral self-management. C Screening for serious mental illness: provide an increased level of support to patients with diabetes and serious mental illness through enhanced monitoring of and assistance with diabetes self-management behaviors. B Show 2 more Screening for disordered eating behavior: Consider screening for disordered or disrupted eating using validated screening measures when hyperglycemia and weight loss are unexplained based on self-reported behaviors related to medication dosing, meal plan, and physical activity. Review the medical treatment plan to identify potential treatment-related effects on hunger/caloric intake. C Consider reevaluating the treatment plan of patients with diabetes presenting with symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating, in consultation with a qualified professional as available. C https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 4/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Screening for gastroparesis: Measure blood glucose levels in patients with diabetes before gastric emptying testing, and treat hyperglycemia with a test started after blood glucose is < 275 mg/dL. B Measure blood glucose levels in patients with diabetes before gastric emptying testing, and treat hyperglycemia with a test started after blood glucose is < 275 mg/dL. B 3. Medical management Glycemic targets: set a HbA1c goal of < 7% (53 mmol/mol) without significant hypoglycemia in many nonpregnant adult patients with diabetes. A Show 4 more Insulin therapy, indications: As per ADA 2023 guidelines, prescribe multiple daily injections of prandial and basal insulin, or continuous SC insulin infusion in most patients with T1DM. A Show 2 more As per ES 2022 guidelines, consider prescribing long-acting insulin analogs rather than human NPH insulin in adult and pediatric outpatients on basal insulin therapy at high risk for hypoglycemia. C Show 2 more As per ES 2016 guidelines, prescribe continuous subcutaneous insulin infusion over analog- based basal-bolus multiple daily injections in patients with T1DM not achieving the HbA1c goal, as long as the patient and caregivers are willing and able to use the device. B Show 3 more Insulin therapy (delivery systems): prefer insulin pens for most patients with insulin-requiring diabetes on multiple daily injections. Consider prescribing insulin syringes for insulin delivery taking into account individual and caregiver preference, insulin type, dosing therapy, cost, and self-management capabilities. B Show 6 more Monoclonal antibodies: consider administering teplizumab-mzwv infusion in a specialized setting with appropriately trained personnel to delay the onset of symptomatic T1DM in selected 8 years old patients with stage 2 T1DM. C Management of hypoglycemia: As per ADA 2023 guidelines, review occurrence and risk for hypoglycemia at every encounter and investigate as indicated. Consider assessing for awareness of hypoglycemia using validated tools. B Show 5 more As per ES 2022 guidelines, administer glucagon (preparations not requiring reconstitution) in outpatients with severe hypoglycemia. B Management of diabetic nephropathy, general principles: As per ADA 2023 guidelines, optimize glucose control to reduce the risk or slow the progression of CKD. A Show 5 more https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 5/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway As per KDIGO 2022 guidelines, treat patients with diabetes mellitus and CKD with a comprehensive strategy to reduce risks of kidney disease progression and CVD. B Management of diabetic neuropathy: optimize glucose control to prevent or delay the development of neuropathy in patients with T1DM. B Show 2 more Management of diabetic foot: ensure a multidisciplinary approach for patients with foot ulcers and high-risk feet (such as patients on dialysis, patients with Charcot foot, history of ulcers or amputation, or peripheral arterial disease). B Show 4 more Management of hypertension (BP targets): individualize BP targets in patients with diabetes and hypertension through a shared decision-making process addressing cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. B Show 2 more Management of hypertension (lifestyle modifications): advise lifestyle interventions in patients with BP > 120/80 mmHg, consisting of weight loss when indicated, a DASH-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. A Management of hypertension (pharmacotherapy): initiate and titrated pharmacologic therapy to achieve BP goal of < 130/80 mmHg in patients with confirmed office-based BP 130/80 mmHg. A Show 6 more Management of cardiovascular disease (antihypertensives): Initiate ACEI or ARB therapy to reduce the risk of cardiovascular events in patients with known ASCVD, particularly coronary artery disease. A Initiate -blockers with proven cardiovascular outcomes benefits in patients with HFrEF, unless otherwise contraindicated. A Continue -blockers for 3 years after myocardial infarction. B Management of cardiovascular disease (antiplatelets): consider initiating aspirin therapy (75-162 mg/ day) as a primary prevention strategy in patients with diabetes at increased cardiovascular risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding. B Show 6 more Management of cardiovascular disease (revascularization): perform CABG surgery (with a left internal mammary artery to the left anterior descending artery) over PCI to reduce mortality and