1
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Phillip M, Achenbach P, Addala A, Albanese-O'Neill A, Battelino T, Bell KJ, Besser REJ, Bonifacio E, Colhoun HM, Couper JJ, Craig ME, Danne T, de Beaufort C, Dovc K, Driscoll KA, Dutta S, Ebekozien O, Larsson HE, Feiten DJ, Frohnert BI, Gabbay RA, Gallagher MP, Greenbaum CJ, Griffin KJ, Hagopian W, Haller MJ, Hendrieckx C, Hendriks E, Holt RIG, Hughes L, Ismail HM, Jacobsen LM, Johnson SB, Kolb LE, Kordonouri O, Lange K, Lash RW, Lernmark Å, Libman I, Lundgren M, Maahs DM, Marcovecchio ML, Mathieu C, Miller KM, O'Donnell HK, Oron T, Patil SP, Pop-Busui R, Rewers MJ, Rich SS, Schatz DA, Schulman-Rosenbaum R, Simmons KM, Sims EK, Skyler JS, Smith LB, Speake C, Steck AK, Thomas NPB, Tonyushkina KN, Veijola R, Wentworth JM, Wherrett DK, Wood JR, Ziegler AG, DiMeglio LA. Consensus guidance for monitoring individuals with islet autoantibody-positive pre-stage 3 type 1 diabetes. Diabetologia 2024; 67:1731-1759. [PMID: 38910151 PMCID: PMC11410955 DOI: 10.1007/s00125-024-06205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Given the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programmes are being increasingly emphasised. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk of (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in non-specialised settings. To inform this monitoring, JDRF in conjunction with international experts and societies developed consensus guidance. Broad advice from this guidance includes the following: (1) partnerships should be fostered between endocrinologists and primary-care providers to care for people who are IAb+; (2) when people who are IAb+ are initially identified there is a need for confirmation using a second sample; (3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; (4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; (5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and (6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasises significant unmet needs for further research on early-stage type 1 diabetes to increase the rigour of future recommendations and inform clinical care.
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Affiliation(s)
- Moshe Phillip
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Peter Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kirstine J Bell
- Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rachel E J Besser
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre Human Genetics, Nuffield Department of Medicine Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ezio Bonifacio
- Center for Regenerative Therapies Dresden, Faculty of Medicine, Technical University of Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden, Helmholtz Centre Munich at the University Clinic Carl Gustav Carus of TU Dresden and Faculty of Medicine, Dresden, Germany
| | - Helen M Colhoun
- The Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Public Health, NHS Fife, Kirkcaldy, UK
| | - Jennifer J Couper
- Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Division of Paediatrics, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Maria E Craig
- Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Discipline of Paediatrics & Child Health, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
| | | | - Carine de Beaufort
- International Society for Pediatric and Adolescent Diabetes (ISPAD), Berlin, Germany
- Diabetes & Endocrine Care Clinique Pédiatrique (DECCP), Clinique Pédiatrique/Centre Hospitalier (CH) de Luxembourg, Luxembourg City, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-Belval, Luxembourg
| | - Klemen Dovc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kimberly A Driscoll
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Department of Pediatrics, University of Florida Diabetes Institute, Gainesville, FL, USA
| | | | | | - Helena Elding Larsson
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Pediatrics, Skåne University Hospital, Malmö and Lund, Sweden
| | | | - Brigitte I Frohnert
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Carla J Greenbaum
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA, USA
| | - Kurt J Griffin
- Sanford Research, Sioux Falls, SD, USA
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - William Hagopian
- Pacific Northwest Diabetes Research Institute, University of Washington, Seattle, WA, USA
| | - Michael J Haller
- Department of Pediatrics, University of Florida Diabetes Institute, Gainesville, FL, USA
- Division of Endocrinology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, VIC, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, VIC, Australia
- Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Emile Hendriks
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Heba M Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura M Jacobsen
- Division of Endocrinology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Suzanne B Johnson
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Leslie E Kolb
- Association of Diabetes Care & Education Specialists, Chicago, IL, USA
| | | | - Karin Lange
- Medical Psychology, Hannover Medical School, Hannover, Germany
| | | | - Åke Lernmark
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Ingrid Libman
- Division of Pediatric Endocrinology and Diabetes, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Markus Lundgren
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Pediatrics, Kristianstad Hospital, Kristianstad, Sweden
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - M Loredana Marcovecchio
- Department of Pediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | - Holly K O'Donnell
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tal Oron
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shivajirao P Patil
- Department of Family Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Marian J Rewers
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Desmond A Schatz
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Rifka Schulman-Rosenbaum
- Division of Endocrinology, Long Island Jewish Medical Center, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Kimber M Simmons
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Emily K Sims
- Division of Pediatric Endocrinology and Diabetology, Herman B Wells Center for Pediatric Research, Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Laura B Smith
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Cate Speake
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA, USA
| | - Andrea K Steck
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Ksenia N Tonyushkina
- Division of Endocrinology and Diabetes, Baystate Children's Hospital and University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - Riitta Veijola
- Research Unit of Clinical Medicine, Department of Pediatrics, Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - John M Wentworth
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Diane K Wherrett
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jamie R Wood
- Department of Pediatric Endocrinology, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anette-Gabriele Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
| | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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2
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Phillip M, Achenbach P, Addala A, Albanese-O'Neill A, Battelino T, Bell KJ, Besser REJ, Bonifacio E, Colhoun HM, Couper JJ, Craig ME, Danne T, de Beaufort C, Dovc K, Driscoll KA, Dutta S, Ebekozien O, Elding Larsson H, Feiten DJ, Frohnert BI, Gabbay RA, Gallagher MP, Greenbaum CJ, Griffin KJ, Hagopian W, Haller MJ, Hendrieckx C, Hendriks E, Holt RIG, Hughes L, Ismail HM, Jacobsen LM, Johnson SB, Kolb LE, Kordonouri O, Lange K, Lash RW, Lernmark Å, Libman I, Lundgren M, Maahs DM, Marcovecchio ML, Mathieu C, Miller KM, O'Donnell HK, Oron T, Patil SP, Pop-Busui R, Rewers MJ, Rich SS, Schatz DA, Schulman-Rosenbaum R, Simmons KM, Sims EK, Skyler JS, Smith LB, Speake C, Steck AK, Thomas NPB, Tonyushkina KN, Veijola R, Wentworth JM, Wherrett DK, Wood JR, Ziegler AG, DiMeglio LA. Consensus Guidance for Monitoring Individuals With Islet Autoantibody-Positive Pre-Stage 3 Type 1 Diabetes. Diabetes Care 2024; 47:1276-1298. [PMID: 38912694 PMCID: PMC11381572 DOI: 10.2337/dci24-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 06/25/2024]
Abstract
Given the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programs are being increasingly emphasized. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk for (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in nonspecialized settings. To inform this monitoring, JDRF, in conjunction with international experts and societies, developed consensus guidance. Broad advice from this guidance includes the following: 1) partnerships should be fostered between endocrinologists and primary care providers to care for people who are IAb+; 2) when people who are IAb+ are initially identified, there is a need for confirmation using a second sample; 3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; 4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; 5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and 6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasizes significant unmet needs for further research on early-stage type 1 diabetes to increase the rigor of future recommendations and inform clinical care.
