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Incipient Juvenile Diabetes: Warning Signs, Prevention


My patient is a 10-year-old boy with asthma. After an exacerbation of his asthmawas treated with albuterol and solumedrol, his blood glucose level was 250 mg/dLwith 1+ glucosuria (no ketones).

My patient is a 10-year-old boy with asthma. After an exacerbation of his asthmawas treated with albuterol and solumedrol, his blood glucose level was 250 mg/dLwith 1+ glucosuria (no ketones). A subsequent diabetic workup revealed a fastingblood glucose level of 105 mg/dL and the presence of anti-insulin antibodies. Is itpossible to prevent full-blown type 1 diabetes mellitus from developing? Are thereany clinical trials I could enroll him in?---- Mark Weinreb, MD
Westminster, Mass
An important observation is that your patient had anti-insulin antibodiesfollowing what was perhaps corticosteroid-induced diabetes.However, it is not clear to me that he is destined to havetype 1 diabetes. A fasting blood glucose level of 105 mg/dL is stillin the nondiabetic range, according to the recent classification ofthe American Diabetes Association.1 Anti-insulin antibodies are associated withseveral syndromes in addition to type 1 diabetes and are not overwhelminglypredictive of this entity. The titer can vary enormously; a high titer is seen inHirata syndrome, which is characterized by hypoglycemia and hyperglycemiabut not by type 1 diabetes.An oral glucose tolerance test would be helpful, and insulin and C-peptideresponses might be measured.2 In addition, it would be useful to know the patient'sbody mass index and whether he has a family history of type 1 or type 2diabetes or other autoimmune diseases. Asthma is associated with type 2 diabetesand obesity. It is also possible that your patient has a strong tendency towardinsulin resistance.The anti-glutamic acid decarboxylase (GAD) antibody titer is used to predicttype 1 diabetes. The test for this antibody is available at the Mayo Clinicand other laboratories.If type 1 diabetes appears to be developing--as demonstrated by increasingblood glucose levels and a positive anti-GAD antibody titer--your patientmight be eligible for a few studies that are currently under way. One is beingconducted by Dr Kevan Herold at Columbia University in New York. Otherthan Herold and colleagues'3 anti-CD3 trial and a few other studies, no approvedimmune intervention is available. A list of type 1 diabetes preventiontrials may be available in the future at the Trial Net Web site: http://www.diabetestrialnet.org.---- Louis Philipson, MD, PhD
Professor of Medicine, Endocrinology Section
University of Chicago



American Diabetes Association. Diagnosis and classification of diabetes mellitus.

Diabetes Care.



Steele C, Hagopian WA, Gitelman S, et al. Insulin secretion in type 1 diabetes.




Herold KC, Hagopian W, Auger JA, et al. Anti-CD3 monoclonal antibody in new-onset type 1 diabetes mellitus.

N Engl J Med.


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