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Question:

From Scranton, Pennsylvania, USA:

I was recently diagnosed with diabetes, but my doctor isn't actually sure if I am Type 1 or 2. For one thing, I do not take insulin. I control my sugars with diet, exercise, herbs, and a sulfonylurea medication. I'm 26 and in excellent health (active, not overweight in the least) so isn't it more likely that I am Type 1? Anyway, I just read Type 1 diabetics are not supposed to take oral medications, but it didn't say why. Could you please answer this for me?

Answer:

You say you were recently diagnosed with diabetes and you have been able to manage your blood sugar with practically everything except insulin. Therefore, you and your doctor are both raising some doubts whether you are actually suffering from Type 1 or Type 2 diabetes mellitus. That's very important to clarify because the type of medical treatment is different.

You don't say whether you have any relative with diabetes (as a classical rule, family history is more frequently positive in Type 2 diabetes as well as in the MODY forms than in Type 1, where 90% of cases are sporadic, meaning with no relatives suffering from diabetes) although nowadays we are better ascertaining more and more often new Type 1 diabetes cases with familiar history positive for either Type 1 and/or 2 diabetes.

By far, given your negative past medical history for other diabetes-causing disorders, your age and your normal body weight, the most likely cause of your diabetes is late-onset autoimmune Type 1 diabetes.

The apparent insulin independency in the beginning doesn't contradict this diagnosis because this period could represent a "mild" honeymoon period that generally lasts longer in young adults than in children. In this case, insulin secretion is slowly decreasing along the years down to a very low residual level when insulin dependency is total and treatment is mandatory for life.

It is not possible on the basis of the information you gave in your letter to precisely answer your question, mainly for the reasons you are probably not tested for multiple antibodies (given your age I would suggest GADA as well ICA512) and endogenous insulin secretion, assessed by basal and post-glucagon insulin levels. Nevertheless, you must be well aware that negative antibodies test is not necessarily against Type 1 diabetes and, although not yet understood, one hypothesis can be the length of the preclinical phase in the adult form of this type of autoimmune diabetes leading in some cases to a seroconversion of autoantibodies and therefore immunonegative autoantibody single test.

It might be worth discussing with your doctor whether to be test for the above tests and in the meantime, though, I would suggest that you keep on testing urine and blood sugars at home frequently and, if your diabetes will be Type 1, to discuss with your doctor whether there is the case to start very small doses of insulin not to control blood sugar but to modify the lymphocyte response that damages the beta-cells of the pancreas that produce insulin. In this case, oral agents, often prescribed to control blood sugar in cases such yours, can shorten your honeymoon phase.

MS

[Editor's comment: I agree with Dr. Songini. Most young adults with diabetes that doesn't seem to require insulin injections probably have a slowly-developing form of Type 1 diabetes, and will require insulin within a few years. Whether to do the antibody studies is a matter of balancing cost versus curiosity: I would abandon the oral agents in favor of insulin rapidly if/when the blood sugar control deteriorates. WWQ]

Original posting 27 Sep 97

  
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Last Updated: Tuesday April 06, 2010 15:08:54
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