We all know the adage “One size doesn’t fit all” and the practical implications for this. Same is true for the treatment and management of the very common chronic condition- diabetes.
This article is contributed by Padma Shri Dr. V Mohan, eminent Indian Diabetologist who has been working in the field of diabetes for over 30 years in Chennai in southern India.
The diagnosis and treatment of diabetes has evolved rapidly in recent times.Till the 1980’s, it was considered that there were only two types of diabetes : insulin dependent (now called type 1) , or non insulin dependent (now called type 2), diabetes. With refinements in technology and advances in genomics and other fields, we now know that there are at least 20 types of diabetes. The diagnosis of each one of these types is based on certain tests which will help the diabetologist to clinch the diagnosis. The advantage of knowing which type of diabetes one has, is that the treatment can be tailored accordingly. For eg., in patients with type 1 diabetes, if insulin injections are withdrawn, the patient may die or at the very least, become very severely ill.
On the other hand, the ‘common garden’ variety of type 2 diabetes is a condition where the body usually produces insulin but the main defect is insulin ‘resistance’ i.e. the insulin fails to act properly. Thus in many cases of type 2 diabetes, the tablets may work even better than insulin! However, in addition to these two well known types, there are other forms of diabetes. One instance in point, is the ‘monogenic’ form of diabetes where there is a single gene defect. The commonest of this variety of diabetes, is called as Maturity Onset Diabetes of Youth (MODY). The main defect in MODY, is ‘insulin secretion’ and not insulin resistance. It is now known that there are at least 14 different types of MODY itself. Several types of MODY like MODY 3, MODY 1, MODY 11 and MODY 12 respond much better to ‘sulphonylurea’ tablets which correct the defect in insulin secretion. In contrast, metformin is the drug of choice for ‘type 2 diabetes’ as it corrects insulin resistance. All this underscores the importance of making an accurate diagnosis of the type of diabetes one has.
Dr V Mohan speaks
"There are many instances where patients are unfortunately wrongly diagnosed to have type1 diabetes. "
"I recall a 16 year old girl who was lean and had severe diabetes and was therefore diagnosed by her physician to have type 1 diabetes and was told that she has to take four injections of insulin all her life. Devasted, the family came for a second opinion. When I reviewed her history I saw that she had a strong family history of diabetes going through four generations. She also had good pancreatic beta cell function. On further investigations, it was found that the markers for type 1 diabetes like GAD antibody test were negative. Encouraged by this, genetic testing for MODY was carried out and it revealed that she had MODY 3, a form of diabetes which responds to the common sulphonylurea tablets. The insulin injections were therefore stopped and she ws put on Glibenclamide, one of the cheapest anti-diabetic drugs and she responded beautifully. It was later found that her younger sister also had MODY 3, as did her mother and several other members in her family and they could all be switched over to the sulphonylurea tablets. If the genetic testing had not been done for this patient, she would probably have been continued on life long insulin therapy."
"This is one example of ‘Precision Diabetes’. There are several such miracles which have happened in treating diabetes, thanks to the introduction of Precision Diabetes."
Fibrocalculous Pancreatic Diabetes (FCPD) is yet another type of diabetes where calculi (stones) develop in the pancreas. This type of diabetes apart from requiring insulin, also require pancreatic enzyme replacement as therapy because these patients develop indigestion, malabsorption and diarrhoea because the ‘exocrine’ part of the pancreas which is involved in digestion, is also affected along with the endocrine part of the pancreas (which is responsible for diabetes). There are many other types of diabetes such as genetic syndromes associated with diabetes, endocrine diabetes, and others.
Over the last several years, Dr. Mohan and his team have developed algorithms by which a precise diagnosis of diabetes can be made. These are examples of “Precision Diabetes”. They will now be undertaking a major research collaboration with the of Dundee at Scotland with Prof. Colin Palmer, and his team to delve deep into the field of ‘pharmacogenomics’ of diabetes’.
Dr. Mohans explains, "What this means is that by studying genes, we can hopefully, predict which patient will respond to a particular anti-diabetic drug and who is likely (or unlikely) to develop a side effect with a particular drug. Applying the principles of ‘Precision Diabetes’, it will be possible in the near future to very accurately classify a patient and determine the type of diabetes he or she has and then decide the type of treatment that this patient is likely to respond to."
These are indeed exciting times in the field
"Maturity onset diabetes of the young" (MODY) refers to any of several hereditary forms of diabetes mellitus caused by mutations in an autosomal dominant gene disrupting insulin production. MODY is often referred to as "monogenic diabetes" to distinguish it from the more common types of diabetes (especially type 1 and type 2), which involve more complex combinations of causes involving multiple genes and environmental factors. MODY 2 and MODY 3 are the most common forms. MODY should not be confused with latent autoimmune diabetes of adults (LADA) — a form of type 1 DM, with slower progression to insulin dependence than child-onset type 1 DM, and which occurs later in life.
