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Type 1 Diabetes Mellitus – Symptoms, Causes & Insulin Treatment

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TYPE 1 DIABETES MELLITUS – INDIA

CLINICAL MANAGEMENT GUIDELINE

📋 For Healthcare Professionals Only | Not for Public Use

Scope: Diagnosis | Insulin Therapy | Monitoring | Dose Adjustments | Emergencies | Special Situations

🔰 SYMBOL LEGEND

Symbol	Meaning
✅	Recommended / First-line
⚠️	Caution / Monitor
❌	Contraindicated / Avoid
💊	Drug/Insulin name
🇮🇳	India-specific
📌	Key point
➡️	Next step
🧮	Calculation required

SECTION 1: DIAGNOSIS

1.1 WHEN TO SUSPECT TYPE 1 DIABETES

Clinical Presentation

Feature	T1DM (Typical)	T2DM (Typical)
Age of onset	Usually < 30 years (can occur at any age)	Usually > 40 years
Onset	Acute (days to weeks)	Gradual (months to years)
Symptoms	Marked polyuria, polydipsia, weight loss	Often asymptomatic or mild
Body habitus	Usually lean	Often overweight/obese
Ketosis/DKA at presentation	Common (30-40%)	Rare
Family history of DM	Less common	Very common
Autoimmune diseases	Associated (thyroid, celiac, Addison’s)	Not associated
Insulin requirement	Immediate, lifelong	Eventually (years later)

Red Flags for T1DM (Even in Adults)

Suspect T1DM if:

Age < 35 years with classic symptoms

Lean patient with new diabetes

Rapid progression to insulin requirement

DKA at presentation or soon after diagnosis

Poor response to oral agents

Presence of other autoimmune conditions

No family history of T2DM

Absence of metabolic syndrome features

📌 LADA (Latent Autoimmune Diabetes in Adults): T1DM presenting in adults (usually > 30 years); initially may not need insulin; Often misdiagnosed as T2DM. Test autoantibodies if suspected.

1.2 DIAGNOSTIC CRITERIA

Same Glucose Criteria as T2DM

Test	Diagnostic Cut-off
Fasting Plasma Glucose	≥ 126 mg/dL
2-hr OGTT	≥ 200 mg/dL
HbA1c	≥ 6.5%
Random glucose + symptoms	≥ 200 mg/dL

Confirming T1DM (vs T2DM)

Test	Finding in T1DM	Notes
Autoantibodies	Positive (one or more)	Confirms autoimmune etiology
C-peptide	Low or undetectable	Indicates insulin deficiency

Autoantibody Testing

Autoantibody	Abbreviation	Sensitivity	Notes
Glutamic Acid Decarboxylase	GAD65	~70-80%	Most commonly positive; persists longest
Insulinoma-associated antigen-2	IA-2	~60%	High specificity
Zinc Transporter 8	ZnT8	~60-80%	Newer; adds sensitivity
Insulin autoantibodies	IAA	~50%	Best in children < 5 years; less useful after insulin started
Islet Cell Antibodies	ICA	~70-80%	Older test; less specific

Testing Strategy

Scenario	Test
Suspected T1DM (classic presentation)	GAD65 + IA-2 (or panel)
Uncertain (could be T1DM or T2DM)	GAD65 + C-peptide
Adult with ”T2DM“ not responding to oral agents	GAD65 (screen for LADA)
Established T1DM, uncertain	Fasting C-peptide (< 0.2 nmol/L confirms)

C-Peptide Interpretation

C-Peptide Level	Interpretation
< 0.2 nmol/L (< 0.6 ng/mL)	Absent insulin secretion → T1DM
0.2-0.6 nmol/L	Reduced → Possible LADA or late T1DM
> 0.6 nmol/L (> 1.8 ng/mL)	Preserved → More likely T2DM

⚠️ C-peptide should be measured fasting, ideally when glucose is > 144 mg/dL (8 mmol/L) for accurate interpretation

1.3 CLASSIFICATION OF TYPE 1 DIABETES

Subtype	Features
T1DM Type 1A (Autoimmune)	~90%; Autoantibody positive; Autoimmune destruction of beta cells
T1DM Type 1B (Idiopathic)	~10%; Autoantibody negative; More common in African/Asian ancestry
LADA	Adult-onset (> 30 years); Initially non-insulin requiring; GAD+
Fulminant T1DM	Very rapid onset (days); DKA with near-normal HbA1c; More common in East Asians

1.4 ASSOCIATED CONDITIONS – SCREEN FOR THESE

Condition	Prevalence in T1DM	How to Screen	When
Autoimmune Thyroid Disease	15-30%	TSH	At diagnosis; then annually
Celiac Disease	5-10%	tTG-IgA + Total IgA	At diagnosis; repeat if symptoms or growth issues
Addison’s Disease	~0.5%	If symptoms (fatigue, hypoglycemia, hyperpigmentation)	Clinical suspicion
Pernicious Anemia	~2-4%	B12, Anti-parietal cell antibodies	If symptoms
Vitiligo	~2-8%	Clinical examination	Observation

📌 All patients with T1DM should have TSH checked annually

SECTION 2: TREATMENT TARGETS

2.1 GLYCEMIC TARGETS

Parameter	General Target	Notes
HbA1c	< 7.0% (< 53 mmol/mol)	Individualize
Fasting / Pre-meal glucose	80-130 mg/dL (4.4-7.2 mmol/L)
Post-meal glucose (1-2 hr)	< 180 mg/dL (< 10 mmol/L)
Bedtime glucose	100-140 mg/dL (5.6-7.8 mmol/L)
Time in Range (CGM)	> 70% (70-180 mg/dL)	Key metric if on CGM
Time Below Range	< 4% (< 70 mg/dL); < 1% (< 54 mg/dL)	Minimize hypoglycemia

Individualizing HbA1c Target

Tighter Target (< 6.5-7%)	Relaxed Target (< 7.5-8%)
Short duration of diabetes	Long duration (> 20 years)
No hypoglycemia unawareness	Hypoglycemia unawareness
Good support system	Limited support
No significant complications	Established complications
Pregnancy (pre-conception and during)	Elderly with comorbidities
Motivated patient with CGM	Frequent severe hypoglycemia

