Treatments and drugs

By Mayo Clinic Staff

Treatment for type 1 diabetes is a lifelong commitment to:

  • Taking insulin
  • Exercising regularly and maintaining a healthy weight
  • Eating healthy foods
  • Monitoring blood sugar

The goal is to keep your blood sugar level as close to normal as possible to delay or prevent complications. Although there are exceptions, generally, the goal is to keep your daytime blood sugar levels before meals between 80 and 120 mg/dL (4.4 to 6.7 mmol/L) and your bedtime numbers between 100 and 140 mg/dL (5.6 to 7.8 mmol/L).

If managing your diabetes seems overwhelming, take it one day at a time. And remember that you're not alone. You'll work closely with your diabetes treatment team to keep your blood sugar level as close to normal as possible.

Insulin and other medications

Anyone who has type 1 diabetes needs insulin therapy. After the diagnosis, there may be a "honeymoon" period, during which blood sugar is controlled with little or no insulin. However, this phase doesn't last.

Types of insulin are many and include:

  • Rapid-acting insulin
  • Long-acting insulin
  • Intermediate options

Examples are regular insulin (Humulin 70-30, Novolin 70/30, others), insulin isophane (Humulin N, Novolin N), insulin lispro (Humalog) and insulin aspart (Novolog). Long-acting insulins include glargine (Lantus) and detemir (Levemir).

Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night.

Insulin can be administered using:

  • A fine needle and syringe
  • An insulin pen — a device that looks like an ink pen, except the cartridge is filled with insulin
  • An insulin pump — a device about the size of a cellphone worn on the outside of your body. A tube connects a reservoir of insulin to a catheter that's inserted under the skin of your abdomen. There's also a wireless pump option that's available in most areas. You wear a reservoir of insulin on your body that has a tiny catheter that's inserted under your skin. The insulin pod can be worn on your abdomen, lower back, or on a leg or an arm. The programming is done with a wireless device that communicates with the pod.

    Pumps are programmed to dispense specific amounts of rapid-acting insulin automatically. This steady dose of insulin is known as your basal rate, and it replaces whatever long-acting insulin you were using. When you eat, you program the pump with the amount of carbohydrates you're eating and your current blood sugar, and it will give you what's called a "bolus" dose of insulin to cover your meal and to correct your blood sugar if it's elevated. Some research has found that in some people an insulin pump can be more effective at controlling blood sugar levels than injections.

An emerging treatment approach, not yet available, is closed loop insulin delivery, also known as the artificial pancreas. It links a continuous glucose monitor to an insulin pump. The device automatically delivers the correct amount of insulin when the monitor indicates the need for it. Testing has shown encouraging results, but more research is needed.

Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action.

Oral medications, however, are sometimes prescribed, such as:

  • High blood pressure medications. Even if you don't have high blood pressure, your doctor may prescribe medications known as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), because these medications also can help keep your kidneys healthy. It's recommended that people with diabetes have blood pressures less than 130/80 millimeters of mercury (mm Hg).
  • Aspirin. Your doctor may recommend you take baby or regular aspirin daily to protect your heart.
  • Cholesterol-lowering drugs. As with high blood pressure drugs, your doctor may not wait until your cholesterol is elevated before he or she prescribes cholesterol-lowering agents known as statins. Cholesterol guidelines are more aggressive for people with diabetes because of the elevated risk of heart disease. The American Diabetes Association recommends that low-density lipoprotein (LDL, or "bad") cholesterol be below 100 mg/dL (2.6 mmol/L) and that high-density lipoprotein (HDL, or "good") cholesterol be over 50 mg/dL (1.3 mmol/L). Triglycerides, another type of blood fat, are ideal when they're less than 150 mg/dL (1.7 mmol/L).

Your doctor might also prescribe pramlintide (Symlin). An injection of this medication before you eat can slow the movement of food through your stomach to curb the sharp increase in blood sugar that occurs after meals.

Healthy eating and monitoring carbohydrates

Contrary to popular perception, there's no such thing as a diabetes diet. You won't be restricted to a lifetime of boring, bland foods. Instead, you'll need to center your diet on nutritious, low-fat, high-fiber foods such as:

  • Fruits
  • Vegetables
  • Whole grains

You'll eat fewer animal products and refined carbohydrates, such as white bread and sweets. This is the best overall eating plan, even for people without diabetes.

You'll need to learn how to assess the carbohydrates in the foods you eat so that you can give yourself enough insulin to properly metabolize those carbohydrates. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle.

Physical activity

Everyone needs regular aerobic exercise, and people who have type 1 diabetes are no exception. Get your doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. Make physical activity part of your daily routine. Aim for at least 30 minutes of aerobic exercise most days of the week. Flexibility and strength training exercises are important, too. If you haven't been active for a while, start slowly and build up gradually.