repeat revascularizations in patients with diabetes and multivessel coronary artery disease with the involvement of the left anterior descending artery being appropriate candidates for CABG. A Show 3 more Management of dyslipidemia (lifestyle modifications): Advise lifestyle modifications focusing on weight loss (if indicated), following a Mediterranean style or DASH eating pattern, reducing consumption of saturated fat and trans fat, increasing dietary omega-3 fatty acids, viscous fiber, and plant stanols/sterols intake, and increasing https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 6/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway physical activity to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes. A Intensify lifestyle therapy and optimize glycemic control in patients with elevated triglyceride levels ( 150 mg/dL) and/or low HDL cholesterol (< 40 mg/dL for males, < 50 mg/dL for females). B Management of dyslipidemia, statin therapy: As per ADA 2023 guidelines, initiate moderate-intensity statin therapy, in addition to lifestyle therapy, in 40-75 years old patients with diabetes without ASCVD. A Show 5 more As per ES 2020 guidelines, consider initiating statin therapy, irrespective of the cardiovascular risk score, to reduce cardiovascular risks in 40 years old patients with T1DM and/or with duration of diabetes > 20 years and/or microvascular complications. C Show 3 more Management of dyslipidemia (non-statin lipid-lowering therapy): consider adding ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy in 40-75 years old patients with diabetes at higher cardiovascular risk, especially patients with multiple ASCVD risk factors and an LDL cholesterol 70 mg/dL. C Show 3 more Management of dyslipidemia (lipid profile monitoring): Consider obtaining a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years or more frequently if indicated, in adult patients with diabetes not taking statins or other lipid-lowering therapy. C Obtain lipid profile at the initiation of statins or other lipid-lowering therapy, 4-12 weeks after initiation or a change in dose, and annually thereafter to monitor the response to therapy and inform medication taking. B Management of dyslipidemia (hypertriglyceridemia): evaluate for secondary causes of hypertriglyceridemia and consider initiating medical therapy to reduce the risk of pancreatitis in patients with fasting triglyceride levels 500 mg/dL. B Show 2 more Management of diabetic nephropathy (smoking cessation): Advise patients with diabetes mellitus and CKD to quit using tobacco products. B Counsel patients with diabetes mellitus and CKD to reduce secondhand smoke exposure. B Management of diabetic nephropathy, RAAS blockade: As per ADA 2023 guidelines, initiate either ACEIs or ARBs in nonpregnant patients with diabetes and hypertension with severely increased albuminuria (urinary albumin-to-creatinine ratio 300 mg/g creatinine) and/or eGFR < 60 mL/min/1.73 m . A Show 4 more As per KDIGO 2022 guidelines, initiate an ACEI or an ARB in patients with diabetes, hypertension and albuminuria and titrate the medications to the highest approved dose that is tolerated. B Show 7 more Management of diabetic nephropathy (kidney transplantation): https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 7/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Consider performing kidney transplantation in kidney transplant candidates with T1DM. C Consider performing simultaneous pancreas-kidney transplantation in kidney transplant candidates with end-stage kidney disease and T1DM in regions where this procedure is available. C Management of diabetic retinopathy: optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. A Show 7 more 4. Inpatient care Management of hospitalized patients, general principles: As per ADA 2023 guidelines, consult with a specialized diabetes or glucose management team, when possible, when caring for hospitalized patients with diabetes. B As per ES 2022 guidelines, consider providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process in adult patients with diabetes hospitalized for a non-critical illness. C Management of hospitalized patients (HbA1C testing): obtain HbA1c testing in all patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL; 7.8 mmol/L) admitted to the hospital, if not performed in the prior 3 months. B Management of hospitalized patients, glucose monitoring: As per ADA 2023 guidelines, support patients to continue using diabetes devices, such as insulin pumps and continuous glucose monitoring systems, in an inpatient setting or during outpatient procedures, once competency in safely using these devices is established and proper supervision is available. B As per ES 2022 guidelines, consider obtaining real-time continuous glucose monitoring with confirmatory bedside point-of-care blood glucose monitoring for adjustments in insulin dosing (in hospital settings where resources and training are available) in adult patients with insulin- treated diabetes at high risk of hypoglycemia hospitalized for a non-critical illness. C As per ES 2022 guidelines, consider initiating continuous glucose monitoring in the inpatient setting for selected patients at high risk for hypoglycemia. C Show 2 more Management of hospitalized patients, insulin therapy: As per ADA 2023 guidelines, use validated written or computerized protocols for insulin administration allowing for predefined adjustments in the insulin