Q&A: New guidance for monitoring pre-symptomatic type 1 diabetes
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NEW ORLEANS — In part two of a three-part video exclusive series, Jonathan D. Leffert, MD, talks with Rifka C. Schulman-Rosenbaum, MD, FACE, FACP, about the steps providers should take when a patient screens positive for type 1 diabetes.
As Healio previously reported, researchers recently published new international consensus guidance on monitoring people who test positive for islet autoantibodies associated with type 1 diabetes. Leffert, managing partner at North Texas Endocrine Center, a past president of the American Association of Clinical Endocrinology and a Healio | Endocrine Today Editorial Board Member discussed some of the key takeaways from the guideline with Schulman-Rosenbaum professor of medicine and director of inpatient diabetes at Long Island Jewish Medical Center, Northwell Health in New Hyde Park, New York.
Read the interview transcript, edited for clarity, below and/or watch the Healio Video Exclusive series linked here:
- Video 1: Screening for type 1 diabetes may help slow disease progression
- Video 3: Assess full glucose profile, set a plan for treating early-stage type 1 diabetes
Leffert: I think you're really on the forefront of an area of diabetes which is really going to open up in the next several years. If someone is screening for the early preclinical stages of type 1 diabetes, and screens positive, what do you do next?
Schulman-Rosenbaum: That's really a great question. There is not a ton of literature on what to do next, and that is why JDRF sponsored a consensus guidance document, I represented AACE on that document. The reason that this whole project was started was because this is an area of poor understanding, especially amongst clinicians out in the community, even in academic centers. Aside from specialized centers, mostly pediatric, that have studied this in the research setting, out in the endocrine world, most providers would have no idea what to do when a patient screens positive. Therefore, we worked on these consensus guidelines.
There were four major sections: pediatric monitoring, adult monitoring, education and psychosocial support. I was co-chairing the adult section since I'm an adult endocrinologist. It was an international group, there's in total, nine societies co-sponsoring it.
Just to tell you a little bit about what we came up with, it's so important to know what to do once you get the positive antibodies. Two positive or more antibodies gives you the diagnosis of presymptomatic type 1 diabetes, but there's also cases where there's one single antibody, and then what do you do?
To give a short summary, there are several different methods that can be used to monitor patients, and the frequency varies based on the patient, their age and their status. We wanted to not have very strict requirements for the monitoring because it has to be possible to do it in various settings. Out in the community, in a rural area where they may not have access to an academic center nearby, they may need to use telehealth. There may be primary care vs. endocrinology managing the patient. We wanted to give options. Examples of methods would be an oral glucose tolerance test (OGTT), which is typically used in the research setting, but very intensive. [HbA1c], self-monitoring of blood glucose, continuous glucose monitoring, a random serum glucose, even a C-peptide level can be helpful in some cases. These are the types of methods that we have been focusing on. Then we have different recommendations based on adult vs. pediatric. The interesting thing is, while there has been a lot more research in the pediatric area, the adult patients have been much less studied. There’s actually some interesting differences between adult and pediatric.
Leffert: Tell us a little bit about those differences.
Schulman-Rosenbaum: Firstly, we have just more data on pediatrics, so we know that they progress more quickly than adults. Adults do progress and become stage 3 type 1 diabetes, but they do so at a slower rate, and it is variable amounts of time.
Misdiagnosis is a huge problem. A lot of patients who are adults get auto-diagnosed for type 2 [diabetes] just because they're an adult, because there is an assumption that adult is type 2 and pediatric is type 1. That's completely false.
The other thing is that the entity of LADA, latent autoimmune diabetes of adults, feeds into this misdiagnosis because patients can start off as a type 2 phenotype and over a number of years become a type 1 phenotype. Sometimes, they only have one antibody positive, which is usually [glutamic acid decarboxylase autoantibodies].
Leffert: But they were type 1 all along?
Schulman-Rosenbaum: Well, they were LADA all along, and there's a lot of controversy over how to define LADA. Is it just type 1 or is it its own kind of offshoot of type 1? In the beginning, in the type 2 phenotype, they can be treated with oral agents or non-insulin injectables, and what you need to do is catch it with the C-peptide before they become the type 1 phenotype. DKA is obviously the concern if it's not picked up on time.
For pediatrics. because they do progress more quickly, the frequency of monitoring is shorter intervals. For adults, the intervals are a little bit longer, but we did want to make sure that they were being monitored over time. For example. for patients with stage 1 type 1 diabetes, we did recommend having an HbA1c every 12 months, which can be easily done with a primary care doctor. If they get to the point of stage 2, we increase the frequency to every 6 months. Plus, because there are some limitations with HbA1c, add a second option of glycemic monitoring, which could be a CGM, which could be an OGTT or just doing point of care glucoses more frequently.
Leffert: I think one of the things that you're really getting at is the misdiagnosis ... of not type 1 diabetes in patients who are being diagnosed as type 2 diabetes. As a clinician in practice, I see that all the time. I think it's really something that the endocrinologist is really almost the only one who makes those kinds of diagnoses. So this kind of guideline that you're going to bring out is going to be very important, I think, for not only endocrinologists, but for primary care doctors as well. I think it's a really nice and important document that you're bringing out.
Schulman-Rosenbaum: We wanted to make sure that it was geared toward all the groups. Geared toward primary care and geared toward endocrinology, because we understand that primary care is going to be the bulk of catching a lot of these patients, because endocrinology is already overwhelmed just seeing patients who are high HbA1cs and really uncontrolled to begin with.
Reference:
Phillip M, et al. Diabetologia. 2024;doi:10.1007/s00125-024-06205-5.
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