October 10, 2005
Diagnosis and Symptoms
Question from Twin Lakes, Wisconsin, USA:
In May 2005, my 20 year old daughter was diagnosed with diabetes. Her blood sugar was over 460 mg/dl [25.6 mmol/L] and her A1c was 10.6. She is on oral medications and her sugars are under excellent control, in the 80 to 90 mg/dl [4.4 to 5.0 mmol/L] range and her A1c is lower, but we were still unsure of which type of diabetes she has. My daughter seems to exhibit symptoms of both type 1 and type 2, though she is not overweight, and the medications are controlling her sugars. We saw an endocrinologist, who tested her for GAD antibodies, and the results were positive for one (GAD-65 antibody). He thinks she probably has a slowly progressing type 1 and we should watch her sugars very closely for any spiking and that she may be in a “honeymoon” period. We are discussing adding insulin. She also has polycystic ovarian syndrome. Is there any possibility she has type 2 or type 1.5 even with positive antibodies? Should she not wait for her blood sugars to rise and go on a combination of oral medications, metformin, to treat the PCOS, and a long acting insulin? Her blood tests show she is still producing insulin, although at the low end. Is it safe for her to continue on oral medications only since they are working so well? She exercises every day and watches her diet closely.
Answer:
You ask some good, but very difficult, questions. If she has positive antibodies, then it is likely this represents type 1 diabetes. Her age might suggest a slower onset. Her not being overweight suggests that this is not type 2, but PCOS makes this more difficult as well to know for sure. Time will answer this question better than any tests currently available. There is some suggestion that using insulin early saves the damaged beta cells and promotes longer functioning of damaged insulin production, so, in a non-obese 20 year old, most, but not all, diabetologists would likely use insulin. I would suggest that you discuss these options carefully with your diabetes team and then all of you together can decide what makes the most sense since there is no definite right or wrong treatment plan under these circumstances.
If she has positive thyroid antibodies and/or positive celiac antibodies (transglutaminase antibodies), then this is more evidence that this is type 1 and not type 2.
SB
Additional comments from Dr. David Schwartz:
While many women with PCOS are obese, it is not universal. PCOS is more of a biochemical profile characterized by the measurement of elevated “free” testosterone concentrations and often an increased ratio of the pituitary hormones LH and FSH, which control the ovaries.
DS
