Type 1 diabetes in adults: detect earlier, treat later

The FEDERATE-Can project, launched in Montreal in March, aims to assess the feasibility of early screening for certain adults at risk of type 1 diabetes (T1D). At first glance, the topic seems to boil down to a fairly simple question: is it better to detect the disease before it develops? But upon closer examination, the real problem emerges elsewhere. In Quebec, several endocrinologists interviewed by Profession Santé assert that even before expanding screening, other, more immediate blind spots persist in patients already diagnosed.“Screening alone is not enough. If those screened are not followed up, we lose most of the benefit,” acknowledges Dr. Rémi Rabasa-Lhoret, principal investigator of FEDERATE-Can at the Montreal Clinical Research Institute (IRCM). In other words, the challenge is not simply to identify certain cases earlier. It's also crucial to make the correct diagnosis, avoid confusion with type 2 diabetes, and, once the disease is confirmed, provide a coherent care pathway."The biggest benefit of FEDERATE-Can in the long run will be for family physicians. These tools will help identify adults who are initially misdiagnosed as having type 2 diabetes." - Dr. Rémi Rabasa-LhoretType 1 diabetes is no longer just a childhood disease. A review published in 2021 in Diabetes Care already pointed out that more than half of new cases occur in adults. And the practical guide from Diabetes Quebec confirms this: more than 50% of people living with T1D received their diagnosis after age 18. Yet, in perceptions and sometimes in clinical practice, the old stereotype persists—T1D in a thin young person, T2D in an overweight adult. “The association between type 1 diabetes and the absence of excess weight, and between type 2 diabetes and obesity, is much less clear-cut than before,” emphasizes endocrinologist Nadine Taleb, a researcher at the University of Montreal Hospital Centre (CHUM).The confusion isn’t solely due to weight or age. Certain slower-developing forms, grouped under the label LADA—for Latent Autoimmune Diabetes in Adults—can more easily be mistaken for type 2 diabetes, precisely because they don’t make the individual insulin-dependent from the outset. “LADA is a slower autoimmune process. That’s precisely what makes it easier to miss,” observes Dr. Taleb, who is particularly interested in this form of diabetes, also called “type 1.5 diabetes.”The first step is not to diagnose type 1 diabetes in every adult with a new diagnosis. Rather, it's to recognize when the clinical picture no longer quite matches that of classic type 2 diabetes. "When, at each visit, we have to add a pill or significantly increase the treatment, we need to ask ourselves: do I have the correct diagnosis?" recommends Dr. Taleb. In her practice, this doubt arises primarily in patients who are not overly obese, who respond less well than expected to treatment, or whose condition becomes unusually difficult to stabilize.Other indicators should also raise suspicion. Slight overweight, weight loss, a personal or family history of autoimmune disorders—such as Hashimoto's thyroiditis, celiac disease, or lupus—may point toward an autoimmune process rather than simple type 2 diabetes. If in doubt, further investigation is necessary. The endocrinologist reminds us that antibody tests should be ordered and that the readily available C-peptide provides an indication of pancreatic reserve.Standard treatment still out of reachHowever, the real gap in the care pathway for adult patients isn't just at the time of diagnosis. It also begins once the disease is confirmed. "In my opinion, the main blind spot remains the coverage of insulin pumps," states endocrinologist Jean-François Yale of the McGill University Health Centre. "There's no logic to it. It's indefensible," he adds, denouncing the fact that adults diagnosed after age 18 still don't have access to them under the Quebec public program.His colleague Nadine Taleb agrees, noting that automated systems have, in practice, become the standard treatment for type 1 diabetes. However, in Quebec, the pump access program remains reserved for individuals under 18 who meet certain clinical criteria, with continued access for those already enrolled after age 18. In its response to Profession Santé, the Ministry of Health and Social Services (MSSS) defends this choice. “The program is currently being maintained in its existing form, which prioritizes pediatric patients,” it writes, adding that expanding it would require additional investment.“The data is now very clear: the automated pump is the standard treatment for type 1 diabetes. The real question is why this option is still not available to all adults.” – Dr. Nadine TalebWhat INESSS saysThis budgetary argument has already been substantiated by the National Institute of Excellence in Health and Social Services (INESSS). In an opinion published in 2022, the organization estimated the cost of adding pump systems to the List of Medications at $62.7 million over five years, and the cost of expanding the program to the adult population at $328.8 million over five years.INESSS also believed that the same accessibility criteria should apply to adults—in other words, that public access should not be reserved for minors only. For the clinicians interviewed, the problem therefore lies less in the lack of analysis than in the fact that this recommendation has still not been followed by the government.Tests deemed sufficient by the MinistryRegarding diagnosis and screening, the Ministry of Health and Social Services (MSSS) does not share the same perspective as Drs. Taleb, Yale, and Rabasa-Lhoret. In its response to Profession Santé, the Ministry states that type 1 diabetes in adults “does not raise major access issues in Quebec,” that a structured or targeted screening program is not being considered, and that autoantibody testing is already offered centrally in university laboratories.The MSSS says it is instead relying on clinical judgment, continuing education, and the appropriate use of diagnostic tools when the situation warrants it. In short, in its view, the problem lies neither in access to tests nor in the lack of analysis, but in the prioritization of resources.This is precisely where the disagreement with clinicians emerges. They advocate for better identification of certain atypical cases and, above all, for providing standard treatment more equitably.Ultimately, FEDERATE-Can at least has the merit of bringing a fundamental question back to the forefront. Yes, better screening of certain adults at risk for type 1 diabetes may seem desirable. But even before expanding this screening, the clinicians interviewed point to other priorities. “FEDERATE-Can is about feasibility. The real challenge is implementation,” summarizes Rémi Rabasa-Lhoret.This article has been translated from its original French and first appeared on our sister site Profession Santé.

Type 1 diabetes in adults: detect earlier, treat later

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