Type 1 Diabetes Mellitus

Aka: Type 1 Diabetes Mellitus, Type I Diabetes Mellitus, Insulin Dependent Diabetes Mellitus, IDDM, Type I Diabetes

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II. Epidemiology

  1. Typical onset before age 30 years
  2. Non-obese patients
    1. However, teens with Type I Diabetes are more Overweight than teens without diabetes
  3. Prevalence (2015, U.S.): 1.25 Million (4% of the 30.3 Million Diabetes Mellitus cases in U.S.)
    1. http://www.diabetes.org/diabetes-basics/statistics/
  4. Ethnic disparity in management (based on T1D registry data)
    1. White patients have a higher utilization of Insulin Pumps than black or hispanic patients
    2. Black patients have higher Hemoglobin A1C levels than white or hispanic patients

III. Pathophysiology

  1. Type 1A
    1. Environmental and genetic factors
    2. HLA-DR4 association
    3. Cell mediated pancreatic beta cell destruction
  2. Type 1B (uncommon)
    1. Primary Autoimmune Condition
    2. Associated with other Autoimmune Conditions
      1. Hashimoto's Thyroiditis
      2. Grave's Disease
      3. Myasthenia Gravis
    3. HLA-DR3 association
    4. Incidence highest in 30-50 year olds
  3. Secondary Diabetes Mellitus
    1. Cystic Fibrosis
  4. Environmental Factors
    1. Medications
      1. Streptozocin
      2. Pentamidine
    2. Viruses
      1. Mumps
      2. Cytomegalovirus (CMV)
      3. Coxsackie
        1. Enterovirus IgM linked to IDDM in adolescents
          1. Studied 128 children with new onset IDDM
          2. Non-specific to subtype (coxsackie, echovirus)
          3. Helfand (1995) J Infect Dis 172:1206-11 [PubMed]
      4. Congenital Rubella
        1. Late Type I Diabetes Mellitus develops in 40%

IV. Findings: Symptoms and Signs

  1. See Diabetes Mellitus

V. Findings: Common Presentations

  1. Diabetic Ketoacidosis
    1. Major presenting syndrome in 25% of cases
    2. More common in under 3 years and adolescence
  2. Incidental glucosuria or Hyperglycemia
  3. Acute Abdominal Pain
  4. Influenza-like illness

VI. Diagnosis

  1. See Diabetes Mellitus
  2. Oral Glucose Tolerance Test
  3. Fasting Blood Glucose or Random Blood Glucose
  4. Two hour post-prandial Glucose
  5. Intravenous Glucose Tolerance Test

VII. Labs

  1. Initial studies
    1. Urinalysis
    2. Blood Glucose
    3. Electrolytes
    4. Glycosylated Hemoglobin (Hemoglobin A1C)
    5. Thyroid Stimulating Hormone (TSH)
    6. Consider Celiac Sprue testing (if suggestive symptoms)
  2. Diagnostics in Atypical Presentation
    1. Anti-Glutamic Acid Decarboxylase Antibody (Anti-GAD65 Antibody) - most useful of markers
      1. Test Sensitivity in Type I Diabetes: 60% in adults (60-73% in children)
      2. Not specific, also found in 7-34% in adults and children with Type II Diabetes
        1. Absence of Antibody makes requring inulin withn 6 years in adults unlikely (NPV 94%)
    2. Anti-islet cell surface Antibody (ICA)
      1. Test Sensitivity in Type I Diabetes: 75-85% in adults and children
      2. Not specific for Type I Diabetes (seen in up to 21% of Type II Diabetes adults)
    3. Anti-insulin Antibody (IA-2a and IA-2b)
      1. Test Sensitivity in Type I Diabetes: 40% in adults and 40-86% in children
      2. More specific for Type I Diabetes (only present in ~2% of Type II Diabetes)
    4. C-peptide low or absent (<1.51 ng)
      1. Consider after Sustacal challenge
      2. Not specific for Type I Diabetes Mellitus (also seen in Type II)
    5. Zinc transporter 8 autoantibody
      1. May confirm autoimmune-mediated Diabetes Mellitus when other autoantibody tests are negative
  3. References
    1. Patel (2010) Am Fam Physician 81(7): 863-70 [PubMed]

VIII. Management: Initial

  1. Treat acute problems (includes non-diabetic issues)
  2. Set initial goals and targets
    1. See Diabetes Mellitus Glucose Management
  3. Initiate Insulin therapy
    1. See Insulin Dosing
    2. If atypical presentation, then base on Ketones (unclear if Type I or Type II)
      1. Ketones positive: Start Insulin
      2. Ketones negative: Consider treating as Type II
  4. Education
    1. See Diabetes Mellitus Education
    2. Teach survival skills
    3. Establish plan for ongoing care and education
    4. Review importance of intensive therapy (compared with conventional care)
      1. See Diabetes Mellitus Glucose Management

