Guidelines on Screening for T1D

The following Frontline Insights transcript has been edited for clarity and length.

Javier Morales, MD: When it comes to identifying patients with type 1 diabetes (T1D), several challenges persist. Various professional societies, including the American Diabetes Association (ADA) and the American Association of Clinical Endocrinology, provide guidance. Today, we’ll focus on the ADA’s recommendations. Dr. Natalie Bellini will guide us through the current guidelines.

Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES: Thank you. Over the past few years, the ADA has developed recommendations to address these challenges. The first key point is the importance of screening for type 1 diabetes. Early screening, coupled with consistent monitoring and education about the signs and symptoms of T1D, can prevent individuals in early stages from progressing to diabetic ketoacidosis (DKA). This proactive approach reduces emergency room visits, hospitalizations, and even mortality associated with stage 3 T1D, which represents the stage we commonly treat today.

Another critical aspect is antibody screening, which offers insights into cases often misclassified as type 2 diabetes (T2D). Notably, 60% of individuals diagnosed with T1D are adults, and up to 40% of those over 30 are initially misdiagnosed as having T2D. Historically, T1D was depicted as affecting children—specifically, the classic case of a 12-year-old with significant weight loss and a low body mass index (BMI). However, with the increasing prevalence of obesity and overweight in the U.S., T1D now presents across a broader demographic spectrum, both in age and BMI.

The ADA’s new screening recommendations have received endorsements from multiple organizations, including the American College of Osteopathic Family Physicians, the American Academy of Physician Associates, and the International Society of Pediatric and Adolescent Diabetes (ISPAD).

Morales: You raise an excellent point about reclassification. Even in long-standing cases of T2D, if glycemic control becomes increasingly difficult despite intensification of therapy, we must reconsider the diagnosis. Two possibilities come to mind: subclinical hypercortisolism, which is more common than often recognized, and late-onset T1D. The latter involves an autoimmune process with rapid beta-cell deterioration, often leading to critical presentations such as DKA.

To our audience, are you familiar with the concept that T1D progresses through distinct stages? Please indicate yes or no.

When I was in training, we approached diabetes as either type 1 or type 2, with distinct management pathways. However, this binary thinking has evolved. Natalie, what are your thoughts?

Bellini: Absolutely, the landscape has shifted significantly. Today, we recognize crossover conditions more frequently. For instance, we manage insulin resistance in patients with T1D and initiate insulin earlier in T2D to mitigate complications. Gone are the days when insulin was viewed as a last resort, a “threat” for noncompliance. Instead, we emphasize its role as a hormone therapy that improves glycemic control and enhances quality of life. This shift reflects a more patient-centered, proactive approach to care.

Morales: Indeed, the evolution in diabetes management is striking. To our audience, how confident are you in defining the stages of T1D progression? Select the option that best reflects your confidence level.

As we continue, we’ll delve deeper into these stages and explore how the paradigm of diabetes management has transformed—both for T2D and T1D. Let’s proceed with the next slide, and Natalie, I’m sure your insights will bolster the audience’s confidence as we advance.