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Cause And Symptoms

Complications

Diagnosis And Treatment

Overview

Prevention

References

other-diabetes-topics

Other Diabetes Topics

Screening and monitoring are critical to managing autoimmune T1D and reducing the likelihood of diabetic ketoacidosis (DKA) hospitalization or emergency care at the time of Stage 3 autoimmune T1D diagnosis.1

<h4>Testing for islet autoantibodies against four major pancreatic autoantigens is currently available:</h4>

A combination of these four primary types of autoantibodies is recommended to detect autoimmunity.1-3
The presence of islet autoantibodies alongside metabolic status defines the three stages of T1D.4
These screening criteria are recommended by the most recent ADA Standards of Care.1

<h3>At-risk ≤1 autoantibody Normoglycemia</h3>
How to confirm single IAb+ status1
CONFIRM RESULTS

After first detection of single IAb, follow the ‘rule of twos’, using two independent methods to confirm negative results for other IAbs.1

MONITORING FREQUENCY (children &lt;3 years old)

Monitor IAb+ status every 6 months for 3 years, then annually thereafter for 3 more years.1

Metabolic monitoring includes random venous or capillary blood glucose and HbA1c values at the same frequency.1

If no progression, stop autoantibody and metabolic monitoring and counsel for risk of clinical disease.1

MONITORING FREQUENCY (children ≥3 years old)

Monitor IAb+ status annually for 3 years.1

Metabolic monitoring includes annual random venous or capillary blood glucose and HbA1c testing for 3 years.1

Critical monitoring during early years 
 (first two years after seroconversion):1
<ul>
 <li>Islet autoantibody status and metabolic monitoring are most critical during this time.</li>
 <li>Ongoing metabolic monitoring is not essential beyond this period.</li>
</ul>

<h3>Stage 1 (early stage) ≥2 autoantibodies 
 Normoglycemia</h3>
How to confirm multiple IAb+ status1

After first detection of ≥2 IAbs, follow the ‘rule of twos’, using two independent methods to confirm positive status for other islet autoantibodies.1

TWO-TEST CONFIRMATION NOT POSSIBLE? A single blood test positive for multiple islet autoantibody status identifies a person with sufficient risk for metabolic monitoring.1

REVERTED STATUS? For adults with previously confirmed multiple IAb+ status who revert to single IAb+ or IAb− status, metabolic monitoring should follow the guidelines below for Stage 1.1

GENERAL GUIDELINES FOR METABOLIC MONITORING1
<figure class="table" style="width:671.989px;">
 <table style="background-color:rgb(255, 255, 255);border-bottom-width:1px;border-color:rgb(201, 201, 201);border-left-width:0px;border-right-width:0px;border-style:solid;border-top-width:0px;">
 <tbody>
 <tr>
 <td style="border-bottom-color:rgb(229, 231, 235);border-bottom-width:0px;border-left-color:rgb(229, 231, 235);border-left-width:0px;border-right-color:rgb(201, 201, 201);border-right-width:1px;border-top-color:rgb(229, 231, 235);border-top-width:0px;padding:1.5rem;text-align:center;vertical-align:top;">&lt;3 years old 
 Once every 
 3 months1</td>
 <td style="border-bottom-color:rgb(229, 231, 235);border-bottom-width:0px;border-left-color:rgb(229, 231, 235);border-left-width:0px;border-right-color:rgb(201, 201, 201);border-right-width:1px;border-top-color:rgb(229, 231, 235);border-top-width:0px;padding:1.5rem;text-align:center;vertical-align:top;">3–9 years old 
 At least every 
 6 months1</td>
 <td style="border-color:rgb(229, 231, 235);border-width:0px;padding:1.5rem;text-align:center;vertical-align:top;">&gt;9 years old 
 At least every 
 12 months1</td>
 </tr>
 </tbody>
 </table>
</figure>

Conduct monitoring based on staging criteria and modalities described in Tables 1 and 5 of the consensus guidelines.1

