• Figure 2.1 was added as a new figure to provide a structured framework for investigation of suspected type 1 diabetes in newly diagnosed adults. The Standards of Care include that flowchart (Figure 2.1) that recommends the use of autoantibody testing (GAD, IA-2, ZnT8, IAA) in people with suspected type 1 diabetes. The flow chart also indicates that 5-10% of people with adult-onset type 1 diabetes are autoantibody negative. Standardized islet autoantibody tests are recommended for classification of diabetes in adults who have phenotypic risk factors that overlap with those for type 1 diabetes (e.g., younger age at diagnosis, unintentional weight loss, ketoacidosis, or short time to insulin treatment).
• The FDA approved Teplizumab in 2022; this drug allows for the possibility of delaying the onset of symptomatic type 1 diabetes in those at risk who are 8 years and older. The ADA’s Standards of Care now encourages those 8 and older with stage 2 [preclinical] type 1 diabetes to consider using Teplizumab to delay the onset of stage 3 [symptomatic] type 1 diabetes. [A study published in the October 2023 New England Journal of Medicine showed that two 12-day courses of teplizumab in children and adolescents diagnosed with diabetes less than six weeks earlier [i.e., symptomatic T1D] preserved their ability to make their own insulin.]
• The Standards of Care diabetes technology section now begins with the following statement: “Diabetes devices should be offered to people with diabetes” and the Standards of Care also recommends that continuous glucose monitors be offered to people with type 1 diabetes at the time of diagnosis [emphasis mine].
• The Standards of Care now recommend that people with diabetes, their caregivers, and family members be screened for diabetes distress at least yearly, and potentially more frequently if warranted. Recommendation 5.39 was changed to specify the frequency for diabetes distress screening and to highlight the role of health care professionals in addressing diabetes distress. The accompanying text also includes links to validated measures of diabetes distress.
• People with diabetes should be classified into appropriate diagnostic categories [for example, type 1 diabetes] to aid in personalized management.
• During the COVID-19 pandemic, cases of hyperglycemia, DKA, and new diabetes increased, suggesting that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a trigger for or can unmask type 1 diabetes.
What is not new in 2024 but should be reiterated are standards that are applicable to those with adult-onset type 1 diabetes:
• Type 1 diabetes is due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency, including latent autoimmune diabetes in adults.
• Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably. Classification is important for determining personalized therapy, but some individuals cannot be clearly classified as having type 1 or type 2 diabetes at the time of diagnosis. The traditional paradigms of type 2 diabetes occurring only in adults and type 1 diabetes only in children are not accurate, as both diseases occur in all age-groups. The onset of type 1 diabetes may be more variable in adults; they may not present with the classic symptoms seen in children and may experience temporary remission from the need for anticipated full-dose insulin replacement.
• A person with possible type 1 diabetes who is not treated with insulin will require careful monitoring and education so that insulin can be rapidly initiated in the event of glycemic deterioration.
• LADA: There is debate as to whether slowly progressive autoimmune diabetes with an adult onset should be termed latent autoimmune diabetes in adults (LADA) or type 1 diabetes. The clinical priority with detection of LADA is awareness that slow autoimmune β-cell destruction can occur in adults, leading to a long duration of marginal insulin secretory capacity. For this classification, all forms of diabetes mediated by autoimmune β-cell destruction independent of age of onset are included under the rubric of type 1 diabetes. Use of the term LADA is common and acceptable in clinical practice and has the practical impact of heightening awareness of a population of adults likely to have progressive autoimmune β-cell destruction, thus accelerating insulin initiation prior to deterioration of glucose management or development of DKA.
• It is important for health care professionals to realize that classification of diabetes type is not always straightforward at presentation and that misdiagnosis is common [emphasis mine] and can occur in ∼40% of adults with new type 1 diabetes (e.g., adults with type 1 diabetes misdiagnosed as having type 2 diabetes).
