Incipient Juvenile Diabetes: Warning Signs, Prevention

December 31, 2006

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

References:

REFERENCES:
1.

American Diabetes Association. Diagnosis and classification of diabetes mellitus.

Diabetes Care.

2004;27:S5-S10.

2.

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

Diabetes.

2004;53:426-433.

3.

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

N Engl J Med.

2002;346:1692-1698.