You’re likely aware of the two main types of diabetes – type 1 and type 2. But have you ever heard of LADA?
LADA is an acronym for Latent Autoimmune Diabetes in Adults, and it’s the most commonly missed diagnosis in diabetes. This is partly due to misconceptions by healthcare providers about the condition. Many people with LADA are mistakenly diagnosed with type 2 diabetes instead of type 1, and it can often take years for people to get the right diagnosis.
What Is LADA?
LADA is simply type 1 diabetes that’s diagnosed in adulthood. Many people – healthcare providers included, unfortunately – still think of type 1 diabetes as a childhood condition. In fact, it used to be referred to as “juvenile diabetes” but the terminology is changing because more and more adults are being diagnosed with type 1 diabetes than ever before. You can develop type 1 diabetes at any age!
There are characteristics of LADA that make it a little different than “classic” type 1 diabetes, which is why it can mislead healthcare providers into thinking it’s type 2.
To fully understand LADA, it’s important to first know the key differences between type 1 and 2 diabetes.
Key Characteristics of Type 1 Diabetes
- It typically has a sudden onset – people often get really sick and go into DKA (diabetic ketoacidosis) right before they are diagnosed.
- Insulin is needed immediately to manage glucose levels.
- It often occurs in people who on the younger side, and not overweight.
- Signs of metabolic syndrome are absent, meaning cholesterol and triglyceride levels are not elevated.
- One or more T1D autoantibodies are present in the blood at diagnosis.
- Family history of type 1 diabetes is uncommon.
Management of type 1 diabetes always involves daily insulin, given as injections or via an insulin pump.
Key Characteristics of Type 2 Diabetes
- It typically (but not always) develops during adulthood, and the incidence increases with age.
- Onset is slow. People are often first diagnosed with prediabetes, and if they take actions such as eating healthier, exercising, losing weight, and perhaps starting on a glucose-lowering medication, they may be able to reverse or delay the onset of type 2 diabetes.
- A person with type 2 is typically overweight, often in the abdominal area.
- Signs of metabolic syndrome are common, including high LDL-cholesterol, low HDL-cholesterol, high triglycerides, high blood pressure, and elevated blood sugar.
- Family history of type 2 diabetes is extremely common.
- If tested, there are negative results for one or more autoantibodies. (It is unusual for a person with a clear diagnosis of type 2 to be tested for autoantibodies).
Management of type 2 diabetes can vary based on how it progresses and how one responds to various treatments. Eating healthier and being physically active are two key elements to all type 2 diabetes care. Glucose-lowering medications can assist with weight management. Due to the progressive nature of type 2 diabetes, some people eventually do need to take insulin.
Key Characteristics of LADA
- It occurs in adulthood.
- Beta cell function decline in LADA is much slower than in “classic” type 1 diabetes, meaning it takes longer for blood sugars to become elevated, and DKA is not as common as it is with the typical onset of T1D.
- Insulin is not always needed at the time of diagnosis. Some people with LADA will respond to some degree to type 2 diabetes medications if they are prescribed them by their PCP.
- If tests are run for type 1 diabetes autoantibodies, positive results for one or more autoantibodies are present.
Sometimes it takes years and years for a person with LADA to get the correct diagnosis, which is extremely frustrating if they are not responding well to the type 2 medications prescribed by their HCP. Eventually everyone with LADA will need to take both long-acting and rapid-acting insulin, just like the run-of-the-mill people with T1D.
Why is LADA Often Misdiagnosed and Mistreated?
LADA is often misdiagnosed for type 2 diabetes for several reasons. Among the most common is that people with LADA typically receive their diabetes care from primary care providers who are not aware of LADA and how it should be differentiated as a diagnosis from type 1 and 2 diabetes.
A healthcare provider may assume a person has type 2 diabetes simply due to their age and the slow onset of the condition. The HCP may even prescribe type 2 diabetes glucose-lowering medications, but they will ultimately prove unsuccessful.
A misdiagnosis can sometimes take months or years to remedy, depending on the HCP’s knowledge and a patient’s personal advocacy.
