Current screening protocols for autoantibody-positive individuals at risk for type 1 diabetes (T1D) are evolving to align with disease-modifying intervention availability.1 There is a need for consensus guidelines for systematic autoantibody screening in first-degree relatives of individuals with T1D, with testing for glutamic acid decarboxylase (GAD)-65, insulinoma-associated protein 2 (IA-2), insulin autoantibodies (IAA), and zinc transporter 8 (ZnT8) antibodies.2 The presence of diabetes-related autoantibodies peaks between 9 months and 2 years in children with a genetic risk of T1D. For individuals with Stage 1, risk of progressing to Stage 3 is over 40% after 5 years from seroconversion. For individuals with Stage 2, this risk increases to over 70% in just 4-5 years from seroconversion, establishing a clear need for consensus screening guidelines and early intervention.2
Successful preservation of C-peptide in patients with T1D with immunotherapy agents including teplizumab and low-dose antithymocyte globulin (ATG) has intensified the imperative for broader population-level screening beyond familial risk assessment.2,3 International consensus now emphasizes metabolic staging through oral glucose tolerance testing with C-peptide measurement and continuous glucose monitoring to detect subclinical dysregulation.4 These diagnostic frameworks identify appropriate candidates for disease-modifying therapy when maximal beta cell preservation remains achievable.4,5 ICD-10 diagnosis codes have recently been expanded to support documentation of early-stage, presymptomatic T1D.2
Widespread implementation requires addressing substantial infrastructural barriers including point-of-care assay availability, standardized screening protocols in pediatric and primary care settings, and clear pathways for specialist referral.1 However, upfront costs associated with screening are likely offset by cost savings secondary to a reduction in DKA events and hospitalizations.1 In addition to financial concerns, consideration must also be given to the psychological toll of screening positive and the potential for false positives. Clinical data has shown that individuals who are aware of their T1D through early screening do experience lower rates of DKA and have better glycemic control.1
Social determinants of health significantly impact access to emerging therapies for T1D. Insurance coverage variability creates disparities in obtaining disease-modifying treatments, continuous glucose monitors, and specialist consultation for metabolic staging.6 Geographic limitations restrict access to centers offering clinical trials or advanced interventions, disproportionately affecting rural and underserved communities in the US and worldwide.7 Financial barriers extend beyond medication costs to include travel expenses for specialized care, time away from employment and the subsequent impact on insurance coverage, and inability to afford complementary diabetes management technologies.6
Healthcare systems must proactively address equity considerations in deploying novel therapeutics.1,7 Establishing telemedicine pathways for metabolic monitoring, implementing universal screening programs in accessible primary care settings, and developing insurance advocacy resources represent essential strategies.1,7 Clinicians should recognize that treatment eligibility extends beyond clinical criteria to encompass practical accessibility factors including insurance status, geographic location, and socioeconomic resources when counseling patients about emerging disease-modifying options.
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