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      Chapter 2

       The Diagnosis and Classification of Diabetes in Nonpregnant Adults

      Irl B. Hirsch, MD, MACP,¹ and Linda M. Gaudiani, MD, FACP, FACE²

      ¹Professor of Medicine, University of Washington School of Medicine, Seattle, WA. ²Medical Director, Braden Diabetes Center, Marin Endocrine Care and Research, Greenbrae, CA; Associate Clinical Professor of Medicine, University California San Francisco, CA.

      DOI: 10.2337/9781580406086.02

      Much has been learned about the diverse pathogenesis of diabetes over the previous two decades resulting in alterations in the traditional classification of this disease. Although former classifications focused largely on age at onset of initial clinical presentations, such as acute diabetic ketoacidosis (DKA) versus chronic hyperglycemia, the newer position statements on classification by the American Diabetes Association (ADA) have focused on etiologies rather than phenotype. New genetic testing capabilities, expanded immunologic characterizations, and case reports of novel presentations in special disease states have further expanded diagnostic and classification schemes. This has resulted in nomenclature that is more complex than type 1 diabetes (T1D) and type 2 diabetes (T2D), recognizing the heterogeneous characteristics of the major classes of diabetes as well as the phenotypic and mechanistic overlap both initially and over the course of the disease state. Although assigning a type of diabetes to any given patient may be confounded by the circumstances at the time of diagnosis or by acute illness in the hospitalized patient, misdiagnosis of the type of diabetes, failure to attempt to classify the patient accurately, or failure to recognize that the hospitalized patient has diabetes all are critical errors that may affect treatment decisions in the hospital and following discharge and also may contribute to readmissions. An incorrect diabetes classification during the hospital admission and discharge could have especially significant consequences in our current protocol-driven system of diabetes management and certainly on safe transitions of aftercare.

      Unfortunately, misclassification of diabetes is not uncommon. Reasons include the fact that age and obesity are traditional discriminating factors for T1D and T2D. Although the exact number is not known, it is estimated that as many as 50% of patients with T1D are diagnosed after the age of 18 years. The impact of this change in the demographics of T1D is not yet clear; however, misdiagnosis of T1D is responsible for admissions for DKA and the development of DKA in the hospital setting.

      Several other issues are contributing to a more complex classification of diabetes type. The recent increase in the use of insulin to treat T2D has blurred the prior differentiating schemes based on therapy, as has the expanded uses of noninsulin injectable and oral agents to augment insulin therapy