endo.t1dm.v1

Type 1 diabetes (chronic outpatient — pediatric + adult)

endocrinologychronicpediatricadultoutpatienttransition

Start encounter →Print handoutPRODUCTION

Drug guidance grounded in ADA Standards of Care in Diabetes 2026 + ISPAD 2022/2024 + ATTD/Battelino time-in-range consensus + DCCT/EDIC; action plan provides three zones (green/yellow/red) covering sick-day rules and hypoglycaemia management with weight-based glucagon; sibling differentiation from endo.dm2.core.v1 and endo.dka.core.v1. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template-mirrored dossier) added: (1) co-located endo.t1dm.v1._design-brief.md + endo.t1dm.v1._research-bundle.md per §5.5 items 1+2 (15 verified PMIDs live-fetched via PubMed MCP, named trials + effect sizes + 95% CI + retrieval-dated 2026-05-16, Consensus→WebSearch/WebFetch fallback logged); design_brief field repointed from _briefs/ to co-located path. (2) Deepened prisma/seed/ros-and-ddx/endo.t1dm.v1.{differentials,ros,finding-lrs}.ts in place — 11 differentials (diabetes-classification partition T1/LADA/ketosis-prone-T2/MODY/T3c/neonatal + acute-decompensation DKA/eu-DKA-on-SGLT2i/severe-hypo) with cohort-anchored priors, 13 ROS, 39 LR rows (each carries lr_positive AND lr_negative; 25 forward-positive >1, 25 negative-discriminating <1 → ≥15 LR+ AND ≥15 LR− satisfied) with 3 conditional-dependency rules, T_test≈2%/T_treat≈15%. (3) 2nd regimen axis t1dm_phenotype_matrix (phenotype × insulin/adjunct/CGM gating as data) added — 3 axes total. (4) RxCUI bugs fixed vs RxNav/DrugEffectProfile: pregnancy NPH 253182→253181 (isophane), pump/AID aspart+lispro 253182→51428/86009, glargine-U-300 253182→274783; pramlintide 139953 added; faster-aspart normalised to aspart 51428; glargine 274783 / lispro 86009 / dapagliflozin 1488564 confirmed canonical; glucagon 4832 RxNav-correct (registry 4833 pre-existing baseline fail OUT OF SCOPE; insulin_regular 5856 pre-existing fail unrelated). (5) ADA-2026 content refresh: AID/hybrid-closed-loop now PREFERRED delivery (Rec 7.25a), no C-peptide/autoAb/duration pre-req for CSII/AID (Rec 7.8a), CGM standard-of-care at onset (Rec 7.15), TIR >70% / TBR <4% individualised targets, teplizumab stage-2 delay routed to prevention path (TN-10 HR 0.41), SGLT2i adjunct with explicit euglycemic-DKA caution; dose-effect rationale enriched with onset/peak/duration + A1c/TIR Δ + severe-hypo RR + microvascular/CV HR; evidence.pmids 4 stale off-disease (DELIVER/DAWN/POINT/REDUCE)→18 verified; status PLANNED-notes→PRODUCTION. Pediatric + adult A1c target <7.0% per ADA 2026 §6 (individualised — relax for hypo unawareness, severe/recurrent hypo, limited life expectancy, comorbidities); CGM TIR band individualised by health status (pregnancy tighter, older-adult relaxed) per ADA 2026 Fig 6.1. Open gaps (deferred, not this depth shard): manifest at prisma/seed/manifests/endo.t1dm.v1.ts not yet on disk (manifest field points to intended path); calculator-registry entries for ICR (500/TDD), CF (1800/TDD), eA1c-from-CGM, time-in-range not yet present — flagged for the P0 orphan-calculator sweep (owned by UI-fix terminal).

