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testinal surgery. Refer to the American\nCollege of Surgeons website for informa-tion on accreditation and to locate an ac-credited program (https://www.facs.org/quality-programs/accreditation-and-\nverifi cation/metabolic-and-bariatric-surgery-\naccreditation-and-quality-improvement-\nprogram/).\nBeyond the perioperati... | [
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program/).\nBeyond the perioperative period, longer-\nterm risks include vitamin and mineral de fi-\nciencies, anemia, osteoporosis, dumpingsyndrome, and severe hypoglycemia (130).Nutritional and micronutrient de ficiencies\nand related complications occur with a vari-\nable frequency depending on the type of | [
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able frequency depending on the type of\nprocedure and require routine monitoringof micronutrient and nutritional status andlifelong vitamin/nutritional supplementa-\ntion (130). Dumping syndrome usually oc-\ncurs shortly (10 –30 min) after a meal and | [
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curs shortly (10 –30 min) after a meal and\nmay present with diarrhea, nausea, vom-iting, palpitations, and fatigue; hypoglyce-mia is usually not present at the time of\nsymptoms but, in some cases, may de-\nvelop several hours later. Post –metabolic\nsurgery hypoglycemia can occur withRYGB, VSG, and other gastrointest... | [
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procedures and may severely impact\nquality of life (131 –133). Post –metabolicdiabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S153\n©AmericanDiabetesAssociation | [
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surgery hypoglycemia is driven in part by\naltered gastric emptying of ingestednutrients, leading to rapid intestinal\nglucose absorption and excessive post-\nprandial secretion of GLP-1 and othergastrointestinal peptides. As a result, over-stimulation of insulin release and a sharp\ndrop in plasma glucose occur, most ... | [
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drop in plasma glucose occur, most com-\nmonly 1 –3 h after a high-carbohydrate\nmeal. Symptoms range from sweating,tremor, tachycardia, and increased hunger\nto impaired cognition, loss of conscious-\nness, and seizures. In contrast to dumpingsyndrome, which often occurs soon aftersurgery and improves over time, post ... | [
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bariatric surgery hypoglycemia typically\npresents >1 year post-surgery. Diagnosis\nis primarily made by a thorough history,\ndetailed records of food intake, physicalactivity, and symptom patterns, and ex-\nclusion of other potential causes (e.g., | [
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clusion of other potential causes (e.g.,\nmalnutrition, side effects of medicationsor supplements, dumping syndrome, andinsulinoma). Initial management includes\neducation to facilitate reduced intake of\nrapidly digested carbohydrates while en-suring adequate intake of protein andhealthy fats, and vitamin/nutrient sup... | [
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ments. When available, individuals should\nbe offered medical nutrition therapy withad i e t i t i a ne x p e r i e n c e di np o s t –bariatric sur-\ngery hypoglycemia and the use of continu-ous glucose monitoring (ideally real-time\ncontinuous glucose monitoring, which can | [
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continuous glucose monitoring, which can\ndetect dropping glucose levels before severehypoglycemia occurs), especially for thosewith hypoglycemia unawareness. Medica-\ntion treatment, if needed, is primarily aimed\nat slowing carbohydrate absorption (e.g.,acarbose) or reducing GLP-1 and insulin se-cretion (e.g., diazox... | [
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People who undergo metabolic surgery\nmay also be at increased risk for sub-\nstance abuse, worsening or new-onset\ndepression and/or anxiety disorders, andsuicidal ideation (130,135 –140). Candi-\ndates for metabolic surgery should be as-sessed by a behavioral health professional\nwith expertise in obesity management | [
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with expertise in obesity management\nprior to consideration for surgery (141).\nSurgery should be postponed in individu-\nals with alcohol or substance use disor-\nders, severe depression, suicidal ideation,\nor other signi ficant behavioral health con-\nditions until these conditions have beensufficiently addressed. In... | [
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preoperative or new-onset psychopathol-\nogy should be assessed regularly followings u r g e r yt oo p t i m i z eb e h a v i o r a lh e a l t ha n dpostsurgical outcomes.\nReferences\n1. Narayan KM, Boyle JP, Thompson TJ, Gregg\nEW, Williamson DF. Effect of BMI on lifetime risk\nfor diabetes in the U.S. Diabetes Care ... | [