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Affiliation(s)
- Moshe Phillip
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Peter Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA
| | | | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kirstine J Bell
- Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel E J Besser
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre Human Genetics, Nuffield Department of Medicine Oxford National Institute for Health and Care Research Biomedical Research Centre, University of Oxford, Oxford, U.K
- Department of Paediatrics, University of Oxford, Oxford, U.K
| | - Ezio Bonifacio
- Center for Regenerative Therapies Dresden, Faculty of Medicine, Technical University of Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden, Helmholtz Centre Munich at the University Clinic Carl Gustav Carus of Technical University of Dresden, and Faculty of Medicine, Technical University of Dresden, Dresden, Germany
| | - Helen M Colhoun
- The Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, U.K
- Department of Public Health, NHS Fife, Kirkcaldy, U.K
| | - Jennifer J Couper
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Division of Paediatrics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Maria E Craig
- Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Paediatrics & Child Health, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | | | - Carine de Beaufort
- International Society for Pediatric and Adolescent Diabetes (ISPAD), Berlin, Germany
- Diabetes & Endocrine Care Clinique Pédiatrique (DECCP), Clinique Pédiatrique/Centre Hospitalier (CH) de Luxembourg, Luxembourg City, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-Belval, Luxembourg
| | - Klemen Dovc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kimberly A Driscoll
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL
- Department of Pediatrics, University of Florida Diabetes Institute, Gainesville, FL
| | | | | | - Helena Elding Larsson
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Pediatrics, Skåne University Hospital, Malmö and Lund, Sweden
| | | | - Brigitte I Frohnert
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | - Carla J Greenbaum
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA
| | - Kurt J Griffin
- Sanford Research, Sioux Falls, SD
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| | - William Hagopian
- Pacific Northwest Diabetes Research Institute, University of Washington, Seattle, WA
| | - Michael J Haller
- Department of Pediatrics, University of Florida Diabetes Institute, Gainesville, FL
- Division of Endocrinology, University of Florida College of Medicine, Gainesville, FL
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Emile Hendriks
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, U.K
| | - Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, U.K
- National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, U.K
| | | | - Heba M Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Laura M Jacobsen
- Division of Endocrinology, University of Florida College of Medicine, Gainesville, FL
| | - Suzanne B Johnson
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL
| | - Leslie E Kolb
- Association of Diabetes Care & Education Specialists, Chicago, IL
| | | | - Karin Lange
- Medical Psychology, Hannover Medical School, Hannover, Germany
| | | | - Åke Lernmark
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Ingrid Libman
- Division of Pediatric Endocrinology and Diabetes, University of Pittsburgh, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, PA
| | - Markus Lundgren
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Pediatrics, Kristianstad Hospital, Kristianstad, Sweden
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - M Loredana Marcovecchio
- Department of Pediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, U.K
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | - Holly K O'Donnell
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tal Oron
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shivajirao P Patil
- Department of Family Medicine, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI
| | - Marian J Rewers
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Desmond A Schatz
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Rifka Schulman-Rosenbaum
- Division of Endocrinology, Long Island Jewish Medical Center, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Kimber M Simmons
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Emily K Sims
- Division of Pediatric Endocrinology and Diabetology, Herman B Wells Center for Pediatric Research, Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Laura B Smith
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Cate Speake
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA
| | - Andrea K Steck
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nicholas P B Thomas
- National Institute of Health and Care Research Clinical Research Network Thames Valley and South Midlands, Oxford, U.K
| | - Ksenia N Tonyushkina
- Division of Endocrinology and Diabetes, Baystate Children's Hospital and University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Riitta Veijola
- Research Unit of Clinical Medicine, Department of Pediatrics, Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - John M Wentworth
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Diane K Wherrett
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jamie R Wood
- Department of Pediatric Endocrinology, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Anette-Gabriele Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
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3