Maturity onset diabetes of the young (monogenic diabetes)
Classification and external resources
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History of the concept and treatment of MODY
The term MODY dates back to 1964, when diabetes mellitus was considered to have two main forms: juvenile-onset and maturity-onset, which roughly corresponded to what we now call type 1 and type 2. MODY was originally applied to any child or young adult who had persistent, asymptomatic hyperglycemia without progression to diabetic ketosis or ketoacidosis. In retrospect we can now recognize that this category covered a heterogeneous collection of disorders which included cases of dominantly inherited diabetes (the topic of this article, still called MODY today), as well as cases of what we would now call type 2 diabetes occurring in childhood or adolescence, and a few even rarer types of hyperglycemia (e.g., mitochondrial diabetes or mutant insulin). Many of these patients were treated with sulfonylureas with varying degrees of success.
The current usage of the term MODY dates from a case report published in 1974.
Since the 1990s, as the understanding of the pathophysiology of diabetes has improved, the concept and usage of MODY have become refined and narrower. It is now used as a synonym for dominantly inherited, monogenic defects of insulin secretion occurring at any age, and no longer includes any forms of type 2 diabetes.
Signs, symptoms and differential diagnosis
EditCurrently,[when?] MODY is the final diagnosis in 1%–2% of people initially diagnosed with diabetes. The prevalence is 70–110 per million population. 50% of first-degree relatives will inherit the same mutation, giving them a greater than 95% lifetime risk of developing MODY themselves. For this reason, correct diagnosis of this condition is important. Typically patients present with a strong family history of diabetes (any type) and the onset of symptoms is in the second to fifth decade.
There are two general types of clinical presentation.
▪ Some forms of MODY produce significant hyperglycemia and the typical signs and symptoms of diabetes: increased thirst and urination (polydipsia and polyuria).
▪ In contrast, many people with MODY have no signs or symptoms and are diagnosed either by accident, when a high glucose is discovered during testing for other reasons, or screening of relatives of a person discovered to have diabetes. Discovery of mild hyperglycemia during a routine glucose tolerance test for pregnancy is particularly characteristic.
MODY cases may make up as many as 5% of presumed type 1 and type 2 diabetes cases in a large clinic population. While the goals of diabetes management are the same no matter what type, there are two primary advantages of confirming a diagnosis of MODY.
▪ Insulin may not be necessary and it may be possible to switch a person from insulin injections to oral agents without loss of glycemic control.
▪ It may prompt screening of relatives and so help identify other cases in family members.
As it occurs infrequently, many cases of MODY are initially assumed to be more common forms of diabetes: type 1 if the patient is young and not overweight, type 2 if the patient is overweight, or gestational diabetes if the patient is pregnant. Standard diabetes treatments (insulin for type 1 and gestational diabetes, and oral hypoglycemic agents for type 2) are often initiated before the doctor suspects a more unusual form of diabetes.
In some forms of MODY, standard treatment is appropriate, though exceptions occur:
▪ In MODY2, oral agents are relatively ineffective and insulin is unnecessary.
▪ In MODY1 and MODY3, insulin may be more effective than drugs to increase insulin sensitivity.
▪ Sulfonylureas are effective in the KATP channel forms of neonatal-onset diabetes. The mouse model of MODY diabetes suggested that the reduced clearance of sulfonylureas stands behind their therapeutic success in human MODY patients, but Urbanova et al. found that human MODY patients respond differently to the mouse model and that there was no consistent decrease in the clearance of sulfonylureas in randomly selected HNF1A-MODY and HNF4A-MODY patients.
The following characteristics suggest the possibility of a diagnosis of MODY in hyperglycemic and diabetic patients:
▪ Mild to moderate hyperglycemia (typically 130–250 mg/dl, or 7–14 mmol/l) discovered before 30 years of age. However, anyone under 50 can develop MODY.
▪ A first-degree relative with a similar degree of diabetes.
▪ Absence of positive antibodies or other autoimmunity (e.g., thyroiditis) in patient and family. However, Urbanova et al. found that about one quarter of Central European MODY patients are positive for islet cell autoantibodies (GADA and IA2A). Their expression is transient but highly prevalent. The autoantibodies were found in patients with delayed diabetes onset, and in times of insufficient diabetes control. The islet cell autoantibodies are absent in MODY in at least some populations (Japanese, Britons).
▪ Persistence of a low insulin requirement (e.g., less than 0.5 u/kg/day) past the usual "honeymoon" period.
▪ Absence of obesity (although overweight or obese people can get MODY) or other problems associated with type 2 diabetes or metabolic syndrome (e.g., hypertension, hyperlipidemia, polycystic ovary syndrome).
▪ Insulin resistance very rarely happens.
▪ Cystic kidney disease in patient or close relatives.
▪ Non-transient neonatal diabetes, or apparent type 1 diabetes with onset before six months of age.
▪ Liver adenoma or hepatocellular carcinoma in MODY type 3
▪ Renal cysts, rudimentary or bicornuate uterus, vaginal aplasia, absence of the vas deferens, epidymal cysts in MODY type 5
The diagnosis of MODY is confirmed by specific gene testing available through commercial laboratories.
