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Diagnosing Diabetes Not So Simple

In the first of a four-part series, Anne Peters, MD, explains why diagnosing diabetes isn't necessarily easy. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- This is the first in a series of videos in which I'm discussing how to diagnose diabetes. In the past, when I trained, it seemed as though this was simple. First, there were people who didn't have diabetes. There were people with type 1 diabetes who basically had an absolute deficiency of insulin. Then there were people with type 2 diabetes who both didn't make enough insulin and also had insulin resistance. The world was simple. We treated those types of diabetes differently and there wasn't much confusion. There's also prediabetes, which I'm not discussing, and both pre–type 2 diabetes and pre–type 1 diabetes. Ideally, we'd prevent people from developing overt diabetes if we diagnosed them earlier. The American Diabetes Association Standards of Care classifies diabetes in this way. First, they say type 1 diabetes is due to autoimmune beta-cell destruction, usually leading to absolute insulin deficiency. This includes latent autoimmune diabetes of adulthood (LADA). LADA is a form of type 1. I think there's subtlety here because there are people with type 1 who don't have measurable autoantibodies. There are people with LADA who are treated much like they have type 2 diabetes, at least for a while. We know from the Joslin 50-year follow-up study that people with type 1 diabetes after 50 or more years may still make a little bit of measurable C-peptide. In theory, type 1 diabetes is autoimmune beta-cell destruction that leads to insulin deficiency. Type 2 diabetes is due to a non-autoimmune, progressive loss of adequate beta-cell insulin secretion, frequently on the background of insulin resistance and metabolic syndrome. I'm going to point out that metabolic syndrome can occur in anybody, and I have many patients with type 1 diabetes who also have metabolic syndrome. I think that's a separate issue for many of our patients, but it's very important because it confers a higher risk for cardiovascular disease. Then there are subtypes of diabetes due to other causes. Frankly, these are the patients that I see most often. There are patients who have monogenic diabetes syndromes such as neonatal diabetes and maturity-onset diabetes of the young (MODY); diseases of the exocrine pancreas such as cystic fibrosis and pancreatitis; patients who are post-pancreatectomy; patients who have drug or chemically induced diabetes, such as with glucocorticoid use; people who are treated for HIV/AIDS; and those who have organ transplants. There is gestational diabetes, which is diabetes diagnosed in the second or third trimester of pregnancy that was not present prior to the pregnancy and tends to go away after the pregnancy but confers an increased risk for type 2 diabetes in the future. Almost everything we do depends on the patient's clinical status and how they respond to treatment, not necessarily just based on a label. There is no single specific test that separates people with type 1 diabetes from type 2 diabetes. Islet autoantibodies can be present in every type of diabetes, from type 1 diabetes to type 2 diabetes to MODY. There are people with type 1 diabetes who don't have measurable insulin autoantibodies. https://www.medscape.com/viewarticle/...