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-0.06701105833053589,
-0.03293034806847572,
0.08399809151887894,
-0.05878781899809837,
... |
22. Kahan S, Fujioka K. Obesity pharmacotherapyin patients with type 2 diabetes. Diabetes Spectr2017;30:250– 257 | [
-0.027162136510014534,
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0.0079101687297225,
-0.03175918757915497,
0.01193... |
23. Wiggins T, Guidozzi N, Welbourn R, AhmedAR, Markar SR. Association of bariatric surgerywith all-cause mortality and incidence of obesity-related disease at a population level: a systematicreview and meta-analysis. PLoS Med 2020;17:e1003206\n24. Aminian A, Wilson R, Zajichek A, et al. | [
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-0... |
24. Aminian A, Wilson R, Zajichek A, et al.\nCardiovascular outcomes in patients with type 2diabetes and obesity: comparison of gastric bypass,sleeve gastrectomy, and usual care. Diabetes Care2021;44:2552 –2563\n25. World Health Organization. Obesity, 2023.Accessed 3 September 2023. Available fromhttps://www.who.int/he... | [
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26. WHO Expert Consultation. Appropriate\nbody-mass index for Asian populations and itsimplications for policy and intervention strategies.\nLancet 2004;363:157– 163\n27. Araneta MR, Kanaya AM, Hsu WC, et al.\nOptimum BMI cut points to screen Asian Americansfor type 2 diabetes. Diabetes Care 2015;38:814 –820 | [
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28. Aggarwal R, Bibbins-Domingo K, Yeh RW,et al. Diabetes screening by race and ethnicity inthe United States: equivalent body mass indexand age thresholds. Ann Intern Med 2022;175:765–773\n29. Rubino F, Batterham RL, Koch M, et al.\nLancet Diabetes & Endocrinology Commission onthe de finition and diagnosis of clinical ... | [
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Lancet Diabetes Endocrinol 2023;11:226– 228S154 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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9. Pharmacologic Approaches to\nGlycemic Treatment: Standards\nof Care in Diabetes— 2024\nDiabetes Care 2024;47(Suppl. 1):S158 –S178 |https://doi.org/10.2337/dc24-S009American Diabetes Association\nProfessional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes” in- | [
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cludes the ADA ’s current clinical practice recommendations and is intended to\nprovide the components of diabetes care, general treatment goals and guide-\nlines, and tools to evaluate quality of care. Members of the ADA ProfessionalPractice Committee, an interprofessional expert committee, are responsible for | [
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updating the Standards of Care annually, or more frequently as warranted. For a\ndetailed description of ADA standards, statements, and reports, as well as theevidence-grading system for ADA ’s clinical practice recommendations and a full | [
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list of Professional Practice Committee members, please refer to Introductionand Methodology. Readers who wish to comment on the Standards of Care areinvited to do so at professional.diabetes.org/SOC.\nPHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 1 DIABETES\nRecommendations\n9.1Treat most adults with type 1 diabetes with... | [
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sulin infusion or multiple daily doses of prandial (injected or inhaled) and\nbasal insulin. A\n9.2For most adults with type 1 diabetes, insulin analogs (or inhaled insulin)\nare preferred over injectable human insulins to minimize hypoglycemia risk. A\n9.3Early use of continuous glucose monitoring is recommended for a... | [
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with type 1 diabetes to improve glycemic outcomes and quality of life andminimize hypoglycemia. B\n9.4Automated insulin delivery systems should be considered for all adults\nwith type 1 diabetes. A\n9.5To improve glycemic outcomes and quality of life and minimize hypoglyce-\nmia risk, most adults with type 1 diabetes s... | [
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to match mealtime insulin doses to carbohydrate intake and, additionally, tofat and protein intake. They should also be taught how to modify the insulindose (correction dose) based on concurrent glycemia, glycemic trends (if\navailable), sick-day management, and anticipated physical activity. B | [
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available), sick-day management, and anticipated physical activity. B\n9.6Glucagon should be prescribed for all individuals taking insulin or at high\nrisk for hypoglycemia. Family, caregivers, school personnel, and others provid-\ning support to these individuals should know its location and be educated on | [