The recognised forms of MODY are all due to ineffective insulin production or release by pancreatic beta cells. Several of the defects are mutations of transcription factor genes. One form is due to mutations of the glucokinase gene. For each form of MODY, multiple specific mutations involving different amino acid substitutions have been discovered. In some cases, there are significant differences in the activity of the mutant gene product that contribute to variations in the clinical features of the diabetes (such as degree of insulin deficiency or age of onset).
Some sources make a distinction between two forms of monogenetic diabetes: MODY and neonatal diabetes. However, they have much in common and are often studied together.
MODY is inherited in an autosomal dominant fashion, and most patients therefore have other members of the family with diabetes; penetrance differs between the types (from 40% to 90%).
hepatocyte nuclear factor 4α
Due to a loss-of-function mutation in the HNF4α gene. 5%–10% cases.
Due to any of several mutations in the GCK gene. 30%–70% cases. Mild fasting hyperglycemia throughout life. Small rise on glucose loading. Patients do not tend to get diabetes complications and do not require treatment.
hepatocyte nuclear factor 1α
Mutations of the HNF1α gene (a homeobox gene). 30%–70% cases. Tend to be responsive to sulfonylureas. Low renal threshold for glucose.
insulin promoter factor-1
Mutations of the IPF1 homeobox (Pdx1) gene. < 1% cases. Associated with pancreatic agensis in homozygotes and occasionally in heterozygotes.
hepatocyte nuclear factor 1β
One of the less common forms of MODY, with some distinctive clinical features, including atrophy of the pancreas and several forms of renal disease. Defect in HNF-1 beta gene. 5%–10% cases.
neurogenic differentiation 1
Mutations of the gene for the transcription factor referred to as neurogenic differentiation 1. Very rare: 5 families reported to date.
Kruppel-like factor 11
KLF11 has been associated with a form of diabetes that has been characterized as "MODY7" by OMIM.
Bile salt dependent lipase
CEL has been associated with a form of diabetes that has been characterized as "MODY8" by OMIM. It is very rare with five families reported to date. It is associated with exocrine pancreatic dysfunction.
Pax4 is a transcription factor. MODY 9 is a very rare medical condition.
Mutations in the insulin gene. Usually associated with neonatal diabetes. Rare < 1% cases.
Mutated B-lymphocyte tyrosin kinase, which is also present in pancreatic islet cells. Very rare.
Permanent neonatal diabetes mellitus
KCNJ11 and ABCC8
A newly identified and potentially treatable form of monogenic diabetes is the neonatal diabetes caused by activating mutations of the ABCC8 or KCNJ11 genes which encode subunits of the KATP channel. < 1% cases. Tend to respond to sulfonylureas.
Transient neonatal diabetes mellitus
Some forms of neonatal-onset diabetes are not permanent. < 1% cases. Tend to respond to sulfonylureas.
By definition, the forms of MODY are autosomal dominant, requiring only one abnormal gene to produce the disease; the severity of the disease is moderated by the presence of a second, normal allele which presumably functions normally. However, conditions involving people carrying two abnormal alleles have been identified. Unsurprisingly, combined (homozygous) defects of these genes are much rarer and much more severe in their effects.
▪ MODY2: Homozygous glucokinase deficiency causes severe congenital insulin deficiency resulting in persistent neonatal diabetes mellitus. About 6 cases have been reported worldwide. All have required insulin treatment from shortly after birth. The condition does not seem to improve with age.
▪ MODY4: Homozygous IPF1 results in failure of the pancreas to form. Congenital absence of the pancreas, termed pancreatic agenesis, involves deficiency of both endocrine and exocrine functions of the pancreas.
Homozygous mutations in the other forms have not yet been described. Those mutations for which a homozygous form has not been described may be extremely rare, may result in clinical problems not yet recognized as connected to the monogenic disorder, or may be lethal for a fetus and not result in a viable child.
Chronic hyperglycemia due to any cause can eventually cause blood vessel damage and the microvascular complications of diabetes. The principal treatment goals for people with MODY — keeping the blood sugars as close to normal as possible ("good glycemic control"), while minimizing other vascular risk factors — are the same for all known forms of diabetes.
The tools for management are similar for all forms of diabetes: blood testing, changes in diet, physical exercise, oral hypoglycemic agents, and insulin injections. In many cases these goals can be achieved more easily with MODY than with ordinary types 1 and 2 diabetes. Some people with MODY may require insulin injections to achieve the same glycemic control that another person may attain with careful eating or an oral medication.
When oral hypoglycemic agents are used in MODY, the sulfonylureas remain the oral medication of first resort. When compared to patients with type 2 diabetes, MODY patients are often more sensitive to sulphonylureas, such that a lower dose should be used to initiate treatment to avoid hypoglycaemia. Patients with MODY less often suffer from obesity and insulin resistance than those with ordinary type 2 diabetes (for whom insulin sensitizers like metformin or the thiazolidinediones are often preferred over the sulfonylureas).
According to data from Saxony, Germany, MODY was responsible for 2.4% of diabetes incidence in children younger than 15 years.