dosage based on glycemic fluctuations. B Show 4 more As per ES 2022 guidelines, consider administering scheduled insulin therapy for glycemic control in most adult patients with hyperglycemia hospitalized for a non-critical illness. C Show 7 more As per ES 2016 guidelines, continue continuous subcutaneous insulin infusion in patients admitted to the hospital if the institution has clear protocols for evaluating patients as suitable candidates and appropriate monitoring and safety procedures. B https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 8/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Management of hospitalized patients, treatment targets: As per ADA 2023 guidelines: Set a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of critically ill and non-critically ill patients once insulin therapy is started. A Consider setting more stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L), in selected patients if those can be achieved without significant hypoglycemia. C As per ES 2022 guidelines: Consider targeting preoperative HbA1c levels of < 8% (63.9 mmol/mol) and blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures. C Consider targeting preoperative blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures if a HbA1c < 8% (63.9 mmol/mol) target is not feasible. C Management of hospitalized patients (prevention of hypoglycemia): Review treatment regimens and change as necessary to prevent further hypoglycemia when a blood glucose value of < 70 mg/dL (3.9 mmol/L) is documented. B Adopt a hypoglycemia management protocol and implement it in each hospital or hospital system. Establish a plan for the prevention and treatment of hypoglycemia for each patient. Document episodes of hypoglycemia in the hospital in the medical record and track for quality improvement/quality assessment. B Management of hospitalized patients (oral carbohydrate fluids): avoid administering preoperative carbohydrate-containing oral fluids in adult patients with diabetes undergoing surgical procedures. D 5. Nonpharmacologic interventions Smoking cessation: advise all patients to abstain from using cigarettes and other tobacco products or e-cigarettes. A Show 2 more Physical activity: advise most adults with T1DM to engage in 150 minutes of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Consider advising shorter durations (minimum 75 min/week) of vigorous-intensity or interval training in younger and more physically fit patients. B Show 4 more Dietary modifications (general principles): provide an individualized medical nutrition therapy program as needed to achieve treatment goals, provided by a registered dietitian nutritionist, preferably one who has comprehensive knowledge and experience in diabetes care, in all patients with T1DM. A Show 2 more Dietary modifications (eating patterns): Recognize that there is no ideal macronutrient pattern for patients with diabetes. Individualize meal plans while keeping nutrient quality, total calorie, and metabolic goals in https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 9/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway mind. B Reduce overall carbohydrate intake in patients with diabetes for improving glycemia. Consider applying this to a variety of eating patterns meeting individual needs and preferences. B Dietary modifications (carbohydrates): advise carbohydrate intake emphasizing nutrient- dense carbohydrate sources high in fiber (at least 14 g fiber per 1,000 kcal) and minimally processed. Advise eating plans emphasizing nonstarchy vegetables, fruits, legumes, and whole grains, as well as dairy products, with minimal added sugars. B Show 3 more Dietary modifications (fat): Consider advising an eating plan emphasizing elements of a Mediterranean eating pattern rich in monounsaturated and polyunsaturated fats to improve glucose metabolism and lower CVD risk. C Advise eating foods rich in long-chain omega-3 fatty acids, such as fatty fish (eicosapentaenoic acid and docosahexaenoic acid) and nuts and seeds (alpha-linolenic acid), to prevent or treat CVD. B Dietary modifications (nonnutritive sweeteners): Recognize that the use of nonnutritive sweeteners as a replacement for sugar-sweetened products may reduce overall calorie and carbohydrate intake as long as there is not a compensatory increase in energy intake from other sources. B Encourage patients to decrease both sweetened and nonnutritive-sweetened beverages, with an emphasis on water intake. B Dietary modifications (sodium): limit sodium consumption to < 2,300 mg/day. B Dietary modifications (micronutrients and supplements): insufficient evidence to support the use of dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) to improve outcomes in patients with diabetes not having underlying deficiencies, and for glycemic control. I Dietary modifications (alcohol): Advise adult patients with diabetes drinking alcohol to do so in moderation ( 1 drink/day for adult females and 2 drinks/day for adult males). B Educate patients with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues. Emphasize the importance of glucose monitoring after drinking alcoholic beverages to reduce hypoglycemia risk. B Psychosocial care: provide psychosocial care, integrated with routine medical care and delivered by trained healthcare professionals using a collaborative, person-centered, culturally informed approach, in all patients with diabetes, with the goal of optimizing