The Gift of Time and Key Connection Between Diabetes Mellitus and Autoimmune Disorders

The Gift of Time and Key Connection Between Diabetes Mellitus and Autoimmune Disorders Posted By:
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Are you aware that approximately 64,000 Americans are diagnosed with type 1 diabetes (T1D) each year? Formerly known as “juvenile-onset” diabetes, T1D remains one of the most common chronic childhood diseases. Onset peaks between 10 and 14 years of age, yet 58% of new cases are diagnosed in the adult population, with a steady rise beginning around age 34 years for women and 44 years for men.

As with any chronic disease, the earlier T1D is detected and appropriate treatment is initiated, the better the odds the person will do well and for a longer duration. Approximately 300,000 people currently are at risk for overt T1D. So, how do we identify them?

Screening Considerations for T1D
The American Diabetes Association (ADA) has long published recommendations regarding whom, when, and how often to screen based on defined risk factors for type 2 diabetes (T2D). In the absence of risk factors, we have guidance as to when to screen based solely on age. Until recently, the screening recommendations and the appropriate testing for T1D have not been as clear. It was not until 2017 that the autoantibody tests for T1D were made commercially available. However, they have not yet been widely implemented into clinical practice.

The lack of screening is at least one reason that 29% to 38% of children diagnosed with T1D also will present with the life-threatening hyperglycemic crisis known as diabetic ketoacidosis (DKA)—the leading cause of mortality in youths with T1D. DKA occurs less frequently among children or siblings of people with T1D or those who are aware of their symptoms. Why? They know what to look for and act quickly. Heightened awareness of these symptoms may not only ensure that the person seeks potentially life-saving treatment much sooner, but also that they may not develop DKA at all. 

Addressing Family History and Autoimmune Disorders
Those with one autoimmune disorder are more likely to have another, and those with a family history of autoimmune disorders have a higher risk of developing one themselves. Individuals who have a first-degree family member (ie, mother, father, siblings) with T1D are 8-15 times more likely to develop it than the general population. For those lacking a first-degree relative with T1D but who have second-degree relatives (ie, grandparents, aunts/uncles, nieces/nephews) with T1D, the risk is 2 times greater.

Upwards of 80% of those with new-onset T1D will not have a family history. However, people with T1D have a higher prevalence of other autoimmune disorders coexisting with T1D. Therefore, it is crucial that healthcare professionals (HCPs) are aware of the autoimmune disorders associated with T1D and include this knowledge in our risk assessment when determining whom to screen. An observational study published in the World Journal of Diabetes identified the prevalence of autoimmune disorders found in people with T1D.

  • Autoimmune hypothyroidism (Hashimoto thyroiditis) (56.84%)
  • Autoimmune hyperthyroidism (Graves’ disease) (43.68%)
  • Type A gastritis (42.52%)
  • Vitiligo (18.11%)
  • Neurodermatitis (16.54%)
  • Celiac disease (15.75%)
  • Alopecia (10.24%)
  • Hypogonadism (10%)
  • Psoriasis (9.45%)
  • Urticaria (8.66%)
  • Sjögren syndrome (6.30%)
  • Rheumatoid arthritis (5.51%)
  • Autoimmune hepatitis (3.15%)
  • Addison disease (2.63%)
  • Systematic lupus erythematosus (1.57%)
  • Crohn’s disease (1.57%)
  • Hypoparathyroidism (1.05%)

Unfortunately, the reverse association of risk for those with other autoimmune disorders and future development of T1D is not as clear. However, this study did identify that, compared with people with T1D and without other autoimmune disorders, those with T1D and at least one other autoimmune disorder were more often female and older. Autoimmune thyroid disorders tended to occur in women, and the onset of T1D in people with autoimmune thyroid tends to develop later—after the onset of autoimmune thyroid disorders.

Screening Best Practices
T1D historically has been viewed as a childhood/adolescent disease, yet 42% of adults with T1D are older than 30 years of age when diagnosed. This has led to approximately 10% of adults with T1D being misclassified as having T2D. Therefore, the strong association between these autoimmune disorders with T1D warrants a higher degree of suspicion when screening individuals for diabetes mellitus, starting at age 35 years regardless of risk factor status.

If screening yields abnormal glucose and/or A1C values and the patient has a personal or family history of any of the above autoimmune disorders, yet they lack the signs, symptoms, and disorders typically associated with insulin resistance and T2D (ie, acanthosis nigricans, polycystic ovarian syndrome, elevated triglycerides/low HDL cholesterol, hypertension), we should screen for T1D.

This recommendation also includes any adults with preexisting diabetes mellitus who have been classified as having T2D and either have a personal or family history of other autoimmune disorders associated with T1D or are not responding to appropriate and effective treatment designated for T2D. They may have delayed-onset T1D, also known as latent autoimmune diabetes in adults (LADA), and were misdiagnosed as having T2D.

The ADA recommends screening for the presence of the following autoantibodies in individuals with a family history of T1D and/or a personal or family history of other autoimmune disorders: autoantibodies to insulin (IAA), zinc transporter 8 (ZnT8), glutamic acid decarboxylase (GAD), or islet antigen 2 (IA-2). Positive findings of at least 2 autoantibodies and glucose/A1C values consistent with prediabetes (stage 2) yields a 44% likelihood of progressing to T1D (stage 3) within 5 years, 70% likelihood within 10 years, and 84% likelihood in within 15 years. The lifetime risk is 100%—it is a matter of when, not if.

Accurately identifying a person’s risk for developing T1D before any symptoms are experienced can empower individuals to become educated about the disease process and how to recognize symptoms of hyperglycemia to prevent DKA. Knowing patients are at risk for T1D will encourage HCPs to refer their patients for much-needed education that includes the latest available treatment options before it develops. We will be able to provide information that will help alleviate the associated shock and anxiety of this diagnosis that typically occurs in the intensive care unit, when patients are least receptive. We have time to ensure that our patients start their journey well-equipped and supported, and we have time to empower them to live their best lives.


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Filed under: Cardiometabolic

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