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Manto M, Hadjivassiliou M, Baizabal-Carvallo JF, Hampe CS, Honnorat J, Joubert B, Mitoma H, Muñiz-Castrillo S, Shaikh AG, Vogrig A. Consensus Paper: Latent Autoimmune Cerebellar Ataxia (LACA). CEREBELLUM (LONDON, ENGLAND) 2024; 23:838-855. [PMID: 36991252 PMCID: PMC10060034 DOI: 10.1007/s12311-023-01550-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/01/2023]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies. Patients with IMCAs develop cerebellar symptoms, characterized mainly by gait ataxia, showing an acute or subacute clinical course. We present a novel concept of latent autoimmune cerebellar ataxia (LACA), analogous to latent autoimmune diabetes in adults (LADA). LADA is a slowly progressive form of autoimmune diabetes where patients are often initially diagnosed with type 2 diabetes. The sole biomarker (serum anti-GAD antibody) is not always present or can fluctuate. However, the disease progresses to pancreatic beta-cell failure and insulin dependency within about 5 years. Due to the unclear autoimmune profile, clinicians often struggle to reach an early diagnosis during the period when insulin production is not severely compromised. LACA is also characterized by a slowly progressive course, lack of obvious autoimmune background, and difficulties in reaching a diagnosis in the absence of clear markers for IMCAs. The authors discuss two aspects of LACA: (1) the not manifestly evident autoimmunity and (2) the prodromal stage of IMCA's characterized by a period of partial neuronal dysfunction where non-specific symptoms may occur. In order to achieve an early intervention and prevent cell death in the cerebellum, identification of the time-window before irreversible neuronal loss is critical. LACA occurs during this time-window when possible preservation of neural plasticity exists. Efforts should be devoted to the early identification of biological, neurophysiological, neuropsychological, morphological (brain morphometry), and multimodal biomarkers allowing early diagnosis and therapeutic intervention and to avoid irreversible neuronal loss.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
| | | | | | | | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | | | - Aasef G Shaikh
- Louis Stokes Cleveland VA Medical Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alberto Vogrig
- Clinical Neurology, Udine University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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4
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Shimada A, Kawasaki E, Abiru N, Awata T, Oikawa Y, Osawa H, Kajio H, Kozawa J, Takahashi K, Chujo D, Noso S, Fukui T, Miura J, Yasuda K, Yasuda H, Imagawa A, Ikegami H. New diagnostic criteria (2023) for slowly progressive type 1 diabetes (SPIDDM): Report from Committee on Type 1 Diabetes of the Japan Diabetes Society (English version). J Diabetes Investig 2024; 15:254-257. [PMID: 38184802 PMCID: PMC10804889 DOI: 10.1111/jdi.14121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024] Open
Abstract
The diagnostic criteria for slowly progressive type 1 diabetes (slowly progressive insulin-dependent diabetes mellitus; SPIDDM) have been revised by the Committee on Type 1 Diabetes of the Japan Diabetes Society. All of the following three criteria must be met for 'a definitive diagnosis of SPIDDM': (1) presence of anti-islet autoantibodies at some point in time during the disease course; (2) absence of ketosis or ketoacidosis at the diagnosis of diabetes with no requirement for insulin treatment to correct hyperglycemia immediately after diagnosis in principle; and (3) gradual decrease of insulin secretion over time, with insulin treatment required at more than 3 months after diagnosis, and the presence of severe endogenous insulin deficiency (fasting serum C-peptide immunoreactivity <0.6 ng/mL) at the last observed point in time. When a patient fulfills only (1) and (2), but not (3), he/she is diagnosed with 'SPIDDM (probable)' because the diabetes is non-insulin-dependent type.
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Affiliation(s)
- Akira Shimada
- Department of Endocrinology and Diabetes, School of MedicineSaitama Medical UniversitySaitamaJapan
| | | | | | - Takuya Awata
- Pancreatic Islet Cell Transplantation CenterNational Center for Global Health and MedicineTokyoJapan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of MedicineSaitama Medical UniversitySaitamaJapan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular GeneticsEhime University Graduate School of MedicineEhimeJapan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology and MetabolismCenter Hospital of the National Center for Global Health and MedicineTokyoJapan
| | - Junji Kozawa
- Department of Diabetes Care MedicineGraduate School of Medicine, Osaka UniversityOsakaJapan
| | - Kazuma Takahashi
- Department of Basic Nursing Science, School of NursingIwate Prefectural UniversityIwateJapan
| | - Daisuke Chujo
- Center for Clinical ResearchToyama University HospitalToyamaJapan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and DiabetesKindai University Faculty of MedicineOsakaJapan
| | - Tomoyasu Fukui
- Department of Medicine, Division of Diabetes, Metabolism and EndocrinologyShowa University School of MedicineTokyoJapan
| | - Junnosuke Miura
- Division of Diabetology and Metabolism, Department of Internal MedicineTokyo Women's Medical University School of MedicineTokyoJapan
| | - Kazuki Yasuda
- Department of Diabetes, Endocrinology and MetabolismKyorin University School of MedicineTokyoJapan
| | - Hisafumi Yasuda
- Department of Public Health, Division of Health SciencesKobe University Graduate School of Health SciencesHyogoJapan
| | - Akihisa Imagawa
- Department of Internal Medicine (I), Faculty of MedicineOsaka Medical and Pharmaceutical UniversityOsakaJapan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and DiabetesKindai University Faculty of MedicineOsakaJapan
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Shimada A, Kawasaki E, Abiru N, Awata T, Oikawa Y, Osawa H, Kajio H, Kozawa J, Takahashi K, Chujo D, Noso S, Fukui T, Miura J, Yasuda K, Yasuda H, Imagawa A, Ikegami H. New diagnostic criteria (2023) for slowly progressive type 1 diabetes (SPIDDM): Report from Committee on Type 1 Diabetes in Japan Diabetes Society (English version). Diabetol Int 2024; 15:1-4. [PMID: 38264233 PMCID: PMC10800325 DOI: 10.1007/s13340-023-00679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/11/2023] [Indexed: 01/25/2024]
Abstract
The diagnostic criteria for slowly progressive type 1 diabetes (slowly progressive insulin-dependent diabetes mellitus; SPIDDM) have been revised by the Committee on Type 1 Diabetes of the Japan Diabetes Society. All of the following three criteria must be met for "a definitive diagnosis of SPIDDM": (1) presence of anti-islet autoantibodies at some point in time during the disease course; (2) absence of ketosis or ketoacidosis at the diagnosis of diabetes with no requirement of insulin treatment to correct hyperglycemia immediately after diagnosis in principle; and (3) gradual decrease of insulin secretion over time, with insulin treatment required at more than 3 months after diagnosis, and presence of severe endogenous insulin deficiency (fasting serum C-peptide immunoreactivity < 0.6 ng/mL) at the last observed point in time. When a patient fulfills the only (1) and (2), but not (3), he/she is diagnosed with "SPIDDM (probable)" because the diabetes is non-insulin-dependent state.