Remember that physical activity lowers blood sugar, often for long after you're done working out. If you begin a new activity, check your blood sugar level more often than usual until you know how that activity affects your blood sugar levels. You might need to adjust your meal plan or insulin doses to compensate for the increased activity. If you use an insulin pump, you can set a temporary basal rate to keep your blood sugar from dropping. Ask your doctor or diabetes educator to show you how.

Blood sugar monitoring

Depending on what type of insulin therapy you select or require — twice daily injections, multiple daily injections or insulin pump — you may need to check and record your blood sugar level at least four times a day, and possibly more often. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. Be sure to wash your hands before checking your blood sugar levels.

Even if you take insulin and eat on a rigid schedule, the amount of sugar in your blood can change unpredictably. With help from your diabetes treatment team, you'll learn how your blood sugar level changes in response to:

  • Food. What and how much you eat will affect your blood sugar level. Blood sugar is typically highest one to two hours after a meal.
  • Physical activity. Physical activity moves sugar from your blood into your cells. The more active you are, the lower your blood sugar level. To compensate, you might need to lower your insulin dose before unusual physical activity.
  • Medication. You need insulin to lower your blood sugar level. But other medications you take may affect your blood sugar level as well, sometimes requiring changes in your diabetes treatment plan.
  • Illness. During a cold or other illness, your body may produce hormones that raise your blood sugar level. This might require changes in your diabetes treatment plan.
  • Alcohol. Alcohol can cause either high or low blood sugar, depending on how much you drink and if you eat at the same time. If you choose to drink, do so in moderation, which means no more than one drink a day for women and two drinks or fewer daily for men.
  • Stress. The hormones your body may produce in response to prolonged stress may prevent insulin from working properly.
  • For women, fluctuations in hormone levels. As your hormone levels fluctuate during your menstrual cycle, so can your blood sugar level — particularly in the week before your period. Menopause may trigger fluctuations in your blood sugar level as well.

Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels, and may be most helpful for people who have developed hypoglycemia unawareness. Continuous glucose monitors attach to the body using a fine needle just under the skin that checks blood glucose level every few minutes. CGM isn't yet considered as accurate as standard blood sugar monitoring, so it's not considered a replacement method for keeping track of blood sugar, but an additional measure for some people.

Situational concerns

Certain life circumstances call for different considerations.

  • Driving. Hypoglycemia can occur at any time, even when you're driving. It's a good idea to check your blood sugar anytime you're getting behind the wheel. If it's below 70 mg/dL (3.9 mmol/L), have a snack and then retest again in 15 minutes to make sure it's risen to a safe level. Low blood sugar makes it hard to concentrate or to react as rapidly as you might need to when you're driving.
  • Working. In the past, people with type 1 diabetes were often refused certain jobs because they had diabetes. Fortunately, advances in diabetes management and anti-discrimination laws have made such blanket bans largely a thing of the past. However, type 1 diabetes can pose some challenges in the workplace. For example, if you work in a job that involves driving or operating heavy machinery, hypoglycemia could pose a serious risk to you and those around you. You may need to work with your doctor and your employer to ensure that certain accommodations are made, such as your having a quick break for blood sugar testing and fast access to food and drink anytime, so you can properly manage your diabetes and prevent low blood sugar levels. There are federal and state laws in place that require employers to make reasonable accommodations for people with diabetes.
  • Being pregnant. Because the risk of pregnancy complications is higher for women with type 1 diabetes, experts recommend that women have a preconception evaluation and that A1C readings should be less than 7 percent before you attempt to get pregnant. Some drugs, such as high blood pressure medications and cholesterol-lowering medications, may need to be stopped before pregnancy. The risk of birth defects is increased for women with type 1 diabetes, particularly when diabetes is poorly controlled during the first six to eight weeks of pregnancy, so planning your pregnancy is key. Careful management of your diabetes during pregnancy can decrease your risk of complications.
  • Being older. As long as you're still active and have normal cognitive abilities, your diabetes management goals will likely be the same as they were when you were younger. But, for those who are frail, sick or have cognitive deficits, tight control of blood sugar may not be practical. If you're caring for a loved one with type 1 diabetes, ask his or her doctor what the new diabetes goals should be.

