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Clarifying LADA (Type 1 Diabetes in Adults)
When I met fellow D-writer Catherine Price for coffee recently, I immediately gushed about everything we had in common: two brunette journalist-types living in the SF Bay Area, both diagnosed a few years ago with LADA (or so I thought). Catherine gave me a sideways look, and then began grilling me about the formal definition of LADA. I had to admit, it’s pretty fuzzy. Today, I gratefully present you with the results of her investigation into this mysterious acronym:
A Guest Post by Catherine Price, of ASweetLife
Having had Type 1 diabetes for nearly ten years now, I can handle most diabetic terms and acronyms thrown my way. Hemoglobin A1c? Got it. Carb ratios? Insulin sensitivity? No problem. But one term has continued to confuse me: LADA.
Short for Latent Autoimmune Diabetes in Adults, it’s also known as Slow-Onset Type 1 Diabetes, Type 1.5 Diabetes or, occasionally, Late-Onset Autoimmune Diabetes of Adulthood. Four names for the same thing? That’s never a good sign.
Until recently, the most common definition I’d heard for LADA was that it was a Type 1-like form of diabetes diagnosed in adulthood. But I didn’t understand the details. Does being diagnosed with Type 1 diabetes as an adult automatically mean you have LADA? Is there a difference between LADA and the classical definition of Type 1?
To answer these questions, I spoke with Marie Nierras, the program officer of the genetics programs at Juvenile Diabetes Research Foundation. She cut right to the chase. “There is a lot of confusion about LADA,” she told me, “but Type 1 diabetes and LADA are not the same thing.”
Here, to get us started, is how JDRF’s Adults With Type 1 toolkit defines LADA:
“Type 1 diabetes diagnosed in adults over 30 may be Latent Autoimmune Diabetes in Adults (LADA), sometimes known as Type 1.5 Diabetes. LADA is often misdiagnosed as type 2 diabetes because of age; however people with LADA do not have insulin resistance like those with type 2. LADA is characterized by age, a lack of family history of type 2 diabetes, a gradual increase in insulin requirements, positive antibodies, and decreasing ability to make insulin as indicated by a low C-peptide.”
And here’s some further detail from the National Institutes of Health:
“Most people with LADA still produce their own insulin when first diagnosed, like those with type 2 diabetes. In the early stages of the disease, people with LADA do not require insulin injections. Instead, they control their blood glucose levels with meal planning, physical activity, and oral diabetes medications. However, several years after diagnosis, people with LADA must take insulin to control blood glucose levels. As LADA progresses, the beta cells of the pancreas may no longer make insulin because the body’s immune system has attacked and destroyed them, as in type 1 diabetes.”
Many people assume that the first line of the JDRF definition – i.e. an older age at diagnosis – is LADA’s most important characteristic. But it turns out that’s not true. According to Nierras, the key difference between Type 1 diabetes and LADA is not the age of the person when they’re diagnosed, but the gradual way the disease progresses. Whereas people with classical Type 1 diabetes tend to be completely insulin-dependent within twelve months after diagnosis (usually less), people with LADA can often survive without artificial insulin for years.
As Nierras explains, “It’s as though they have Type 1 diabetes, but something slows down the disease so they can stay off of insulin much longer than the classically definable Type 1.”
With that said, age does play a part: for reasons not entirely understood, the older you are when you’re diagnosed with autoimmune diabetes (i.e. Type 1), the longer it usually takes for your immune system to kill off all your insulin-producing cells. A five-year-old with autoimmune diabetes typically becomes insulin-dependent more quickly than a 45-year old – a phenomenon researchers are struggling to understand. But it’s possible, says Nierras, for that same 45-year-old to present with a classic, fast-developing case of Type 1, or for a younger person to present with signs of LADA. According to Nierras, our tendency to emphasize age comes from arbitrary lines drawn by clinical trials — since most trials for Type 1 diabetes only accept people under 30 years old, new cases of Type 1 in people over 30 often are tossed into a generic LADA “junk drawer,” even though age itself is not the defining characteristic of the disease.
All of this might sound like semantics if you already know you have insulin-dependent diabetes. But for people whose diabetes is not quite so clear-cut, LADA is associated with a big, under-acknowledged problem: thanks to the ambiguity of its symptoms, it’s often misdiagnosed as Type 2 diabetes.
Imagine you’re a doctor and a patient comes in, 40 years old, not obese but also not lean, with high blood sugar but no signs of diabetic ketoacidosis (a warning sign for Type 1). What’s more, the patient responds well to meal planning and diabetes pills (both of which, according to Diabetes Monitor, are sometimes effective in early stages of LADA). If you aren’t aware of this weird hybrid – I like to think of LADA as the Prius of diabetes – wouldn’t you think she had Type 2?