2.2 CGM-BASED TARGETS (TIME IN RANGE)

Metric	Target	Interpretation
Time in Range (TIR) 70-180 mg/dL	> 70%	~17 hours/day
Time Below Range (TBR) < 70 mg/dL	< 4%	< 1 hour/day
Time Below Range (TBR) < 54 mg/dL	< 1%	< 15 min/day
Time Above Range (TAR) > 180 mg/dL	< 25%	< 6 hours/day
Time Above Range (TAR) > 250 mg/dL	< 5%	< 1 hour/day
Glucose Variability (CV)	< 36%	Lower is better
GMI (Glucose Management Indicator)	Correlates with HbA1c

📌 Each 10% increase in TIR corresponds to ~0.5% decrease in HbA1c

Correlation Between TIR and HbA1c

TIR	Approximate HbA1c
70%	7.0%
60%	7.5%
50%	8.0%
40%	8.5%

2.3 COMPREHENSIVE TARGETS

Parameter	Target
HbA1c	< 7% (individualize)
TIR	> 70%
Blood Pressure	< 130/80 mmHg
LDL Cholesterol	< 100 mg/dL (< 70 if CVD)
Smoking	Cessation
BMI	Healthy range

SECTION 3: INSULIN THERAPY – THE CORNERSTONE

3.1 FUNDAMENTAL PRINCIPLES

Principle	Details
Insulin is ALWAYS required	From diagnosis, lifelong
Mimic physiology	Basal insulin (background) + Bolus insulin (meals)
Basal-Bolus is standard	Most flexible; best control
Individualize doses	Based on glucose patterns, lifestyle, diet
Patient education is essential	Carb counting, dose adjustments, sick days

3.2 INSULIN TYPES

Basal Insulins (Background/Long-Acting)

Insulin	Brand Examples 🇮🇳	Onset	Peak	Duration	Dosing
💊 Glargine U100	Lantus, Basalog, Glaritus	1-2 hr	Peakless	~24 hr	OD (any fixed time)
💊 Glargine U300	Toujeo	1-2 hr	Flat	~36 hr	OD (more stable)
💊 Degludec	Tresiba	1-2 hr	Flat	~42 hr	OD (flexible timing)
💊 Detemir	Levemir	1-2 hr	Mild	12-24 hr	OD-BD
💊 NPH	Huminsulin N, Wosulin N	1-2 hr	4-8 hr	12-18 hr	BD (has peak → hypo risk)

Bolus Insulins (Mealtime/Rapid-Acting)

Insulin	Brand Examples 🇮🇳	Onset	Peak	Duration	Timing
💊 Aspart	NovoRapid, Novomix	10-15 min	1-2 hr	3-5 hr	0-15 min before meals
💊 Lispro	Humalog	10-15 min	1-2 hr	3-5 hr	0-15 min before meals
💊 Glulisine	Apidra	10-15 min	1-2 hr	3-5 hr	0-15 min before meals
💊 Faster Aspart	Fiasp	5-10 min	0.5-1.5 hr	3-5 hr	At start of meal or within 20 min after
💊 Regular (Short-acting)	Actrapid, Huminsulin R	30-60 min	2-4 hr	6-8 hr	30 min before meals

Ultra-Rapid Insulins

Insulin	Advantage	Use
💊 Faster Aspart (Fiasp)	Quicker onset; can dose during/after meal	Unpredictable eating; post-meal corrections
💊 Lispro-aabc (Lyumjev)	Similar to Fiasp	Same

📌 Rapid-acting analogues (Aspart, Lispro, Glulisine) are preferred over Regular insulin for mealtime dosing due to better timing with meals and less hypoglycemia

3.3 BASAL-BOLUS REGIMEN (STANDARD OF CARE)

Overview

TOTAL DAILY DOSE (TDD)

│

┌────────┴────────┐

│ │

~50% BASAL ~50% BOLUS

(once or twice (divided among

daily) meals)

│ │

▼ ▼

Background Covers carbs

insulin needs + corrections

Starting Doses

Component	Calculation	Example (70 kg patient)
Total Daily Dose (TDD)	0.4-0.6 U/kg/day (start conservative)	70 × 0.5 = 35 units/day
Basal insulin	~50% of TDD	35 × 0.5 = ~18 units
Bolus insulin	~50% of TDD, divided among meals	35 × 0.5 = ~17 units (split 3 ways)

Sample Starting Regimen

Time	Insulin	Starting Dose
Breakfast	Rapid-acting (Aspart/Lispro)	5-6 units
Lunch	Rapid-acting	5-6 units
Dinner	Rapid-acting	5-6 units
Bedtime (or fixed time)	Basal (Glargine/Degludec)	16-18 units

⚠️ Start lower (0.3-0.4 U/kg) if:

- New diagnosis with some residual beta-cell function (”honeymoon phase“)
- Lean patient
- History of hypoglycemia
- Renal impairment

3.4 DOSE TITRATION – SYSTEMATIC APPROACH

Step 1: Titrate Basal First

Goal	Fasting glucose 80-130 mg/dL

Fasting Glucose	Basal Adjustment
> 180 mg/dL	↑ by 4 units
130-180 mg/dL	↑ by 2 units
80-130 mg/dL	No change ✅
70-80 mg/dL	↓ by 2 units
< 70 mg/dL	↓ by 4 units (or 10-20%)

Frequency: Adjust every 3-4 days until fasting glucose at target

Step 2: Then Titrate Bolus

Goal	Pre-meal and 2-hr post-meal glucose at target

Approach:

Look at 2-hr post-meal glucose (should be < 180 mg/dL)
If consistently high after a specific meal → Increase bolus for THAT meal
If consistently low before next meal → Decrease bolus for PREVIOUS meal

Post-Meal Glucose	Bolus Adjustment
> 200 mg/dL	↑ by 2 units (or 10-15%)
180-200 mg/dL	↑ by 1 unit
< 180 mg/dL	No change ✅
Pre-next-meal < 70	↓ by 1-2 units

3.5 ADVANCED DOSING – CARBOHYDRATE COUNTING

The Formula

MEAL BOLUS = Carbs eaten ÷ ICR

TOTAL BOLUS = MEAL BOLUS + CORRECTION BOLUS

Insulin-to-Carb Ratio (ICR)

Definition

Units of rapid insulin needed to cover a set amount of carbohydrate

Estimating ICR:

