Harvard Medical School

Diabetes Update 2022

DOES YOUR PATIENT HAVE TYPE 1 OR TYPE 2 DIABETES?

OR NEITHER?
 Faculty
Lucia M. Novak, MSN, ANP-BC, BC-ADM
President
Diabetes Consulting Services
North Bethesda, MD

Co-Executive Director
Capital Health and Metabolic Center
Capital Diabetes and Endocrine Associates
Camp Springs and Silver Spring, MD
 Disclosures
Speakers’ Bureau and Consultant
Abbott Diabetes Care; BI/Lilly; Novo Nordisk; Xeris

Advisory Board Member

Abbott Diabetes Care; Novo Nordisk; Provention Bio; Xeris
Polling Question 1
In your clinical practice, how often do you come across patients that
you suspect have been misdiagnosed with having the “wrong type” of
diabetes mellitus?

1) Never
2) At least once a week
3) At least once a month
4) At least once a year
Polling Question 2
If you have encountered patients that made you suspicious, what was
the issue?

1) Poorly managed diabetes – no matter what

2) Patient did not respond to medications as I expected
3) Other co-morbidities that did not “match” the type of diabetes
4) Other lab results made me question
5) Family medical history
 Learning Objectives
By the end of this session, you should be able to:
• Explain the importance of the correct classification of diabetes when
diagnosing patients with diabetes
• Discern clinical findings that raise suspicion for T1D vs T2D
• Identify laboratory tests that will help you to determine which
classification of diabetes to consider.
 Why is Clarity Important
“Names are not always what they seem.”
Mark Twain,
Following the Equator: A Journey Around the World

• Guide appropriate treatment

• Determine appropriate screening for co-morbid conditions
• Facilitate appropriate screening for and prevention of complications

ADA, Diabetes Care 2022;45:S17-S38.

 Seeing The Trees …
Type 1 DM Type 2 DM
• Auto-immune destruction • Insulin Resistance -> deficiency
• GAD65, I-A2, I-A2b, ZnT8, IAA • Older, > 45 yoa
• Children/adolescents • Overweight/obesity
• Lean • Metabolic Syndrome
• Caucasian • Low HDL, high TG, HTN
• Insulin-requiring • High risk ASCVD
• Absolute • Ethnic minorities
• DKA • Insulin-treated
ADA, Diabetes Care 2022;45:S17-S38.
 … But Missing the Forest?
• Many different subtypes of Type 21 • 2% increase of T1D every year5
• Race, ethnicity • 0.7% White
• MODY, LADA, KPD • 2.7% Black
• 10% of T2D have LADA2 • 4% Hispanic
• 4.4% Asian Pacific
• Age is just a number
• 42% of T1D 31-60 yoa3 • Obesity is prevalent
• 1/3 of new DM in children is T2D4 • 42.4% Adults 20206
• 12/100,000 US vs 2.5/100,000 EU • inc. by 26% from 2008
• 7% increase of T2D every year5 • 19.3% ages 2-19 yr 20207
• 5.5% mid-1970s

1- Kanaya, AM, et al. (2014). Diabetes Care, 37: 1621-1628. 4- Jensen, ET, et al. (2018). Curr Diab Rep, 18(6):36.
2- Naik, RG, et al. (2003). Rev Endocr Metab Disord., 4:233–241. 5-Divers, J, et al. (2020). MMWR, 69(6): 161-165.
3- Thomas, NJ, et al. (2018). Lancet Diabetes Endocrinol, 6(2):122-129. 6- CDC available https://www.cdc.gov/obesity/data/childhood.html
7- CDC available https://www.cdc.gov/obesity/data/adult.html
Things that Make You Go “Hmmm …”
• DKA at diagnosis – but eventually no need for insulin and no DKA
• Hypoglycemia with low doses SU but no significant improvement of glucose with
non-insulin medication like metformin
• Diagnosed with T1D under the age of 18 months
• Long (and I mean long!) remission phase for T1D
• Significant hyper- or hypoglycemia that does NOT match treatment
• Medications WORK if the MOA addresses the underlying pathology
• Presence of Other Medical problems
• Autoimmune?
• HTN, DL?
• NAFL/NASH?
• OSA?
ARS Question
What is THE diagnostic test for differentiating between T1D and T2D?