Unfortunately, this example is not purely hypothetical; according to the National Institutes of Health, up to 10 percent of people who have been diagnosed with Type 2 diabetes may actually have LADA. This can lead to months, if not years, of incorrect treatment – which puts people at risk of going into diabetic ketoacidosis and developing long-term complications (not to mention spending a long period of time feeling inexplicably rotten).
So what’s the bottom line? If you’ve been diagnosed with Type 2 diabetes and your ability to control your blood sugar with oral medications and lifestyle changes has decreased over time, you might want to be tested for LADA – especially if you are normal weight and don’t have any relatives with Type 2 diabetes. (Tests for LADA are the same as for Type 1 – a blood test to see if any autoantibodies are present, and a measure of C-peptide levels to determine how much insulin you are producing.) The bad news of LADA is that if you have it, you will eventually need to take artificial insulin. But there’s positive news as well: once you’ve been diagnosed correctly and start the right treatment, you can get back on the road to good health.
Graph: from an Australian diabetes org
Postscript: Researchers are very interested in the connection between Type 1 diabetes and LADA, but there are only a few clinical trials in progress. Hopefully that will soon change – and in the meantime, you can find one exception here.
Additional information about LADA:
- http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm
- http://www.diabetesmonitor.com/lada.htm
Wow, thank you Catherine. Now I’m confused as ever, though. Guess I really am a classic Type 1 diagnosed super-late — or somewhere in that LADA “junk drawer” you mentioned (?)
Joining Amy in the “junk drawer” – initial dx in Dec 03 at age 36 and slim, ultra low carb diet and 90min exercise a day kept me alive until I started insulin in May 04 (but with a fasting BG in the 200s), all antibodies positive, no insulin resistance… Seems more like the classic T1 onset … pre-1922, thanks to my moron of an ex-doctor.
I usually just say I’m Type 1 – no one knows what that is either, so adding a third unknown label just muddies things further.
Posted by: Val | March 16th, 2010 at 7:53 amI’m just as confused as the rest. I was diagnosed at 25, but I had a very short honeymoon – more like classic Type 1. I wouldn’t have called myself “lean,” but I definitely wasn’t obese. My endo is the one who used the term LADA, and I just latched on.
Unfortunately, I’ve invested so much in that LADA label (my blog, for one), that I feel like I’m stuck with it.
Posted by: Shannon | March 16th, 2010 at 8:12 amSo, if your body stops producing insulin within one year it’s ‘classic’ Type 1 and if it takes longer it’s LADA? Sounds like a bunch of hooey. I think ’semantics’ was the term your guest blogger used.
I’ll wait until more studies are done on people over 30… but even then, who is to say what the cut off age is? I was 26 at diagnosis – a diagnosis of Type 2 from the general practitioner lasted a couple weeks, until I got to an endo who knew immediately it was Type 1. Maybe the real problem is Drs who jump to conclusions based on age and body type!!
Posted by: beth | March 16th, 2010 at 8:31 amThanks for the post, Catherine.
Apparent “type 2″ diabetics who have antibodies to either islet cells or glutamic acid decarboxlase are less likely to respond to oral hypglycemic agents, more likely to require insulin, and more likely to experience diabetic ketoacidosis.
I’m not aware of any clinical guidelines recommending we test all type 2 diabetics for one or both of the antibodies. Type 1.5 is definitely something to keep in mind if the patient isn’t responding as expected to pill therapy.
When I run across a “type 2″ in ketoacidosis at the hospital, I just assume they will probably need insulin from here on out.
-Steve
Posted by: Steve Parker, M.D. | March 16th, 2010 at 8:42 amExcellent post. I certainly fit into that description as LADA, but will really never know, because of the lack of info out there and/or my doc’s total ineptitude. I was treated as Type 2 for two years, getting sicker and sicker. I was in bad shape, and finally convinced the docs I needed insulin. Rapidly got better, but that was just the beginning. They put me on Lantus only. I downward spiraled again, eventually with extremely bad results. But on the good now. Was 31 when diagnosed, very lean and athletic and no family history.
Posted by: Daniel | March 16th, 2010 at 8:56 amThis is great stuff and the word needs to get out. Who knows what I was then, but we know now I need insulin. Other folks need this info (docs) so they don’t have to go through what I did. Thank You.