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Affiliation(s)
- Akira Shimada
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama Japan
| | | | | | - Takuya Awata
- Pancreatic Islet Cell Transplantation Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Junji Kozawa
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kazuma Takahashi
- Department of Basic Nursing Science, School of Nursing, Iwate Prefectural University, Iwate, Japan
| | - Daisuke Chujo
- Center for Clinical Research, Toyama University Hospital, Toyama, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka, Japan
| | - Tomoyasu Fukui
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Junnosuke Miura
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Kazuki Yasuda
- Department of Diabetes, Endocrinology and Metabolism, Kyorin University School of Medicine, Tokyo, Japan
| | - Hisafumi Yasuda
- Division of Health Sciences, Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Akihisa Imagawa
- Department of Internal Medicine (I), Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka, Japan
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6
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Kawasaki E. Anti-Islet Autoantibodies in Type 1 Diabetes. Int J Mol Sci 2023; 24:10012. [PMID: 37373160 PMCID: PMC10298549 DOI: 10.3390/ijms241210012] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Anti-islet autoantibodies serve as key markers in immune-mediated type 1 diabetes (T1D) and slowly progressive T1D (SPIDDM), also known as latent autoimmune diabetes in adults (LADA). Autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), tyrosine phosphatase-like protein IA-2 (IA-2A), and zinc transporter 8 (ZnT8A) are currently employed in the diagnosis, pathological analysis, and prediction of T1D. GADA can also be detected in non-diabetic patients with autoimmune diseases other than T1D and may not necessarily reflect insulitis. Conversely, IA-2A and ZnT8A serve as surrogate markers of pancreatic β-cell destruction. A combinatorial analysis of these four anti-islet autoantibodies demonstrated that 93-96% of acute-onset T1D and SPIDDM cases were diagnosed as immune-mediated T1D, while the majority of fulminant T1D cases were autoantibody-negative. Evaluating the epitopes and immunoglobulin subclasses of anti-islet autoantibodies help distinguish between diabetes-associated and non-diabetes-associated autoantibodies and is valuable for predicting future insulin deficiency in SPIDDM (LADA) patients. Additionally, GADA in T1D patients with autoimmune thyroid disease reveals the polyclonal expansion of autoantibody epitopes and immunoglobulin subclasses. Recent advancements in anti-islet autoantibody assays include nonradioactive fluid-phase assays and the simultaneous determination of multiple biochemically defined autoantibodies. Developing a high-throughput assay for detecting epitope-specific or immunoglobulin isotype-specific autoantibodies will facilitate a more accurate diagnosis and prediction of autoimmune disorders. The aim of this review is to summarize what is known about the clinical significance of anti-islet autoantibodies in the pathogenesis and diagnosis of T1D.
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Affiliation(s)
- Eiji Kawasaki
- Diabetes Center, Shin-Koga Hospital, Kurume 830-8577, Japan
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7
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Kawasaki E, Shimada A, Imagawa A, Abiru N, Awata T, Oikawa Y, Osawa H, Kawabata Y, Kozawa J, Kobayashi T, Takahashi K, Chujo D, Fukui T, Miura J, Yasuda K, Yasuda H, Kajio H, Hanafusa T, Ikegami H. Bivalent GAD autoantibody ELISA improves clinical utility and risk prediction for adult autoimmune diabetes. J Diabetes Investig 2023; 14:570-581. [PMID: 36691729 PMCID: PMC10034953 DOI: 10.1111/jdi.13980] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/17/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Abstract
AIM/INTRODUCTION To investigate the differences in the clinical significance and glutamic acid decarboxylase autoantibody (GADA) affinity between RIA (RIA-GADA) and ELISA (ELISA-GADA) in patients with type 1 diabetes. METHODS A total of 415 patients with type 1 diabetes were enrolled, including 199 acute-onset type 1 diabetes, 168 slowly progressive type 1 diabetes (SPIDDM), and 48 fulminant type 1 diabetes. GADA affinity was measured by a competitive binding experiment using unlabeled recombinant human GAD65 protein, and the diagnostic performance of both assays and the relationship between GADA affinity and the decline of fasting C-peptide (F-CPR) were examined. RESULTS While the ELISA-GADA displayed a higher sensitivity than the RIA method in diagnosing type 1 diabetes in acute-onset patients, about 40% of SPIDDM patients with low-titer RIA-GADA were determined as negative by the ELISA method. Patients with type 1 diabetes with RIA-GADA alone had an older age of onset, less diabetic ketoacidosis, a higher BMI, and a higher F-CPR compared with patients positive for both RIA-GADA and ELISA-GADA. Additionally, 36% of RIA-GADA-positive patients had low-affinity GADA (<1010 L/mol), which was significantly higher than in the ELISA-GADA-positive patients (4%, P < 0.0001). Furthermore, over a 3 year monitoring period, F-CPR levels decreased in ELISA-GADA-positive SPIDDM, whereas it was maintained in patients with RIA-GADA alone, regardless of GADA affinity. CONCLUSIONS These results suggest that bivalent ELISA for GADA is superior to the RIA method in diagnosing type 1 diabetes. Moreover, the diagnostic superiority of the ELISA-GADA made possible the concurrent identification of SPIDDM patients at high-risk of early progression, and allowed for more accurate clinical diagnosis and management.