Ensure monitoring is done when the child is healthy and not experiencing intercurrent illness.1

Provide SMBG meters and strips to all children with multiple islet autoantibody positivity or their parents.1

During intercurrent illness (e.g., a cold), use SMBG to detect hyperglycemia.1

For recent confirmation of multiple IAb+ status, perform SMBG tests on two different days over a 2-week period, then once every 1–3 months.1

<h3>Stage 2 (early stage) ≥2 autoantibodies 
 Glucose intolerance or dysglycemia</h3>
How to confirm multiple IAb+ status1

CONFIRM RESULTS1

After first detection of ≥2 IAbs, follow the ‘rule of twos’, using two independent methods to confirm positive status for other islet autoantibodies.1

REVERTED STATUS? For adults with previously confirmed multiple IAb+ status who revert to single IAb+ or IAb− status, metabolic monitoring should follow the guidelines below for Stage 2.1

GENERAL GUIDELINES FOR METABOLIC MONITORING1

Monitor measures of glucose regulation (glycemic status) every 3 months.

A longitudinal change in HbA1c of ≥10% from the confirmed islet autoantibody date may indicate dysglycemia and disease progression.1

Perform an OGTT to assess T1D stage for therapy eligibility.1

Measure random venous or capillary blood glucose simultaneously with HbA1c.1

Use 10–14-day CGM periodically at a similar frequency as HbA1c measurement.1

Monitor objective weight trends using a growth chart and ensure a healthy meal plan to preclude disordered eating behaviors as a cause of weight change.1

OGTT is the established gold standard to classify Stage 1, Stage 2 or Stage 3 T1D however if OGTT is not possible:1
<ul>
 <li>Obtain a 2-hour postprandial capillary blood glucose measurement after a carbohydrate-rich meal to assess for dysglycemia.1</li>
</ul>

CGM should be blinded to the individual and interpreted by trained HCPs.1

Criteria for CGM metrics to diagnose Stage 2 or Stage 3 T1D require further research.1

<h4>All persons at risk through to Stage 2</h4>
PSYCHOSOCIAL SUPPORT FOR SINGLE AND MULTIPLE IAb+ INDIVIDUALS

Emotional, cognitive and behavioral functioning should be assessed in people at risk of or with early-stage autoimmune type 1 diabetes and their family members, when appropriate. Anxiety, risk perception and behavior changes should specifically be assessed.1

Ask the individual at risk or with early-stage type 1 diabetes and/or their caregivers and family members about their reactions upon receiving the news that they have type 1 diabetes-related autoantibodies. This can be accomplished using guiding questions and standardized and validated questionnaires.1

At each monitoring visit, there should be enquiries into current needs, particularly coping.1

Psychological care should be integrated into routine medical visits and, whenever possible, delivered by providers with diabetes-specific training.1

<h3>Stage 3 ≥1 autoantibodies Persistent hyperglycemia with or without symptoms</h3>

Screening and subsequent monitoring for presymptomatic T1D prior to clinical onset of Stage 3 have several benefits, including reducing the risk of DKA and hospitalization, and providing opportunities for education and preparation for chronic disease management.5,6
The decision to start insulin depends on a range of factors and consideration to do so should be referred to a specialist center.1

For the full guidelines together with the evidence rating (A–E), please consult reference 1.
ADA, American Diabetes Association; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; GAD, glutamic acid decarboxylase; HbA1c, glycated hemoglobin; HCP, healthcare professional; IA-2, insulinoma-associated antigen-2; IAA, insulin autoantibody; IAb, islet autoantibody; OGTT, oral glucose tolerance test; SMBG, self-monitoring of blood glucose; T1D, type 1 diabetes; T2D, type 2 diabetes; ZnT8, zinc-transporter 8.

