Type 1 Diabetes Mellitus

Management Includes

Insulin Preparations

Selection of Insulin Regimen

Insulin Doses

Home Glucose Monitoring

Glucagon

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ICD-10 Code: E10.0-9/ E12.0-9/E13.0-9/E14.0-9

Management Includes

• Maintenance of glycaemic control within acceptable limits.
• Prevention of chronic complications.
• Prevention of acute complications, e.g. hyperglycaemic and hypoglycaemic coma.

Insulin Preparations

• Insulin, short acting SC, three times daily, 30 minutes before meals:
  • Regular human insulin.
  • Onset of action: 30 minutes
  • Peak action: 2-5 hours.
  • Duration of action 5-8 hours
• Insulin, intermediate acting, SC, once or twice daily, usually at night, not later than 22h00.
  • Onset of action: 1–3 hours.
  • Peak action: 6–12 hours.
  • Duration of action: 16–24 hours.
• Insulin, biphasic, SC, once or twice daily.
  • Mixtures of regular human insulin and NPH insulin in different proportions, e.g. 30/70.
  • Onset of action: 30 minutes.
  • Peak action: 2–12 hours.
  • Duration of action: 16–24 hours.

Selection of Insulin Regimen

Basal bolus regimen

• All type 1 diabetics should preferentially be managed with combined intermediate-acting (basal) and short-acting insulin (bolus), the so-called basal bolus regimen. 
• This consists of pre-meal short-acting insulin and bedtime intermediate-acting insulin not later than 22h00.

Insulin Doses

The initial total daily insulin dose: 

• 0.6 units/kg body weight.

The total dose is divided into:

• 40–50% basal insulin
• the rest of the total daily dose (TDD) is given as bolus insulin split equally before each meal.

Adjust dose on an individual basis.

Alternative regimen where blood glucose cannot be measured frequently by the patient or caregiver: Twice daily insulin
Twice daily pre-mixed insulin, i.e. a mixture of intermediate- or short- acting insulin provides adequate control, when used with at least daily blood glucose monitoring. 

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Note:
Optimal glycaemic control is seldom achieved with this regimen.

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LoE:III

Insulin delivery devices
In visually impaired patients prefilled syringes should be used.

Home Glucose Monitoring

• Patients on basal/bolus insulin should measure glucose 3-4 times daily. This may be individualised depending on the clinical need of the patient. 

LoE:III

• All patients with type 2 diabetes, on insulin, should be given test strips for home glucose monitoring appropriate for their care plan.
• It is important to maximise the value of home glucose monitoring by careful review of home glucose records at each visit and appropriate patient education in terms of self dose adjustment.

LoE:I²⁰

Glucagon

• Type 1 diabetics, who are found to be at high risk of hypoglycaemia because of recurrent episodes, should have a glucagon hypoglycaemia kit and both the patient and their family should be trained to use this emergency therapy.
• Repeat prescriptions of glucagon hypoglycaemia kit should only be given if the kit has expired or been utilised.

LoE:III

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition