Final Consensus Report on Type 1 Diabetes Released by ADA, EASD

Leading diabetes research organizations in the United States and Europe have released a final consensus report on management of type 1 diabetes (T1D) in adults, which will serve as a companion to a similar document released 2 years ago for adults with type 2 diabetes (T2D).

The 37-page document was published simultaneously Friday in Diabetes Care, the official journal of the American Diabetes Association (ADA),¹ and Diabetologia, the official journal of the European Association for the Study of Diabetes (EASD).

“This new consensus statement not only brings in the advances that have been made in treating type 1 diabetes in recent years, but also covers other vital areas from a patient perspective—such as the psychosocial consequences of living with the condition, that can sometimes be neglected,” said Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine at the University of Southern California, a coauthor of the document, in a statement.

Her fellow coauthor, Richard Holt, MA, MB, BChir, PhD, professor in diabetes and endocrinology, human development and health at the University of Southampton in the United Kingdom, noted that the document was developed through a process that included a draft presentation during ADA’s June meeting and an invitation for comments.

“Public comments from a range of healthcare professionals on both sides of the Atlantic were received, responding as an individual or on behalf of groups of professionals working in clinical care, academia and the pharmaceutical industry,” Holt said.

People with T1D account for 5% to 10% of all those who have diabetes, but worldwide the number is about 25 million—and growing, for reasons not entirely understood. In the 100 years since the discovery that insulin from animals could be used to save people with T1D from certain death in a matter of months, care for people with the condition is both vastly improved and a daily challenge.

Today’s analog insulins, both basal and fast acting, offer superior glycemic control, but the best ones can be priced out of reach for many patients, and a few years ago the plight of people with T1D unable to afford insulin became the poster child for runaway drug costs in the United States. The major manufacturers have responded with programs for those with gaps in insurance and for people enrolled in Medicare, but cost concerns remain, both for insulin and for continuous glucose monitoring (CGM) technology, which many use to achieve recommended levels of glycated hemoglobin.

The joint ADA/EASD guidance covers a range of topics, including the following:

• diagnosis, including the challenge of differentiating T1D and T2D;
• goals of therapy and blood sugar targets, as well as the more recent emphasis on time in range;
• schedule of care, including the need to customize treatment schedules;
• diabetes self-management education and additional behavioral considerations;
• glucose monitoring, including the rise of CGM as a standard of care;
• insulin therapy, including a discussion of different modes of delivery and patient preferences;
• managing hypoglycemia;
• psychosocial care;
• diabetic ketoacidosis;
• pancreas and islet cell transplantation;
• additional therapies, including a discussion of trials using sodium glucose co-transporter 2 (SGLT2) class therapies to reduce glycemic variability;
• special populations, including pregnant women and older adults; and
• future technologies and treatments, such as beta-cell replacement and immunotherapy.

Throughout, the guidance calls for respecting the patient’s choices, including the fact that not all patients prefer insulin pumps or can afford them, and most patients are advised to remain skilled at administering insulin through daily injections, in case pump technology fails or software that supports pumps or CGM becomes temporarily inoperable.

The guidance also confronts the diabetes-related emotional distress and depression that a significant share of people with T1D live with; it calls for use of validated screening tools and ongoing assessment of mental health needs.

Despite advances, T1D patients and advocates have at times expressed frustration with the lack of progress in the areas of technology and on the pharmaceutical front. The document acknowledges that clinical trials are under way to test fully closed-loop automated insulin delivery systems, with the expectation that some of these products will soon reach the market. At the same time, some with T1D have jumped ahead of the process with a “do-it-yourself” technology movement that the guidance says regulators cannot formally endorse, but health care professionals should nonetheless “respect.”

“There are still huge gaps in our knowledge about how to prevent, diagnose and treat type 1 diabetes. We are also aware that many people with type 1 diabetes experience inequalities in treatment,” the coauthors stated. “We hope that this report will promote better higher quality research to determine optimal care, while helping to share best clinical practice so that all individuals with type 1 diabetes have access to the care they need.”

Reference

1. Holt RIG, DeVries H, Hess-Fishcl A, et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. Published online October 1, 2021. doi:10.2337/dci21-0043