Adult-Onset Type 1 Diabetes: Current Understanding and Challenges

Adult-Onset Type 1 Diabetes: Current Understanding and Challenges David Leslie, R. et al | 2021 | Diabetes Care | 44| 11| P. 2449-2456 |  DOI: 10.2337/dc21-0770


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.

This Perspective piece published in the journal Diabetes Care , based on that workshop, the participants outline the evidence for a new viewpoint, suggesting future directions of research and ways to alter disease management to help adults living with type 1 diabetes. They also outline a roadmap for addressing these deficiencies (Fig. 1). A cornerstone of this roadmap is a renewed emphasis on the careful consideration of the underlying etiology of diabetes in every adult presenting with diabetes.

Image source: David Leslie et al, 2021. Image shows the roadmap to better understand, diagnose and care for adults with T1D.

The full article is available from Diabetes Care [paper]