Entry points (6)

lab_abnormality
HbA1c ≥6.5% / random glucose ≥200 with symptoms / 2-h OGTT ≥200 / fasting ≥126 (ADA 2026 §2)
a1c_or_glucose_diagnostic
symptom
Polyuria + polydipsia + weight loss + fatigue ± nocturnal enuresis (ADA 2026 §2; ISPAD 2022)
classic_T1DM_presentation
lab_abnormality
Positive GAD65 / IA-2 / ZnT8 / insulin autoantibody (ADA 2026 §2; ISPAD 2022)
positive_islet_autoantibody
lab_abnormality
Low C-peptide with hyperglycemia — T1 phenotype (ADA 2026 §2)
low_c_peptide_with_hyperglycemia
problem_list
Established T1DM — titration / annual review / pump or CGM optimisation (ADA 2026 §7)
type_1_diabetes_existing
history
Recent DKA — typical onset for new T1DM (ISPAD 2022)
recent_DKA_presentation

Required inputs (20)

agerequired
demographic • used at CONTEXT
Pediatric (ISPAD 2022) vs adult (ADA 2026) framework; technology eligibility (pump, CGM, AID); A1c target individualisation
weightrequired
demographic • used at CONTEXT
Insulin TDD weight-based 0.4-0.8 U/kg/day (ADA 2026 §7; ISPAD 2022); ICR / CF derivation
sbprequired
vital • used at CONTEXT
BP control reduces CV and renal events (DCCT NEJM 1993; Nathan NEJM 2005); ADA 2026 target <130/80 if higher CV risk
a1crequired
lab • used at INITIAL_WORKUP
Diagnostic + target tracking + regimen titration (ADA 2026 §2, §7)
glucoserequired
lab • used at INITIAL_WORKUP
Random / fasting / OGTT; severity at presentation (ADA 2026 §2)
c_peptide
lab • used at INITIAL_WORKUP
Low C-peptide differentiates T1 vs T2 (ADA 2026 §2)
islet_autoantibodies
lab • used at INITIAL_WORKUP
GAD65, IA-2, ZnT8, insulin autoantibodies — confirms T1 (ADA 2026 §2; ISPAD 2022)
bhbrequired
lab • used at INITIAL_WORKUP
Ketone screen at diagnosis and during sick days (ISPAD 2022; NICE 2024 NG18)
bicarbonaterequired
lab • used at INITIAL_WORKUP
DKA screen at presentation (ISPAD 2022)
creatininerequired
lab • used at INITIAL_WORKUP
Baseline renal function (ADA 2026 §11)
uacrrequired
lab • used at MONITORING
Diabetic kidney disease screening — annual ≥5 yr after diagnosis or at puberty in peds (ADA 2026 §11; ISPAD 2022)
lipid_panel
lab • used at INITIAL_WORKUP
Annual lipid; statin candidacy in adolescents (ADA 2026 §10; ISPAD 2022)
tsh
lab • used at INITIAL_WORKUP
Autoimmune thyroid disease comorbidity — Hashimoto, Graves (ADA 2026 §4; ISPAD 2022)
ttg_iga
lab • used at INITIAL_WORKUP
Celiac screen — high T1DM comorbidity (ADA 2026 §4; ISPAD 2022)
pregnancy_status
history • used at CONTEXT
Pregnancy mandates strict targets, pump / AID often preferred, retinopathy screen (ADA 2026 §15)
family_history_autoimmune
history • used at CONTEXT
Autoimmune cluster — thyroid, celiac, Addison (ADA 2026 §4; ISPAD 2022)
cgm_or_pump_userequired
history • used at CONTEXT
Drives technology workflow; AID is PREFERRED delivery with NO C-peptide/autoAb/duration pre-req (ADA 2026 Rec 7.25a / 7.8a)
hypoglycemia_historyrequired
history • used at CONTEXT
Frequency, severity, awareness — drives target relaxation + CGM / AID (ADA 2026 §7; ISPAD 2022)
mental_health
history • used at CONTEXT
Depression, eating disorder (diabulimia), DKA risk (ADA 2026 §5)
current_medsrequired
medication • used at CONTEXT
Insulin formulations + ratios; β-blocker masking; steroid effect (ADA 2026 §7)

12-phase flow (12)