Method	Formula	Example
Rule of 500	500 ÷ TDD = grams of carb covered by 1 unit	TDD 50 → 500÷50 = 10 → 1:10 ratio
Starting point	1 unit : 10-15 g carb	Adjust based on response

Example:

ICR = 1:10 (1 unit covers 10g carbs)
Meal contains 60g carbs
Meal bolus = 60 ÷ 10 = 6 units

Correction Factor / Insulin Sensitivity Factor (ISF)

Definition

How much 1 unit of rapid insulin lowers blood glucose

Estimating ISF:

Method	Formula	Example
Rule of 100 (mg/dL)	100 ÷ TDD	TDD 50 → 100÷50 = 2 → 1 unit drops BG by 2 mmol/L
Rule of 1800 (mg/dL)	1800 ÷ TDD	TDD 50 → 1800÷50 = 36 → 1 unit drops BG by 36 mg/dL

Correction Dose Formula

CORRECTION DOSE = (Current BG – Target BG) ÷ ISF

Example:

Current glucose: 250 mg/dL
Target glucose: 120 mg/dL
ISF: 40 mg/dL per unit
Correction = (250 – 120) ÷ 40 = 3.25 units → Round to 3 units

Complete Bolus Calculation Example

Parameter	Value
Pre-meal glucose	200 mg/dL
Target glucose	120 mg/dL
Meal carbs	60 g
ICR	1:10 AM
ISF	40 mg/dL/unit

Calculation:

Meal bolus = 60 ÷ 10 = 6 units
Correction = (200 – 120) ÷ 40 = 2 units
Total bolus = 6 + 2 = 8 units

📌 ICR and ISF vary throughout the day – Often need more insulin in the morning (dawn phenomenon) and less at night

3.6 PATTERN MANAGEMENT – INTERPRETING GLUCOSE DATA

Common Patterns and Solutions

Pattern	Likely Cause	Solution
High fasting glucose	Insufficient basal; Dawn phenomenon; Somogyi effect	↑ Basal; Check 3 AM glucose to differentiate
High pre-lunch	Insufficient breakfast bolus	↑ Breakfast bolus
High post-meal (any)	Insufficient meal bolus; Incorrect ICR	↑ Meal bolus; Recalculate ICR
Low pre-meal	Previous meal bolus too high	↓ Previous meal bolus
Low overnight / 3 AM	Basal too high	↓ Basal
Variable glucose	Inconsistent carb counting; Injection site issues	Education; Rotate sites

Dawn Phenomenon vs Somogyi Effect

Feature	Dawn Phenomenon	Somogyi Effect
3 AM glucose	Normal or slightly high	LOW (< 70 mg/dL)
Fasting glucose	High	High (rebound)
Mechanism	Normal physiology (↑ cortisol, GH)	Rebound from nocturnal hypoglycemia
Solution	↑ Basal or give later	↓ Basal or evening bolus; Bedtime snack

📌 Check 3 AM glucose to differentiate – This guides whether to increase or decrease insulin

3.7 INJECTION TECHNIQUE

Injection Sites

Site	Absorption Speed	Notes
Abdomen	Fastest	Preferred for bolus insulin; Avoid 2-inch radius around navel
Outer thigh	Slower	Good for basal
Upper arm (back)	Moderate	May need assistance
Buttocks	Slowest	Good for basal; Children

Rotation Rules

✅ Do	❌ Don’t
Rotate within the SAME region	Inject into same spot repeatedly
Use a systematic pattern	Random rotation between regions
Move at least 1 cm from previous injection	Inject into lipohypertrophy sites
Keep bolus in abdomen, basal in thigh (consistency)	Switch regions day to day for same insulin

Injection Steps

Step	Action
1	Wash hands
2	Check insulin (clarity, expiry)
3	Attach new needle (pen)
4	Prime pen (2 units into air)
5	Dial dose
6	Choose site; clean if needed
7	Pinch skin (for shorter needles, may not need)
8	Insert needle at 90° (45° if very thin)
9	Inject; count to 10 before withdrawing
10	Release pinch; remove needle
11	Dispose needle safely

Needle Length Selection

Needle Length	Who to Use
4 mm	All adults (preferred); All children
5 mm	Alternative for adults
6 mm	Adults with more subcutaneous tissue
8 mm	Rarely needed; 45° angle if used

📌 4 mm needles are recommended for most patients – Reduces risk of intramuscular injection

3.8 INSULIN STORAGE

Storage	Details
Unopened insulin	Refrigerator (2-8°C); Until expiry date
In-use insulin (pen/vial)	Room temperature (< 25-30°C); 28-42 days depending on type
Never freeze	Destroys insulin
Avoid extreme heat	Do not leave in car, direct sunlight
When traveling	Carry in hand luggage (not checked baggage – freezing risk); Use cooling case if hot climate

SECTION 4: ALTERNATIVE REGIMENS

4.1 TWICE-DAILY PREMIXED INSULIN

When to Consider

Situation

Patient unable/unwilling to do multiple daily injections

Limited access to healthcare/education

Stable lifestyle with consistent meals

Resource-limited setting 🇮🇳

Transitioning from T2DM regimen

Premixed Insulin Options

Insulin	Composition	Dosing
💊 NovoMix 30	30% Aspart + 70% Protamine Aspart	BD (before breakfast & dinner)
💊 Humalog Mix 25	25% Lispro + 75% Protamine Lispro	BD
💊 Humalog Mix 50	50% Lispro + 50% Protamine Lispro	BD
💊 Mixtard 30/70	30% Regular + 70% NPH	BD

Starting Premixed Regimen

Step	Action
1	Calculate TDD: 0.4-0.5 U/kg/day
2	Split: 2/3 before breakfast, 1/3 before dinner
3	Titrate based on glucose patterns

Example (70 kg patient):

TDD = 70 × 0.5 = 35 units
Breakfast: 35 × 2/3 = ~24 units
Dinner: 35 × 1/3 = ~12 units

Limitations of Premixed Insulin

❌ Limitations

Less flexibility (fixed ratio)

Cannot adjust basal and bolus independently

Must eat consistent carbs at consistent times

Higher hypoglycemia risk if meals delayed

Not ideal for most T1DM patients

⚠️ Basal-bolus remains the preferred regimen for T1DM. Premixed is a compromise when MDI not feasible.

4.2 INSULIN PUMP THERAPY (CSII)

What is an Insulin Pump?

