Unless there is a clear clinical diagnosis (e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL ), diagnosis requires two abnormal test results, either from the same sample ( 44) or in two separate test samples. Use of the term LADA is common and acceptable in clinical practice and has the practical impact of heightening awareness of a population of adults likely to develop overt autoimmune β-cell destruction ( 11), thus accelerating insulin initiation prior to deterioration of glucose control or development of DKA ( 4, 12). For the purpose of this classification, all forms of diabetes mediated by autoimmune β-cell destruction are included under the rubric of type 1 diabetes. The clinical priority is awareness that slow autoimmune β-cell destruction can occur in adults leading to a long duration of marginal insulin secretory capacity. There is debate as to whether slowly progressive autoimmune diabetes with an adult onset should be termed latent autoimmune diabetes in adults (LADA) or type 1 diabetes. Three distinct stages of type 1 diabetes can be identified ( Table 2.1) and serve as a framework for future research and regulatory decision-making ( 8, 10). Glucose and A1C levels rise well before the clinical onset of diabetes, making diagnosis feasible well before the onset of DKA. The rate of progression is dependent on the age at first detection of autoantibody, number of autoantibodies, autoantibody specificity, and autoantibody titer. It is now clear from studies of first-degree relatives of patients with type 1 diabetes that the persistent presence of two or more islet autoantibodies is a near certain predictor of clinical hyperglycemia and diabetes. Although difficulties in distinguishing diabetes type may occur in all age-groups at onset, the diagnosis becomes more obvious over time in people with β-cell deficiency.Ĭharacterization of the underlying pathophysiology is more precisely developed in type 1 diabetes than in type 2 diabetes. It is important for the provider to realize that classification of diabetes type is not always straightforward at presentation and that misdiagnosis is common (e.g., adults with type 1 diabetes misdiagnosed as having type 2 diabetes individuals with maturity-onset diabetes of the young misdiagnosed as having type 1 diabetes, etc.). Occasionally, patients with type 2 diabetes may present with DKA ( 6), particularly ethnic and racial minorities ( 7). The onset of type 1 diabetes may be more variable in adults they may not present with the classic symptoms seen in children and may experience temporary remission from the need for insulin ( 3– 5). Children with type 1 diabetes typically present with the hallmark symptoms of polyuria/polydipsia, and approximately one-third present with diabetic ketoacidosis (DKA) ( 2). The traditional paradigms of type 2 diabetes occurring only in adults and type 1 diabetes only in children are no longer accurate, as both diseases occur in both age-groups. Classification is important for determining therapy, but some individuals cannot be clearly classified as having type 1 or type 2 diabetes at the time of diagnosis. Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably.
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