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Affiliation(s)
| | - Akira Shimada
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Iruma, Japan
| | - Akihisa Imagawa
- Department of Internal Medicine (I), Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Takuya Awata
- Pancreatic Islet Cell Transplantation Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Iruma, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yumiko Kawabata
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka, Japan
| | - Junji Kozawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | | | - Daisuke Chujo
- Center for Clinical Research, Toyama University Hospital, Toyama, Japan
| | - Tomoyasu Fukui
- Division of Diabetes and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Junnosuke Miura
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kazuki Yasuda
- Department of Diabetes, Endocrinology, and Metabolism, Kyorin University, Mitaka, Japan
| | - Hisafumi Yasuda
- Division of Health Sciences, Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka, Japan
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8
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Ma H, Murphy C, Loscher CE, O’Kennedy R. Autoantibodies - enemies, and/or potential allies? Front Immunol 2022; 13:953726. [PMID: 36341384 PMCID: PMC9627499 DOI: 10.3389/fimmu.2022.953726] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/24/2022] [Indexed: 08/13/2023] Open
Abstract
Autoantibodies are well known as potentially highly harmful antibodies which attack the host via binding to self-antigens, thus causing severe associated diseases and symptoms (e.g. autoimmune diseases). However, detection of autoantibodies to a range of disease-associated antigens has enabled their successful usage as important tools in disease diagnosis, prognosis and treatment. There are several advantages of using such autoantibodies. These include the capacity to measure their presence very early in disease development, their stability, which is often much better than their related antigen, and the capacity to use an array of such autoantibodies for enhanced diagnostics and to better predict prognosis. They may also possess capacity for utilization in therapy, in vivo. In this review both the positive and negative aspects of autoantibodies are critically assessed, including their role in autoimmune diseases, cancers and the global pandemic caused by COVID-19. Important issues related to their detection are also highlighted.
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Affiliation(s)
- Hui Ma
- School of Biotechnology, Dublin City University, Dublin, Ireland
| | - Caroline Murphy
- School of Biotechnology, Dublin City University, Dublin, Ireland
| | | | - Richard O’Kennedy
- School of Biotechnology, Dublin City University, Dublin, Ireland
- Research, Development and Innovation, Qatar Foundation, Doha, Qatar
- Hamad Bin Khalifa University, Doha, Qatar
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9
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Takeda M, Abe T, Toyama Y, Tominaga K, Yano S, Nabika T, Yamasaki M. Combined association of oral and skeletal muscle health with type 2 diabetes mellitus among community-dwelling older adults in Japan: a cross-sectional study. J Rural Med 2022; 17:67-72. [PMID: 35432640 PMCID: PMC8984617 DOI: 10.2185/jrm.2021-042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022] Open
Abstract
Objective: Although oral health and skeletal muscle status are known to be
risk factors for type 2 diabetes mellitus (T2DM), there is limited information on their
combined effects among community-dwelling older adults. The purpose of this study was to
investigate the association between oral health and skeletal muscle status among older
adults with T2DM in Japan. Participants and Methods: This cross-sectional study included data from
individuals aged ≥60 years. T2DM was defined as a glycosylated hemoglobin A1c level ≥48
mmol/mol (≥6.5%) or the use of hypoglycemic agents. For oral health status, dental
hygienists assessed the number of teeth (NT) and masticatory function (MF). Skeletal
muscle status was assessed using skeletal muscle mass index (SMI) and handgrip strength
(HGS). Logistic regression analysis examined T2DM in nine-category combinations of oral
health status (each of the three categories in NT and MF) and skeletal status (each of the
three categories in SMI and HGS). Results: T2DM was prevalent in 83 participants (16.4%) and was significantly
associated with low NT and SMI (odds ratio [OR] = 5.93, 95% confidence interval [CI]:
1.37–25.73) and low MF and SMI (OR = 4.48, 95% CI: 1.23–16.35) compared to high NT and SMI
and high MF and SMI, respectively. Conclusion: Our findings indicate that low muscle mass with tooth loss or
masticatory dysfunction is associated with T2DM among community-dwelling older adults.
This suggests that maintaining oral health and muscle mass may be an effective strategy
for the prevention of T2DM.
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Affiliation(s)
- Miwako Takeda
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Japan
| | - Takafumi Abe
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Japan
| | - Yuta Toyama
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Japan
| | | | - Shozo Yano
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Japan
| | - Toru Nabika
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Japan
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10
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Leslie RD, Evans-Molina C, Freund-Brown J, Buzzetti R, Dabelea D, Gillespie KM, Goland R, Jones AG, Kacher M, Phillips LS, Rolandsson O, Wardian JL, Dunne JL. Adult-Onset Type 1 Diabetes: Current Understanding and Challenges. Diabetes Care 2021; 44:2449-2456. [PMID: 34670785 PMCID: PMC8546280 DOI: 10.2337/dc21-0770] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Abstract
Recent epidemiological data have shown that more than half of all new cases of type 1 diabetes occur in adults. Key genetic, immune, and metabolic differences exist between adult- and childhood-onset type 1 diabetes, many of which are not well understood. A substantial risk of misclassification of diabetes type can result. Notably, some adults with type 1 diabetes may not require insulin at diagnosis, their clinical disease can masquerade as type 2 diabetes, and the consequent misclassification may result in inappropriate treatment. In response to this important issue, JDRF convened a workshop of international experts in November 2019. Here, we summarize the current understanding and unanswered questions in the field based on those discussions, highlighting epidemiology and immunogenetic and metabolic characteristics of adult-onset type 1 diabetes as well as disease-associated comorbidities and psychosocial challenges. In adult-onset, as compared with childhood-onset, type 1 diabetes, HLA-associated risk is lower, with more protective genotypes and lower genetic risk scores; multiple diabetes-associated autoantibodies are decreased, though GADA remains dominant. Before diagnosis, those with autoantibodies progress more slowly, and at diagnosis, serum C-peptide is higher in adults than children, with ketoacidosis being less frequent. Tools to distinguish types of diabetes are discussed, including body phenotype, clinical course, family history, autoantibodies, comorbidities, and C-peptide. By providing this perspective, we aim to improve the management of adults presenting with type 1 diabetes.