Feature	Details
Delivery	Continuous subcutaneous insulin infusion
Insulin used	Rapid-acting only (Aspart, Lispro)
Basal	Programmable hourly rates
Bolus	Delivered on demand (meals, corrections)
Site change	Every 2-3 days

Candidates for Pump Therapy

Good Candidates	Not Ideal Candidates
Motivated patients	Poor adherence
Frequent hypoglycemia on MDI	Unwilling to monitor frequently
Hypoglycemia unawareness	Cannot troubleshoot pump issues
High glucose variability	Unrealistic expectations
Dawn phenomenon difficult to control
Pregnancy (planning or current)
Athletes, shift workers
Children (parental support)

Advantages and Disadvantages

✅ Advantages	❌ Disadvantages
Flexible basal rates	Cost 🇮🇳
Precise dosing (0.025-0.1 unit increments)	Requires training
Temporary basal rates (exercise, illness)	Site issues (infection, dislodgement)
Bolus calculator	Always attached
Fewer injections	DKA risk if interrupted
Better TIR in many patients

Pump Settings to Know

Setting	Definition
Basal rate	Units/hour (can vary by time of day)
ICR	Insulin-to-carb ratio
ISF	Correction factor
Target glucose	Goal for corrections
Active insulin time (DIA)	Duration of insulin action (usually 3-5 hrs)

📌 Pump therapy requires significant education and commitment. Refer to specialized diabetes center for initiation.

4.3 HYBRID CLOSED-LOOP SYSTEMS (Automated Insulin Delivery)

How They Work

┌─────────────┐

│ CGM │──── Glucose reading every 5 min

└──────┬──────┘

│

▼

┌─────────────┐

│ Algorithm │──── Predicts glucose; Adjusts basal

└──────┬──────┘

│

▼

┌─────────────┐

│ Pump │──── Delivers adjusted insulin

└─────────────┘

Available Systems

System	Components	Notes
Medtronic 780G	Guardian 4 CGM + Pump	Auto-adjusts basal + auto-corrections
Tandem Control-IQ	Dexcom G6/G7 + t:slim pump	Predicts and prevents highs/lows
Omnipod 5	Dexcom G6/G7 + Omnipod (tubeless)	Tubeless option
DIY Loops	Various (OpenAPS, Loop)	User-built; Not officially approved

What User Still Does

User Responsibility

Enter carbs for meals (bolus)

Calibrate CGM (some systems)

Change infusion sets and CGM sensors

Monitor for system issues

Override when needed

📌 Hybrid closed-loop significantly improves TIR and reduces hypoglycemia but requires patient engagement and is expensive 🇮🇳

SECTION 5: CONTINUOUS GLUCOSE MONITORING (CGM)

5.1 WHY CGM?

Benefit	Evidence
↑ Time in Range	Multiple RCTs
↓ HbA1c	0.3-0.5% reduction
↓ Hypoglycemia	Significant reduction, especially nocturnal
↓ Hypoglycemia unawareness	Early warning
Better quality of life	Less finger pricks; Trend information
Real-time feedback	See effect of food, exercise, insulin

Who Should Use CGM?

Strong Indication	Consider
All T1DM (if affordable)	T2DM on intensive insulin
Frequent hypoglycemia	Pregnancy
Hypoglycemia unawareness	High glucose variability
Children with T1DM	Athletes
Pregnancy	Occupational requirements

5.2 CGM SYSTEMS AVAILABLE

Real-Time CGM (rtCGM)

System	Sensor Duration	Calibration	Alerts	Notes
Dexcom G7	10 days	No	Yes	Gold standard; Integrates with pumps
Dexcom G6	10 days	No	Yes	Widely used
Medtronic Guardian 4	7 days	No	Yes	Works with Medtronic pumps
FreeStyle Libre 3	14 days	No	Yes	Real-time; Small sensor

Intermittently Scanned CGM (isCGM / Flash)

System	Sensor Duration	Calibration	Alerts	Notes
FreeStyle Libre 2	14 days	No	Optional (hypo/hyper)	Must scan to see glucose; Affordable 🇮🇳
FreeStyle Libre 1	14 days	No	No	Basic; Must scan

📌 FreeStyle Libre is more affordable and widely available in India – Good starting point for CGM

5.3 INTERPRETING CGM DATA

Key Metrics to Review

Metric	What It Tells You
TIR (Time in Range)	Overall control
GMI	Estimated HbA1c equivalent
Average glucose	Overall mean
CV (Coefficient of Variation)	Glucose variability (< 36% is good)
Time below range	Hypoglycemia burden
Time above range	Hyperglycemia burden

AGP (Ambulatory Glucose Profile) – How to Read

Component	What to Look At
Median line	Typical glucose through the day
Interquartile range (25th-75th)	Where glucose usually is
10th-90th percentile	Variability/outliers
Patterns	Recurring highs or lows at specific times

Pattern Recognition

Time of Day	High Glucose	Low Glucose
Overnight	Insufficient basal; Bedtime snack	Basal too high; Evening bolus too high
Fasting / Wake up	Dawn phenomenon; Insufficient basal	Basal too high
After breakfast	ICR too high; Insufficient breakfast bolus	Bolus too high; Overestimated carbs
Before lunch	—	Breakfast bolus too high
After any meal	Insufficient bolus; Wrong ICR	Bolus too high
Post-exercise	—	Didn’t reduce bolus; Delayed hypo

5.4 CGM ALERTS – SETTING UP

Recommended Alert Settings

Alert	Suggested Setting	Notes
Low (urgent)	55 mg/dL (3.1 mmol/L)	Do not turn off
Low	70 mg/dL (3.9 mmol/L)
High	250 mg/dL (13.9 mmol/L)	Adjust based on targets
Rise rate	> 2-3 mg/dL/min	Optional; Warns of rapid rise
Fall rate	> 2-3 mg/dL/min	Important; Warns of impending low

⚠️ Alert fatigue is real – Set meaningful alerts; Don’t set too many or too tight initially

SECTION 6: HYPOGLYCEMIA MANAGEMENT

6.1 DEFINITIONS

Level	Glucose	Clinical
Level 1 (Alert)	< 70 mg/dL (< 3.9 mmol/L)	Needs treatment; May be asymptomatic
Level 2 (Serious)	< 54 mg/dL (< 3.0 mmol/L)	Clinically significant; Requires immediate action
Level 3 (Severe)	Any	Requires assistance from another person

6.2 SYMPTOMS

Autonomic (Adrenergic)	Neuroglycopenic
Trembling / Shaking	Confusion
Sweating	Difficulty concentrating
Palpitations	Slurred speech
Anxiety	Drowsiness
Hunger	Incoordination
Pallor	Behavioral changes
Tingling (perioral)	Visual disturbances
	Seizures
	Loss of consciousness

⚠️ Hypoglycemia unawareness: Loss of autonomic warning symptoms; Patient goes directly to neuroglycopenic symptoms. Very dangerous – higher risk of severe hypoglycemia.