1FRAME
Confirm T1DM — autoantibody / low C-peptide / DKA at onset / classic presentation in young patient; rule out T2 / MODY / steroid-induced (ADA 2026 §2; ISPAD 2022)
inputs: age, islet_autoantibodies, c_peptide
advance: T1DM diagnosis confirmed
2ENTRY
Trigger captured — new diagnosis / DKA presentation / titration visit / annual review (ADA 2026 §7)
inputs: age, weight
advance: Trigger captured
3CONTEXT
Diabetes duration, current insulin regimen, CGM/pump status, hypoglycaemia history, autoimmune comorbidity, mental health, pregnancy plans, education needs — carb counting, sick day, hypo (ADA 2026 §7; ISPAD 2022)
inputs: cgm_or_pump_use, hypoglycemia_history, current_meds
advance: Context complete
4RED_FLAGS
DKA at presentation / sick day; severe hypoglycaemia with seizure / unconsciousness; suspected eating disorder + insulin omission; cerebral oedema in pediatric DKA (ISPAD 2022; NICE 2024 NG18)
inputs: bhb, bicarbonate
actions: protocol.dka_peds, protocol.dka
advance: Red flags actioned or excluded
5INITIAL_WORKUP
A1c, fasting glucose, BMP, C-peptide, autoantibodies (if not done), lipid panel, TSH, tTG-IgA (celiac), urinalysis, UACR, LFT (ADA 2026 §2, §4; ISPAD 2022)
inputs: a1c, glucose, creatinine, bhb, bicarbonate, lipid_panel, tsh, ttg_iga
actions: panel.glucose_a1c, panel.lipid, panel.thyroid, panel.renal
advance: Initial labs sent
6BRANCHING_WORKUP
Retinal exam at diagnosis (adult) or by puberty / 5 y duration (peds) per ADA 2026 §12; ECG if older adult; bone health if amenorrhoea / poor control; mental health / eating disorder screen; reproductive counselling
advance: Specialty referrals placed
7DIFFERENTIAL
Diabetes-classification partition: T1 (autoimmune, ≥1 islet autoAb, low C-peptide|concurrent-glucose) vs LADA (adult slow-onset autoimmune) vs ketosis-prone/DKA-presenting T2 (obese adolescent/young adult) vs MODY (AD family hx, autoAb-negative, C-peptide preserved) vs pancreatogenic-T3c (post-pancreatectomy/CF/chronic pancreatitis) vs neonatal/monogenic (<6 mo). Stage-1/2 presymptomatic T1D (≥2 autoAb, not stage-3) → route OUT to prevention path (teplizumab stage-2; TN-10 HR 0.41 (0.22–0.78), PMID 31180194). See endo.t1dm.v1.{differentials,finding-lrs}.ts (ADA 2026 §2)
advance: Phenotype assigned (insulin never delayed pending classification)
8RISK_STRATIFICATION
Glycaemic burden — A1c, time-in-range (ATTD/Battelino consensus, TIR >70%/TBR <4%), hypo risk + awareness, CV/renal risk per DCCT (PMID 8366922) / DCCT-EDIC 30-yr (PMID 26861924), pregnancy planning
inputs: a1c, sbp
advance: Risk profile + targets individualised
9TREATMENT
AID/hybrid-closed-loop PREFERRED delivery (ADA 2026 Rec 7.25a; iDCL Control-IQ TIR +11 pp (9–14), PMID 31618560) OR MDI basal-bolus 0.4-0.8 U/kg/day (ADA 2026 §7; ISPAD 2022) as alternative; ICR = 500/TDD, CF = 1800/TDD; CGM standard-of-care at onset (ADA 2026 Rec 7.15; DIAMOND HbA1c −0.6%, PMID 28118453); carb counting education; statin per ADA 2026 §10; ACE/ARB if UACR ≥30 per ADA 2026 §11
inputs: weight, a1c, creatinine
advance: Regimen + technology + education + statin/RAAS decision documented
10DISPOSITION
Outpatient endocrinology / diabetes team; admit only if DKA, severe hypo with neuro deficit, eating disorder needing inpatient, pregnancy with poor control (ADA 2026 §7)
advance: Disposition set
11MONITORING
A1c q3 mo or q6 mo if stable (ADA 2026 §6), CGM TIR/TBR/TAR monthly (TIR >70%, TBR <70 <4%; ATTD/Battelino; ADA 2026 Fig 6.1 individualised), BP each visit, UACR + creatinine annually (ADA 2026 §11), lipid annually (ADA 2026 §10), retinal annually (ADA 2026 §12), foot exam annually (adults), TSH q1-2 yr, tTG-IgA periodically (ISPAD 2022); pump / AID download review
inputs: a1c, creatinine, uacr, lipid_panel, tsh, ttg_iga
actions: panel.glucose_a1c, panel.renal, panel.lipid
advance: Surveillance schedule active
12FOLLOWUP
Continued education, technology upgrades, mental health, reproductive counselling, transition — adolescent to adult care (ADA 2026 §14; ISPAD 2022), vaccinations (ADA 2026 §4)
advance: Long-term plan documented