Establishing Screening Programs for Presymptomatic Type 1 Diabetes: Practical Guidance for Diabetes Care Providers

Abstract

Type 1 diabetes (T1D) is an autoimmune disease with 2 presymptomatic stages (stages 1 and 2) that precede its clinical onset (stage 3). The presymptomatic stages of T1D are characterized by circulating autoantibodies that can be reliably detected by autoantibody screening panels. Identifying people in the presymptomatic stages of T1D can allow for monitoring and prevention of diabetic ketoacidosis. A disease-modifying therapy that has been shown to delay onset of stage 3 T1D is now also available for individuals with stage 2 disease, highlighting the importance of early detection. This intervention may delay the onset of stage 3 T1D. Updated guidance and protocols are needed to integrate autoantibody screening into standard practice. This report provides guidance for endocrinology providers on establishing clinical autoantibody screening programs within their practices, institutions, healthcare networks, and/or communities. Key steps include nominating a champion for the program, building a team to implement screening, and motivating other providers to participate. Implementation of screening requires standardizing several steps in the screening process, including communicating with individuals at risk, integrating screening into existing workflows, and streamlining logistics such as ordering and coding for autoantibody panels. Providers must have a plan to interpret and communicate results and to ensure that individuals may be appropriately followed in the future. Here, common barriers to screening are addressed, and practical solutions to facilitate the adoption and success of screening initiatives are offered.

Keywords: autoantibody; autoimmune; endocrinology; screening; type 1 diabetes.

Figure 1.

Benefits of establishing an AAb screening program for early T1D and how to identify individuals at risk for developing T1D.

Figure 2.

Suggested risk stratification approach for AAb screening programs for presymptomatic T1D. Using an approach to AAb screening that prioritizes individuals at increased risk for T1D may be pragmatic for clinics/institutions that do not have the infrastructure to screen all individuals. Individuals with a first-degree family member with T1D could be given the highest priority for screening, followed by those with second-degree relatives with T1D (A); followed by individuals with a personal or family history of other autoimmune diseases such as celiac, Hashimoto, Graves, or Addison disease, or those with a new prediabetes or diabetes diagnosis (B); followed by general screening of all individuals in the absence of an identified risk factor, and this could be done at certain ages or in parallel with other routine screening tests (C). Although this approach will fail to capture all individuals who will go on to develop T1D, establishing a tiered screening program may build infrastructure and pilot key processes that can be scaled up in the future. *For patients without typical features of T2D.

Figure 3.

Establishing a clinical AAb screening program for early T1D: guidance for endocrinology providers.