Essential Takeaways about LADA
There can be a few benefits of developing LADA vs. “classic” type 1 diabetes. If you are still producing some insulin, it can help make the adjustment to living with diabetes a little easier because it provides time to learn how to manage the condition. Making some insulin can decrease glucose variability (the ups and downs of blood sugar levels), and it can allow a person to be a little less precise with insulin dosing and counting carbs.
Getting diabetes as an adult typically translates to fewer years with diabetes, fewer years with elevated glucose levels, and fewer years with glycemic variability. Combined, these factors can lead to fewer diabetes complications. Plus, better treatments (medications) and technologies (insulin pumps, continuous glucose monitors, and more) are constantly being improved upon and newer ones are being developed.
Dr. Edelman and Dr. Pettus explain the different stages of LADA and how to adjust to the natural progression of the disease in this video here:
If you have been diagnosed with type 2 diabetes but wonder if you may have LADA, talk to your healthcare provider about getting tested for type 1 diabetes autoantibodies. The most important islet autoantibody to get tested is called GAD (glutamic acid decarboxylase) and it involves a blood draw at the laboratory. Advocate for yourself (you can show your doctor this article!) so you can get the answers you need for optimal diabetes care.
It was disappointing to see this text in the article, as it’s incorrect: “Eventually everyone with LADA will need to take both long-acting and rapid-acting insulin…” I would be very surprised if the majority of LADA patients in the U.S. are taking long-acting insulin. And it’s definitely NOT true that everyone with LADA will need long-acting insulin (most will never need it; they need pumps). I see that you’ve published another article on a single “LADA Patient Who Chose MDI Over Pump Therapy.” Most LADA patients should use a closed loop pump/sensor system, and I suspect that most do (with the possible exception of uninsured or underinsured patients). Living with LADA is difficult enough. Misinformation such as that in this article could do harm. Closed loop pump/sensor systems can and do save lives. They also improve the quality of life for LADA patients (especially now that some of the newer systems have gotten past the problems in first generation systems of over-sensitive or over-aggressive alarm systems that prevent proper sleep).
You are right in that not every patient needs basal and fast-acting insulin because there are different gradations of LADA. In the very early stages of LADA, one might only need to bolus if they pancreas still works to some degree. I agree with you that as the insulin requirements of each individual person goes up, ideally they should be on a hybrid closed-loop system. The pump gives a little bit of insulin all the time, which is the basal rate. The basal rate of the pump takes the place of basal insulin when you’re injecting. And yes, some people do choose MDI over pumps.
To add to this, T1D can also be diagnosed in adulthood. Not everyone diagnosed in adulthood fits the LADA profile. I was diagnosed at 33 with all the classic signs of T1: rapid onset, DKA, immediate need for insulin and auto-antibody positive. I have T1D and not LADA. In the end I don’t think it matters that much what we call it as we both end up at the same endpoint of needing to be insulin managed. This is simply a small distinction worth noting.
Second clarification; not all T1D or LADA are antibody positive. There are a smaller subset of individuals with all the other signs of T1 or LADA who are antibody negative.
Additionally I would add that I actually think LADA can be harder to manage in some instances. I am helping a neighbour who was diagnosed as LADA at 63 yrs old. Her clinical presentation is an extremely slow and variable onset. I think it is harder for her to manage with insulin with the very slow beta cell death b/c her body randomly dumps insulin into her system with so much variability making it difficult to establish ratios for treatment. Also this results in so many unpredictable lows for her b/c her body is still unpredictably producing some insulin. From meal to meal even with meticulous carb counting her responses are extremely varied. In looking at our two very different adult onset diagnoses, I think it was actually easier for me to narrow down basals and carb ratios than it is for her. The rollercoaster is quite pronounced.
Laura, you are right on all three points! T1D that’s not LADA can be diagnosed in adulthood. And you are right about the category of autoantibody-negative type 1s. Thank you for your comments and for educating the group. Just admit to us that you are an endocrinologist, aren’t you?!?