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how to administer it. Glucagon preparations that do not require reconstitu-\ntion are preferred. E\n9.7Insulin treatment plan and insulin-taking behavior should be reevaluated at\nregular intervals (e.g., every 3 –6 months) and adjusted to incorporate speci fic*A complete list of members of the American | [
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Diabetes Association Professional Practice Committeecan be found at https://doi.org/10.2337/dc24-SINT.\nDuality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nSuggested citation: American Diabetes Association\nProfessional Practice Committee. 9. Pharmacologicapproaches to g... | [
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Care in Diabetes —2024. Diabetes Care 2024;47\n(Suppl. 1):S158– S178\n© 2023 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for pro fit, and the work is not altered. | [
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More information is available at https://www.diabetesjournals.org/journals/pages/license.9. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENTS158 Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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factors that impact choice of treat-\nment and ensure achievement of in-dividualized glycemic goals. E\nInsulin Therapy\nInsulin treatment is essential for individu-\nals with type 1 diabetes because thehallmark of type 1 diabetes is absent ornear-absent b-cell function. In addition | [
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to hyperglycemia, insulinopenia can con-tribute to other metabolic disturbanceslike hypertriglyceridemia and ketoacido-\nsis as well as tissue catabolism that can\nbe life threatening. Severe metabolic de-compensation can be, and was, mostly\nprevented with once- or twice-daily in- | [
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prevented with once- or twice-daily in-\njections for the six or seven decades af-ter the discovery of insulin. Over thepast four decades, evidence has accumu-\nlated supporting more intensive insulin\nreplacement, using multiple daily injec-tions of insulin or continuous subcutane-\nous administration through an insul... | [
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ous administration through an insulin\npump, as providing the best combinationof effectiveness and safety for peoplewith type 1 diabetes.\nThe Diabetes Control and Complications\nTrial (DCCT) demonstrated that intensivetherapy with multiple daily injections orcontinuous subcutaneous insulin infusion\n(CSII) reduced A1C... | [
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(CSII) reduced A1C and was associated\nwith improved long-term outcomes (1 –3).\nThe study was carried out with short-acting\n(regular) and intermediate-acting (NPH)\nhuman insulins. In this landmark trial,lower A1C with intensive control (7%) ledto/C2450% reductions in microvascular com- | [
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plications over 6 years of treatment. How-ever, intensive therapy was associatedwith a higher rate of severe hypoglycemia\nthan conventional treatment (62 com-\npared with 19 episodes per 100 patient-years of therapy) (1). Follow-up of partici-\npants from the DCCT demonstrated fewer | [
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pants from the DCCT demonstrated fewer\nmacrovascular and microvascular compli-cations in the group that received intensivetreatment. Achieving intensive glycemic\ngoals during the active treatment period of\nthe study had a bene ficial impact over the\n20 years after the active treatment compo-\nnent of the study ended... | [
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nent of the study ended (1 –3).\nInsulin replacement plans typically con-\nsist of basal insulin, mealtime insulin, and\ncorrection insulin (4). Basal insulin includes\nNPH insulin, long-acting insulin analogs,\nand continuous delivery of rapid-acting in-sulin via an insulin pump. Basal insulinanalogs have longer durat... | [
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withflatter, more constant and consistentplasma concentrations and activity pro-\nfiles than NPH insulin; rapid-acting analogs\n(RAA) have a quicker onset and peak ands h o r t e rd u r a t i o no fa c t i o nt h a nr e g u l a rh u -man insulin. In people with type 1 diabe-\ntes, treatment with analog insulins is | [
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tes, treatment with analog insulins is\nassociated with less hypoglycemia andweight gain as well as lower A1C com-pared with injectable human insulins\n(5–7). More recently, two injectable ultra-\nrapid-acting analog (URAA) insulin formu-\nlations were developed to accelerate ab-sorption and provide more activity in th... | [
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first portion of their profi le compared with\nthe other RAA (8,9). Inhaled human insulin\nhas a rapid peak and shortened durationof action compared with RAA (10) (seealso subsection\nALTERNATIVE INSULIN ROUTES in\nPHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 2\nDIABETES ). These newer formulations may | [
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DIABETES ). These newer formulations may\ncause less hypoglycemia, while improvingpostprandial glucose excursions and ad-\nministration flexibility (in relation to pran-\ndial intake), compared with RAA (10 –12).\nIn addition, longer-acting basal analogs\n(U-300 glargine or degludec) may confer a\nlower hypoglycemia ris... | [
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lower hypoglycemia risk compared with\nU-100 glargine in individuals with type 1diabetes (13,14).\nDespite the advantages of insulin ana-\nlogs in individuals with type 1 diabetes,\nthe expense and/or intensity of treat- | [
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the expense and/or intensity of treat-\nment required for their use may be pro-hibitive. There are multiple approachesto insulin treatment. The central preceptin the management of type 1 diabetes is\nthat some form of insulin be given in a\ndefined treatment plan tailored to the | [
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defined treatment plan tailored to the\nindividual to prevent diabetic ketoacido-sis (DKA) and minimize clinically relevant\nhypoglycemia while achieving the indi-\nvidual ’s glycemic goals. The impact of the\nintroductionofinterchangeablebiosimilarsand unbranded versions of some analog\nproducts as well as current and ... | [
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... |
products as well as current and upcoming\nprice reductions on insulin access need tobe evaluated. Reassessment of insulin-taking behavior and adjustment of treat-ment plans to account for speci ficf a c t o r s ,\nincluding cost, that impact choice of treat-ment is recommended at regular intervals(every3 –6months). | [
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Most studies comparing multiple daily\ninjections with CSII have been relatively\nsmall and of short duration. A systematic\nreview and meta-analysis concluded thatCSII via pump therapy has modest advan-tages for lowering A1C ( /C00.30% [95% CI\n/C00.58 to /C00.02]) and for reducing severe | [
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0.0... |
/C00.58 to /C00.02]) and for reducing severe\nhypoglycemia rates in children and adults(15). Use of CSII is associated with im-provement in quality of life, particularly inareas related to fear of hypoglycemia anddiabetes distress, compared with multipledaily injections of insulin (16,17). How-\never, there is no conse... | [
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ever, there is no consensus to guide the\nchoice of injection or pump therapy in agiven individual, and research to guidethis decision-making is needed (4). Inte-\ngration of continuous glucose monitoring\n(CGM) into the treatment plan soon afterdiagnosis improves glycemic outcomes,decreases hypoglycemic events, and im... | [
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proves quality of life for individuals with\ntype 1 diabetes (18 –23). Its use is now\nconsidered standard of care for most peo-ple with type 1 diabetes (4) (see Section 7,\n“Diabetes Technology ”). Reduction of noc-\nturnal hypoglycemia in individuals with | [
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turnal hypoglycemia in individuals with\ntype 1 diabetes using insulin pumps withCGM is improved by automatic suspensionof insulin delivery at a preset glucose level,\nwith further improvements when using de-\nvices with predictive low glucose insulindelivery suspension (24,25).\nAutomated insulin delivery (AID) system... | [
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Automated insulin delivery (AID) systems\nare safe and effective for people with type1 diabetes. Randomized controlled trialsand real-world studies have demonstratedthe ability of commercially available sys-tems to improve achievement of glycemic\ngoals while reducing the risk of hypoglyce-\nmia (26 –31). Data are emer... | [
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mia (26 –31). Data are emerging on the\nsafety and effectiveness of do-it-yourselfsystems (32,33). Evidence suggests that an\nAID hybrid closed-loop system is superior\nto AID sensor-augmented pump therapyfor increased percentage of time in rangeand reduction of hypoglycemia (34,35).\nIntensive insulin management using... | [
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Intensive insulin management using a\nversion of CSII and CGM should be consid-ered in individuals with type 1 diabeteswhenever feasible. AID systems are pre-ferred and should be considered for indi-\nviduals with type 1 diabetes who are | [
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viduals with type 1 diabetes who are\ncapable of using the device safely (eitherby themselves or with a caregiver) to im-p r o v et i m ei nr a n g ea n dr e d u c eA 1 Ca n d\nhypoglycemia (26,28 –31,36– 42). When\nchoosing among insulin delivery systems, | [
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choosing among insulin delivery systems,\nindividual preferences, cost, insulin type,dosing plan, and self-management capabil-ities should be considered. See Section 7,\n“Diabetes Technology, ”for a full discussion\nof insulin delivery devices.\nIn general, individuals with type 1 dia-\nbetes require approximately 30 –... | [
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betes require approximately 30 –50% of\ntheir daily insulin as basal and the re-mainder as prandial (43). This proportion\nis dependent on a number of factors,diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S159\n©AmericanDiabetesAssociation | [
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including but not limited to carbohydrate\nconsumption, age, pregnancy status, andpuberty stage (4,44– 48). Total daily insulin\nrequirements can be estimated based onweight, with typical doses ranging from\n0.4 to 1.0 units/kg/day. Higher amounts\nmay be required during puberty, menses,and medical illness. The America... | [
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tes Association/JDRF Type 1 Diabetes\nSourcebook notes 0.5 units/kg/day as a\ntypical starting dose in adults with type 1\ndiabetes who are metabolically stable,with approximately one-half administered\nas prandial insulin given to manage blood | [
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as prandial insulin given to manage blood\nglucose after meals and the remainingportion as basal insulin to manage glyce-mia in the periods between meal absorp-tion (49). Starting doses and those soon\nafter diagnosis may be higher, if an individ-\nual presents with ketoacidosis, or lower(0.2–0.6 units/kg), particularl... | [
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0.06482679396867752,
0.014926624484360218,
-0.07031282782554626,
0.015992186... |
children and those with continued endoge-\nnous insulin production (during the partial\nremission phase or “honeymoon period,”\nor in people who present with type 1 dia-betes in adulthood) (49 –52). This guideline\nprovides detailed information on intensi fi- | [
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0.009750192984938622,
-0.08946742117404938,
0.0175... |
provides detailed information on intensi fi-\ncation of therapy to meet individualizedneeds. In addition, the American DiabetesAssociation (ADA) position statement “Type 1\nDiabetes Management Through the Life\nSpan” provides a thorough overview of\ntype 1 diabetes treatment (53).\nTypical multidose treatment plans for | [
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-0.027678... |
type 1 diabetes treatment (53).\nTypical multidose treatment plans for\nindividuals with type 1 diabetes combine\npremeal use of prandial insulins with a\nlonger-acting formulation. The long-acting\nbasal dose is titrated to regulate overnightand fasting glucose. Postprandial glucoseexcursions are best managed by a wel... | [
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0.05977296456694603,
0.0799054428935051,
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0.07240039110183716,
-0.10805147141218185,
-0.0319384... |
timed injection or inhalation of prandial\ninsulin. Prandial insulin should ideally beadministered prior to meal consumption;however, the optimal time to administer\nvaries based on the pharmacokinetics of | [
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0.07... |
varies based on the pharmacokinetics of\nthe formulation (regular, RAA, or inhaled),the premeal blood glucose level, and carbo-hydrate consumption. Recommendationsfor prandial insulin dose administration\nshould therefore be individualized. Physio- | [
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should therefore be individualized. Physio-\nlogic insulin secretion varies with glycemia,meal size, meal composition, and tissue de-mands for glucose. To approach this vari-\nability in people using insulin treatment,\nstrategies have evolved to adjust prandialdoses based on predicted needs. Thus, edu-cation on how to... | [
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account for nutritional intake and the cor-\nrection dose based on premeal glucoselevels, anticipated activity, and sick-daymanagement can be effective and should\nbe offered to most individuals (54 –59). Ed- | [
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be offered to most individuals (54 –59). Ed-\nucation regarding adjustment of prandialinsulin dose for glycemic trends should beprovided to individuals who are using CGMalone or an AID system (60 –63). Further ad-\njustment of prandial insulin doses for nutri-tional intake of protein and fat, in additionto carbohydrate... | [
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be more feasible for individuals using CSII\nthan for those using multiple daily injections(56). With some AID systems, use of a sim-plified meal announcement method may\nbe an alternative for prandial insulin dosing(31,64) (see Section 5, “Facilitating Positive\nHealth Behaviors and Well-being to Im-prove Health Outcom... | [
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“Diabetes Technology ”).\nD u et ot h er i s ko fh y p o g l y c e m i aw i t h\ninsulin treatment, all individuals withtype 1 diabetes should be prescribed glu-cagon. Individuals with type 1 diabetesand/or those in close contact with indi-viduals with type 1 diabetes should beeducated on the use and administration | [
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of the individual ’s prescribed glucagon\nproduct. The glucagon product availableto individuals may differ based on cover-\nage and cost, however those that do notrequire reconstitution are preferred forease of administration (65,66). Clinicians\nshould routinely review the individual ’sa c -\ncess to glucagon, as appr... | [
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0.0281... |
cess to glucagon, as appropriate glucagon\nprescribing is low (67,68). See Section 6,“Glycemic Goals and Hypoglycemia, ”\nfor additional information on hypoglycemiaa n dg l u c a g o ni ni n d i v i d u a l sw i t hd i a b e t e s .The 2021 ADA/European Association forthe Study of Diabetes (EASD) consensus re-\nport on... | [
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port on the management of type 1 diabe-\ntes in adults summarizes different insulinplans and glucose monitoring strategies in\nindividuals with type 1 diabetes (Fig. 9.1\nandTable 9.1 )( 4 ) .\nInsulin Administration Technique\nEnsuring that individuals and/or caregiversunderstand correct insulin administrationtechniqu... | [
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mic management and insulin use safety.\nThus, it is important that insulin be deliv-ered into the proper tissue in the correctway. Recommendations have been pub-\nlished elsewhere outlining best practices\nGreater flexibilityRepresentative relative attributes of insulin deliveryRepresentative relative attributes of ins... | [
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approaches in people with type 1 diabetesapproaches in people with type 1 diabetes1\nInjected insulin plans Greater flexibility Higher costsLower risk of\nhypoglycemia\nHigher costsLower risk of\nhypoglycemiaContinuous insulin infusion plansMDI with LAA + RAA or URAA\nMDI with NPH + RAA or URAA\nMDI with NPH + short-ac... | [
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0.009924370795488358,
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-0.003... |
MDI with NPH + short-acting (regular) insulin\nAutomated Insulin delivery systems\nInsulin pump therapy without automationInsulin pump with threshold/\npredictive low-glucose suspendTwo daily injections with NPH + short-acting (regular)\ninsulin or premixedLess-preferred, alternative injected insulin plans | [
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0... |
insulin or premixedLess-preferred, alternative injected insulin plans\nFigure 9.1 —Choices of insulin plans in people with type 1 diabetes. Continuous glucose moni-\ntoring improves outcomes with injected or infused insulin and is superior to blood glucose | [
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0.021... |
monitoring. Inhaled insulin may be used in place of injectable prandial insulin in the U.S.1The\nnumber of plus signs ( 1) is an estimate of relative association of the plan with increased flexi- | [
-0.019080091267824173,
0.039723336696624756,
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0.013961384072899818,
0.06397068500518799,
-0.02670385129749775,
0.01... |
bility, lower risk of hypoglycemia, and higher costs between the considered plans. LAA, long-acting insulin analog; MDI, multiple daily injections; RAA, rapid-acting insulin analog; URAA,ultra-rapid-acting insulin analog. Adapted from Holt et al. (4).S160 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Vol... | [
-0.026629431173205376,
-0.03092656470835209,
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-0.02967233583331108,
0.07391393184661865,
-0.04886631295084953,
-0.... |
to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024 | [
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0.04411124438047409,
-0.06625044345855713,
-0.1056... |
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