health-related quality of life and health outcomes. A Refer to qualified mental health professionals for additional targeted mental health care, when indicated and available. B Show 4 more 6. Specific circumstances https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 10/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Elderly patients (screening for comorbidities): consider assessing medical, psychological, functional (self-management abilities), and social domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management. C Show 2 more Elderly patients (screening for hypoglycemia): ascertain and address episodes of hypoglycemia in older adults with diabetes at routine visits because they have a greater risk of hypoglycemia than younger adults. B Show 3 more Elderly patients (treatment goals): set lower glycemic goals (such as HbA1c < 7.0-7.5%; 53- 58 mmol/mol) in older patients otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status. B Show 5 more Elderly patients (lifestyle modifications): Ensure optimal nutrition and protein intake in older patients. B Encourage regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training, in all older patients able to safely engage in such activities. B Elderly patients (pharmacotherapy): avoid overtreatment of diabetes in older patients. D Show 3 more Elderly patients (residing in nursing facilities): obtain careful assessment in patients with diabetes residing in long-term care facilities to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. B Show 2 more Elderly patients (end-of-life care): Initiate conversations regarding the goals and intensity of care when palliative care is required in older patients with diabetes. Avoid strict glucose and BP control. B Consider simplifying regimens. Consider relaxing the intensity of lipid management or withdrawing lipid-lowering therapy. A Set overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity as primary goals for diabetes management at the end of life. B Pregnant patients (preconception counseling and care): incorporate preconception counseling into routine diabetes care starting at puberty and continuing in all patients with diabetes and reproductive potential. A Show 6 more Pregnant patients (nutrition): encourage a balanced intake of macronutrients including nutrient-dense fruits, vegetables, legumes, whole grains, and healthy fats with omega-3 fatty acids (including nuts, seeds, and fish) in the eating pattern. B Pregnant patients (glycemic targets): obtain fasting and postprandial blood glucose monitoring in both gestational diabetes mellitus and preexisting diabetes in pregnancy, to achieve optimal glucose levels. Set the following glucose targets: fasting plasma glucose < 95 mg/dL (5.3 mmol/L) and either 1-hour postprandial glucose < 140 mg/dL (7.8 mmol/L) or 2- hour postprandial glucose < 120 mg/dL (6.7 mmol/L). Obtain blood glucose preprandially in some patients with preexisting diabetes. B https://web.pathway.md/diseases/recJxJJDGtvUMVAC9 11/18 6/29/23, 10:11 PM Diabetes mellitus type 1 Pathway Show 5 more Pregnant patients (management of preexisting diabetes): Prescribe insulin for the management of T1DM in pregnancy. A Consider prescribing either multiple daily injections or insulin pump technology in pregnancy complicated by T1DM. C Pregnant patients (management of gestational diabetes): offer lifestyle behavior changes for the management of gestational diabetes mellitus. Add insulin if needed to achieve glycemic targets. A Show 5 more Pregnant patients (BP targets): consider targeting a BP of 110-135/85 mmHg in pregnant patients with diabetes and chronic hypertension in the interest of reducing the risk for accelerated maternal hypertension. B Titrate therapy from a BP threshold of 140/90 mmHg for better pregnancy outcomes with no increase in the risk of small-for-gestational-age birth weight. B Lessen therapy for BP < 90/60 mmHg. C Pregnant patients (prevention of preeclampsia): prescribe low-dose aspirin 100-150 mg/day (162 mg/day may also be acceptable) starting at 12-16 weeks of gestation to lower the risk of preeclampsia in patients with T1DM. B Pregnant patients (postpartum care): evaluate and adjust insulin requirements postpartum as insulin resistance decreases dramatically immediately postpartum and the requirements are often roughly half the prepregnancy requirements for the initial few days postpartum. B Show 7 more Pediatric patients (screening for hypertension): measure BP at every routine visit. Consider obtaining ambulatory BP monitoring in young patients with high BP (BP 90th percentile for age, sex, and height or, in adolescents aged 13 years, BP 120/80 mmHg) on three separate measurements. B Pediatric patients (screening for dyslipidemia): obtain initial lipid profile soon after diagnosis, preferably after glycemia has improved and age is 2 years. Obtain subsequent testing at 9-11 years of age if initial LDL cholesterol is 100 mg/dL (2.6 mmol/L). B Show 2 more Pediatric patients (screening for autoimmune thyroid disease): assess for additional autoimmune conditions soon after the diagnosis of T1DM and if symptoms develop. B Show 2 more Pediatric patients (screening for celiac disease): screen young patients with T1DM for celiac disease by measuring anti-tTG (IgA) with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or anti-tTG (IgG) and deamidated gliadin antibodies if IgA is deficient. B 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