A nationwide population-based study on the risk of coma, ketoacidosis and hypoglycemia in patients with celiac disease and type 1 diabetes

The prevalence of celiac disease in Saudi patients with type 1 diabetes mellitus

BACKGROUND

Celiac disease (CD) is an autoimmune disease that is highly associated with type 1 diabetes mellitus (T1DM). The reported prevalence of CD in patients with T1DM in Saudi Arabia varies and the number of studies is limited.

OBJECTIVES

Determine the prevalence of CD diagnosed with anti-tissue transglutaminase (anti-tTG) antibodies or by endoscopic biopsy in adolescents and adults with T1DM.

DESIGN

Cross-sectional, retrospective medical record review.

SETTING

Tertiary care center.

PATIENTS AND METHODS

The study population included adolescents and adults with T1DM who were screened for CD between 2010 and 2019. The study variables included age, sex, age at diagnosis of T1DM, age of positive celiac screening, glycated hemoglobin (HbA1c), total daily insulin dose, frequency of diabetic ketoacidosis (DKA) and other autoimmune diseases.

MAIN OUTCOME MEASURES

The prevalence of celiac disease in adolescents and adults with T1DM.

SAMPLE SIZE

539 patients.

RESULTS

The prevalence of positive celiac test results was 11.5% (n=62). A small proportion (n=5, 8%) of the positive CD group was diagnosed with T1DM after they tested positive with the celiac screening test. Ten (16%) were diagnosed with T1DM and CD in the same year. The rest of the sample had a positive screening test after being diagnosed with T1DM. There was no statistically significant difference between the CD positive and negative groups for HbA1C, DKA frequency, microvascular complications of diabetes or thyroid disorder. For histopathological confirmation of CD, only 37% (n=23) of the group with a positive screening test underwent endoscopy. In this group, 43% (n=10) had normal endoscopic biopsy findings, 21.7% (n=5) had partial villous atrophy and 34.7% (n=8) had total villous atrophy.

CONCLUSIONS

This study highlights the importance of screening for CD in T1DM patients. CD prevalence is high in patients with T1DM, despite the high likelihood of underdiagnosis. Additional studies of different age groups and the use of different study methods are required. In addition, a unified national strategy to diagnose CD in T1DM patients is highly advisable.

LIMITATIONS

Retrospective, single-center, few confirmations of CD by intestinal biopsy.

CONFLICT OF INTEREST

None.

Does concomitance of Hashimoto's disease and type 1 diabetes affect diabetes control and development of its complications?

INTRODUCTION

Autoimmune diseases concomitant with diabetes may complicate the treatment and adversely affect the prognosis. The most common is Hashimoto's disease (HD). We compared diabetes control and prevalence of chronic complications in type 1 diabetes patients differing in the coexistence of HD.

MATERIAL AND METHODS

Medical records of 188 type 1 diabetics were analysed. Hashimoto's disease was diagnosed based on medical history, as well as determination of the levels of thyroid peroxidase antibodies, hormones and ultrasound examination. Statistical analysis was performed using Statistica 10PL.

RESULTS

HD was diagnosed in 43 (23%) patients. The mean HbA_1c was 8.8 ±1.5% in the group with HD, and 9 ±1.6% in the group without HD (ns). The prevalence of diabetes complications was similar in both groups: ischaemic heart disease was diagnosed in 19% of patients with HD and 19% without HD, cerebral vascular insufficiency - 8% and 7%, peripheral neuropathy - 14% and 12%, sensory polyneuropathy - 47% and 46%, diabetic foot - 7% and 8%, Charcot osteoarthropathy - 7% and 2%, cardiovascular neuropathy - 21% and 28%, neuropathy of the gastrointestinal tract - 5% and 6%, nephropathy - 12% and 19%, retinopathy - 42% and 43%, and cataract in 28% and 19%, respectively. Impaired hypoglycaemia perception was rarer in the group with HD: 9% vs. 25% (p ≈ 0.04).

CONCLUSIONS

Hashimoto's disease does not significantly affect the level of type 1 diabetes control or the development of its complications. Only autonomic neuropathy in the form of impaired awareness of hypoglycaemia is rarer in patients with that thyroiditis.

