Within the past 15 years, tremendous advances in diabetes care have occurred, including increases in the number of medication classes approved to treat type 2 diabetes and technologies to help manage type 1 and type 2 diabetes. In addition, many of the newer classes of medications have been used more extensively given their efficacy in terms of glycemia, weight loss, and cardiovascular and renal protection. None of these new agents have been approved for the treatment of type 1 diabetes, yet they are occasionally used off-label. This article reviews diabetes treatment and self-care practices for adults and youth with type 1 and type 2 diabetes in the U.S. population.
Among insured adults with type 1 diabetes whose claims are included in the 2019 Optum Clinformatics Data Mart database, insulin is used as the single antihyperglycemic agent 88% of the time, with the remaining 12% of individuals using insulin plus another agent, most often metformin. In youth with type 1 diabetes, insulin remains the mainstay treatment. Use of continuous glucose monitors (CGMs) has become a common mode of glucose monitoring for both adults and youth with type 1 diabetes.
From a public health perspective, diabetes technology, especially CGM, is underutilized by persons with type 1 diabetes, perhaps even more so in adults than children. For example, only 41% of adults with type 1 diabetes used CGM in 2020. Inequities in technology usage persist. Increased use of insulin pumps, CGM, sensor-augmented pumps, and automated insulin delivery is associated with a greater proportion of individuals achieving target glycated hemoglobin (A1C) in both adults and children with type 1 diabetes.
For adults with type 2 diabetes, the most common antihyperglycemic drug class used was biguanide (i.e., metformin), followed by sulfonylurea and insulin, whereas thiazolidinedione was the least used medication in 2015–2020. In adults with type 2 diabetes, increased use of the GLP-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors, when appropriate, could have a beneficial impact on cardiovascular and renal disease. Use of CGM has become more common among adults with type 2 diabetes and is now covered by most private insurance and by the Centers for Medicare and Medicaid Services (CMS). The cost of and access to these newer technologies and medications have been major barriers.
Type 2 diabetes has become increasingly more common among youth over the past two decades, and compared to type 2 diabetes diagnosed in adults, it is a more aggressive disease and less responsive to metformin. Biguanides and insulin are antihyperglycemic medications approved for youth with type 2 diabetes in conjunction with lifestyle modifications. Very few data are available on technology use among youth with type 2 diabetes.