From the Guidelines
In a 12-year-old with type 1 diabetes (T1D), the most critical comorbid autoimmune disorders to assess include autoimmune thyroid disease, celiac disease, and Addison's disease, as these conditions are more prevalent in individuals with T1D and can significantly impact morbidity, mortality, and quality of life. The assessment for these conditions should be based on the latest and highest quality evidence available. According to the most recent guidelines 1,
- Autoimmune thyroid disease should be evaluated by measuring thyroid stimulating hormone (TSH) and anti-thyroid antibodies annually,
- Celiac disease screening should include tissue transglutaminase antibodies (tTG-IgA) and total IgA levels at diagnosis and periodically thereafter, typically every 1-2 years,
- For Addison's disease, clinical vigilance for symptoms is crucial, with 21-hydroxylase autoantibodies and morning cortisol levels checked if symptoms arise. Additional conditions to consider, though they typically don't require routine screening unless symptoms develop, include autoimmune gastritis/pernicious anemia, vitiligo, and juvenile idiopathic arthritis. These screenings are vital because autoimmune disorders frequently cluster together due to shared genetic susceptibility, and early detection allows for timely intervention before significant complications develop, thus improving outcomes in terms of morbidity, mortality, and quality of life 1. It's also important to note that many of these conditions present with subtle or nonspecific symptoms that might be attributed to diabetes itself, making systematic screening essential for optimal management of the child's overall health. Given the potential for these autoimmune disorders to impact the patient's health significantly, it is crucial to follow the most recent and highest quality guidelines for screening and management, such as those provided by the Diabetes Care standards 1.
From the Research
Comorbid Autoimmune Disorders in Type 1 Diabetes
Comorbid autoimmune disorders are common in individuals with type 1 diabetes (T1D). The following autoimmune diseases are often associated with T1D:
- Autoimmune thyroid disease (ATD) 2, 3, 4, 5
- Celiac disease (CD) 2, 3, 4, 5, 6
- Autoimmune gastritis (AIG) 2, 5
- Pernicious anemia (PA) 2, 5
- Vitiligo 2, 5
- Addison's disease 2, 5
Screening and Diagnosis
Screening for these comorbid autoimmune disorders is essential to prevent complications and improve quality of life. The American Diabetes Association (ADA) and the International Society for Pediatric and Adolescent Diabetes (ISPAD) recommend testing for thyroid function, thyroid antibodies, and anti-tissue transglutaminase antibodies (TTG) IgA soon after diagnosis of T1D 3.
- Thyroid function tests (TFT) should be repeated every 1-2 years 3
- TTG IgA should be tested for within 2 and 5 years 3
- Screening for CD and thyroid antibodies has increased over the past decade, with 11% of patients having positive CD-specific antibodies and 15% having positive thyroid antibodies 6
Prevalence of Comorbid Autoimmune Disorders
The prevalence of comorbid autoimmune disorders in T1D varies:
- ATD: 15-30% of T1D subjects have autoimmune thyroid disease (Hashimoto's or Graves' disease) 5
- CD: 4-9% of T1D subjects present with CD 5
- AIG/PA: 5-10% of T1D subjects are diagnosed with AIG and/or PA 5
- Vitiligo: 2-10% of T1D subjects show vitiligo 5
- Addison's disease: 0.5% of T1D subjects have Addison's disease 5