Reference

Consensus Guidance for Monitoring Children with Islet Autoantibody-Positive Pre-Stage 3 Autoimmune Type 1 Diabetes (T1D)

OTHER-DIABETES-TOPICS

DIABETES

Real-world evidence of treatment intensification in people with T2D inadequately controlled on GLP-1 RAs

Insights from Prof. Timothy Baily on new Real-world evidence in deliver G study and the implications of adding Toujeo®&nbsp;to people with T2D inadequately controlled on GLP-RAs.

<h2>Insulin dose adjustments for Type 1 Diabetes</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td>Premixed (analogue or conventional)&nbsp;&nbsp; &nbsp;</td>
 <td>
 <ul>
 <li>Move usual morning dose to Iftar</li>
 <li>Take 50% of pre-Ramadan evening dose at Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>CSII/Insulin pump</td>
 <td>
 Basal rate adjustment
 <ul>
 <li>Decrease 20–40% for last 3–4 hours of fast</li>
 <li>Increase 10–30% for first few hours after iftar</li>
 </ul>
 Bolus doses
 <ul>
 <li>Apply same principles as before Ramadan</li>
 </ul></td>
 </tr>
 <tr>
 <td>MDI (basal bolus) with conventional insulin</td>
 <td>
 NPH insulin
 <ul>
 <li>Take usual morning dose in the evening during Ramadan</li>
 <li>Take 50% of pre-Ramadan dose at Suhoor</li>
 </ul>
 Regular insulin
 <ul>
 <li>Evening meal dose remains unchanged - Take 50% of pre-Ramadan evening dose at Suhoor</li>
 <li>Skip afternoon dose</li>
 </ul></td>
 </tr>
 <tr>
 <td>MDI (basal bolus) with analogue insulin</td>
 <td>
 Basal insulin
 <ul>
 <li>Reduce dose by 30–40%</li>
 <li>Take at Iftar</li>
 </ul>
 Rapid analogue insulin
 <ul>
 <li>Reduce Suhoor dose by 30–50%</li>
 <li>Skip pre-lunch dose</li>
 <li>Adjust Iftar dose based on 2-hour post-Iftar glucose reading</li>
 </ul></td>
 </tr>
 </tbody>
</table>
CSII, continuous subcutaneous insulin infusion; MDI, multiple-dose injections; NPH, natural protamine Hagedorn Diabetes and Ramadan:&nbsp;Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: <a href="http://www.idf.org/news/idf-dar-diabetes-in-ramadan%20guidelines" target="_blank">www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines</a>

<h2>Insulin dose adjustments for Type 2 Diabetes</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td>Long/intermediate-acting (basal) insulin</td>
 <td>
 NPH/detemir/glargine/glargine 300/ degludec, once daily
 <ul>
 <li>Reduce dose by 15–30%</li>
 <li>Take at Iftar</li>
 </ul>
 NPH/detemir/glargine, twice daily
 <ul>
 <li>Take usual morning dose at Iftar</li>
 <li>Take 50% of evening dose at Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>Short-acting insulin</td>
 <td>
 <ul>
 <li>Normal dose at Iftar</li>
 <li>No lunch-time dose</li>
 <li>Reduce Suhoor dose by 25–50%</li>
 </ul></td>
 </tr>
 <tr>
 <td>Premixed insulin dosing</td>
 <td>
 Once daily
 <ul>
 <li>Normal dose at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>Take normal dose at Iftar</li>
 <li>Reduce Suhoor dose by 20–50%</li>
 </ul>
 Three times daily
 <ul>
 <li>No afternoon dose</li>
 <li>Adjust Iftar and Suhoor doses</li>
 <li>Dose-titration every 3 days</li>
 </ul></td>
 </tr>
 <tr>
 <td>Insulin pump dosing</td>
 <td>
 Basal rate
 <ul>
 <li>Reduce dose by 20–40% in last 3–4 hours of fasting</li>
 <li>Increase dose by up to 20% early after Iftar</li>
 </ul>
 Bolus rate
 <ul>
 <li>Normal carbohydrate counting and insulin sensitivity principles apply</li>
 </ul></td>
 </tr>
 </tbody>
</table>
For unit-specific titration recommendations as determined by individual blood glucose readings, see Chapter 10 of the IDF-DAR guidelines. 
 degludec, insulin degludec; detemir, insulin detemir; glargine, insulin glargine; NPH, neutral protamine Hagedorn&nbsp; Diabetes and Ramadan:&nbsp;Practical Guidelines International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. January 2021. Available at: <a href="http://www.idf.org/news/idf-dar-diabetes-in-ramadan%20guidelines" target="_blank">www.idf.org/news/idf-dar-diabetes-in-ramadan guidelines</a>

