Treatment of Type 1 Diabetes: Physiologic Insulin Replacement
Clinical Overview
Type 1 diabetes mellitus requires lifelong insulin replacement. The evidence-based approach prioritises delivery strategies that replicate normal physiologic insulin secretion as closely as possible, supported by continuous glucose monitoring (CGM preferred).
Treatment Approach
Management centres on subcutaneous physiologic insulin replacement — involving both basal and mealtime insulin components — combined with continuous glucose monitoring. More than one delivery strategy is recognised, and selection is guided by individual clinical circumstances. Insulin analogs are the insulins of choice.
The complete protocol specifies the regimen options, delivery technologies, and decision algorithm in full.
Clinical Targets
- HbA1c <53 mmol/mol (<7.0%) without significant hypoglycaemia
- Preprandial capillary plasma glucose 4.4–7.2 mmol/L (80–130 mg/dL)
- Peak 1–2 h postprandial capillary plasma glucose <10.0 mmol/L (<180 mg/dL)
- Time in range (TIR) above 70%
References
DOI: 10.2337/dci21-0043
- Most people with type 1 diabetes should use regimens that mimic physiology as closely as possible, irrespective of the presentation.
- This is best achieved with either MDI of subcutaneous basal insulin analogs and mealtime rapid-acting or ultra-rapid-acting insulin analogs, or with continuous subcutaneous insulin infusion of a rapid-acting insulin analog via a pump, delivered as continuous basal insulin combined with manual mealtime boluses.
- Insulin analogs are, therefore, considered the insulins of choice.
- Preferably MDI but other regimens, including pump or hybrid closed-loop technology, can be started based on individual circumstances.
- An HbA1c goal for most adults of <53 mmol/mol (<7.0%) without significant hypoglycemia is appropriate.
- A preprandial capillary plasma glucose target of 4.4–7.2 mmol/L (80–130 mg/dL) is appropriate for many people.
- A peak postprandial capillary plasma glucose of <10.0 mmol/L (<180 mg/dL) is appropriate for most people with diabetes.
- For most adults with type 1 diabetes, a target TIR should be above 70%, with TBR less than 4% and less than 1% for clinically significant hypoglycemia.
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