Here’s a good piece about LADA with some good links.
http://www.phlaunt.com/diabetes/18382053.php
I fit in there somewhere, I still have a little insulin production but use a pretty typical type 1 insulin routine, tried pretty much all the oral meds, each worked for a short time to some degree, diagnosed at 27, decreased c-peptide and insulin production over the last 3 years, tested very positive for GAD65 recently, no family history of diabetes, not overweight at diagnosis, never tested positive for ketones, etc, etc.
As long as I don’t get any complications I’m good with whatever type somebody wants to call me!
Posted by: kdroberts | March 16th, 2010 at 8:59 amThis for the most part is really useful information and can help to get a misdiagnosed person the correct diagnosis and treatment. But Marie Nierras is the one who is wrong about LADA. People get irrational when you say that LADA (autoimmune diabetes) is Type 1 diabetes (autoimmune diabetes). They cling to the myths (most Type 1s are childhood-onset) when scientific fact shows otherwise. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus does not mention LADA, they include it in Type 1 diabetes (“Type 1 diabetes results from a cellular-mediated autoimmune destruction of the beta-cells of the pancreas. Markers of the immune destruction of the beta-cell include islet cellautoantibodies (ICAs), autoantibodies to insulin (IAAs), autoantibodies to glutamic acid decarboxylase (GAD65), and autoantibodies to the tyrosine phosphatases (IA-2). In Type 1, the rate of beta-cell destruction is quite variable, being rapid in some individuals (mainly infants and children) and slow in others (mainly adults).”) Clearly the Expert Committee’s definition of Type 1 includes LADA, and pushes aside Marie Nierra’s argument about the rate of beta cell destruction. And most people with LADA who were kept off of exogenous insulin for any length of time will tell you that they suffered horrifically and that it was such a relief to finally be put on insulin.
Posted by: Melitta | March 16th, 2010 at 10:39 amThis article could not be more timely for me. I’m one of those 10% who was mis-diagnosed with type 2, but am really in the LADA category. Like others, I’ve just been telling people that I’m a type 1. It’s been a tough lifestyle change to be a type 1 or LADA or whatever they’re calling it (especially since I’m 47), but at least I can treat the disease properly now, and I’m feeling better than ever.
Posted by: Will | March 17th, 2010 at 7:22 amThat makes much more sense now, LADA is diabetes in adults, but that is in between type 1 and type 2 diabetes. Thank you for posting this blog about that, I always did wonder what exactly it was and how it differs.
Posted by: Max | March 17th, 2010 at 7:09 pmI was diagnosed at age 59, initially put on oral meds for 2 weeks, but the numbers kept climbing. Got the correct diagnosis and have been on insulin ever since. There was nothing gradual about it.
Posted by: Suzy | March 19th, 2010 at 6:55 amI was diagnosed at age 57, also put on oral meds which did nothing to bring down my high blood sugar readings. Then the doctor tried Lantus only, which helped some but not enough. Grudgingly the doctor agreed to try Ultra Lente which caused me to have severe hypoglycemia. Finally I went to see an Endocrinologist who ordered a c-peptide test which came back 0.1. The Endocrinologist was the doctor who correctly diagnosed me as Type 1, not Type 2. When I think of all the office visits where I was accused of not taking my oral meds because my A1C tests would always come back high……..I get annoyed. Thank you for this article……wish I had seen it a long time ago.
Posted by: Kathy | March 19th, 2010 at 9:00 amI was also diagnosed at age 57 having lost so much weight quickly that I looked like a skeleton. I had BGs off the scale of a normal meter, but because I presented with only minor ketones and my age I was dx T2 and given Gliclazide (a sulfonylurea). This didn’t work at all. 2 desperate weeks later I was put onto Novomix30 and immediately felt better. The oral med was discontinued and 7 years down the line I have a basal/bolus regime which keeps me in good control with no apparent insulin resistance. Tests for antibodies are rare in the UK and C-Peptide tests almost unheard of. I was diagnosed by the guesswork of the GP’s nurse! I am still “officially” T2 on my medical records and this diagnosis has denied me any formal diabetic education and a certainty that I will never be offered pump therapy. Bitter? Yes, I’m afraid I am! However, since I have researched the condition I realise that there are more types of diabetes out there than they recognise and until proper tests are conducted as routine then people will continue to be misdiagnosed
Posted by: Patti Evans | March 19th, 2010 at 12:39 pmThanks for the article. I’m an LADA who has seen a slow progression of my diabetes over a seven year period. Only one difference though — this happened in my 20s, not 30s.
Posted by: Liz | March 21st, 2010 at 6:04 pmFirst, Not a real Doctor, I was a Navy Corpsman for many years and accrued the title Doc over the years.