<h2>Oral Anti-Diabetic drugs (OADs) recommended dose adjustments</h2>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td style="background-color: rgb(244, 242, 246);">
 Metformin</td>
 <td style="background-color: rgb(244, 242, 246);">
 Sulphonylureas</td>
 <td style="background-color: rgb(244, 242, 246);">
 Arcarbose</td>
 </tr>
 <tr>
 <td colspan="1" rowspan="4">
 Once daily
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul>
 Three times daily
 <ul>
 <li>Take morning dose before Suhoor</li>
 <li>Combine afternoon dose with Iftar dose</li>
 </ul>
 Prolonged-release
 <ul>
 <li>No adjustment usually required</li>
 <li>Take at Iftar</li>
 </ul></td>
 <td colspan="1" rowspan="4">
 Once daily
 <ul>
 <li>Reduce dose for those well-controlled blood glucose</li>
 <li>Take at Iftar</li>
 </ul>
 Twice daily
 <ul>
 <li>No adjustment at Iftar</li>
 <li>Reduce Suhoor dose for those with well-controlled blood glucose</li>
 </ul>
 Older drugs e.g. glibenclamide
 <ul>
 <li>Should be avoided</li>
 </ul>
 Second generation sulphonylureas e.g. glicazide, glimepiride
 <ul>
 <li>Should be used in preference</li>
 </ul></td>
 <td>
 <ul>
 <li>No adjustment required</li>
 <li>Take at Iftar</li>
 </ul></td>
 </tr>
 <tr>
 <td>
 Thiazolidinediones
 <ul>
 <li>No adjustment</li>
 <li>Take with Iftar rather than Suhoor</li>
 </ul></td>
 </tr>
 <tr>
 <td>
 Short-acting insulin secretagogue 
 Three-meal dosing may be reduced/ redistributed to two doses</td>
 </tr>
 <tr>
 <td>
 SGLT-2 inhibitors
 <ul>
 <li>No adjustment</li>
 <li>Taken with Iftar</li>
 </ul></td>
 </tr>
 </tbody>
</table>

<table border="1" cellpadding="1" cellspacing="1" style="width:100%;">
 <tbody>
 <tr>
 <td colspan="2" style="background-color: rgb(244, 242, 246);">
 Incretin-based therapies</td>
 </tr>
 <tr>
 <td>
 DPP-4 inhibitors</td>
 <td>
 GLP-1 RAs</td>
 </tr>
 <tr>
 <td>
 No adjustment required</td>
 <td>
 No adjustment if appropiate dose titration prior to Ramadan (&gt;2–4 weeks before) has occured</td>
 </tr>
 </tbody>
</table>
Adapted from IDF-DAR Guidelines (2021)
For patients on multiple types of medication, please see Chapter 10 of the IDF-DAR guidelines
DPP-4, dipeptidyl peptidase-4; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; SGLT-2, sodium-glucose co-transporter-2

Other Diabetes Topics

Latest Articles

Consensus Guidance for Monitoring Children with Islet Autoantibody-Positive Pre-Stage 3 Autoimmune Type 1 Diabetes (T1D)

Real-world evidence of treatment intensification in people with T2D inadequately controlled on GLP-1 RAs

Latest Resources

Insulin and Other Medications Dose Adjustments for Type 1 and 2 Diabetes in Ramadan