6.3 TREATMENT – RULE OF 15

Conscious Patient – Self-Treat

Step	Action
1	STOP activity (especially driving)
2	CHECK glucose if possible (don’t delay treatment if symptomatic)
3	TREAT with 15-20 g fast-acting carbohydrate
4	WAIT 15 minutes
5	RECHECK glucose
6	REPEAT if still < 70 mg/dL
7	EAT snack/meal if next meal > 1 hour away

Fast-Acting Carbohydrate Options (15-20 g)

Option	Amount
Glucose tablets	4 tablets (4 g each)
Fruit juice	150-200 mL (½ cup)
Regular soda (not diet)	150 mL
Sugar/Glucose powder	3-4 teaspoons (15-20 g)
Honey	1 tablespoon
Candy (non-chocolate)	5-6 pieces
Glucose gel	1 tube

❌ Do NOT use: Chocolate (fat slows absorption), Diet drinks, Protein bars

Severe Hypoglycemia (Unconscious / Unable to Swallow)

Setting	Treatment
At home / Out of hospital	💊 Glucagon 1 mg IM or SC
	Or Nasal Glucagon 3 mg (if available)
	Place in recovery position
	Call emergency services
	Do NOT give oral glucose
In hospital / IV access	💊 Dextrose 25% 50-100 mL IV (or D50% 25-50 mL)
	Then D10% infusion if needed
	If no IV: Give glucagon IM

Post-Hypoglycemia Actions

Action	Details
Identify cause	Missed meal? Too much insulin? Exercise? Alcohol?
Adjust regimen	Reduce relevant insulin dose by 10-20%
Educate	Prevention; Recognition; Treatment
Check for recurrence	Glucose may drop again (especially with long-acting SU in T2DM, rare in T1DM)

6.4 PREVENTING HYPOGLYCEMIA

General Strategies

Strategy	Details
Appropriate targets	Don’t aim too low; Individualize
CGM	Predictive alerts; Identifies patterns
Carb counting	Match insulin to food
Consistent meals	Don’t skip; Especially if on fixed insulin doses
Exercise adjustments	Reduce insulin before/after; Snack if needed
Alcohol caution	Can cause delayed hypoglycemia; Never drink without food
Regular SMBG/CGM	Catch lows early
Patient education	Recognition; Treatment; When to call for help

Hypoglycemia Unawareness – Management

Step	Action
1	Relax glucose targets (HbA1c 7.5-8%)
2	Strict avoidance of hypoglycemia for 2-3 weeks (awareness can recover)
3	Use CGM with predictive alerts
4	Consider insulin pump with predictive low-glucose suspend
5	Structured education programs (e.g., DAFNE, BERTIE)
6	Frequent glucose monitoring

6.5 GLUCAGON – PATIENT/FAMILY EDUCATION

Who Should Have Glucagon?

All T1DM patients should have glucagon available

Teach family members/close contacts how to use

Keep one at home; Consider one at work/school

Check expiry date regularly

How to Use Injectable Glucagon

Step	Action
1	Reconstitute powder with diluent in kit
2	Mix gently until clear
3	Draw up full vial (1 mg for adults; 0.5 mg for children < 25 kg)
4	Inject into outer thigh, upper arm, or buttock (IM or SC)
5	Turn person on their side (recovery position)
6	Expect response in 10-15 minutes
7	Give oral carbs when awake and able to swallow
8	Seek medical attention

Nasal Glucagon (if available)

Step	Action
1	Insert nozzle into one nostril
2	Press plunger fully
3	Dose is delivered (no inhalation needed)

SECTION 7: DIABETIC KETOACIDOSIS (DKA) (See Emergency Section)

SECTION 8: SPECIAL SITUATIONS

8.1 EXERCISE AND T1DM

Glucose Response to Exercise

Exercise Type	Effect on Glucose	Mechanism
Aerobic (prolonged)	↓↓ Usually drops	↑ Glucose uptake by muscles
Anaerobic / High-intensity	↑ May rise initially, then drop	Stress hormone release
Mixed	Variable	Combination

Strategies to Prevent Hypoglycemia

Timing	Strategy
Before exercise	Reduce bolus for preceding meal by 25-75%
	Have snack if glucose < 100 mg/dL (without bolus)
	Check glucose; Don’t exercise if < 90 or > 250 with ketones
During exercise	Carry fast-acting carbs
	Monitor glucose (CGM ideal)
	Consume 15-30 g carbs per 30-60 min of moderate activity
After exercise	Reduce next bolus
	Consider reducing basal by 10-20% for several hours
	Monitor for delayed hypoglycemia (up to 24 hrs later)
	Bedtime snack if exercised in evening

Adjustments Based on Glucose

Pre-Exercise Glucose	Action
< 90 mg/dL	Delay exercise; Take 15-30 g carbs; Recheck
90-150 mg/dL	May need 10-15 g carbs before starting
150-250 mg/dL	Okay to exercise
> 250 mg/dL	Check ketones
> 250 + ketones positive	Do NOT exercise; Correct first

📌 CGM with trend arrows is invaluable for exercise – Shows direction of glucose change

8.2 ALCOHOL AND T1DM

Key Risks

Risk	Explanation
Delayed hypoglycemia	Alcohol inhibits hepatic gluconeogenesis; Hypo can occur 6-12 hrs later
Masked symptoms	Intoxication mimics hypoglycemia; May not recognize
Impaired judgment	Forget to check glucose, eat, or take insulin
DKA risk	If drinking instead of eating; Vomiting

Safe Drinking Guidelines

Rule	Details
Never drink on empty stomach	Always eat carbs with alcohol
Limit intake	≤ 2 standard drinks
Choose wisely	Dry wine, spirits with sugar-free mixers better than beer or sweet cocktails
Do NOT reduce bedtime insulin	Basal still needed; Reduces overnight hypo from dawn effect
Eat before bed	Long-acting carbs (sandwich, crackers)
Check glucose at bedtime and overnight	Set alarm for 3 AM check if drank significantly
Tell companions	They should know symptoms of hypoglycemia
Wear ID	Medical alert
Reduce morning bolus	May need less insulin next day

What is a Standard Drink?

