Monitor stage 1 and stage 2 type 1 diabetes to prevent DKA: guidance

Type 1 diabetes

By Mardi Chapman

1 Jul 2024

The new Consensus Guidance for Monitoring Individuals With Islet Autoantibody–Positive Pre-Stage 3 Type 1 Diabetes recognises the fact that screening alone will not prevent individuals with new onset type 1 diabetes presenting in DKA.

The guidance, developed by more than 70 experts across four continents including Australia, was presented at the recent ADA Scientific Sessions and published in both Diabetes Care [link here] and Diabetologia [link here].

It covers both paediatric and adult diabetes and is targeted at a wide range of health professionals including GPs, endocrinologists, diabetes educators, and those providing psychosocial support to individuals and families.

Children

Paediatric endocrinologist Dr Kurt Griffin, from the Sanford School of Medicine at the University of South Dakota, told the ADA meeting that monitoring was only required in children with persistent antibodies.

Therefore it was critical that any positive islet autoantibody (IAb) screening test was confirmed by a second positive test, ideally performed in an accredited lab.

He said it would be worthwhile for parents of children with an initial, transient islet antibody to receive education on the symptoms of type 1 diabetes and how to intervene in case something changed, but otherwise they didn’t require any formal follow-up.

The guidance recognises that the risk of progression in those with persistent islet antibodies varies with the age of the child. For example, the recommendations for children with a single persistent antibody include:

  • education on the symptoms of type 1 diabetes and DKA
  • in children <3 years, monitor IAb+ status every 6 months for 3 years, then annually thereafter for 3 more years then stop if no progression
  • in children ≥3 years, monitor IAb+ status annually for 3 years then stop if no progression
  • metabolic monitoring e.g. random blood glucose and HbA1c should be performed with antibody monitoring for two years from the initial positive IAb test.

Dr Griffin said the choice of metabolic monitoring included SMBG, random serum glucose, HbA1c, CGM, C-peptide and the gold standard of OGTT and should be tailored based on clinical setting, access, cost, invasiveness, and age of patient.

“Part of this consensus is the realisation that not every place is Orlando, Florida; not every place has access to the same resources,” he said.

Reinforcing the importance of patient/family education of symptoms of diabetes and DKA, he said some children can bounce between stages.

“Some of these kids will go from stage one to stage two and occasionally from stage one to stage three while we’re not looking, so having the families be aware of symptoms is really important,” he said.

“And I’m saying this as somebody who’s still seeing patients and in our system across our footprint, 70% of the kids who come in with new onset type 1 diabetes are already in DKA, and we know that that has long term impacts.”

Adults

Dr Rifka Schulman-Rosenbaum, from the Long Island Jewish Medical Center in New York, said separate guidance for adults was required to account for differences such as:

  • early stage, type 1 diabetes is far less studied in adults than children
  • high rates of misdiagnosis in adults with type 1 diabetes
  • much slower rate of progression in adults
  • the challenge of latent autoimmune diabetes in adults (LADA)
  • pregnancy.

She said annual metabolic monitoring was recommended for adults with a persistent single antibody and additional risk factors, such as a first degree relative with type 1 diabetes, elevated type 1 diabetes genetic risk score, dysglycaemia or history of stress hyperglycaemia.

In adults with a persistent single antibody and no additional risk factors, metabolic monitoring was recommended every three years.

“There is a risk for them. It’s not a very high risk so we felt that we did not need to give very aggressive recommendations, but we still wanted them to be monitored in some fashion and the reason that we picked every three years is based on the fact that that is the frequency used for screening for type 2 diabetes in the general population, age over 35, etc.”

“For stage one, type 1 diabetes for adults, again we recommend confirming persistence of the antibodies in a second sample and preferably in a reference lab.”

“We recommend that patients are given a glucose meter so that they can self monitor blood glucose at home, particularly with illness or symptoms as they arise. Importantly, for stage one, we recommend HbA1c every 12 months as part of their primary care visit, which is very doable, as most patients would have an annual physical and get annual blood work.”

She said a change of ≥10% in HbA1c should trigger an OGTT to assess T1D stage in order to determine eligibility for therapy.

The session heard that much of the initial antibody screening and monitoring in stage 1 type 1 diabetes can be conducted in primary care, however by stage 2, patients should be referred to an endocrinologist.

Pregnancy

Dr Schulman-Rosenbaum said the recommendations were deliberately conservative including that any pregnant woman who was antibody positive should their glucose measured ideally by eight weeks.

“And we did give options. It could be an OGTT, a HbA1c or CGM. If those are all negative, then they should still undergo standard OGTT at 24 to 28 weeks, as is recommended for all pregnant women.”

“We do know that pregnancy is a very high risk time for mother and foetus when it comes to hyperglycaemia, which can be associated with foetal anomalies especially in the first trimester, and other challenges in the second and third trimesters. And we felt that it would be a shame to not diagnose someone with stage three in the first trimester if we could.”

Another recommendation was an endocrine consult for postpartum assessment of the need for ongoing insulin in patients who were diagnosed with diabetes during pregnancy.

Dr Kirstine Bell, Professor Maria Craig, Professor Jennifer Couper, Dr Christele Hendreckx and Professor John Wentworth were the Australian co-authors on the guidance.

The guidance has been endorsed by Advanced Technologies & Treatments for Diabetes (ATTD), the American Association of Clinical Endocrinology (AACE), the American Diabetes Association (ADA), the Association of Diabetes Care and Education Specialists (ADCES), the Association for the Endocrine Society, the Australian Diabetes Society (ADS), the European Association for the Study of Diabetes (EASD), the International Society for Pediatric and Adolescent Diabetes (ISPAD) and Breakthrough T1D (formerly JDRF).

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