IX. Management: Follow-up

  1. Initial
    1. Daily phone contact for first 3 days
    2. Office visit within 2 weeks
    3. Emergency 24 hour phone number given
  2. Adjustment phase
    1. Consider weekly phone call
    2. Monthly office visit
  3. Maintenance Phase
    1. Office visit every 3-4 months
    2. Review Blood Sugar Log
      1. Hypoglycemic Episodes
      2. Hyperglycemia
      3. Ketones
    3. Review food plan
    4. Review Exercise program
    5. Review Medications
    6. Exam
      1. Height, Weight and Body Mass Index (BMI)
      2. Growth rate (pediatric Diabetes Mellitus)
      3. Blood Pressure
    7. Labs
      1. Check Glucose Meter against Serum Glucose
      2. Hemoglobin A1C
    8. Education
      1. Nutrition in Diabetes Mellitus
      2. Exercise in Diabetes Mellitus
      3. Tobacco Cessation
      4. Contraception or Preconception Counseling
        1. See Diabetes Mellitus Preconception Counseling
    9. Manage Comorbidities
      1. Hypertension in Diabetes Mellitus
      2. Hyperlipidemia in Diabetes Mellitus
      3. Diabetic Retinopathy
      4. Diabetic Nephropathy
      5. Diabetic Neuropathy
  4. Yearly Exam
    1. Health Maintenance Exam
    2. Fasting lipid profile within 6 months of diagnosis (and then every 5 years if otherwise low risk)
      1. Triglycerides commonly elevated
    3. Neurologic Exam
    4. Dental exam
    5. Skin exam
      1. Evaluate injection sites (or pump insertion sites) for lipodistrophy
    6. Foot exam
      1. See Diabetic Neuropathy Testing (5.07-Gauge Monofilament)
      2. See Diabetic Foot Care
      3. Inspect feet for lesions
      4. Obtain dorsalis pedis and posterior tibial pulses
      5. Perform monofilament testing
    7. Optometry or Ophthalmology Exam
      1. See Diabetic Retinopathy
      2. Age over 12 years or Diabetes Mellitus for 5 years
    8. Urine Microalbumin yearly
      1. See Diabetic Nephropathy
      2. Age over 12 years or Diabetes Mellitus for 5 years
  5. Vaccination
    1. Pneumovax-23
    2. Influenza Vaccine yearly
    3. Hepatitis B Vaccine (if age <60 years old)

X. Management: New Strategies

  1. Monitoring
    1. Continuous Glucose Monitoring
      1. Reduces average Hemoglobin A1C 7.6% to 7.1% over 6 months
      2. Tamborlane (2008) N Engl J Med 359(14): 1464-76 [PubMed]
    2. Transcutaneous Serum Glucose monitoring (watch)
  2. Treatment options
    1. Islet Cell Transplants (high efficacy in trials)
    2. Insulin Pump
    3. Other medications
      1. Pramlintide (Symlin) has been FDA approved in Type I Diabetes
        1. Lee (2010) Ann Fam Med 8(6): 542-9 [PubMed]
      2. Metformin is not effective in Type I Diabetes
        1. Petrie (2017) Lancet Diabetes Endocrinol 5(8): 597-609 [PubMed]

XI. Resources

  1. T1D Registry
    1. https://t1dexchange.org/pages/resources/clinic-registry/
  2. American Diabetes Association Type I (patients)
    1. http://www.diabetes.org/diabetes-basics/type-1/

XII. References

  1. Smith (2018) Am Fam Physician 98(3): 154-62 [PubMed]

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Related Studies

Ontology: Diabetes Mellitus, Insulin-Dependent (C0011854)

Definition (MEDLINEPLUS)

Diabetes means your blood glucose, or blood sugar, levels are too high. With type 1 diabetes, your pancreas does not make insulin. Insulin is a hormone that helps glucose get into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious problems with your heart, eyes, kidneys, nerves, and gums and teeth.