Drink	Amount
Beer (5%)	350 mL
Wine (12%)	150 mL
Spirits (40%)	45 mL

8.3 TRAVEL AND T1DM

Preparation

Item	Details
Medical letter	From doctor; States diagnosis, medications, need for supplies
Supplies	Pack 2-3× what you need; Divide between carry-on and checked bags
Carry-on must have	Insulin, glucose meter, CGM receiver, hypo treatment, glucagon, snacks
Storage	Insulin in carry-on (checked baggage can freeze); Cooling case if needed
Medical ID	Wear at all times
Insurance	Travel insurance that covers diabetes
Emergency contacts	Local diabetes services at destination

Time Zone Changes

Eastward Travel (Shorter Day)

May need LESS total basal insulin for that day

Keep bolus insulin with meals

Adjust timings gradually after arrival

Westward Travel (Longer Day)

May need MORE total basal insulin for that day

May need extra bolus for extra meal

Adjust timings gradually after arrival

Simple Approach

Step	Action
1	Keep watch on HOME time until arrival
2	Take insulin at usual home times during travel
3	After arrival, switch to LOCAL time
4	Adjust basal timing by 2-hour increments per day until aligned
5	Monitor frequently during adjustment

📌 For short trips (< 3-4 time zones), minimal adjustment needed

8.4 FASTING (Religious or Medical)

Risks of Fasting in T1DM

Risk	Explanation
Hypoglycemia	No carb intake while insulin continues
Hyperglycemia / DKA	If insulin reduced too much; Stress of fasting
Dehydration	Especially in hot weather

General Guidance

Fasting Type	Recommendation
Short-term (< 24 hrs)	Often possible with adjustments
Prolonged (> 24 hrs)	Generally discouraged in T1DM; Higher risk
Ramadan	Possible for some; Requires careful planning

Ramadan Fasting (If Patient Chooses to Fast)

Pre-Ramadan (4-6 weeks before)

Medical assessment; Risk stratification

Structured education

Adjust insulin regimen; Practice with dose changes

Teach sick day rules; When to break fast

During Ramadan

Basal insulin: Reduce by 15-30%; May shift timing to Iftar

Suhoor bolus: Reduce by 25-50%

Iftar bolus: May need usual or slightly reduced

Monitor frequently: Before Iftar, 2-3 hrs after Iftar, before Suhoor

Break fast immediately if: Glucose < 70 mg/dL, symptoms of hypo, glucose > 300 mg/dL, illness

⚠️ High-risk patients should NOT fast: Recurrent hypoglycemia, Hypoglycemia unawareness, Poor control (HbA1c > 9%), Recent DKA, Pregnancy, CKD on dialysis

8.5 PREGNANCY AND T1DM

Pre-Conception

Action	Target
HbA1c	< 6.5% (ideally < 6%) before conception
Contraception	Until optimal control achieved
Folic acid	5 mg/day (high dose) from pre-conception through first trimester
Review medications	Stop ACE-I/ARB, Statins (teratogenic)
Retinal screening	Baseline and monitor (can worsen in pregnancy)
Renal function	Baseline; Counsel if CKD

During Pregnancy

Trimester	Insulin Needs	Notes
First	↓ (Slightly less)	Hypoglycemia common; Morning sickness
Second	↑ (Start increasing)	Placental hormones cause resistance
Third	↑↑ (May need 2-3× pre-pregnancy dose)	Peak resistance
Immediately post-partum	↓↓ (Dramatic drop)	Return to pre-pregnancy doses or less

Glucose Targets in Pregnancy

Timing	Target
Fasting	< 95 mg/dL (5.3 mmol/L)
1-hr post-meal	< 140 mg/dL (7.8 mmol/L)
2-hr post-meal	< 120 mg/dL (6.7 mmol/L)

Monitoring

Parameter	Frequency
SMBG	≥ 7 times/day (fasting, pre/post meals, bedtime)
CGM	Highly recommended
HbA1c	Monthly (may underestimate due to ↑ RBC turnover)
Eye exam	Each trimester
Renal function	Each trimester
Fetal monitoring	As per obstetric protocol

Delivery and Post-Partum

Phase	Insulin Management
Labor	IV insulin infusion; Hourly glucose; Target 70-110 mg/dL
Immediately post-delivery	Insulin needs drop dramatically
	Reduce to ~50% of pre-pregnancy dose
	Risk of hypoglycemia (especially if breastfeeding)
Breastfeeding	May need 10-20% less insulin
	Snack before or during feeds

📌 Pregnancy in T1DM is high-risk and requires specialist care – Multidisciplinary team (endocrinologist, obstetrician, diabetes educator, dietitian)

8.6 SURGERY AND T1DM

Pre-Operative

Step	Action
1	Optimize glucose control pre-operatively
2	Schedule surgery early in the day
3	Assess for complications (cardiac, renal, autonomic neuropathy)
4	Hold oral intake as per protocol
5	Adjust insulin (see below)

Insulin Adjustments

Surgery Type	Night Before	Day of Surgery
Minor (local anesthesia)	Usual basal	Usual basal; Hold bolus if NPO
Major (general anesthesia)	Reduce basal by 20%	Hold bolus; Start IV insulin infusion

Intraoperative / Post-Operative

Parameter	Target
Glucose	140-180 mg/dL
Monitoring	Hourly during surgery
Insulin	IV infusion; Transition to SC when eating
Potassium	Monitor (insulin shifts K⁺ intracellularly)

Transition Back to SC Insulin

Step	Action
1	Patient must be eating / tolerating PO
2	Calculate SC dose (use pre-op regimen as guide)
3	Give SC basal + bolus
4	Continue IV insulin for 1-2 hours after SC basal given
5	Stop IV infusion
6	Adjust SC doses based on glucose