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Affiliation(s)
- R David Leslie
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, U.K.
| | - Carmella Evans-Molina
- Departments of Pediatrics and Medicine and Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | | | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity & Diabetes Center, Colorado School of Public Health, and Departments of Epidemiology and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kathleen M Gillespie
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K
| | - Robin Goland
- Naomi Berrie Diabetes Center, Columbia University, New York, NY
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter, Exeter, U.K
| | | | - Lawrence S Phillips
- Atlanta VA Medical Center and Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Olov Rolandsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jana L Wardian
- College of Medicine, University of Nebraska Medical Center, Omaha, NE
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11
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Wada E, Onoue T, Kinoshita T, Hayase A, Handa T, Ito M, Furukawa M, Okuji T, Kobayashi T, Iwama S, Sugiyama M, Takagi H, Hagiwara D, Suga H, Banno R, Goto M, Arima H. Adult-onset autoimmune diabetes identified by glutamic acid decarboxylase autoantibodies: a retrospective cohort study. Diabetologia 2021; 64:2183-2192. [PMID: 34268631 DOI: 10.1007/s00125-021-05516-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/05/2021] [Indexed: 12/26/2022]
Abstract
AIMS/HYPOTHESIS Patients with GAD antibodies (GADAb) showing clinical features of type 2 diabetes typically exhibit progression to an insulin-dependent state in several months or years. This condition is diagnosed as slowly progressive insulin-dependent (type 1) diabetes mellitus (SPIDDM) or latent autoimmune diabetes in adults, a subtype of adult-onset autoimmune diabetes. However, some patients diagnosed with adult-onset autoimmune diabetes do not progress to an insulin-dependent state. We conducted a retrospective cohort study to identify patients with non-insulin-dependent diabetes among those diagnosed with adult-onset autoimmune diabetes using measurable indicators in routine clinical practice. METHODS We surveyed data from the electronic medical records of all patients with GADAb from eight medical centres in Japan for selecting and analysing patients who matched the diagnostic criteria of SPIDDM. RESULTS Overall, 345 patients were analysed; of these, 162 initiated insulin therapy (insulin therapy group), whereas 183 did not (non-insulin therapy group) during the follow-up period (median 3.0 years). Patients in the non-insulin therapy group were more likely to be male and presented a later diabetes onset, shorter duration of diabetes, higher BMI, higher blood pressure levels, lower HbA1c levels, lower GADAb levels and lesser antidiabetic agent use than those in the insulin therapy group when GADAb was first identified as positive. A Cox proportional hazards model showed that BMI, HbA1c levels and GADAb levels were independent factors for progression to insulin therapy. Kaplan-Meier analyses revealed that 86.0% of the patients with diabetes having GADAb who presented all three factors (BMI ≥ 22 kg/m2, HbA1c < 75 mmol/mol [9.0%] and GADAb <10.0 U/ml) did not require insulin therapy for 4 years. CONCLUSIONS/INTERPRETATION Higher BMI (≥22 kg/m2), lower HbA1c (<75 mmol/mol [9.0%]) and lower GADAb levels (<10.0 U/ml) can predict a non-insulin-dependent state for at least several years in Japanese patients with diabetes having GADAb.
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Affiliation(s)
- Eri Wada
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tamaki Kinoshita
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ayaka Hayase
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Handa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Furukawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Okuji
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Sugiyama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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12
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Sugihara S, Yokota I, Mukai T, Mochizuki T, Nakayama M, Tachikawa E, Kawada Y, Minamitani K, Kikuchi N, Urakami T, Kawamura T, Kawasaki E, Kikuchi T, Amemiya S. Increased diagnosis of autoimmune childhood-onset Japanese type 1 diabetes using a new glutamic acid decarboxylase antibody enzyme-linked immunosorbent assay kit, compared with a previously used glutamic acid decarboxylase antibody radioimmunoassay kit. J Diabetes Investig 2020; 11:594-602. [PMID: 31756289 PMCID: PMC7232289 DOI: 10.1111/jdi.13184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/24/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS/INTRODUCTION We compared the results of testing for glutamic acid decarboxylase antibodies (GADAb) using a radioimmunoassay (RIA) and an enzyme-linked immunosorbent assay (ELISA) in individuals with childhood-onset type 1 diabetes mellitus. MATERIALS AND METHODS Serum specimens were collected from 1,024 Japanese children (426 boys and 598 girls) in 2013. The median age at diagnosis was 7 years (0-18 years). The blood specimens were obtained at a median age of 13 years (2-22 years). RESULTS Among the 628 children whose serum specimens were collected within 5 years after diagnosis, the rate of GADAb positivity was 47.9% using RIA and 69.4% using ELISA. The participants were divided into four groups according to their RIA and ELISA results for GADAb as follows: group I (RIA+/ELISA+), group II (RIA+/ELISA-), group III (RIA-/ELISA+) and group IV (RIA-/ELISA-). The clinical and genetic characteristics of group I and group III were quite similar in terms of age at diagnosis, male/female ratio, relatively high positive rates for both autoantibody to protein tyrosine phosphatase IA-2 and autoantibody to the cation efflux transporter zinc transporter 8, and human leukocyte antigen genotype. Group II contained just five patients, and was characterized by a younger age at diagnosis, low positive rates for both autoantibody to protein tyrosine phosphatase IA-2 and autoantibody to the cation efflux transporter zinc transporter 8, and a unique human leukocyte antigen genotype. If the positive rates of either autoantibody to protein tyrosine phosphatase IA-2 or autoantibody to the cation efflux transporter zinc transporter 8 or both were added to the GADAb results using RIA, the percentage of autoimmune type 1 diabetes increased from 47.9% to 78.5%. CONCLUSIONS The diagnosis of autoimmune childhood-onset Japanese type 1 diabetes increased when GADAb results were obtained using a new ELISA method, compared with a previously utilized RIA method.
