Endocrinologists outline treatment for type 1 diabetes

With almost no rigorous scientific study of type 1 diabetes, there has been no clear road map for managing conditions that can result from the disorder, such as heart and kidney disease. Individuals with type 1 diabetes have a life expectancy 13 years shorter than average, and cardiovascular disease is the primary cause of that shortened life expectancy. 

To fill this void, a group of endocrinologists has drafted a peer-reviewed standard-of-care document designed to guide primary-care physicians, who provide frontline treatment to 50% of adults with type 1 diabetes. 

“We have all these great studies of cardiovascular risk prevention in type 2 diabetes,” said study co-author Irl Hirsch, professor of medicine, Division of Metabolism, Endocrinology and Nutrition, and UW Medicine’s diabetes treatment and teaching chair. “Here in the United States, we have 1.8 million people with type 1 diabetes and yet we have almost no direct studies. I went to the New England Journal of Medicine and said, ‘Look, this is a huge problem.’ 

“If you go around the world and you look at the guidelines, there's not complete agreement, especially when we start looking at diabetes in adolescents and young adults.”

The result of that conversation is an article published April 3. It clearly and simply explains how heart, kidney and liver disease manifest in type 1 patients, and identifies best treatment options for high blood glucose, hypertension, obesity and several specific heart conditions.

Hirsch and his colleagues think the guidance is critical. A 2014 Swedish study found that individuals with type 1 diabetes with well-regulated blood sugar are nonetheless twice as likely to die from a cardiovascular event. Women are two times as likely to die as men. 

“This went through rigorous peer review, and even the reviewers were not all in agreement because we don't have clear evidence,” Hirsch said. “I think some of our conclusions potentially could be open to academic disagreement, which is fine. But we did this as well as we could, and we gave a case presentation with a very typical patient.”

Hirsch said the care of patients with kidney disease is one area where the new guidance could have significant impact.

“Kidney disease, even just albumin in the urine without any change in kidney function, dramatically changes the risk of cardiovascular disease,” Hirsch said. “That's a very important point. Here at UW Medicine, we are about to start two clinical trials funded by the Juvenile Diabetes Research Foundation assessing drugs used for type 2 diabetes and kidney disease and their effectiveness in type 1 diabetes.” 

Treatments for type 2 diabetes have boomed lately. Unfortunately, people with type 1 diabetes have not had access to the GLP-1 drugs (Ozempic, Wegovy) that are approved for type 2 diabetes and obesity and also have shown effectiveness against heart and kidney disease. People with type 1 diabetes also are not candidates for SGLT2 inhibitors (Jardiance, Farxiga) due to their risk of diabetic ketoacidosis. 

“These drugs are very effective in type 2 diabetes,” Hirsch said. “But the SGLT2 inhibitors have a black-box warning and are contraindicated in type 1 diabetes. The point is we don't have the tools for type 1 diabetes that we do for type 2 diabetes, either for the kidney, which is so closely aligned with cardiovascular disease, or cardiovascular disease prevention in general. There is no one treatment that fits both types of diabetes.” 

To learn more, access downloadable, broadcast-ready soundbites and a Spanish-language version of the news release at the UW Medicine Newsroom.

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