SECTION 9: COMPLICATIONS – SCREENING AND MANAGEMENT

9.1 SCREENING SCHEDULE

When to Start Screening

Complication	When to Start	Frequency
Retinopathy	5 years after diagnosis (or at puberty if diagnosed before)	Annually
Nephropathy	5 years after diagnosis (or at puberty)	Annually
Neuropathy	5 years after diagnosis (or at puberty)	Annually
CVD risk assessment	From diagnosis	Annually
Thyroid (TSH)	At diagnosis	Annually
Celiac (tTG-IgA)	At diagnosis	Repeat if symptoms

📌 In T1DM, start screening at 5 years duration or at puberty (unlike T2DM where screening starts at diagnosis because duration is unknown)

9.2 RETINOPATHY

Screening

Method	Frequency
Dilated fundoscopy OR Retinal photography	Annually
More frequent if retinopathy present	3-6 months
Pregnancy	Each trimester

Classification and Action

Stage	Action
No retinopathy	Annual screening
Mild NPDR	Annual screening; Optimize glucose, BP, lipids
Moderate NPDR	6-monthly screening; Ophthalmology referral
Severe NPDR / PDR	Urgent ophthalmology; Laser / Anti-VEGF
DME	Anti-VEGF; Laser

9.3 NEPHROPATHY

Screening

Test	Frequency
eGFR	Annually
Urine ACR	Annually

Action Based on Results

Finding	Action
Normal ACR, normal eGFR	Continue annual screening
Microalbuminuria (ACR 30-300 mg/g)	Confirm on repeat; Start ACE-I/ARB; Optimize BP, glucose
Macroalbuminuria (ACR > 300 mg/g)	ACE-I/ARB; BP < 130/80; Nephrology referral
eGFR < 60	Nephrology referral if progressive; Adjust medications
eGFR < 30	Nephrology referral

9.4 NEUROPATHY

Screening

Test	Frequency
10-g monofilament	Annually
128 Hz tuning fork (vibration)	Annually
Ankle reflexes	Annually
Ask about symptoms	Every visit

Treatment of Painful Neuropathy

Line	Options
First	💊 Pregabalin 75-300 mg BD OR 💊 Duloxetine 60-120 mg OD OR 💊 Gabapentin 300-1200 mg TID
Second	💊 Amitriptyline 10-75 mg at bedtime; Tramadol (short-term); Topical capsaicin
Combination	May combine agents from different classes

9.5 CARDIOVASCULAR RISK

Risk Factors to Manage

Factor	Target
Blood Pressure	< 130/80 mmHg; ACE-I/ARB first-line
LDL Cholesterol	< 100 mg/dL (< 70 if CVD); Statin therapy
Smoking	Cessation
HbA1c	< 7%

Statin Therapy in T1DM

Age	Recommendation
< 40 years	Consider if CVD risk factors present (duration > 10 years, nephropathy, retinopathy, hypertension, dyslipidemia)
40-75 years	Moderate-intensity statin (High-intensity if CVD or high risk)
> 75 years	Individualize

Aspirin in T1DM

Scenario	Recommendation
Established CVD	Yes (75-150 mg/day)
Primary prevention (high CV risk)	Consider if risk > 10% and low bleeding risk
Primary prevention (low CV risk)	Not routinely recommended

9.6 FOOT CARE

Screening

Component	How	Frequency
Inspection	Skin, nails, deformities, ulcers	Every visit
Sensation	10-g monofilament	Annually
Vibration	128 Hz tuning fork	Annually
Pulses	Dorsalis pedis, posterior tibial	Annually

Patient Education – Foot Care Rules

✅ Do	❌ Don’t
Inspect feet daily	Walk barefoot
Wash daily; Dry between toes	Use hot water
Moisturize (not between toes)	Cut nails too short
Wear well-fitting shoes	Wear tight shoes
Check inside shoes before wearing	Ignore blisters or cuts
See podiatrist if high-risk	Use sharp instruments
Report problems immediately	Self-treat wounds

SECTION 10: PSYCHOSOCIAL ASPECTS

10.1 DIABETES DISTRESS

Recognize It

Features

Feeling overwhelmed by diabetes self-management

Burnout; Feeling defeated

Fear of hypoglycemia or complications

Guilt about glucose levels

Frustration with variability

Feeling different from peers

Address It

Strategy

Acknowledge feelings; Validate

Simplify regimen where possible

Set realistic, achievable goals

Peer support groups

Psychological support (counseling, CBT)

Technology to reduce burden (CGM, pumps)

Regular follow-up and support

10.2 EATING DISORDERS

Higher Risk in T1DM

Disorder	Features
Diabulimia	Intentionally omitting or reducing insulin to lose weight; Very dangerous (DKA, accelerated complications)
Bulimia	Binge eating followed by purging
Anorexia	Restricted eating

Warning Signs

Sign

Recurrent DKA without clear cause

Unexplained high HbA1c

Weight loss or preoccupation with weight

Avoiding injections in front of others

Requesting less insulin

Secret eating behaviors

Management

Action

Non-judgmental discussion

Involve mental health professional (essential)

Diabetes team collaboration

Focus on health, not weight

More frequent follow-up

May need inpatient treatment

10.3 DEPRESSION AND ANXIETY

Prevalence

Condition	Prevalence in T1DM
Depression	2-3× general population
Anxiety	2× general population

Screening

Tool	Use
PHQ-2 / PHQ-9	Depression screening
GAD-7	Anxiety screening

Impact on Diabetes

Effect

Poor self-management

Worse glucose control

Higher complication rates

Lower quality of life

Management

Action

Screening at routine visits

Psychological support / Counseling

CBT effective for both conditions

Antidepressants if indicated (SSRIs generally safe)

Address diabetes-related contributors

Peer support

SECTION 11: PATIENT EDUCATION CHECKLIST

11.1 SURVIVAL SKILLS (Teach at Diagnosis)

Topic	Key Points
What is T1DM	Autoimmune; Lifelong insulin needed
Insulin administration	Injection technique; Sites; Rotation; Storage
Glucose monitoring	How to check; When to check; Targets
Hypoglycemia	Symptoms; Treatment (Rule of 15); When to use glucagon
Hyperglycemia / DKA	Warning signs; When to seek help
Sick day rules	Never stop insulin; Check ketones; Stay hydrated
When to call for help	Contact numbers; Emergency situations
Identification	Wear medical alert

