Stages and Symptoms of Type 1 Diabetes

EP: 1.Living with Type 1 Diabetes

EP: 2.Screening Guidelines for Type 1 Diabetes

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EP: 3.Stages and Symptoms of Type 1 Diabetes

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: Shira, could you walk us through the stages of type 1 diabetes?

Shira Eytan, MD: Sure! It’s great that people are starting to understand the concept of staging because it’s relatively new. Traditionally, we thought of type 1 diabetes as something that presented suddenly, often with DKA. But with screening, we can now identify it much earlier.

In stage 1 type 1 diabetes, we can detect 2 or more autoantibodies in the blood. There are 5 antibodies we can screen for, and having at least 2 confirms the presence of type 1 diabetes. At this stage, blood sugar levels are still normal, the patient is asymptomatic, and no insulin is needed. However, the immune system has started attacking the β cells.

In stage II type 1 diabetes, the antibodies remain, and the attack on β cells progresses. By this point, about 50% of β-cell function is lost. Blood sugar levels begin to fall slightly outside the normal range—what we'd call dysglycemia—similar to what we would see in prediabetes. This might show up in routine lab work, but the patient is still asymptomatic and not requiring insulin.

Stage III, or frank type 1 diabetes, is when the impact becomes more apparent. At this stage, most pancreatic β cells are destroyed, and the body can no longer produce enough insulin. Blood sugar levels are consistently high, requiring exogenous insulin to reduce the hyperglycemic state. Patients usually develop symptoms like frequent urination, extreme thirst, dry mouth, fatigue, weakness, unexplained weight loss, and increased appetite. As we have discussed, many individuals present with DKA at this point.

Morales: What if I screen a patient and only one antibody is positive? What should I do?

Eytan: That’s a great question. First, ensure you’ve screened for all 5 antibodies, as some panels only test for 3 or 4. If only one antibody is positive, recheck it, and keep the patient on your radar. Antibody levels can fluctuate, so they may develop a second antibody later. For younger patients, who tend to progress faster, I’d recheck sooner. In adults, I’d repeat testing within a year. Additionally, monitor their blood sugar levels every six to 12 months, depending on their starting point and risk factors.

Morales: David, since you work with adults, many of whom have chronic illnesses or are on immunosuppressive therapies like prednisone, how does this affect antibody screening?

David Robertson. MD: If a patient is on a short course of steroids for an acute condition, like bronchitis, it’s best to delay screening until they’re off the medication for a few weeks. However, chronic steroid use typically doesn’t suppress antibody levels below detection.

For transplant patients on maintenance immunosuppressants, screening is fine once they’ve stabilized on their long-term doses—typically after about 6 months. Screening during the initial high-dose immunosuppressive phase, such as the first three or four months post-transplant, isn’t ideal because antibody levels may be harder to detect.