1) C-peptide level
2) Presence or absence of islet cell autoantibodies
3) Insulin, TG and HDL levels
4) There is no one test that accurately differentiates
 Please Point Me in the Right Direction
• C-Peptide level (with a glucose)1 ⇢ “Well … it depends”
• Presence of antibodies2 ⇢ more often T1D, but also KPD
• GAD65, ZnT8, IA-2, IAA – OTHERS???
• 15-fold inc. risk of T1D in people with 1st or 2nd degree relative
• 80% have NO FAMILY HISTORY
• Absence of antibodies ⍯ T2D
• Elevated Fasting Insulin3 ⇢ T2D
• “normal” < 25 uIU/L HOWEVER should be < 10 uIU/L
• Lipids are a CLUE - Elevated TG and low HDL4 ⇢ T2D
There is no ONE test that differentiates T1D from T2D
1- Katta S, et al. (2019). EndoText 3- Muniyappa, R, et al. (2018). Endotext
2- ADA. (2022). Diabetes Care 45 (Suppl 1) 4- Freeman, AM, et al. (2020). StatPearls
 References
• American Diabetes Association. (2022). Standards of medical care in diabetes -2022. Diabetes Care, 45, Suppl. 1.
• Centers for Disease Control and Prevention. Adult overweight and obesity. Available from: https://www.cdc.gov/obesity/data/adult.html Accessed Mar 30, 2022.
• Centers for Disease Control and Prevention. Childhood obesity facts. Available from: https://www.cdc.gov/obesity/data/childhood.html Accessed Mar 30, 2022.
• Divers, J., Mayer-Davis, E. J., Lawrence, J. M., et al. (2020). Trends in incidence of type 1 and type 2 diabetes among youths – selected countries and Indian
reservations, United States, 2002-2015. Morb Mortal Wkly Rep, 69(6): 161-165.
• Freeman, A. M., & Pennings, N. (2020). Insulin Resistance. In StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507839/
• Jensen, E. T., & Dabelea, D. (2018). Type 2 Diabetes in Youth: New Lessons from the SEARCH Study. Current Diabetes Reports, 18(6), 36.
https://doi.org/10.1007/s11892-018-0997-1
• Kanaya, A. M., Herrington, D., Vittinghoff, E., Ewing, S.K., Liu, K., Blaha, M.j., Dave, S.S., Qureshi, F., & Kandula, N.R. (2014). Understanding the high prevalence of
diabetes in US South Asians compared with four racial/ethnic groups: the MASALA and MESA studies. Diabetes Care, 37, 1621-1628.
• Katta, S., Desimone M. E., Weinstock R. S. Pancreatic Islet Function Tests. [Updated 2021 March 16]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext
[Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.endotext.org/chapter/pancreatic-islet-function-tests/
• Muniyappa, R., Madan, R., & Varghese, R. Assessing Insulin Sensitivity and Resistance in Humans. [Updated 2021 July 16]. In: Feingold KR, Anawalt B, Boyce A, et
al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-Available from: https://www.endotext.org/chapter/diabetes-treatment-
diagnosis/assessing-insulin-sensitivity-and-resistance-in-humans/
• Naik, R. G., & Palmer, J. P. (2003). Latent autoimmune diabetes in adults (LADA). Reviews in Endocrine & Metabolic Disorders, 4(3), 233–241.
https://doi.org/10.1023/a:1025148211587
• Thomas, N. J., Jones, S. E., Weedon, M. N., Shields, B. M., Oram, R. A., & Hattersley, A. T. (2018). Frequency and phenotype of type 1 diabetes in the first six decades
of life: a cross-sectional, genetically stratified survival analysis from UK Biobank. The Lancet. Diabetes & Endocrinology, 6(2), 122–129.
https://doi.org/10.1016/S2213-8587(17)30362-5