Type 1 Diabetes In Adults DrMitraNiafar Department of Endocrinology Tabriz University of Medical sciences
Agenda • Introduction • Prevalence • Misdiagnosis • Differential Diagnosing Diabetes In Adults– Type 1, LADA, or Type 2? • Management of Type 1 Diabetes in Older Adults
Introduction • The term diabetes mellitus describes several diseases of abnormal carbohydrate metabolism that are characterized by hyperglycemia. • It is associated with a relative or absolute impairment in insulin secretion, along with varying degrees of peripheral resistance to the action of insulin. Diaz-Valencia et al. BMC Public Health (2015) 15:255
Definition • Type 1 diabetes is a disease in which autoimmune destruction of pancreatic β-cells leads to insulin deficiency. • Controlling blood glucose with an acceptable range is a major goal of therapy. Point Care. 2017 March ; 16(1): 37–40.
Management • Regular and life-long insulin administration is necessary to prevent: • Hyperglycemia • Metabolic decompensation • Life-threatening diabetic ketoacidosis (DKA) Diabetes Metab J 2018;42:3-18
Diabetes: A global emergency Diabetes: A global emergencyNumber of people with diabetes worldwide and per region in 2017 and 2045 (20-79 years) The IDF Diabetes Atlas 8thEdition. 2017
Worldwide prevalence of DM According to the International Diabetes Federation (IDF), there were approximately 425 million people living with diabetes worldwide in 2017, out of which 5% to 10% are estimated to have T1DM.
Comparison of male and female T1D adult incidences • The mean male-to-female ratio in our review was 1.47 (95% CI for mean 1.33-1.60, SD = 0.49, n = 54, p = < 0.0001). Diaz-Valencia et al. BMC Public Health (2015) 15:255
Type 1 Diabetes Mellitus in Adults • Although type 1 diabetes (T1D) can affect patients of all ages, most epidemiological studies of T1D focus on disease forms with clinical diagnosis during childhood and adolescence. • Clinically, adult T1D is difficult to discriminate from certain forms of Type 2 Diabetes (T2D) and from Latent Autoimmune Diabetes in Adults (LADA). Diaz-Valencia et al. BMC Public Health (2015) 15:255
Differential Diagnosis • Many of those with type 1 diabetes after the age of 30 are thought to have type 2 diabetes at first, and not initially treated with insulin to control blood sugar levels. • Previous published research found that, on average, it took a year for those with type 1 diabetes who had been misdiagnosed with type 2 to be put on insulin.
Misdiagnosis Among the adults with type 1 diabetes to have been misdiagnosed is Theresa May, the Prime Minister, who was initially told by doctors she had type 2 diabetes and given tablets which did not control her blood sugar .
Findings • 3·5% of white European individuals in UK Biobank had developed diabetes in the first six decades of life. • 13 250 (3·5%) of 379 511 white European individuals in UK Biobank had developed diabetes in the first six decades of life. 1286 had type 1 diabetes. • 537 (42%) were in individuals diagnosed when aged 31–60 years, representing 4% (537/12 233) of all diabetes cases diagnosed after age 30 years.
Findings The clinical characteristics of the group diagnosed with type 1 diabetes when aged 31–60 years were similar to the clinical characteristics of the group diagnosed with type 1 diabetes when aged 30 years or younger. Lancet Diabetes Endocrinol 2018;6: 122–29
Clinical characteristics differences between type1 and type 2 diabetes mellitus in adults • They had a lower BMI 27·4 kg/m² vs 32·4 kg/m² • Were more likely to use insulin in the first year after diagnosis 89% vs 6% • Were more likely to have diabetic ketoacidosis 11% vs 0·3% Lancet Diabetes Endocrinol 2018;6: 122–29
Incidence of genetically defined type 1 and type 2 diabetes in the first six decades of life
Current Diabetes Classification • Note the OVERLAP • Diagnosis is Often IMPRECISE
Heterogeneity of Diabetes Diabetes Metab J 2018;42:451-464
Visualization of the Overlap IMMUNITY AGE GENES BMI INSULIN THERAPY HLA++ HLA+ HLA ? child adult adult adult Strong +++ ++ + weak T1DM In children T1DM In adults LADA T2DM low normal normal high Immediate Intermediate Immediate Variable Infrequent Adapted from Leslie et al. Diabetes Metab Res Rev. 2008 Oct;24(7):511-9
1. 30 years of age 2. Positive for at least one of the four antibodies commonly found in T1D 3. Not treated with insulin within the first 6 months after diagnosis Implies: antibody positive adults, that may be on insulin, but may not be insulin dependent ‘Definitions of LADA’ The Immunology of Diabetes Society –LADA, and Action LADA ADA recognizes LADA as a variation of T1DM 1. Also called: • Type 1.5 • ‘Slowly’ progressive Type 1D • Latent-onset Type 1D • Implies: insulin-dependent antibody-positive adults
Etiology and Pathogenesis of Latent Autoimmune Diabetes in Adults (LADA) Compared to Type 2 Diabetes Frontiers in Physiology. March 2019 Volume 10 ,Article 320
Etiology and Pathogenesis Despite the autoimmune nature of LADA and clear genetic overlap with type 1 diabetes, studies on lifestyle and LADA risk indicate that factors such as overweight and physical inactivity that are associated with insulin resistance and type 2 diabetes may also promote LADA. Frontiers in Physiology. March 2019 Volume 10 ,Article 320
Relative risk for LADA and type 2 diabetes in relation to lifestyle factors Frontiers in Physiology. March 2019 Volume 10 ,Article 320
Etiology of LADA, model based on current knowledge Frontiers in Physiology March 2019 | Volume 10 | Article 320
Summary • Studies conducted to date indicate that LADA, similar to type 2 diabetes, results from an imbalance between insulin sensitivity and insulin secretion. • The relative contribution of insulin deficiency to disease progression is greater in LADA. Frontiers in Physiology March 2019 | Volume 10 | Article 320
Managing Type 1Diabetes in Older Adults Older adults with complex or intermediate health status have: • Multiple chronic illnesses • Have mild to moderate cognitive impairment • Dependency in activities of daily living • Susceptible to hypoglycemia • Complex insulin regimens may become difficult for them to follow Diabetes Spectrum Volume 27, Number 1, 2014
Take Home Message • Type 1 diabetes is not predominantly a 'disease of childhood‘ • Adults are as likely to develop type 1 diabetes as children, with more than 40 per cent of type 1 diabetes cases occurring after the age of 30. • Not all cases of late onset diabetes are type 2. • An individualized approach to managing type 1 diabetes becomes crucial in this population, with consideration of an A1C goal of < 8.0%
DrMitraNiafar Professor Department of Endocrinology Tabriz University of Medical sciences E-mail: firstname.lastname@example.org