Type 1 diabetes happens most often in children and young adults but can appear at any age. Symptoms may include

  • Being very thirsty
  • Urinating often
  • Feeling very hungry or tired
  • Losing weight without trying
  • Having sores that heal slowly
  • Having dry, itchy skin
  • Losing the feeling in your feet or having tingling in your feet
  • Having blurry eyesight

A blood test can show if you have diabetes. If you do, you will need to take insulin for the rest of your life.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI) A chronic condition characterized by minimal or absent production of insulin by the pancreas.(NICHD)
Definition (MSH) A subtype of DIABETES MELLITUS that is characterized by INSULIN deficiency. It is manifested by the sudden onset of severe HYPERGLYCEMIA, rapid progression to DIABETIC KETOACIDOSIS, and DEATH unless treated with insulin. The disease may occur at any age, but is most common in childhood or adolescence.
Definition (CSP) subtype of diabetes mellitus that is characterized by insulin deficiency; it is manifested by the sudden onset of severe hyperglycemia, rapid progression to diabetic ketoacidosis, and death unless treated with insulin; the disease may occur at any age, but is most common in childhood or adolescence.
Concepts Disease or Syndrome (T047)
MSH D003922
ICD10 E10
SnomedCT 154673001, 267469001, 190322003, 46635009, 190362004
LNC LP36797-6, MTHU020217, LA10551-2
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Swedish Typ 1-diabetes
Czech diabetes mellitus se sklonem ke ketóze, diabetes mellitus insulin dependentní, diabetes mellitus náhle vzniklý, diabetes mellitus labilní, diabetes mellitus 1. typu, diabetes mellitus juvenilní, Inzulindependentní diabetes mellitus, Diabetes mellitus se sklonem k ketoacidóze, Diabetes mellitus typu 1, Juvenilní diabetes mellitus, Juvenilní diabetes, Inzulindependentní diabetes, Diabetes mellitus I.typu
Spanish Diabetes mellitus de comienzo juvenil, Diabetes mellitus insulinodependiente, Diabetes mellitus con riesgo de cetosis, Diabetes mellitus dependiente de insulina, DMID, Diabetes insulinodependiente, Diabetes juvenil, Diabetes mellitus tipo 1, Diabetes mellitus tipo I, diabetes mellitus tipo 1 (trastorno), diabetes mellitus dependiente de insulina, diabetes mellitus dependiente de insulina (trastorno), diabetes mellitus tipo 1, diabetes mellitus insulino - dependiente, diabetes mellitus tipo I, Diabetes Mellitus con Propensión a la Cetosis, Diabetes Mellitus de Inicio Súbito, Diabetes Mellitus Insulino-Dependiente, Diabetes Mellitus Juvenil Inicial, Diabetes Mellitus Tipo 1, Dmid, Diabetes Mellitus Inestable
French Diabète insulino-dépendant, Diabétique insulino-dépendant, Apparition juvénile de diabète sucré, Diabète sucré de type I, DID, DID1, Diabète de type I, Diabète insulinodépendant, Diabète juvénile, Diabète de type 1, DSID, Diabète instable, Diabète sucré de type 1, Diabète sucré insulino-dépendant, Diabète sucré insulinodépendant
Dutch diabetes mellitus insuline-afhankelijk, juveniele diabetes, type I diabetes mellitus, diabetes mellitus, juveniel, type 1 diabetes mellitus, IADM, insuline-afhankelijke diabeet, ketosis-geneigde diabetes mellitus, insuline-afhankelijke diabetes mellitus, Insuline-afhankelijke diabetes, diabetes; insuline-afhankelijk, diabetes; juvenile-onset, diabetes; neiging tot ketose, diabetes; type I, insuline-afhankelijk; diabetes, juvenile-onset; diabetes, ketose, neiging tot; diabetes, type I; diabetes, Diabetes mellitus type 1, Diabetes mellitus, 'sudden-onset', Diabetes mellitus, brittle, Diabetes mellitus, insuline-afhankelijke, Diabetes mellitus, juveniele, Diabetes mellitus, ketose-gevoelige, IDDM ("Insulin-Dependent Diabetes Mellitus"), Insuline-afhankelijke diabetes mellitus, Mellitus, insuline-afhankelijke diabetes