11.2 ONGOING EDUCATION (Over First Year and Beyond)

Topic	Key Points
Carb counting	How to estimate; ICR; Reading labels
Dose adjustment	Correction doses; ISF; Pattern management
Exercise	Effects on glucose; Adjustments
Alcohol	Risks; Safe drinking
Diet	Healthy eating; GI; Meal planning
Foot care	Daily inspection; Proper footwear
Screening	Eyes, kidneys, feet – why and when
Pregnancy planning	Importance of pre-conception care
Psychosocial support	Available resources
Driving	Rules; Check before driving; Carry hypo treatment

11.3 MEDICAL IDENTIFICATION

All T1DM Patients Should Wear Medical ID

Options

Medical alert bracelet

Medical alert necklace

Medical ID card in wallet

Smartphone medical ID feature

Information to include:

Type 1 Diabetes
Insulin-dependent
Emergency contact
Allergies (if any)

SECTION 12: SUMMARY TABLES

12.1 INSULIN TYPES – QUICK REFERENCE

Type	Examples	Onset	Peak	Duration
Rapid-acting	Aspart, Lispro, Glulisine	10-15 min	1-2 hr	3-5 hr
Short-acting	Regular	30-60 min	2-4 hr	6-8 hr
Intermediate	NPH	1-2 hr	4-8 hr	12-18 hr
Long-acting	Glargine, Detemir	1-2 hr	Minimal	18-24 hr
Ultra-long	Degludec, Glargine U300	1-2 hr	Flat	24-42 hr

12.2 KEY FORMULAS

Formula	Calculation
TDD (Starting)	0.4-0.6 U/kg/day
Basal dose	~50% of TDD
Bolus dose	~50% of TDD (divided among meals)
ICR (Rule of 500)	500 ÷ TDD
ISF (Rule of 1800)	1800 ÷ TDD
Correction dose	(Current BG – Target) ÷ ISF
Meal bolus	Carbs ÷ ICR

12.3 TARGETS – QUICK REFERENCE

Parameter	Target
HbA1c	< 7% (individualize)
Fasting glucose	80-130 mg/dL
Post-meal glucose	< 180 mg/dL
TIR (70-180)	> 70%
TBR (< 70)	< 4%
BP	< 130/80 mmHg
LDL	< 100 mg/dL

12.4 HYPOGLYCEMIA TREATMENT – QUICK REFERENCE

Conscious	Unconscious
15-20 g fast-acting carbs	Glucagon 1 mg IM/SC
Wait 15 min; Recheck	OR Dextrose 25-50% IV
Repeat if still < 70	Recovery position
Eat meal/snack	Call emergency services

12.5 DKA MANAGEMENT – QUICK REFERENCE

Priority	Action
1	Fluids: 0.9% NS 1-1.5 L in hour 1
2	K⁺: Check before insulin; Replace if < 5.3
3	Insulin: 0.1 U/kg/hr IV after K⁺ ≥ 3.3
4	Monitor: Hourly glucose; 2-4 hourly electrolytes
5	D5: Add when glucose < 200
6	Transition: SC insulin when eating and resolved

12.6 SICK DAY RULES – QUICK REFERENCE

✅ Do	❌ Don’t
Continue insulin (may need MORE)	Stop insulin
Check glucose every 2-4 hrs	Ignore high readings
Check ketones if BG > 250	Wait until very unwell
Stay hydrated
Seek help if ketones high or vomiting

12.7 SCREENING SCHEDULE – QUICK REFERENCE

Complication	Start	Frequency
Retinopathy	5 years (or puberty)	Annually
Nephropathy	5 years (or puberty)	Annually
Neuropathy	5 years (or puberty)	Annually
Thyroid (TSH)	Diagnosis	Annually
Celiac (tTG-IgA)	Diagnosis	If symptoms
CV risk	Diagnosis	Annually

📚 ABBREVIATIONS

Abbreviation	Full Form
T1DM	Type 1 Diabetes Mellitus
T2DM	Type 2 Diabetes Mellitus
LADA	Latent Autoimmune Diabetes in Adults
DKA	Diabetic Ketoacidosis
GAD	Glutamic Acid Decarboxylase
IA-2	Insulinoma-associated Antigen-2
ZnT8	Zinc Transporter 8
IAA	Insulin Autoantibodies
ICA	Islet Cell Antibodies
TDD	Total Daily Dose
ICR	Insulin-to-Carb Ratio
ISF	Insulin Sensitivity Factor
CGM	Continuous Glucose Monitoring
rtCGM	Real-Time CGM
isCGM	Intermittently Scanned CGM
TIR	Time in Range
TBR	Time Below Range
TAR	Time Above Range
GMI	Glucose Management Indicator
CV	Coefficient of Variation
AGP	Ambulatory Glucose Profile
SMBG	Self-Monitoring of Blood Glucose
MDI	Multiple Daily Injections
CSII	Continuous Subcutaneous Insulin Infusion (Pump)
AID	Automated Insulin Delivery
HbA1c	Glycated Hemoglobin
FPG	Fasting Plasma Glucose
NPDR	Non-Proliferative Diabetic Retinopathy
PDR	Proliferative Diabetic Retinopathy
DME	Diabetic Macular Edema
ACR	Albumin-to-Creatinine Ratio
eGFR	Estimated Glomerular Filtration Rate
CVD	Cardiovascular Disease
ACE-I	Angiotensin-Converting Enzyme Inhibitor
ARB	Angiotensin Receptor Blocker
NPH	Neutral Protamine Hagedorn (Intermediate insulin)
SC	Subcutaneous
IV	Intravenous
IM	Intramuscular
OD	Once Daily
BD	Twice Daily
TID	Three Times Daily
NPO	Nil Per Os (Nothing by mouth)

📖 REFERENCES

Source	Year
ADA Standards of Care in Diabetes	2024
ISPAD Clinical Practice Consensus Guidelines	2022
Diabetes UK / ABCD Position Statements	2023
Endocrine Society Guidelines	2023
International Consensus on CGM	2019

Document Version: 1.0

Last Updated: December 2024

For: Healthcare Professionals Only

Disclaimer: Clinical judgment must be exercised for individual patients. T1DM management is complex and often requires specialist input. Local protocols and resource availability should guide management. Do not self-medicate.

End of Guideline

🛡️

Medical Advisory

Clinical guidelines are subject to change. Physicians should exercise their regular clinical judgment. This protocol does not replace individual institutional policies. Verified for Q1 2026.

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