ADA/EASD have just come out with a consensus report on the management of Type 1 diabetes in adults, and address adult onset T1D/LADA. Here is my commentary:
The Good:
There is so much good about this ADA/EASD consensus report on the management of Type 1 diabetes in adults, and the authors address adult-onset Type 1 diabetes with a large amount of valuable information. Here are some takeaways for adult-onset T1D/LADA:
- “Most people with Type 1 diabetes should use regimens that mimic physiology as closely as possible, irrespective of the presentation.” Regarding adjunct therapies (metformin, pramlintide, GLP-1s, SGLT inhibitors), the authors state, “before these drugs are prescribed, insulin therapy should be optimized.” In other words, don’t treat patients with T1D/LADA as if they have Type 2 diabetes. The authors do recognize that some of the adjunct therapies can preserve beta cell mass in the newly diagnosed, and the authors also recognize that for some newly diagnosed, insulin therapy is not appropriate; however, the authors caution that, “Those whose diabetes is treated without insulin will require careful monitoring and education so that insulin can be rapidly initiated in the event of glycemic deterioration.”
- The ADA/EASD Consensus Report authors recognize that misdiagnosis of Type 1 diabetes in adults is common, and that they are typically misdiagnosed as having Type 2 diabetes. The authors state, “from a patient perspective, a misdiagnosis can cause confusion and misunderstanding. This can impair the acceptance of the diagnosis and future management plans.”
- The authors encourage autoantibody testing at diagnosis as the primary investigation of an adult with suspected Type 1 diabetes. I don’t think this recommendation is strong enough, because due to blind spots and myths, many doctors are unaware of how common adult-onset Type 1 diabetes actually is. Autoantibody testing in all newly diagnosed adults would identify the 1 in 10 who have Type 1 diabetes (as I detail in other blogs, ~10% of people diagnosed with “Type 2” diabetes are autoantibody positive, have been misdiagnosed, and in fact have Type 1 autoimmune diabetes).
- The authors state, “The absence of autoantibodies does not exclude Type 1 diabetes, since approximately 5-10% of White European people with new-onset Type 1 diabetes have negative islet antibodies” and “if there is a clinical suspicion of Type 1 diabetes, the individual should be treated with insulin.”
- I also really appreciate the authors’ emphasis on nutrition, exercise, and psychosocial issues.
The Not-So-Good:
At the beginning of the consensus report, the authors state, “Type 1 diabetes accounts for approximately 5-10% of all cases of diabetes. Although the incidence peaks in puberty and early adulthood, new-onset Type 1 diabetes occurs in all age-groups.” But later in the report, the authors state, “Misclassification of Type 1 diabetes in adults is common, and over 40% of those developing Type 1 diabetes after age 30 years are initially treated as having Type 2 diabetes.” Obviously, if those who are misdiagnosed are not counted amongst those with Type 1 diabetes, T1D is undercounted, and the peak age is not in puberty and early adulthood.
