Impact of Delayed Intervention in Stage 2 Type 1 Diabetes

EP: 1.Living with Type 1 Diabetes

EP: 2.Screening Guidelines for Type 1 Diabetes

EP: 3.Stages and Symptoms of Type 1 Diabetes

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EP: 4.Impact of Delayed Intervention in Stage 2 Type 1 Diabetes

The following transcript has been edited for clarity and length.

Javier Morales, MD: Let’s discuss the consequences of delaying intervention in stage II type 1 diabetes. Could it lead to a higher risk of progression to stage III T1D, an increased likelihood of complications like diabetic ketoacidosis (DKA), a decline in quality of life due to uncontrolled blood sugar, or irreversible damage to pancreatic β cells? What are your thoughts, Quentin?

Quentin Van Meter, MD: Honestly, all these outcomes are significant. There's no single "right" answer here because they’re all critical to address. These are the consequences we aim to avoid through early intervention.

Morales: Absolutely. The polling reflects that sentiment—participants feel all these factors are equally important. Shira, can you walk us through stage III T1D?

Shira Eytan, MD: Of course. stage III represents the final stage of T1D progression, often occurring suddenly, especially if the patient’s risk wasn’t identified earlier. This highlights the importance of early intervention to prevent progression. Delaying intervention in stage II can lead to irreversible β cell damage and loss of insulin production. It also increases the risk of life-threatening DKA and severe complications. Not only is DKA a critical event, but it can also set the stage for long-term poor glycemic control. Our goal should be to prevent that outcome and to have time to educate the patient and family which will have long-term positive effects. We can't prevent stage III but we can at least try to delay and to educate patients before it happens.

Van Meter: The clinical trials supporting the FDA approval of teplizumab clearly showed the benefits of intervention in delaying stage III. While we don’t yet fully understand which patients progress rapidly, expanding screening efforts could help identify patterns and risk factors for faster progression from stage I or II to stage III.

Morales: To our audience, who do you typically refer patients to for confirmation of stage II to stage III progression and specialized management? Endocrinologists, pediatric endocrinologists, immunologists, diabetes specialist nurses—or do you lack access to these resources? In the Northeast, we have many options, but access can be more challenging in rural areas. Bethany, what’s your experience?

Bethany Kinsey, NP: We have patients that drive almost 2 hours to reach us and we are the closest endocrine practice. In rural areas like North Georgia and the Blue Ridge Mountains, the services just aren't available. When I worked in Savannah, Georgia, we saw patients who drove from 10 counties away. Access to care is a significant challenge in rural America.

Morales: Exactly. Another question for the audience—how often do you screen for T1D progression during routine appointments? Awareness is key that T1D may be happening "in the background." Many patients may be type 1 but misdiagnosed as type 2, so screening is crucial. The second thing that will be important is taking action based on the information. Out polling shows that 22% never screen, but I hope this presentation will shift that mindset.

One more question: Why is screening for T1D progression important? Is it to detect early signs of progression, tailor treatment strategies, mitigate long-term complications, or all of the above? David, what’s your take?

David Robertson, MD: Active screening can achieve all these goals. Detecting progression early helps us focus efforts and evaluate eligibility for interventions at stage II.

Morales: Our audience seems to agree—most chose "all of the above." Now, how do you screen for T1D risk factors during routine appointments? Options include autoantibody tests, oral glucose tolerance test (OGTT), clinical assessment of symptoms, or a combination. Shira, could you comment on the OGTT?

Eytan: Sure. The OGTT is not pleasant for the patient; it's time-consuming and uncomfortable, so it’s not typically part of routine testing. However, it was critical in the TrialNet study that led to the recent teplizumab approval and is required as part of the confirmatory tests for these patient. But it's not part of routine testing at our clinic. We typically get an HbA1c level which I think will give us more clues to potential issues in the general population.

Morales: Our audience seems spot-on again, with most favoring a combination of methods.