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  • ADA Provides New HbA1c Target for Type 1 Diabetes

     

    Along with today's burgeoning knowledge and understanding of diabetes comes more complexity regarding diagnosis and treatment. In June 2014, the American Diabetes Association (ADA) published a new position statement about the HbA1c goal for pediatric patients with type 1 diabetes. These changes will go along with the glycemic goals of the International Society for Pediatric and Adolescent Diabetes, the Pediatric Endocrine Society, and the International Diabetes Federation of considering a single HbA1c goal of <7.5% in all pediatric age-groups.

     

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    As a chronic condition characterized by an immune-mediated depletion of β-cells, type 1 diabetes necessitates perpetual dependence on exogenous insulin. The U.S. has an estimated 3 million individuals with type 1 diabetes, about 166,000 of whom are children. It is possibly due to diagnostic challenges and the gradual nature of new-onset type 1 diabetes that its specific incidence in individuals over 20 years of age is not known.

    The most recent ADA effort to boost capabilities for recognizing and managing type 1 diabetes stems from the historical challenges associated with distinguishing between type 1 and type 2 diabetes and the need to consider each type independently. Traditionally, the diagnosis of type 1 diabetes has been based on the clinical catabolic symptoms that suggest insulin deficiency, which include hyperglycemia (nonresponsive to oral agents), polyuria, polydipsia, and weight loss. The ADA has provided a set of criteria for the diagnosis of diabetes.

    The specific criteria presented are as follows:

    • A1C ≥6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*
    • OR

    • FPG ≥126mg/dL (7.0mmol/L). Fasting is defined as no caloric intake for at least 8 hrs.*
    • OR

    • Two-hour plasma glucose ≥200mg/dL (11.1mmol/L) during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water.*
    • OR

    • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200mg/dL (11.1mmol/L).

    *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.

    The diagnostic criteria for type 1 and type 2 diabetes are the same. Therefore, the ADA recommends consideration for measurement of pancreatic autoantibodies to confirm the diagnosis of type 1 diabetes.

    Based on recent data, the ADA determined that alteration of traditional goals for pediatric patients was required. The new pediatric glycemic control target of HbA1c is less than 7.5%, across all ages. This replaces the varied targets by age (less than 8.5% for children aged under 6 years, less than 8% for those aged 6 to 12 years, and less than 7.5% for adolescents between the ages of 13 and 19 years) that were part of previous guidelines. The ADA also indicated that this goal should be achieved if possible, to minimize the risk of severe, recurrent hypoglycemia. For adults with type 1 diabetes, the HbA1c target of less than 7% has stayed the same. Individualized lower or higher targets for adults should still be based on a patient's needs.

    With all the different insulin formulations now available, meeting this new target will be much easier and will come with less risk of hypoglycemia. The following Insulin Formulations table (based on FDA-approved labeling as of February 2014, and provided as part of the 2015 PDR Nurse's Drug Handbook) is another useful resource while treating your patients with diabetes.


    INSULIN FORMULATIONS
    Type of Insulin Brand Class (Rx/OTC) Onset* Peak* Duration*
    Rapid-acting
     Insulin glulisine
     Insulin lispro
     Insulin aspart

    Apidra
    Humalog
    Novolog

    Rx
    Rx
    Rx

    15 min
    15 min
    15 min

    0.5–1.5 hrs
    0.5–1.5 hrs
    0.5–1.5 hrs

    3–5 hrs
    3–5 hrs
    3–5 hrs
    Short-acting
     Regular insulin

    Humulin R
    Novolin R
    OTC
    OTC
    30–60 min
    30–60 min
    2–4 hrs
    2–4 hrs
    5–8 hrs
    5–8 hrs
    Intermediate-acting
     NPH

    Humulin N
    Novolin N
    OTC
    OTC
    1–3 hrs
    1–3 hrs
    8 hrs
    8 hrs
    12–16 hrs
    12–16 hrs
    Long-acting
     Insulin glargine
     Insulin detemir

    Lantus
    Levemir

    Rx
    Rx

    1 hr
    1 hr

    Peakless
    Peakless

    20–26 hrs
    20–26 hrs
    Combinations
     NPH (70%)/regular insulin (30%)
     NPH (70%)/regular insulin (30%)
     Insulin aspart protamine (70%)/
      insulin aspart (30%)
     Insulin lispro protamine (50%)/
      insulin lispro (50%)
     Insulin lispro protamine (75%)/
      insulin lispro (25%)

    Humulin 70/30
    Novolin 70/30
    NovoLog Mix 70/30

    Humalog Mix50/50

    Humalog Mix75/25


    OTC
    OTC
    Rx

    Rx

    Rx


    30–60 min
    30–60 min
    5–15 min

    10–15 min

    10–15 min


    Varies
    Varies
    Varies

    Varies

    Varies


    10–16 hrs
    10–16 hrs
    10–16 hrs

    10–16 hrs

    10–16 hrs

    Refer to full FDA-approved labeling for detailed information.

    *Onset, peak, and duration will vary among patients and dosage should be determined by the healthcare provider familiar with the patient's metabolic needs, eating habits, and other lifestyle variables.

    Also available as 500 U/mL (Rx only) for insulin-resistant patients (rapid onset [within 30 min]; up to 24-hr duration).


    Source: Types of Insulin. National Diabetes Information Clearinghouse (NDIC) website.
    http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/insert_C.aspx. Updated February 16, 2012. Accessed February 4, 2013.

    For patients who require mealtime insulin, a new treatment option is now available. Afrezza (insulin human) Inhalation Powder, a rapid-acting inhaled insulin to improve glycemic control in adults with diabetes mellitus, is to be used in combination with long-acting insulin in patients with type 1 diabetes. PDR Network is a valuable resource for this and thousands of other available products, offering alerts and specific product labeling. Keep current by using PDR.net and by providing updated contact information. If you use the electronic health record channel, please ask for it to include the PDR drug data feeds, including PDR BRIEF. Updated drug information, full labeling, and safety warnings will be integrated into your electronic prescribing system automatically, and at no cost to you.

    Salvatore Volpe, MD, FAAP, FACP, CHCQM
    Chief Medical Officer
    PDR Network