Portuguese Diabetes mellitus insulinodependente, Diabético insulinodependente, Diabetes mellitus com início na juventude, Diabetes mellitus com tendência para cetose, Dibetes mellitus tipo I, Diabetes juvenil, Diabetes Mellitus Dependente de Insulina, Diabetes Mellitus com Tendência à Cetose, Diabetes Mellitus de Início na Juventude, Diabetes Mellitus de Início Súbito, Diabetes Mellitus Instável, Diabetes Mellitus Insulino-Dependente, Diabetes Mellitus Tipo 1, Dmid
German Diabetes mellitus insulinpflichtig, Diabetes mellitus, Einsetzen im jugendlichen Alter, insulinabhaengiger Diabetes mellitus, Diabetes mellitus Typ 1, Typ I Diabetes mellitus, Ketose-anfaelliger Diabetes mellitus, insulinpflichtiger Diabetiker, juveniler Diabetes, Primaer insulinabhaengiger Diabetes mellitus [Typ-I-Diabetes], Brittle-Diabetes, Diabetes mellitus, Brittle-, Diabetes mellitus, Typ I, Diabetes mellitus, juveniler Typ, Diabetes mellitus, mit Ketoseneigung, IDDM, Diabetes mellitus, insulinabhängiger, Diabetes mellitus, plötzlicher Beginn, Diabetes mellitus, Typ 1, Typ-1-Diabetes mellitus, Typ-I-Diabetes mellitus
Italian Diabete mellito ad esordio giovanile, Diabete giovanile, Diabete mellito tendente alla acidosi, Diabetico insulino-dipendente, Diabete mellito di tipo 1, Diabete mellito insulino-dipendente, Chetosi incline al diabete mellito, Diabete mellito a insorgenza giovanile, IDDM, Diabete mellito a insorgenza improvvisa, Diabete mellito instabile, Diabete mellito di tipo I
Japanese １型糖尿病, 1ｶﾞﾀﾄｳﾆｮｳﾋﾞｮｳ, ｹﾄｰｼｽｹｲｺｳﾄｳﾆｮｳﾋﾞｮｳ, ｲﾝｽﾘﾝｲｿﾞﾝｾｲﾄｳﾆｮｳﾋﾞｮｳ, ｼﾞｬｸﾈﾝﾊｯｼｮｳﾄｳﾆｮｳﾋﾞｮｳ, 若年性糖尿病, ｼﾞｬｸﾈﾝｾｲﾄｳﾆｮｳﾋﾞｮｳ, インシュリン依存性糖尿病, 若年発症糖尿病, 糖尿病-若年発症型, I型糖尿病, 自己免疫性糖尿病, 糖尿病-インスリン依存型, 糖尿病-ケトーシス傾向, 糖尿病-不安定型, ケトーシス傾向糖尿病, 糖尿病-若年発症, インスリン依存性糖尿病, 若年発症型糖尿病, 糖尿病-インスリン依存性, インシュリン依存型糖尿病, インスリン依存型糖尿病, 若年糖尿病, 不安定型糖尿病, 糖尿病-インシュリン依存型, 糖尿病-自己免疫性, 糖尿病1型, 1型糖尿病, 糖尿病-1型
Finnish Tyypin 1 diabetes
Russian DIABET SAKHARNYI NESTABIL'NYI, SAKHARNYI DIABET INSULINZAVISIMYI, DIABET AUTOIMMUNNYI, DIABET SAKHARNYI LABIL'NYI, DIABET SAKHARNYI S VNEZAPNYM NACHALOM, DIABET SAKHARNYI, TIP 1, DIABET SAKHARNYI IUNOSHESKII, DIABET SAKHARNYI, SKLONNOST' K KETOATSIDOZU, DIABET SAKHARNYI INSULINZAVISIMYI, DIABET SAKHARNYI, TIP I, ДИАБЕТ АУТОИММУННЫЙ, ДИАБЕТ САХАРНЫЙ ИНСУЛИНЗАВИСИМЫЙ, ДИАБЕТ САХАРНЫЙ ЛАБИЛЬНЫЙ, ДИАБЕТ САХАРНЫЙ НЕСТАБИЛЬНЫЙ, ДИАБЕТ САХАРНЫЙ С ВНЕЗАПНЫМ НАЧАЛОМ, ДИАБЕТ САХАРНЫЙ, СКЛОННОСТЬ К КЕТОАЦИДОЗУ, ДИАБЕТ САХАРНЫЙ, ТИП I, ДИАБЕТ САХАРНЫЙ ЮНОШЕСКИЙ, САХАРНЫЙ ДИАБЕТ ИНСУЛИНЗАВИСИМЫЙ, ДИАБЕТ САХАРНЫЙ, ТИП 1
Korean 인슐린-의존 당뇨병
Croatian DIJABETES MELITUS, TIP 1
Polish Cukrzyca typu 1, Cukrzyca młodzieńcza
Hungarian Fiatalkori diabetes mellitus, Insulin-dependens diabetes mellitus, I típusú cukorbetegség, IDDM, Insulindependens diabetes mellitus, 1. típusú cukorbetegség, Ketosisra hajlamosító diabetes mellitus, Insulin dependens diabeteses, Fiatalkori diabetes
Norwegian Type 1 diabetes, Diabetes, type 1
Derived from the NIH UMLS (Unified Medical Language System)

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