Abstract
While the incidence of type 1 diabetes continues to rise by 3% each year, the ability to prevent this disease remains elusive. Hybrid closed loop devices, artificial pancreas systems, and continuous glucose monitoring technology have helped to ease the daily burden for many people living with type 1 diabetes. However, the artificial pancreas is not a cure; more research is needed to achieve our ultimate goal of preventing type 1 diabetes. The preceding decades have generated a wealth of information regarding the natural history of pre-type 1 diabetes. Islet autoimmunity in the form of multiple autoantibodies is known to be highly predictive of progression to disease. Staging systems have been devised to better characterize pre-type 1, direct mechanistic understanding of disease, and guide the design of prevention studies. However, there are no evidence-based recommendations for practitioners caring for autoantibody patients other than to encourage enrollment in research studies. Close monitoring of high-risk patients in natural history studies markedly reduces diabetic ketoacidosis rates at diagnosis and research participation is critical to finding a means of preventing type 1 diabetes. The discovery of an effective preventative strategy for type 1 diabetes will justify universal risk screening for all children.
Highlights
As is the case for type 2 diabetes, the incidence and prevalence of type 1 diabetes is increasing annually
We have gained incredible knowledge and understanding of the natural history of type 1 diabetes thanks to the international natural history and birth cohort studies described in this review
While whole population screening for human leukocyte antigen (HLA) risk or islet autoimmunity is not yet justified, several groups continue to create networks that will be poised to provide this screening as soon as meaningful prevention is identified
Summary
As is the case for type 2 diabetes, the incidence and prevalence of type 1 diabetes is increasing annually. A practical approach to the management of islet autoantibody positivity starts with how islet autoantibody positivity is determined This may occur through [1] testing of islet autoantibodies in patients found to have a mildly elevated blood glucose found incidentally (not meeting criteria for diabetes), [2] hyperglycemia detected during an acute illness that resolves but in whom autoantibody testing was done, [3] screening in the setting of multiple other autoimmune conditions, [4] screening of family members of probands diagnosed with clinical type 1 diabetes as part of a research study, or [5] population screening (only in the context of research). Initiation of insulin early in disease was previously thought to provide for beta cell rest and recovery even without severe metabolic derangement or markedly elevated HbA1c More recent studies, such as the DPT-1, have shown that this is not the case, and others looking at intensive insulin therapy initiated shortly after diabetes diagnosis fail to show increased preservation of C-peptide compared to conventional treatment [37, 38]. Will there be a role for adjunctive therapies other than insulin such as glucagon-like peptide-1 agonists or metformin? These and other preventative therapies are being studied
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