Consequences of Delaying Intervention

The following transcript has been edited for clarity and length.

Javier Morales, MD: Let's engage the audience for a moment. For those of you listening, what do you think are the consequences of delaying intervention in stage 2 type 1 diabetes? Please select all that apply.

Abha Choudhary, MD: While you're responding, I'd like to add to what Dr. Bellini mentioned earlier. When someone has just one antibody, we refer to them as "at risk." With two or more antibodies, it’s classified as "early stage type 1 diabetes." The International Society for Pediatric and Adolescent Diabetes (ISPAD) and the ADA recently released guidelines on screening based on age, antibody presence, and recommended lab tests. These guidelines simplify decision-making in practice. Screen these patients, and specialists like us will handle the rest.

Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES: I completely agree. The goal is not to burden primary care providers but to identify these individuals early because of the evidence linking screening to reduced rates of diabetic ketoacidosis (DKA). The science on early intervention in type 1 diabetes is evolving rapidly.

Morales: Looking at the poll results, it seems most of you agree that delaying intervention has significant consequences. The top concern is the increased risk of DKA. Aubrey, what’s your take on "irreversible damage to pancreatic beta cells"?

Aubrey Molgaard, DNP, ARNP, FNP-BC, CDCES: Personally, my daughter received teplizumab at age 8, and I’ve observed outcomes that make me question if we fully understand the long-term potential of preserving beta cell function.

Professionally, I’ve seen promising results in my adult population, but there’s still so much to uncover. The focus remains on preventing DKA and intervening early to change the disease trajectory. Screening is critical for this progress.

Morales: This is an autoimmune process. Once beta cells are destroyed, they don’t regenerate. Preserving those cells before full-blown type 1 diabetes develops is key. Natalie, can you walk us through stage 3?

Bellini: Stage 3 can progress quickly or gradually. The more antibodies present, the faster the progression. For example, someone with four or five positive antibodies is likely to progress faster than someone with just one or two.

Delaying intervention means missing the chance to preserve remaining beta cell function. By the time someone reaches stage 3, their beta cells are nearly depleted. This not only increases the risk of DKA but can also lead to long-term glucose variability.

Patients diagnosed in DKA often face greater challenges in managing glucose levels. Early diagnosis and gradual education allow for better outcomes. It’s much easier to help someone transition into type 1 diabetes when they aren’t in crisis.

Choudhary: Screening also provides what we call a "smooth landing" into the diagnosis. It opens opportunities for participation in research studies, which are vital for advancing treatment. There’s a shortage of patients in these studies, so screening helps both the individual and the broader medical community.

Bellini: Exactly. Organizations like Breakthrough T1D, formerly JDRF, emphasize the need for more screened participants. Preserving beta cells is the ultimate goal because they outperform any external insulin or transplant options.

Now, let’s discuss symptoms:

• Stage 2: No symptoms. Zero. Patients feel completely fine.
• Stage 3: Classic signs of type 1 diabetes—excessive thirst (polydipsia), frequent urination (polyuria), and unexplained weight loss due to insufficient insulin. Other symptoms include fatigue, weakness, slow wound healing, and DKA in severe cases.

Without insulin, glucose levels rise dangerously, leading to dehydration, electrolyte imbalances, kidney damage, cerebral edema, or even cardiac complications.

We often see these scenarios during life transitions, like kids going off to college and forgetting their insulin or adults delaying care due to barriers like cost or misinformation. Other triggers include illnesses or steroid injections. Consistent insulin use and prompt treatment of infections are crucial for managing this stage.

Choudhary: Ultimately, early screening and intervention transform outcomes by reducing the risk of DKA and other complications. It’s all about catching the disease before it progresses.