Lower HbA1c in patients with type 1 diabetes and celiac disease who reached celiac-specific antibody-negativity-A multicenter DPV analysis

OBJECTIVES

To study celiac-specific antibody status over 3 years in patients with type 1 diabetes and biopsy-proven celiac disease (T1D + CD). Furthermore, to determine clinical differences after diagnosis between patients reaching constant antibody-negativity (Ab-neg) and staying antibody-positive (Ab-pos).

METHODS

A total of 608 pediatric T1D + CD patients from the multicenter DPV registry were studied longitudinally regarding their CD specific antibody-status. Differences between Ab-neg (n = 218) and Ab-pos (n = 158) patients 3 years after biopsy were assessed and compared with 26 833 T1D patients without CD by linear and logistic regression adjusted for age, gender, diabetes duration and migration background.

RESULTS

Thirty-six percent of T1D + CD patients reached and sustained antibody-negativity 3 years after CD diagnosis. The median time until patients returned to Ab-neg was 0.86 (0.51;1.16) years. Three years after diagnosis, HbA1c was lowest in Ab-neg and highest in Ab-pos patients compared to T1D-only patients (adjusted mean (95%CI): 7.72 (7.51-7.92) % vs 8.44 (8.20-8.68) % vs 8.19 (8.17-8.21) %, adjusted P < 0.001, respectively). Total cholesterol, LDL-cholesterol and frequency of dyslipidemia were significantly lower in Ab-neg compared to T1D-only patients (167 (161-173) mg/dl vs 179 (178-179) mg/dl, P < .001; 90 (84-96) mg/dl vs 99 (98-99) mg/dl, P = .005; 15.7 (10.5-22.9) % vs 25.9 (25.2-26.6) %, P = .017). In longitudinal analyses over 6 years after diagnosis, a constantly higher HbA1c (P < .001) and a lower height-SDS (P = .044) was observed in Ab-pos compared to Ab-neg patients.

CONCLUSION

Only one third of T1D + CD patients reached constant Ab-negativity after CD diagnosis. Achieving Ab-negativity after diagnosis seems to be associated with better metabolic control and growth, supposedly due to a higher adherence to therapy in general.

The Prevalence of Celiac Disease-Specific Auto-Antibodies in Type 1 Diabetes in a Moroccan Population

OBJECTIVE

We aimed to determine the prevalence of specific auto-antibodies to celiac disease (CD) in Moroccan type 1 diabetic (T1D) patients and compare the clinical and biological characteristics of seropositive and seronegative cases.

PATIENTS AND METHODS

A cross-sectional study was carried out on 276 T1D patients including 109 adults and 167 pediatric cases. The screening for CD was performed by an Elisa IgA anti-tissue transglutaminase antibody (tTGA) testing, combined with IgA quantification by nephelometry. Positive-IgA-tTGA cases were secondly tested for anti-endomysial antibodies (EMA) using an immunofluorescence technique, and the IgA deficiency cases were screened for IgG-tTGA. Patients with low positive tTGA titers underwent HLA-DQ2/DQ8 typing. Sociodemographic and clinical data of the patients were collected using a hetero-administered questionnaire. The comparison of clinical and biological data between seropositive and seronegative diabetics was done using independent T, Mann-Whitney U, chi-squared, and Fisher tests, which were considered significant if p value <0.05.

RESULTS

The prevalence of CD-specific auto-antibodies was estimated to be 9.1% (IC = 95%), with 25 positive cases in tTGA and EMA testing. Eight cases displayed low titers of IgA-tTGA, among which 4 were positive for HLA-DQ2, 1 for HLA-DQ8, and 1 for both DQ2 and DQ8. The other 2 cases had a biopsy-proven CD. Compared to seronegative patients, seropositive cases had a higher percentage of associated autoimmune disorders (16% vs. 2.4%, p=0.008), with a significant lower height Z-scores (median: -0.90 (-3.93 to 0.95) vs. -0.51 (-4.54 to 2.18), p=0.029) and a higher HbA1c level (median: 11.30% (7.31 to 16.00) vs. 9.30% (4.40 to17.31), p=0.022).

CONCLUSION

The current study gave evidence of a high prevalence of CD specific auto-antibodies in T1D population. The co-existence of these two conditions was associated with a poor glycemic control, a lower height, and other autoimmune diseases. These findings may suggest the necessity of a systematic screening of CD in T1D patients.

