The DCCT clearly showed that intensive insulin therapy, defined as three or more injections per day of insulin or continuous subcutaneous insulin infusion (CSII) (or insulin pump therapy), was a key part of improved glycemia and better outcomes.[43,63] The study was carried out with short- and intermediate-acting human insulins. Despite better microvascular outcomes, intensive insulin therapy was associated with a high rate of severe hypoglycemia (62 episodes per 100 patient-years of therapy). Since the completion of the DCCT, a number of rapid-acting and long-acting insulin analogs have been developed. These analogs are associated with less hypoglycemia than human insulin while offering the same amount of A1C lowering in people with type 1 diabetes.[64,65]
The Sensor-Augmented Pump Therapy for A1C Reduction (STAR 3) study was a large (n = 485) randomized clinical trial comparing insulin pump therapy and CGM with insulin injections in youth and adults with type 1 diabetes. The two study groups started with the same baseline A1C of 8.3%. After 1 year, the group using insulin pump therapy and CGM had lower A1C levels (7.5% vs. 8.1%, P < 0.001) without significant nocturnal hypoglycemia compared with the insulin injection cohort. Recently, a large randomized trial in patients with type 1 diabetes and nocturnal hypoglycemia reported that the use of sensor-augmented insulin pump therapy with the threshold-suspend feature reduced nocturnal hypoglycemia without increasing glycated hemoglobin values. In general, intensive management using pump therapy/CGM should be strongly encouraged, with active patient/family participation enhancing successful outcomes.[67–69]
Most individuals with type 1 diabetes should be treated with multiple daily insulin injections (three or more injections per day of prandial insulin and one to two injections of basal insulin) or CSII. (A)
Most individuals with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. (E)
Most individuals with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. (A)
All individuals with type 1 diabetes should be taught how to manage blood glucose levels under varying circumstances, such as when ill or receiving glucocorticoids or for those on pumps, when pump problems arise. (E)
Child caregivers and school personnel should be taught how to administer insulin based on provider orders when a child cannot self-manage and is out of the care and control of his or her parent/guardian. (E)
Diabetes Care. 2014;37(7):2034-2054. © 2014 American Diabetes Association, Inc.