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Affiliation(s)
- Shigetaka Sugihara
- Department of PediatricsTokyo Women’s Medical University Medical Center EastTokyoJapan
| | - Ichiro Yokota
- Department of Pediatric Endocrinology and MetabolismShikoku Medical Center for Children and AdultsKagawaJapan
| | - Tokuo Mukai
- Department of PediatricsAsahikawa‐Kosei General HospitalAsahikawaJapan
| | | | | | - Emiko Tachikawa
- Department of PediatricsTokyo Women's Medical University HospitalTokyoJapan
| | - Yasumasa Kawada
- Department of PediatricsKyushu Rousai HospitalKitakyushuJapan
| | - Kinship Minamitani
- Department of PediatricsTeikyo University Chiba Medical CenterChibaJapan
| | - Nobuyuki Kikuchi
- Department of PediatricsYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Tatsuhiko Urakami
- Department of PediatricsNihon University School of MedicineTokyoJapan
| | - Tomoyuki Kawamura
- Department of PediatricsOsaka City University School of MedicineOsakaJapan
| | - Eiji Kawasaki
- Department of Diabetes and EndocrinologyShin‐Koga HospitalKurumeJapan
| | - Toru Kikuchi
- Department of PediatricsSaitama Medical UniversityIrumaSaitamaJapan
| | - Shin Amemiya
- Department of PediatricsSaitama Medical UniversityIrumaSaitamaJapan
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13
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Jörns A, Wedekind D, Jähne J, Lenzen S. Pancreas Pathology of Latent Autoimmune Diabetes in Adults (LADA) in Patients and in a LADA Rat Model Compared With Type 1 Diabetes. Diabetes 2020; 69:624-633. [PMID: 31974139 DOI: 10.2337/db19-0865] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/11/2020] [Indexed: 11/13/2022]
Abstract
Approximately 10% of patients with type 2 diabetes suffer from latent autoimmune diabetes in adults (LADA). This study provides a systematic assessment of the pathology of the endocrine pancreas of patients with LADA and for comparison in a first rat model mimicking the characteristics of patients with LADA. Islets in human and rat pancreases were analyzed by immunohistochemistry for immune cell infiltrate composition, by in situ RT-PCR and quantitative real-time PCR of laser microdissected islets for gene expression of proinflammatory cytokines, the proliferation marker proliferating cell nuclear antigen (PCNA), the anti-inflammatory cytokine interleukin (IL) 10, and the apoptosis markers caspase 3 and TUNEL as well as insulin. Human and rat LADA pancreases showed differences in areas of the pancreas with respect to immune cell infiltration and a changed ratio between the number of macrophages and CD8 T cells toward macrophages in the islet infiltrate. Gene expression analyses revealed a changed ratio due to an increase of IL-1β and a decrease of tumor necrosis factor-α. IL-10, PCNA, and insulin expression were increased in the LADA situation, whereas caspase 3 gene expression was reduced. The analyses into the underlying pathology in human as well as rat LADA pancreases provided identical results, allowing the conclusion that LADA is a milder form of autoimmune diabetes in patients of an advanced age.
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Affiliation(s)
- Anne Jörns
- Institute of Clinical Biochemistry, Hannover Medical School, Hannover, Germany
| | - Dirk Wedekind
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Joachim Jähne
- Department of General and Visceral Surgery, Diakovere, Henriettenstift, Hannover, Germany
| | - Sigurd Lenzen
- Institute of Clinical Biochemistry, Hannover Medical School, Hannover, Germany
- Institute of Experimental Diabetes Research, Hannover Medical School, Hannover, Germany
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Takagi S, Miura J, Hoshina S, Uchigata Y, Babazono T. Clinical and genetic characteristics of people with type 1 diabetes who have discrepancies in titers of anti-glutamic acid decarboxylase antibody measured by radioimmunoassay and enzyme-linked immunosorbent assay. J Diabetes Investig 2020; 11:356-362. [PMID: 31267698 PMCID: PMC7078079 DOI: 10.1111/jdi.13111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 11/03/2022] Open
Abstract
AIMS/INTRODUCTION The aim of the present study was to compare the clinical and genetic characteristics between people with type 1 diabetes who were positive and negative for autoantibodies against glutamic acid decarboxylase (GADA) measured by enzyme-linked immunosorbent assay (ELISA) with low-titer GADA measured by radioimmunoassay. MATERIALS AND METHODS Among Japanese people with type 1 diabetes in whom GADA were measured by both ELISA and radioimmunoassay, those who had low titers of GADA measured by radioimmunoassay (1.5-10 U/mL), regardless of positivity for GADA measured by ELISA, were studied. There were 65 participants with acute-onset type 1 diabetes and 30 participants with slowly progressive insulin-dependent diabetes mellitus. Clinical characteristics and human leukocyte antigen types were compared in ELISA-positive (≥5 U/mL) and ELISA-negative participants. Endogenous insulin secretion was evaluated by C-peptide index. RESULTS Among participants with slowly progressive insulin-dependent diabetes mellitus, postprandial C-peptide index was significantly higher in ELISA-negative participants than in ELISA-positive participants (r = 0.619, P = 0.002). Among 52 participants whose human leukocyte antigen typing was carried out, all of the participants with slowly progressive insulin-dependent diabetes mellitus who had DRB1*09:01 were positive by GADA-ELISA (P = 0.021). In acute-onset type 1 diabetes participants, there were no significant differences for the C-peptide index and human leukocyte antigen genotypes. CONCLUSIONS The difference in the positivity for GADA-ELISA might reflect cytotoxicity toward pancreatic β-cells and preservation of endogenous insulin secretion in people with slowly progressive insulin-dependent diabetes mellitus. We also suggest that the difference in the GADA-ELISA-specific epitope depends on the human leukocyte antigen genotype.
