Latent Autoimmune Diabetes of Adults Case Study PresentationAngelica AdragnaSodexo Dietetic Intern July 31, 2013

Objectives

•Define diabetes•Differentiate between types of diabetes—

pathophysiology, diagnosis criteria, medications

•Present case study

Diabetes

•Diabetes is defined by the American Diabetes Association (ADA) as a group of diseases where the body cannot utilize or produce insulin correctly, which results in elevated blood sugar levels

•There are different types including type 1, 2, gestational, and latent autoimmune diabetes of adults (LADA)

Blood Test Levels for Diagnosis of Diabetes and Prediabetes American Diabetes Association

Oral Glucose Tolerance Test (mg/dL)

Fasting Plasma Glucose (mg/dL)

Hemoglobin A1C (%)

Normal 139 or below ≤99 ~5.0

Prediabetes 140 to 199 100-125 5.7-6.4

Diabetes >200 >126 ≥6.5

Type 1 Diabetes (T1DM)

•Was previously known as “juvenile” diabetes because it is commonly diagnosed in children and young adults.

•Chronic, autoimmune disorder•People with type 1 diabetes do not

produce any insulin, and need constant self administration of insulin through an insulin pump or multiple insulin injections

Signs/Symptoms of T1DM

•Presence of ketones•Positive antibodies: insulin

autoantibodies, islet cell antibodies, glutamic acid decarboxylase (GAD)

•Insulin/C-peptide levels very low at diagnosis

•Common diabetes symptoms: increased thirst, urination, weight loss, lethargy, hunger

Type 2 Diabetes (T2DM)

•Most commonly linked to obesity and occurs when the body makes the insulin needed, but does not use it properly or resists it

•Can occur at any age, most commonly adulthood

•90-95% of people with diabetes are type 2•Signs and symptoms are similar to those

of T1DM, with the exception of obesity, rather than weight loss

Treatment of T2DM

•Lifestyle changes▫Increase physical activity▫Modify diet for overall health, lower carb

•Oral medications•Insulin may be required to help maintain

BGs

Latent Autoimmune Diabetes of Adults•First discovered in the 1970’s

▫While researching antibodies present in T1DM, some antibodies were also found in patients with T2DM

•Accounts for 10% of phenotypic T2DM•Often misdiagnosed as T2DM •Some still not comfortable with the

diagnosis of LADA—slowly becoming more accepted

Criteria for Diagnosing LADA

•Presence of antibodies▫GAD, insulin autoantibody, islet cell

antibody, islet antigen, insulin/C-peptide low

•Adult age at onset ▫Typically between ages 30-50 years

•Need for insulin within 6 months of diagnosis

•Lower BMI than T2DM▫Typically <25 kg/m2

Treatment of LADA

•Goal is to obtain glycemic control•Overall healthy diet and lifestyle,

carbohydrate counting•Initiate insulin as needed, usually within 6

months of diagnosis▫Earlier insulin therapy has shown to

improve A1Cs, when compared to LADA patients who received oral meds alone (Thunander, et al. B-cell function and metabolic control in latent autoimmue diabetes in adults with early insulin versus conventional treatment: a 3-year follow-up. European Journal of Endocrinology. 2011. 164(2): 239-45.)

Case Study•CK, 63 YOF•Ht: 59” (149.86cm) Wt: 164# (74.5 kg) BMI:

33 kg/m2

•Past Medical Hx includes: hyperlipidemia, hypertension, hypercholesterolemia, hypothyroidism, arthritis, and uncontrolled diabetes (type 2 in August 2011)▫Family Medical Hx includes: mother passed

away from CVA @ age 78, father passed away post-op @ age 78. Three sons, one with celiac disease.

•Social history includes: nonsmoker, occasional alcohol, no physical activity, no drug use

Initial visit @ Helwig

• Pt denies polyuria, polydipsia, or polyphagia. No hypoglycemia, blurred vision, fatigue

•Pt is testing BG at home BID, counting carbohydrates with a “very acceptable” diet, good compliance

•Pt had been prescribed Metformin & Glimepiride, with little success in controlling BGs

Medication list@ first visit in September 2011

1) Cozaar 50 Mg Tabs (Losartan potassium) .... Daily2) Synthroid 50 Mcg Tabs (Levothyroxine sodium) .... Daily3) Famotidine 20 Mg Tabs (Famotidine) .... Daily4) Hydrochlorothiazide 25 Mg Tabs (Hydrochlorothiazide) .... 1 daily5) Aspirin Adult Low Strength 81 Mg Tbec (Aspirin) .... Daily6) Ferrex 150 Plus Caps (Fe-succ ac-c-thre ac caps) .... Daily7) Metoprolol Tartrate 25 Mg Tabs (Metoprolol tartrate) .... Daily8) Simvastatin 40 Mg Tabs (Simvastatin) .... Daily9) Potassium Chloride Cr 10 Meq Cr-tabs (Potassium chloride)...Daily10) Nexium 40 Mg Cpdr (Esomeprazole magnesium) .... Prn11) One Touch Delica Lancets Misc (Lancets) .... Tests 2 times daily. 12) Onetouch Ultra Test Strp (Glucose blood) .... Tests 2 times daily. 13) Metformin Hcl 1000 Mg Tabs (Metformin hcl) .... Take one tablet

twice a day14) Lantus Solostar 100 Unit/ml Soln (Insulin glargine) .... 30 units hs