Investigational treatments

  • Pancreas transplant. With a successful pancreas transplant, you would no longer need insulin. But pancreas transplants aren't always successful — and the procedure poses serious risks. You would need a lifetime of potent immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection and organ injury. Because the side effects can be more dangerous than the diabetes itself, pancreas transplants are generally reserved for those with very difficult-to-control diabetes.
  • Islet cell transplantation. Researchers are experimenting with islet cell transplantation, which provides new insulin-producing cells from a donor pancreas. Although this experimental procedure has met with problems in the past, new techniques and better drugs to prevent islet cell rejection may improve its future chance for success. However, islet cell transplantation still requires the use of immune-suppressing medications, and just as it did with its own natural islet cells, the body often destroys transplanted islet cells, making the time off injected insulin short-lived. Additionally, a sufficient supply of islet cells isn't available for this treatment to become more widespread.
  • Stem cell transplant. In a 2007 Brazilian study, a small number of people newly diagnosed with type 1 diabetes were able to stop using insulin after being treated with stem cells made from their own blood. Although stem cell transplants — which involve shutting down the immune system and then building it up again — can be risky, the technique may one day provide an additional treatment option for type 1 diabetes.

Signs of trouble

Despite your best efforts, sometimes problems will arise. Certain short-term complications of type 1 diabetes require immediate care. Left untreated, these conditions can cause seizures and loss of consciousness (coma).

Low blood sugar (hypoglycemia). This occurs when your blood sugar level drops below your target range. Ask your doctor what's considered a low blood sugar level for you. Blood sugar levels can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin.

Learn the symptoms of low blood sugar, and test your blood sugar if you think your blood sugar levels are dropping. When in doubt, always do a blood sugar test. Early signs and symptoms of low blood sugar include:

  • Sweating
  • Shakiness
  • Hunger
  • Weakness
  • Anxiety
  • Dizziness or lightheadedness
  • Pale skin
  • Rapid or irregular heart rate
  • Fatigue
  • Headaches
  • Blurred vision
  • Irritability

Later signs and symptoms of low blood sugar, which can sometimes be mistaken for alcohol intoxication in teens and adults include:

  • Lethargy
  • Confusion
  • Behavior changes, sometimes dramatic
  • Poor coordination
  • Convulsions

If you develop hypoglycemia during the night, you might wake with sweat-soaked pajamas or a headache. Thanks to a natural rebound effect, nighttime hypoglycemia might cause an unusually high blood sugar reading first thing in the morning.

If you have a low blood sugar reading:

  • Have some fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar.
  • Retest your blood sugar in about 15 minutes to make sure it's normal.
  • If it's not normal, have more juice, candy, glucose tablets or other source of sugar, and retest in another 15 minutes.
  • Repeat until you get a normal reading.
  • Eat a mixed food source, such as peanut butter and crackers, to help stabilize your blood sugar.

If a blood glucose meter isn't readily available, treat for low blood sugar anyway if you have symptoms of hypoglycemia, and then test as soon as possible.

Always carry a source of fast-acting sugar with you. Left untreated, low blood sugar will cause you to lose consciousness. If this occurs, you may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. Be sure you always have a glucagon emergency kit available — at home, at work, when you're out — and make sure it hasn't expired.

Hypoglycemia unawareness. Some people may lose the ability to sense that their blood sugar levels are getting low, because they've developed a condition known as hypoglycemia unawareness. With hypoglycemia unawareness, the body no longer reacts to a low blood sugar with symptoms such as lightheadedness or headaches. The more you experience low blood sugars, the more likely you are to develop hypoglycemia unawareness. The good news is that if you can avoid having a hypoglycemic episode for several weeks, you may start to become more aware of impending lows.

High blood sugar (hyperglycemia). Your blood sugar can rise for many reasons, including eating too much, eating the wrong types of foods, not taking enough insulin or illness.

Watch for:

  • Frequent urination
  • Increased thirst
  • Blurred vision
  • Fatigue
  • Nausea
  • Irritability
  • Hunger
  • Difficulty concentrating

If you suspect hyperglycemia, check your blood sugar. You might need to adjust your meal plan or medications. If your blood sugar is higher than your target range, you'll likely need to administer a "correction" using an insulin shot or through an insulin pump. A correction is an additional dose of insulin that should bring your blood sugar back into the normal range. High blood sugar levels don't come down as quickly as they go up. Ask your doctor how long to wait until you recheck. If you use an insulin pump, random high blood sugar readings may mean you need to change the pump site.

If you have two consecutive blood sugar readings above 250 mg/dL (13.9 mmol/L), test for ketones using a urine test stick. Don't exercise if your blood sugar level is very high or if ketones are present. If only a trace or small amounts of ketones are present, drink extra fluids to flush out the ketones.

If your blood sugar is persistently above 300 mg/dL (16.7 mmol/L), call your doctor or seek emergency care.

Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat — producing toxic acids known as ketones.

Signs and symptoms of this serious condition include:

  • Nausea
  • Vomiting
  • Abdominal pain
  • A sweet, fruity smell on your breath
  • Weight loss

If you suspect ketoacidosis, check your urine for excess ketones with an over-the-counter ketones test kit. If you have large amounts of ketones in your urine, call your doctor right away or seek emergency care. Also, call your doctor if you have vomited more than once and you have ketones in your urine.

Jan. 23, 2013