Guidelines for Type 1 Diabetes Screening

The following transcript has been edited for clarity and length.

Javier Morales, MD: Let’s shift gears to discuss type 1 diabetes screening. Dr Eytan, what are the current recommendations for screening for type 1 diabetes?

Shira Eytan, MD: Thank you. The concept of screening for type 1 diabetes is relatively new. Even when we were training as endocrinologists, we didn’t have a reliable method to predict whether someone would develop type 1 diabetes. However, with more research and data, we now know that screening for antibodies—through blood tests, which can be done in the office or, in some cases, even at home—can identify those at higher risk of developing type 1 diabetes. By monitoring these individuals more closely, we can intervene earlier.

Last year, the American Diabetes Association (ADA) held a roundtable that recommended screening, along with consistent monitoring and education about the signs and symptoms of type 1 diabetes. This approach has been shown to prevent people with early-stage type 1 diabetes from progressing to diabetic ketoacidosis, which can prevent emergency room visits, hospitalizations, financial burden, and even death.

Knowing you have these antibodies and being aware of the higher risk, along with the education that comes with it, can significantly reduce the onset of type 1 diabetes and help with long-term glycemic control. Screening for antibodies before clinical symptoms appear is key, and we’ll discuss stages of the disease in a moment.

Morales: I agree. The entire screening process is crucial. This concept even applies to something as nuanced as subclinical hypercortisolism, as we saw in the CATALYST study. It was surprising that about 20% of patients with obesity, despite being well-controlled on multiple medications, had some degree of excess cortisol. When you’re not thinking about it, you’re not going to screen for it. But in that situation, screening was impactful because you can institute appropriate therapies and mitigate the disease and improve outcomes. I think it will apply similarly to type 1 diabetes. I’m glad the ADA is on board, as early diagnosis of type 1 diabetes could really make a difference.

Andrea Stallings, PA​: What’s interesting is that in endocrinology, we focus on patients who already have type 1 diabetes. But it’s important to remember that their first-degree relatives—like siblings—aren’t our patients, and they don’t have type 1 diabetes. That’s why collaborating with primary care physicians is essential to ensure that first-degree family members of patients with type 1 diabetes are screened

Morales: Exactly. This is why patient education is so important. Oftentimes, patients will take that information home and share it with their family and friends, alerting them to the fact that type 1 diabetes exists and encouraging them to consider screening.

Eytan: Absolutely. Screening occurs before there’s any clinical evidence of diabetes. Once a patient is already diabetic and hyperglycemic, it’s too late. That’s why it’s essential to think outside the box to identify high-risk individuals, which we’ll discuss shortly. Screening at the primary care level is critical for prevention.

Additionally, screening offers an opportunity to reclassify patients who might have been misdiagnosed with type 2 diabetes. We often see patients who aren’t responding to oral medications or who don’t fit the classic type 2 diabetes profile. We can appropriately classify patients with the correct disease and get them better treatment once we screen for the right antibodies.

David Robertson, MD​: I had a patient last week who reminded me that even we as endocrinologists can do better. I’ve been seeing this patient for almost 2 decades for his Graves’ disease. His primary care provider sent him for an early visit because his blood sugar was high, and he wasn’t responding to metformin. I was surprised because his HbA1c was 5.8 just a year ago. We advised him to focus on diet and exercise. But did we screen for glutamic acid decarboxylase (GAD) or other antibodies? No, we didn’t. Sure enough, his GAD test was strongly positive. I wish we had done that last year.

Eytan: It’s easy to miss these patients, and they can progress rapidly if we don’t think about it early enough.