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192 Cardio Diabetes Medicine 2017

in Nigeria, suggesting that prevalence of T2DM may major European LADA studies to date . Moreover,
vary with the overall T2DM prevalence in the general the former consistently have higher HbA levels
1c
population, HIV disease progression, and the disease than the latter (OR 1.8 in Sweden) . Clearly, we do
stage when patients access ART . not manage these patients as well as those with non-
5
insulin requiring non-autoimmune diabetes (i.e. type
Immune reactivity influences clinical progression
2 diabetes). Finally, autoimmune diabetic patients,
Islet autoimmunity in early childhood, especially for irrespective of age, have a substantially increased
multiple DAA or for insulinoma-associated antigen-2 risk of thyroid and parietal cell autoimmunity . The
autoantibodies, is strongly linked to rapid disease presence of DAA should encourage regular review of
progression . In diabetic children, those with DAA had comorbidities and the quality of glycaemic control .
6
greater C-peptide decline (48%/year) than those with-
out DAA-negative children (∼8%/year). Importantly,
this decline was independent of demographics, HLA
risk, BMI and insulin resistance; while in children with
non-autoimmune diabetes, there was marked het-
erogeneity, suggesting a mixed group, with a mean
rate of decline in C-peptide comparable to adult type
2 diabetes (∼8%/year).For any given individual with
diabetes, there is substantial variability in the nature
of their disease, risk of complications and response
to any given drug. Based on studies carried out in
2004 on a group of people of the population of North
America and Europe, it is known that anti-GAD are
present in 4.2% of people with newly diagnosed type
2 diabetes previously treated with oral ant diabetic
agents.
Non-autoimmune patients require variable
Autoimmunity impacts management management
strategy As the loss of beta cell function is strongly age-de-
Identifying (DAA) Diabetes-associated auto antibod- pendent and young patients predominantly have
ies is a valuable test for disease management as they autoimmune diabetes, therapeutic decisions are
are characteristic of a form of autoimmune diabetes, usually made without recourse to testing for DAA
especially in adults, which is often inappropriately or C-peptide. This approach courts error, notably
treated and that requires more frequent review and in children, in whom the prevalence of obesity and
a different perspective. Patients with autoimmune both type 1 and type 2 diabetes have increased
non-insulin-requiring diabetes, including (LADA) La- dramatically. By measuring DAA initially and C-pep-
tent autoimmune diabetes in adults should be started tide subsequently, it is possible to identify, as ap-
on insulin or an incretin-based therapy or, potential- propriate, patients with MODY, type 2 diabetes in
ly, a combination of the two. Sulfonylurea treatment children, non-insulin-requiring autoimmune diabetes
should likely be avoided, as patients on this class and non-autoimmune diabetes without the metabol-
of drugs have a faster loss of insulin secretory ca- ic syndrome—potentially some 20–30% of all diabetes
pacity than when treated with insulin . Autoimmunity patients diagnosed under 40 years of age . Such
does not equate with insulin therapy, as indicated by a definition also has utility for setting targets and
a Phase 2 study of adult patients with autoimmune therapy because cardiovascular complications differ
diabetes; the combination of gliptin plus insulin was between the major types of diabetes, e.g. guidelines
superior at sustaining C-peptide than insulin alone . offer statins to type 2 diabetes cases at an earlier
Although patients with typical type 1 diabetes at all age.
ages presenting with ketoacidosis require immediate
insulin therapy, not everyone with adult-onset auto- Summary
immune diabetes such as LADA, need progress to This original study first of its kind in the world has a
insulin therapy; in one study, 44% were still not on significant discovery of 37% were with high levels of
insulin after 12 years of disease . However, disease Hb A1c , a clear indication of high diabetes among
progression to insulin treatment is more rapid in HIV infected,20.5% positive for tTG so that the HIV
LADA than with type 2 diabetes, as reported by all positives prone to developing celiac disease. 13.75%

GCDC 2017