Q&A: Screening for type 1 diabetes may help slow disease progression
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NEW ORLEANS — In part one of a three-part video exclusive series, Jonathan D. Leffert, MD, talks with Anna Casu, MD, about the preclinical stages of type 1 diabetes and who should be screened for the disease.
As Healio previously reported, new guidance was recently published in Diabetologia 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 AACE and a Healio | Endocrine Today Editorial Board Member, and Casu, an associate investigator for AdventHealth Translational Research Institute discuss screening guidelines, including the different stages of pre-symptomatic type 1 diabetes and which people should be selected for screening.
Read the interview transcript, edited for clarity, below and/or watch the rest of the Healio Video Exclusive series linked here:
Video 2: New guidance for monitoring pre-symptomatic type 1 diabetes
Video 3: Assess full glucose profile, set a plan for treating early-stage type 1 diabetes
Leffert: Can you tell us a little bit about what the early stages of type 1 diabetes are?
Casu: It became clear after all the studies that have been done in prediction of type 1 diabetes, that the disease starts way before the clinical manifestation of it. At some point in 2015, the ADA, JDRF, and the Endocrine Society published a statement about the preclinical stages of type 1 diabetes, and this was endorsed by AACE, by ISPAD, and by the Helmsley Charitable Trust.
We know that when people develop multiple islet autoantibodies, the disease will inevitably progress to the clinical stage. The disease is already there, there are nuances of the clinical manifestation. This statement states that stage 1 type 1 diabetes occurs when multiple islet autoantibodies are confirmed in the blood of a person. The glycemia is still normal at that time, so it's a preclinical stage. The situation can progress, and larger beta cell mass is lost. So the autoimmune process is still there, the antibodies are still there, but we start seeing dysglycemia as defined by the different societies in a preclinical stage, and symptoms are not there yet.
The clinical manifestation of type 1 diabetes, as we all know it, is called stage 3, where the glycemic levels of diabetes are fulfilled, and symptoms can be present at that point.
Leffert: From my knowledge from the distant past, I remember that this is a fairly long time frame. [The process] can be up to several years from what I understand. So it needs to be sort of defined in some way in order that we can screen patients for this type of preclinical diabetes. How would you suggest that we do that at this point in time?
Casu: Who should be screened at this point in time is not perfectly understood. The literature so far is being done in people at high genetic risk, and first-degree relatives is clearly a population at high genetic risk. So screening in relatives, first-degree relatives in particular, of people with type 1 diabetes is, I would say, mandatory, because they have a risk of developing diabetes that is 10- to 15-times higher than the general population.
We know that autoimmune disease is clustered and people with other autoimmune diseases might be good candidates for screening, but there's a gray area there.
Another thing that I would like to add is that this is not exactly screening though, people with type 2 diabetes might have an autoimmune process going on. Approximately between 4% and 10% of people with a diagnosis of type 2 diabetes have an autoimmune process happening, so they can be classified as type 1. There's more knowledge that needs to be fulfilled there, but I would like to remind that 50% of the people with type 1 diabetes are diagnosed ... as adults. This is something that we should keep in mind because a large proportion of these people, about 25% of them to up to 47% of them, are treated with oral agents while they most likely need insulin.
Leffert: Just to put this into perspective, why would a patient be screened at this time? Are there medications that are available? I don't think we want to go into a great detail, but just so people understand. I might say to you, ‘Well, I don't really want to be screened because I don't really want to know that I have potential for type 1 diabetes because I can't really do that much about it at this point.’ What would you say to those people who were maybe not interested in being screened because they're concerned that they don’t really have that much that they can do, or a lot that they can do?
Casu: The are benefits for screening because it's been proven, particularly in children, that screening and knowing up front that the disease is going to be clinically developed or manifest, that we can prevent diabetes ketoacidosis that has detrimental complications. It’s a serious condition, particularly in little kids. That can be prevented and reduced from prevalences that varies between 30% and 50% in the general population, to numbers that are as low as 2% to 4%. That is one main reason.
The second reason is that now we have an FDA-approved medication that can at least delay the onset, and I’m sure more will be prescribed and more will be available if we have more people that we could test the medication in, like people that were screened.
The third thing is that the people know that they will develop the disease, but will have time to prepare for it. Instead of having to learn right away that they have to get insulin, maybe they can take more time to digest the problem and learn what to do with it.
Reference:
Phillip M, et al. Diabetologia. 2024;doi:10.1007/s00125-024-06205-5.
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