What are the ISPAD clinical practice consensus guidelines on glycemic control targets and glucose monitoring in type 1 diabetes mellitus (DM)?

Updated: Sep 13, 2019
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

In July 2018, the ISPAD released clinical practice consensus guidelines on glycemic control targets and glucose monitoring in children, adolescents, and young adults with diabetes. These include the following [159] :

  • Glycemic control of children and adolescents must be assessed by both quarterly hemoglobin A1c (HbA1c) measurements and by regular home glucose monitoring; these permit achievement of optimal health in the following ways: (1) by determining with accuracy and precision an individual's glycemic control, including through assessment of each individual's glycemic determinants; (2) by reducing the risks of acute and chronic disease complications; and (3) by minimizing the effects of hypoglycemia and hyperglycemia on brain development, cognitive function, and mood
  • Regular self-monitoring of glucose (using accurate finger-stick blood glucose [BG] measurements, with or without continuous glucose monitoring [CGM] or intermittently scanned CGM [isCGM]), is essential for diabetes management for all children and adolescents with diabetes
  • Each child should have access to technology and materials for self-monitoring of glucose measurements to provide for enough testing for optimized diabetes care
  • When finger-stick BG measurements are used, testing may need to be performed 6-10 times per day to optimize intensive control; regular review of these BG values should be performed with adjustments to medication/nutritional therapies to optimize control
  • Real-time CGM data particularly benefit children who cannot articulate symptoms of hypoglycemia or hyperglycemia and those with hypoglycemic unawareness
  • Intermittently scanned CGM can complement finger-stick BG assessments. Although isCGM provides some benefits similar to those of CGM, it does not alert users to hypoglycemia or hyperglycemia in real time, nor does it permit calibration. Without robust pediatric use efficacy data, it cannot fully replace BG monitoring
  • For children, adolescents, and young adults aged 25 years or younger, ISPAD recommends individualized targets, aiming for the lowest achievable HbA1c without undue exposure to severe hypoglycemia, balanced with quality of life and burden of care
  • For children, adolescents, and young adults aged 25 years or younger who have access to comprehensive care, a target HbA1c of less than 53 mmol/mol (7.0%) is recommended
  • A higher HbA1c goal (in most cases below 58 mmol/mol [7.5%]) is appropriate in the following contexts: (1) inability to articulate symptoms of hypoglycemia; (2) hypoglycemia unawareness/history of severe hypoglycemia; (3) lack of access to analog insulins, advanced insulin delivery technology, and CGM, and lack of ability to regularly check BG; and (4) individuals who are “high glycators,” in whom an at-target HbA1c would reflect a significantly lower mean glucose level than 8.6 mmoL/L (155 mg/dL)
  • A lower goal (6.5%) or 47.5 mmol/mol may be appropriate if achievable without excessive hypoglycemia, impairment of quality of life, and undue burden of care
  • A lower goal may be appropriate during the honeymoon phase of type 1 diabetes
  • For patients who have elevated HbA1c, a stepwise approach to improve glycemic control is advised, including individualized attention to the following: (1) dose adjustments, (2) personal factors limiting achievement of the target, (3) assessment of the psychological effect of goal setting on the individual, and (4) incorporation of available technology to improve glucose monitoring and insulin delivery modalities
  • HbA1c measurement should be available in all centers caring for persons with diabetes
  • HbA1c measurements should be performed at least every 3 months
  • Examining variations in HbA1c between centers can assist in evaluating the care provided by health-care centers, including compliance with agreed-to standards to improve therapies and delivery of pediatric diabetes care

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