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CDE Diabetes

Study Guide: Glycemic Management Across the Lifespan for People With Type 1 Diabetes (2025 Update)

1. Overview & Scope

This is a major update that replaces the 2018 “Glycemic Management in Adults with Type 1 Diabetes” chapter and updates the glycemic sections of the “Type 1 Diabetes in Children and Adolescents” chapter.

  • Goal: To support individuals in living well with type 1 diabetes throughout their lifespan, balancing glycemic optimization with hypoglycemia risk and quality of life.
  • Key Shift: Universal access to advanced insulin therapies (second-generation analogues) and technologies (Automated Insulin Delivery) is advocated for all individuals.

2. Updated Terminology

The guidelines have updated the language to reflect modern clinical practice.

New TermPrevious/
Related Terms		Description
BBI (Basal Bolus Injection)MDI (Multiple Daily Injections)Subcutaneous delivery of rapid and long-acting insulin via pens/syringes.
IPT (Insulin Pump Therapy)CSII (Continuous Subcutaneous Insulin Infusion)Pump therapy without automation.
IPT + PLGSSAP + PLGS (Sensor Augmented Pump)Pump + CGM with Predictive Low Glucose Suspend (automated basal suspension).
AID (Automated Insulin Delivery)Hybrid Closed Loop / Artificial PancreasPump + CGM with automated increases, decreases, and suspensions of basal insulin (and sometimes automated boluses).

3. Glycemic Targets

  • Universal Target: An A1C target of < 7.0% is now recommended for ALL age groups, including children (previously, children had higher targets).
    • Rationale: Evidence suggests chronic hyperglycemia in young children (4–10 years) impacts brain development/cognition. New technologies (AID/CGM) make lower targets safer.
  • Person-Centered: Targets must be individualized. If <7.0% is not attainable without severe hypoglycemia or significant burden, a higher target is appropriate.

4. Insulin Therapy (Formulations)

The guidelines express a clear preference for modern analogues over older insulins to improve A1C and reduce hypoglycemia.

  • Rapid-Acting Analogues (Aspart, Lispro, Glulisine): Preferred over Regular insulin for BBI and IPT.
  • Ultrarapid-Acting Analogues (FiAsp, Lyumjev):
    • Recommendation: Should be considered in place of rapid analogues for BBI (to lower post-prandial glucose) and IPT (to improve Time in Range).
    • Timing: Ideally administered 10–20 minutes prior to meals.
  • Long-Acting Basal Analogues (Glargine U-100, Detemir): Preferred over NPH due to lower hypoglycemia risk.
  • Ultralong-Acting Basal Analogues (Glargine U-300, Degludec):
    • Recommendation: Should be considered in place of long-acting analogues to further minimize hypoglycemia (especially nocturnal) and glycemic variability.
    • Weekly Insulin: Once-weekly Icodec is not generally preferred for T1D due to a 2-fold increase in hypoglycemia risk compared to daily basal.

5. Insulin Delivery Hierarchy (The "Choice" Recommendations)

For the CDE exam, know the hierarchy of preferred treatments based on efficacy:

  1. Automated Insulin Delivery (AID):
    • Gold Standard: Preferred for ALL individuals (adults and children) willing/able to use it.
    • Benefits: Improves A1C, Time in Range (TIR), and Quality of Life; reduces hypoglycemia, diabetes distress, and sleep interruption.
  2. IPT + PLGS (Predictive Low Glucose Suspend):
    • Recommended if AID is not used, specifically to reduce hypoglycemia.
  3. Insulin Pump Therapy (IPT):
    • Preferred over BBI to improve A1C and lifestyle flexibility.
  4. Basal Bolus Injection (BBI):
    • Standard injection therapy. Use of smart apps/bolus calculators is recommended to improve outcomes.

6. Adjunctive Therapies (Adults Only)

Using non-insulin agents to help with weight, insulin dose, and glycemia.

  • Status: Conditional recommendation for Adults only. (Insufficient evidence for children).
  • Classes:
    • Metformin: Reduces weight and insulin dose; minimal A1C effect.
    • GLP-1 RAs: Reduces A1C, weight, and insulin dose. Risk: GI side effects, ketosis.
    • SGLT2 Inhibitors: Reduces A1C, weight, and variability. Risk: Euglycemic DKA and genital infections.
  • Safety: Requires careful monitoring. SGLT2i use requires the STOP DKA protocol (ketone monitoring even if glucose is normal).

7. Acute Complications: Pediatric Updates

New protocols for Hypoglycemia and DKA in children differ from historical teaching.

A. Hypoglycemia Treatment (Children/Adolescents)

  • Dose: 0.3 g/kg of carbohydrate.

    • Age < 5: 5 g

    • Age 5–10: 10 g

    • Age > 10: 15 g.

  • AID Users: May require LESS carbohydrate (e.g., 5–10 g) because the pump has already suspended insulin.
  • Severe Hypoglycemia:
    • Intranasal Glucagon: Recommended for age 4 years.
    • Injectable Glucagon: Standard for all ages; preferred over nasal for < 4 years.

B. Diabetic Ketoacidosis (DKA) Management

  • Fluids: Isotonic fluids (Normal Saline or Balanced Crystalloids) are safe. Aggressive fluid resuscitation does not increase cerebral edema risk in mild/moderate DKA.
  • Insulin: Subcutaneous insulin (rapid-acting analogues every 1–2 hours) is a safe alternative to IV insulin for mild to moderate DKA in both adults and children. This can avoid ICU admission.

8. Diabetes Canada 2025 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Pages 14-15).

  1. Targets: A1C < 7.0% for all ages to reduce microvascular complications, individualized based on context [Grade A/D].
  2. AID Systems: Should be used in all individuals with T1D to improve A1C, TIR, and Quality of Life [Grade A, Level 1A].
  3. Insulin Choice:
    • Ultrarapid analogues should be considered over rapid analogues to lower post-prandial glucose [Grade A, Level 1A].
    • Ultralong basal analogues should be considered over long-acting to minimize hypoglycemia [Grade C].
  4. Adjunctive Therapy (Adults): Metformin, GLP-1RA, or SGLT2i may be used in adults to achieve specific outcomes (weight/A1C) with careful safety review [Grade D, Consensus].
  5. Pediatric DKA: Use isotonic fluids [Grade B] and consider frequent subcutaneous insulin for mild/moderate cases [Grade B].

Reference:

Halperin IJ, Wicklow B, Amed S, et al. Glycemic Management Across the Lifespan for People With Type 1 Diabetes: A Clinical Practice Guideline. Canadian Journal of Diabetes. 2025;49(1):5-18. doi:10.1016/j.jcjd.2025.01.001