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Type 1? Type 2? LADA? A Diagnostic Challenge

Type 1? Type 2? LADA? A Diagnostic Challenge. David Winmill, DNP, CDE, BC-ADM Diabetes Update 2010. Case Study: C. F. 52 year old woman presenting with new onset diabetes, presumably type 1. HPI: 6 week history of fatigue, thirst, blurred vision, polyuria

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Type 1? Type 2? LADA? A Diagnostic Challenge

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  1. Type 1? Type 2? LADA? A Diagnostic Challenge David Winmill, DNP, CDE, BC-ADM Diabetes Update 2010

  2. Case Study: C. F. • 52 year old woman presenting with new onset diabetes, presumably type 1. • HPI: 6 week history of fatigue, thirst, blurred vision, polyuria • PMH: hypothyroidism, hyperlipidemia, depression. • Medications: simvastatin, duloxetine, metformin 850 mg bid, insulin glargine 8 units • Family Hx: Father – Type 2 DM, Son Type 1 DM • SH: Married with 5 children (none > 9 lbs), secretary

  3. Case Study CF • Physical exam • Wt. - 156.4 Ht. – 63” BP 132/82, HR 72, • Normal HEENT, Neck, Chest, Cardiovascular, Abdominal, Neurologic • Laboratories • HgA1C – 10.0%, glucose 268, normal renal and liver function, normal urine microalbumin What do you think of her diagnosis? Type 1, Type 2 or LADA?

  4. Objectives: • Compare and contrast diagnostic and clinical criteria of type 1, type 2 diabetes and latent autoimmune diabetes (LADA) in the adult? • Discuss role of autoimmunity in the pathogenesis of type 1 diabetes and LADA. • Identify clinical characteristics & manifestations of autoimmunity vs. insulin resistance in differentiating diabetes typology.

  5. Definition • Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.* • The name 'diabetes mellitus' derives from: Greek: 'diabetes' – “siphon” or “to pass through” Latin: 'mellitus' – “honeyed” or “sweet”** * Diagnosis and Classification of Diabetes Mellitus. ADA 2009. ** http://science.jrank.org/pages/2044/Diabetes-Mellitus.html

  6. Classification • Type 1 diabetes • Type 2 diabetes • Other • Genetic defects of beta cell function • Genetic defects in insulin action • Diseases of the exocrine pancreas • Endocrinopathies • Drug/ chemical - induced • Infections • Uncommon forms of immune-mediated diabetes • Genetic syndromes sometimes associated with diabetes • Gestational diabetes mellitus

  7. Epidemiology • 20.8 million Americans (7% of US population) • About 10% have Type 1 DM • 14.6 million diagnosed • 6.2 million remain undiagnosed • 41 million have pre-diabetes • Lifetime risk for developing DM (Type 1 or 2) is 33 % in males and 39% in females for individuals born in 2000 • Up to 45% of newly diagnosed cases of DM in US children and adolescents are type 2 AACE Diabetes Mellitus Guidelines, EndocrPract. 2007;13(Suppl 1) 2007

  8. Type 1 diabetes mellitus • Absolute insulin deficiency • Autoimmune destruction of the pancreaticβ cells • Islet-cell antibodies (ICA) • Glutamicacid decarboxylase [anti-GAD] • IA-2 and anti-insulin) • Rapid onset • Ketosis Prone

  9. Atkinson MA and Eisenbarth GS. Lancet 2001;358:221-229.

  10. Diabetes Mellitus Type 1 & Autoimmune Diseases • Hypothyroidism • Celiac disease • Addison’s Disease • Rheumatoid arthritis • Pernicious anemia • Vitiligo

  11. Type 2 diabetes • Central feature: Insulin resistance • Relative impairment in insulin secretion (hyperinsulinemia may exist) • Associated metabolic features (hyperlipidemia) • Ketosis occurs rarely

  12. Type 2 Diabetes: Insulin Resistance & β Cell Dysfunction ­Cell Dysfunction Insulin Resistance Increased Lipolysis Pancreas Liver Elevated Plasma FFA ↓Glucose Uptake ↑Glucose Production Islet ­Cell Degranulation;Reduced Insulin Content Increased Glucose Output Adipose Tissue Muscle Reduced Plasma Insulin Decreased Glucose Transport & Activity (expression) of GLUT4 Hyperglycemia

  13. Type 2 Diabetes and Associated Factors • Obesity • Sedentary lifestyle • Gradual onset • History • Gestational diabetes • Family history • PCOS • Hyperpigmented skin (acanthosisnigricans)

  14. Latent Autoimmune Diabetes in Adults (LADA) • Adult-onset diabetes with circulating islet antibodies but not requiring insulin therapy initially. • Alternate references • Type 1.5 diabetes • Skinny Type 2 diabetes • Typical characteristics • Age of onset > 50 years of age • Gradual onset with initial improvement to oral agents/lifestyle changes. • BMI <25 kg/m2 • Personal or family history of autoimmune disease *A clinical screening tool identifies autoimmune diabetes in adults. Fourlanos S; Perry C; Stein MS; Stankovich J; Harrison LC; Colman PG. Diabetes Care. 2006 May;29(5):970-5

  15. Characteristics of Type 1, Type 2 and LADA Adapted from: Appel et al. (2009). J Am Acad Nurse Pract, 21(3), 156-159.

  16. Followup Case Study – C. F. • FollowupLaboratories • Glutamic Acid Carboxylase (GAD-65) – 94.9 (Reference 0-1.5) • Islet cell antibody IgG 1:16 (Reference <1:4) • C Peptide – 0.9 (1.1-5.0) Your thoughts on this woman’s diagnosis???? Type1 . . . Type 2 . . . LADA

  17. Summary Clinical indicators that can aid in the diagnosis of diabetes type: • History of onset • Family history • Presence of autoimmune indicators • Evidence of insulin resistance

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