Thanks for the post. I have been trying to figure out what is wrong with me. at 40 (2006), Happy Birthday, your Diabetic. At first they wanted to immediately place me on Metformin. Talked them into Diet and Exercise. Hey I was still in the Navy and it did work well for about two years. Then in Jun/Jul 08, Diet and exercise wasn’t doing it anymore. Went on Metformin 500mg twice a day for about a year. Jul of 09, they tried Januvia (gave me hives). Stopped that and went to Metformin 1000mg twice a day. not working, lets add Glipide. Not working by Dec 09, so drop the Glip and decrease Met to 500mg twice a day. 03 March 10, BAM, Lantus 10mg. Begin titration @ 2-3 units every 3-5 days. Fasting SMBG’s are still in the mid to lower 200’s. Except for three in a row that were mid to upper 300’s. Last one was 377.
Lantus is now at 45 units and rising. Now on Novalog 6 units pre-meal.
Family Hx – Mom and all of her sisters and mother were Dx’d DMII.
I am overweight, but not the “classic” obese.
Does this sound like a LADA Ccandidate? Should I approach my Dr’s about this?
Thanks for your info… Doc
Posted by: Doc | April 10th, 2010 at 8:45 amWonderful post, Catherine. Thanks for hosting Amy!
I’m a classic type 1, diagnosed at 21, but nearly two years later, I’m still honeymooning. It’s all very fuzzy.
Posted by: Colleen | April 10th, 2010 at 11:07 amI was diagnosed type 1 at age 14 with a blood sugar of 945 (not kidding), 3 months after a bad flu. Yes, I was in denial. Family type 1 history of 1 uncle, 1 Aunt, 2 cousins, and my Dad at a late age (we are Norwegian and MANY type 1’s are scandinavian). What I have read is that getting homogenized milk (rather than mothers milk) at a young age, a genetic predisposition and a strain of flu – start the destruction of the islets in your pancreas and thus the Tpye 1 into motion. Type 1 is an autimmune disorder so I’ve been told, (and I have two other automimmune issues). So isn’t LADA just late onset type 1? My dad got the flu (1976, at age 56) – and became a type 1 within 2-3 months. He had no complications, low BP, low cholesterol, average weight. He lived well until death at 83.
PS – for all you others with similar stories – I am heavy set and have been told by a few doctors that I am type 2 – until they run the damn tests. No damage so far – 36 years and counting. Stand your ground and keep searching until you find an endo who understands it all!
PSS – The pump rocks.
Posted by: Laurie | May 24th, 2010 at 1:30 pmLate comment. Good article. Long comment (sorry)! LADA and its issues are a big interest for me.
Even though LADA is autoimmune, it apparently shares genetic markers with T2, which is why it got the alternative name Type 1.5 but is classified as T1.
Insulin resistance does occur in thin people, eg in PCOS.
Apparently also if you have GAD antibodies plus another diabetes antibody you’ll progress to insulin dependence more quickly than just GAD alone. Researchers apparently do not yet know why the progression this T1 variant takes so long, whereas in young people with what used to be called ‘juvenile diabetes’, the progression usually fast. I had what we think is about a 20-25 year LADA honeymoon (am in my 50s now)! Or maybe I have double diabetes – no one can tell me for sure. First dx at 25, started insulin in my 50s, but very high GAD antibodies when finally tested.
You don’t have to only be normal weight to think you have LADA. Many overweight and obese have it. Even though it was discovered in the 1970s, so many are still going undiagnosed and so many medical people don’t consider it, if they even know about it in the first place.
My opinion is that early diagnosis goes a long way to beta-cell preservation (by not taking insulin producing drugs), but research is contradictory about this.
The biggest problem seems to be getting a doctor to test for LADA, whatever weight you are, and you continue to be treated as a T2 and eventually a failed and non-compliant T2. I insisted re the testing and to everyone surprise (not me) I was positive. But for those whose doctors won’t listen, it can be psychologically devastating!
Posted by: Sue | August 30th, 2010 at 11:12 ami am a 65 yrs old female,ist dx @28yrs old diabetic,not over weight,by a gp.put on insulin until age 45,then told type 2 by int/medicine dr.put on different types pills,could not keep po meds down.went to endo dr,try another type pill,could not tolerated,told that i was now type 1.please help me to understand.i did have c-peptide done in 2005 or 2006,told then,not making enough insulin so will have to take insulin for the rest of my life.HELP ME TO UNDERSTAND
Posted by: odessa brown | August 30th, 2010 at 8:24 pm