(This was added at first appointment).15) Bd Disp Needles 30g X 1/2" Misc (Needle (disp)) .... Use daily

Lab Values Tested

•With little success in controlling the pt’s BGs with oral meds and carb counting, more labs were drawn▫GAD (+)▫C-peptide 1.1 ng/mL (low)

•These lab values showed little to no insulin was being produced

Treatment

•CK was advised to continue carb counting and overall healthy lifestyle changes

•Glimepiride was removed from med list•Continue to check BG at least BID•Lantus was started @ 15 units HS,

increase by 15 units in one week if AM BG was >150 mg/dL

Follow-up visits• 3 months later

▫A1C 11.3%▫BGs uncontrolled, wt gain, fatigue▫Compliance good, increased Lantus to 30 units▫ Janumet 50/100omg BID added to med list

• 6 months later▫A1C 13.1%▫ Janumet d/c’ed ▫Carbohydrate coverage added: 1 unit of Humalog/10g

CHO▫ ISF added: 1 unit of Humalog/every 25 mg/dL over 120

mg/dL▫ Increase BG tests to 4 times per day

Diabetes Types Summary

Gebel, E. The Other Diabetes: LADA, or Type 1.5. Latent autoimmune diabetes in adults is gradually being understood. Diabetes Forecast. 2010. http://forecast.diabetes.org/magazine/features/other-diabetes-lada-or-type-15?page=0%2C0

Continuum of diabetes?

•Some researchers are moving away from the idea that the various types of diabetes are truly separate entities - Suat Simsek, MD, a professor at VU University Medical Center in the Netherlands

•Some say “diabetes spectrum”•More research is needed!

▫Defining what causes LADA and how to treat it can lead to more potential for finding a cure for both LADA and type 1.

Resources• Diabetes Statistics. American Diabetes Association. 2011. http://www.diabetes.org/diabetes-basics/diabetes-statistics/.•  • Beta Cell Biology Consortium. Insulin-From Secretion to Action. 2002-2013. http://www.betacell.org/content/articleview/article_id/1/.•  • Genetic Health. (2011). Diabetes—What is Type I Diabetes. http://www.genetichealth.com/dbts_what_is_type_1_diabetes.shtml.•  • U.S. Department of Health and Human Services. National Diabetes Information Clearinghouse. Types of Insulin. 2012.

http://diabetes.niddk.nih.gov.•  • Poudel, R. Latent autoimmune diabetes of adults: From oral hypoglycemic agents to early insulin. Indian Journal of Endocrinology

Metabolism. 2012. 16 Suppl 1:S41-46.•  • von Wartburg, L., Phillips, R. The Story of GAD. Diabetes Health. 2010. http://diabeteshealth.com/read/2010/03/23/6611/the-story-of-gad/.•  • Type 2 Diabetes. Diabetes Treatment: Medications for type 2 diabetes. Mayo Clinic Staff. 2011.

http://www.mayoclinic.com/health/diabetes-treatment/DA00089.•  • Gebel, E. The Other Diabetes: LADA, or Type 1.5. Latent autoimmune diabetes in adults is gradually being understood. Diabetes

Forecast. 2010. http://forecast.diabetes.org/magazine/features/other-diabetes-lada-or-type-15•  • Szepietowska, Gorska, Puch, Glebocka, Szelachowska. Latent autoimmune diabetes in adults in a population-based cohort of Polish

patients with newly diagnosed diabetes mellitus. Archives of Medical Science. 2012. 8(3): 491-5. •  • Poudel. Latent autoimmune diabetes of adults: From oral hypoglycemic agents to early insulin. Indian Journal of Endocrinology

Metaobolism. 2012. 16(Suppl1):S41-S46.•  • Fourlanos, Perry, Stein, Stankovich, Harrison, Colman. A clinical screening tool identifies autoimmune diabetes in adults. Diabetes Care.

2006. 29(5): 970-975.•  • Anderson, Lundgren, Tuomi. Latenet Autoimmune Diabetes in Adults Differs Genetically from Classical Type 1 Diabetes Diagnosed After

the Age of 35 Years. Diabetes Care. 2010. 33(9): 2062-2064. •  • Thunander, Thorgeirsson, Torn, Petersson, Landin-Olsson. B-cell function and metabolic control in latent autoimmue diabetes in adults

with early insulin versus conventional treatment: a 3-year follow-up. European Journal of Endocrinology. 2011. 164(2): 239-45.•  • Academy of Nutrition and Dietetics. Carbohydrate counting for people with diabetes. 2012. •  • Brophy, Davies, Mannan, Brunt, Williams. Interventions for latent autoimmune diabetes in adults (LADA). Cochrane Database of

Systematic Reviews. 2011. (9): CD0006165.

Thank you!!