The Future of Type 1 Diabetes Management - Episode 11

Managing T1D Comorbidities

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Experts in endocrinology share their approach to managing type 1 diabetes along with related health conditions.

Robert Busch, MD: Our patients with type 1 diabetes have many other health issues as well. Dr Simmons, you’re a celiac expert, how does that impact your patients who have type 1 diabetes and some of the other factors they have?

Kimberly Simmons, MD, MPH/MSPH: I don’t think I’m a celiac expert more than anybody else; I think we all to some degree are celiac experts because celiac disease is so common in our patients with type 1 diabetes. The data show about 6%. When we’ve looked in our clinic data, we have almost 8% of our children with type 1 diabetes who have celiac disease. It is a condition that often requires a lot of comanagement. If you ask any patient who has both type 1 diabetes and celiac disease, which disease is harder to manage, I have heard every single patient tell me celiac disease, which is always insightful because it tells you what an impact diet can have on someone’s everyday life. Many of our patients, even though they likely have celiac autoimmunity before they’re diagnosed, most are not diagnosed with celiac disease until after they develop type 1 diabetes. We have a collaborative approach with our GI [gastrointestinal] colleagues that is great, where we try to manage type 1 diabetes and the diagnosis and adjustment period first before they jump into managing an entirely new disease. The other thing we always must remember is that celiac disease can make diabetes management really complicated if they’re not absorbing their food well, for example, with unexplained hypoglycemia and variable insulin dosing day to day. There are many factors to consider, and I think collaborative care is always the best way to approach that if it’s available.

Robin S. Goland, MD: If I could jump in, I think in the 30 years I‘ve been at this, my adult patients are increasingly incredibly healthy. I tell my young trainees that when a 70- or 80-year-old patient with type 1 diabetes comes to the office, puts their arm around my shoulder and calls me sweetheart, this is a visit where no one’s going to do one thing I suggest. But I think that’s fine. I completely agree with Kimberly; a patient I diagnosed with celiac recently, 6 months later, she came back to the office and asked if I could give her type 1 diabetes a second time. Anything would be better than that celiac diagnosis. It was so touching and such a unique perspective, but like what you’re hearing with the children, changing what people eat and that level of vigilance is very difficult and tricky.

Robert Busch, MD: As adult endocrinologists, we’re managing cardiovascular risk protection. Where’s your ACE [angiotensin-converting enzyme] or ARB [angiotensin receptor blocker]? Also aggressive statin management, and beyond statin management, looking for underlying heart disease. There’s a lot of other impactful things as well.

Robin S. Goland, MD: The good news is type 1 diabetes is a disease of 1 problem, the blood sugar. Because I’ve been nagging them for 30 years, these are usually people who exercise and eat a lot of kale. Compared to my people with type 2, they are living healthy and playing tennis, and whatever this pickleball situation is; someday when we cure this, I will learn to play it. They are very healthy. My experience, at least in New York is that—and this is borne out by many of the studies in the older type 1s in the exchange—the patients are doing remarkably well and living complication free. That doesn’t mean it’s easy because the obstacles and burden are remarkable.

Robert Busch, MD: Since you mentioned celiac, I should tell you the first patient I will start on the drug if it is dysglycemia, is like the father I presented about at grand rounds when I was a fellow many years ago. He had primary hypothyroidism, Addison disease, vitiligo, B12 deficiency, and type 1 diabetes. He has never had DKA [diabetic ketoacidosis] since, has managed himself, and is one of my healthiest patients, with 5 endocrine problems. I show him off to every student who comes in. He’s now in his 50s; I met him for short stature when he had hypothyroidism when I was a fellow. He married someone he met at a diabetes meeting, and she has celiac disease and type 1 diabetes. They have 3 kids. The child I treat has Hashimoto disease, and even though I’m not a pediatric endocrinologist, he has 4 out of 4 antibodies positive. He didn’t want to drive to Boston to be in the TrialNet trial, but knowing the drug is approved, that was my first phone call I made to them. So they can‘t wait. As you said, you talk to someone who has a family member with diabetes, and they all want in. The patients I’ve called so far, they all want their kids to be screened uniformly, there’s no question about it. If it prevented diabetes, you said for a year, but if it prevented it for a month, they would be happy with that.

We are often screening our thin patients with type 2 diabetes when they come in for latent autoimmune diabetes and find it, especially if they have any other autoimmune process like vitiligo, or B12 deficiency, or anything else. If we look, we find it.

Robin S. Goland, MD: In my book, that’s…just type 1.

Robert Busch, MD: Very good.

Kimberly Simmons, MD, MPH/MSPH: I think most specialists who are listening to this would know, but for anybody who’s more of a general practitioner, many families assume that the environmental trigger is the flu virus or whatever virus happened immediately before they presented to clinical care. In that respect, those families might think, “It wouldn’t have helped if I had been screened and detected earlier because I didn’t know I was going to get the flu.” It’s really important families realize that that process and being able to detect it has been going on for months to years, and that particular virus is not the initial environmental trigger. It’s what happened at the end that made them sick enough to show up in somebody’s office.

Robin S. Goland, MD: And it wasn’t their fault.

Transcript Edited for Clarity