SARAH: Welcome back. We are continuing our discussion today about the 2025 ADA standards of care. And joining us again is our favorite diabetologist, Dr. Amber Healy. No offense to other diabetologists in the world. And if you hear any strange beeping during this episode or the building begins to shake, it is not my brain or a CGM alarm. It is actually construction outside this building. So with Dr. Healy, today we are going to talk about the classification of diabetes and the diagnosis. So it's chapter two. In the a DA standards of care. So tell us what we're gonna talk about first today, Dr. Healy. 

AMBER: Right. So I recognize this chapter is diagnosis and classification of diabetes.  But we're gonna skip over the diagnosis part of this because you probably already are aware of that. Um, classification, our biggest focus will be on, you know, when is that patient with type two, really not type two. Like what should be your, uh, suspicion for type one diabetes because about a third of patients, and I've heard all the way up to 40% of patients actually, uh, are misdiagnosed as type two when they really have type one. So what are those clinical clues? And if you suspect it, what should you order, uh, to, to help you you know, determine, make sure that your suspicion is correct? 

SARAH:I think this is huge. 'cause I think to myself about how many patients we have who are diagnosed with type two and that A1C still runs so high. And if we are missing that diagnosis of type one, that may really throw off numbers for patients who have type two. 

AMBER: Yeah. Well and it's, it's interesting because we tend to assume if the person sitting in front of you is overweight or obese and we have an, we have an obesity epidemic.

SARAH: Right. Correct. Right. 

AMBER: You know, and you're automatic is well they're obese, they have to be type two and you know, so, but that's not always the case.

SARAH: Exactly. I love That. 

AMBER: Uh, so they have this really nice framework. That they've started to use. Uh, and I'm gonna cheat and look in the text a little bit. It's the AA BBB CC uh, pneumonic basically. So age, if the patient is under 35 and at their diagnosis, you should probably be more suspicious that they have type one rather than type two. Uh, you know, but put it in the framework of what else is going on with the patient. Autoimmunity, do they have a personal history of other autoimmune conditions? So a lot of times the patient might have already have like Hashimoto's thyroiditis, they have celiac disease, maybe they have rheumatoid arthritis or, or lupus, you know, some other autoimmune condition to think about. Or a family history of autoimmune conditions. So, you know, maybe they have um, a parent with type one, maybe they have a parent with Hashimoto's thyroiditis, but if they already have another autoimmune condition in their family, you may wanna consider, uh, looking for this diagnosis. The other thing that we look at as body habit is yes, I mentioned earlier on, you know, if they're obese, but you know Yeah, definitely if the patient is on the thinner side, they have A BMI of less than 25. You know, that's more consistent with a type one diagnosis. And then um, the background, we talked about family history already a little bit. Definitely family history of type one. We know that there's some increased risk. We know if dad had type one, your risk is one in 17. Mom had type one, it's one in 25. You know, they have these different, uh, statistics out there. So it's important to be mindful of that. Uh, and then, uh, control. And I know that control is kind of a bad word now. I mean, you have problems with the patient getting to their goal. And a lot of times these patients have been tried on multiple oral agents. Like, and no matter what they do, no matter what they're put on. They just can't get there. They just can't get to that target. So maybe it's time to consider that they really aren't type two. 

SARAH: That's interesting. That's great. 

AMBER: And then, uh, the sixth point that they have this and the comorbidities, and this is a newer thought, um. You know, yes, we've talked about the autoimmune conditions as a comorbidity, but we have a lot of patients that are now getting immune checkpoint inhibitors for cancer. And it can induce an acute autoimmune diabetes. So like if you have a patient that's received chemo that includes one of those medications, you may wanna go ahead and screen them for type one diabetes. 

SARAH: That is so interesting. I really love this. So in the text, I have noticed that it's on page S 32 in the standards of care, it's the AA BBB CC. And it's age autoimmunity, body habitus background control, are they at goal and comorbidities? That's fantastic. I think that's really Helpful. 

AMBER: I do too. I really, I was excited when I noticed it in the 2024 standards of care. So they brought it back. So they, they thought it was important enough to continue to have it in there. 

SARAH: I love it. We also talked about, sorry, I think you're gonna say this too. 

AMBER: No, you go ahead. 

SARAH: The next thing we were gonna mention too was, um, antibody testing. For differentiating type one from type two. Correct. What do would you like to tell us about that? 

AMBER: So they have a panel commercially available now of four auto antibodies that you can order for your, your patient that you are suspicious of this and. And you know, everyone was aware of GAD 65. The glutamic decarboxlase 65 antibody. We've known about that one a long time. So the GAD 65 antibodies is still included. Uh, but since then they've discovered more antibodies. So you're also able to get the zinc transporter eight antibody. Which is actually the second most common to find positive after gad. Wow. Okay. Uh, they have also, what is the eyelet antigen two antibody. Alright, interesting. Which is actually like, uh, an antibody against like a tyrosine kinase that's involved in the eyelet. And then, um, you can get an insulin antibody. 


SARAH: Okay. I can see all the autoimmunity in there. Okay. 

AMBER: Well, and in general, you know, if a patient has two or more of these positive, it is definitely type one diabetes. You know, because there's even new guidelines out for early stage screening for type one and people that are more likely to be predisposed to having type one. We mentioned some of those risks earlier, right. So there, you know, two antibodies positive even now is considered stage one type one diabetes. So we, they definitely need the two antibodies positive in these folks too, to really call them type one. 

SARAH: That's really interesting to me.

AMBER: But if you, but at the end of the day, I mean, you can, they, you still think they need insulin to help them, even if you don't think they have type one or they don't look like they cleanly have type one or type two because they have a whole chapter on this classification. There's other types of diabetes. If insulin you feel is appropriate, just add it. 

SARAH: Just add insulin. That's fantastic. That's awesome. So there is a commercially available. I just wanted to, to revisit this. For the providers that are listening, there is a commercially available test panel that you can run that includes all these different tests for type one versus type two. 

AMBER: Your hospital might have the panel built. Ours does not. So I actually have my own panel that I created. But those are the antibodies that are commercially available That you would wanna include in a panel. 

SARAH: Okay, I really like that. That's actually really helpful. We may revisit that sometime. That might be a really interesting discussion to have. So... 

AMBER: It might be exciting at some point to talk about early stage type one screening because they, they do have guidelines out that came out and they were presented at the ADA this past summer. 

SARAH: That's awesome. It's, this is really exciting. Awesome. Is there anything else that you wanted to share with this on the staging or classification of diabetes? Or did we get all the points?

AMBER: Uh, we covered all our points today. 

SARAH: Okay. Fantastic. All right. This is really exciting for me. I really appreciate this. I think as a pharmacist, I think about the patients who come in and how many of them are on multiple oral medications for diabetes. And wondering about that classification. So that's really helpful. Thank you Dr. Haley, for your time today.

AMBER: You're welcome. 

SARAH: Thanks everybody. I'm sure we'll be back. Well you hope you have a wonderful day.