Type 1 Diabetes, Celiac Disease, and Neuropathy-A Nationwide Cohort Study

OBJECTIVE

Both type 1 diabetes (T1D) and celiac disease (CD) have been linked to an increased risk of neuropathy. This study examined the risk of neuropathy in patients with T1D compared with patients with both T1D and CD.

METHODS

In a nationwide population-based cohort, T1D was defined as having a diagnosis of diabetes between 1964 and 2009 recorded in the Swedish National Patient Register in individuals ≤30 years of age. CD was defined as having villous atrophy (Marsh histopathology stage III) on small intestinal biopsy. CD cases were identified through biopsies examined between 1969 and 2008 at any of Sweden's 28 pathology departments. Nine hundred fifty-eight patients had both T1D and CD and were matched for sex, age, and calendar period with 4590 controls who only had T1D. Through Cox regression analysis, with CD as the time-dependent covariate, we estimated the risk of neuropathy in T1D patients with CD.

RESULTS

Fifty-four individuals with T1D and CD had later neuropathy (expected: n = 42). This corresponded to an adjusted hazard ratio of 1.27 (95% confidence interval = 0.95-1.71) compared with those who had T1D alone. The hazard ratio was statistically significant in the first 5 years with CD (1.67; 95% confidence interval = 1.13-2.47) but decreased to neutrality thereafter. Risk estimates were similar in men and women, and did not differ by age at CD onset.

CONCLUSIONS

CD does not seem to influence the risk of neuropathy in individuals with T1D, although a small excess risk cannot be ruled out.

Increased prevalence of fracture and hypoglycaemia in young adults with concomitant type 1 diabetes mellitus and coeliac disease

BACKGROUND

Both Type 1 diabetes mellitus (T1DM) and coeliac disease (CD) are independently associated with reduced bone mineral density (BMD) and increased fracture risk. Whilst poorer glycaemic control and increased microvascular complications have been described, the literature examining bone health and fractures in adults with concomitant T1DM and CD (T1DM + CD) is limited.

OBJECTIVE

To evaluate fracture prevalence and explore associations with glycaemic control, hypoglycaemia and microvascular disease in T1DM + CD compared with T1DM alone.

METHODS

We conducted a retrospective cross-sectional study of young adults with T1DM, who attended diabetes clinics at a large tertiary referral centre between August 2016 and February 2017. Clinical information, radiological and biochemistry results were extracted from medical records. Patients with comorbid chronic kidney disease, glucocorticoid use, hypogonadism and untreated hyperthyroidism were excluded.

RESULTS

A total of 346 patients with T1DM alone (median age 23 years) and 49 patients with T1DM + CD (median age 24 years) were included. Median age, gender distribution, BMI, haemoglobin A1c, daily insulin dose and serum 25-hydroxyvitamin D levels were similar between groups. Higher adjusted fracture risk was observed in T1DM + CD compared with T1DM (12.2% vs 3.5%; OR 3.50, 95% CI 1.01-12.12, P = .01), yet BMD was only measured in 6% of patients. The adjusted risk of hypoglycaemia ≥2/week was greater for T1DM + CD (55% vs 38%, OR 3.28, 95% CI 1.61-6.69, P = .001); however, this was not independently associated with fractures. Replete vitamin D (≥ 50 nmol/L) was associated with less hypoglycaemia (OR 0.48, 95% CI 0.29-0.80; P = .005), but not with fractures.

CONCLUSIONS

Coeliac disease status was independently associated with increased fracture prevalence in young adults with T1DM. Recurrent hypoglycaemia was also increased in T1DM + CD, although hypoglycaemia was not independently associated with fractures. Prospective studies are required to determine the long-term impacts of CD on bone health and glycaemic control in patients with T1DM.

Screening for coeliac disease in adult patients with type 1 diabetes mellitus: myths, facts and controversy

This review aims at summarizing the present knowledge on the clinical consequences of concomitant coeliac disease (CD) in adult patients with type 1 diabetes mellitus (T1DM). The cause of the increased prevalence of CD in T1DM patients is a combination of genetic and environmental factors. Current screening guidelines for CD in adult T1DM patients are not uniform. Based on the current evidence of effects of CD on bone mineral density, diabetic complications, quality of life, morbidity and mortality in patients with T1DM, we advise periodic screening for CD in adult T1DM patients to prevent delay in CD diagnosis and subsequent CD and/or T1DM related complications.