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Affiliation(s)
- Satoshi Takagi
- Diabetes CenterTokyo Women's Medical University School of MedicineTokyoJapan
| | - Junnosuke Miura
- Diabetes CenterTokyo Women's Medical University School of MedicineTokyoJapan
| | - Sari Hoshina
- Diabetes CenterTokyo Women's Medical University School of MedicineTokyoJapan
| | - Yasuko Uchigata
- Diabetes CenterTokyo Women's Medical University School of MedicineTokyoJapan
- Tokyo Women's Medical University Medical Center EastTokyoJapan
| | - Tetsuya Babazono
- Diabetes CenterTokyo Women's Medical University School of MedicineTokyoJapan
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15
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Pieralice S, Pozzilli P. Latent Autoimmune Diabetes in Adults: A Review on Clinical Implications and Management. Diabetes Metab J 2018; 42:451-464. [PMID: 30565440 PMCID: PMC6300440 DOI: 10.4093/dmj.2018.0190] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/14/2018] [Indexed: 12/16/2022] Open
Abstract
Latent autoimmune diabetes in adults (LADA) is a heterogeneous disease characterized by a less intensive autoimmune process and a broad clinical phenotype compared to classical type 1 diabetes mellitus (T1DM), sharing features with both type 2 diabetes mellitus (T2DM) and T1DM. Since patients affected by LADA are initially insulin independent and recognizable only by testing for islet-cell autoantibodies, it could be difficult to identify LADA in clinical setting and a high misdiagnosis rate still remains among patients with T2DM. Ideally, islet-cell autoantibodies screening should be performed in subjects with newly diagnosed T2DM, ensuring a closer monitoring of those resulted positive and avoiding treatment of hyperglycaemia which might increase the rate of β-cells loss. Thus, since the autoimmune process in LADA seems to be slower than in classical T1DM, there is a wider window for new therapeutic interventions that may slow down β-cell failure. This review summarizes the current understanding of LADA, by evaluating data from most recent studies, the actual gaps in diagnosis and management. Finally, we critically highlight and discuss novel findings and future perspectives on the therapeutic approach in LADA.
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Affiliation(s)
- Silvia Pieralice
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Paolo Pozzilli
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
- Centre of Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK.
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Uno K, Seki Y, Kasama K, Wakamatsu K, Hashimoto K, Umezawa A, Yanaga K, Kurokawa Y. Mid-term results of bariatric surgery in morbidly obese Japanese patients with slow progressive autoimmune diabetes. Asian J Endosc Surg 2018; 11:238-243. [PMID: 29227039 DOI: 10.1111/ases.12443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Bariatric surgery is recognized as an effective treatment for type 2 diabetes mellitus, but data on its efficacy for type 1 diabetes mellitus, especially slowly progressive insulin-dependent diabetes mellitus, are limited. METHODS We investigated five Japanese patients with slowly progressive insulin-dependent diabetes mellitus who underwent bariatric surgery at our center. RESULTS Five morbidly obese glutamic acid decarboxylase antibody-positive diabetic patients underwent two different types of bariatric surgery. The mean titer of anti-glutamic acid decarboxylase antibody was 4.6 U/mL, and the mean preoperative bodyweight and BMI were 113 kg and 39.6 kg/m2 , respectively. The mean hemoglobin A1c was 8.4%. The mean fasting serum C-peptide was 5.0 ng/mL. Laparoscopic sleeve gastrectomy was performed in two patients, while laparoscopic sleeve gastrectomy with duodenojejunal bypass was performed in three patients. At one year after surgery, the mean bodyweight and BMI significantly dropped, and the mean percentage of excess weight loss was 96.4%. The mean hemoglobin A1c was 5.7%. This favorable trend was maintained at mid-term. CONCLUSION Bariatric surgery for morbidly obese patients with anti-glutamic acid decarboxylase antibody-positive type 1 diabetes mellitus, especially slow progressive autoimmune diabetes, seemed effective in achieving mid-term glycemic control. Longer follow-up with a larger number of patients, as well as validation with more advanced patients with slowly progressive insulin-dependent diabetes mellitus, will be needed.
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Affiliation(s)
- Kohei Uno
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan.,Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yosuke Seki
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Kotaro Wakamatsu
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Kenkichi Hashimoto
- Department of Gastroenterological Surgery/Clinical Research Institute, National Kyushu Medical Center, Fukuoka, Japan
| | - Akiko Umezawa
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshimochi Kurokawa
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
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A high titre of autoantibody at onset does not predict pancreatic beta-cell fate. DIABETES & METABOLISM 2016; 42:475-476. [PMID: 27502116 DOI: 10.1016/j.diabet.2016.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 07/03/2016] [Indexed: 11/22/2022]
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