 
Up Close and Cellular Q & A
Fall 2004 Series - Diabetes: diagnosis, management and emerging treatments
Q: I have heard about someone who has died due to a heart attack and it was related to diabetes. He did not notice that he had diabetes and although he was thirsty all the time, he thought that it was just the heat. I was wondering what would have exactly happened from his coma to his heart attack and the role that diabetes played.
Response from Dr. Metzger
A: The person could have died of a heart attack for a number of reasons. From the story, it appears most likely that the person could have had type 2 diabetes, which is associated with elevated cholesterol, high blood pressure and risk of heart disease and stroke. If the diabetes symptoms were not enough to take him to the doctor, the person could have had high blood sugars, high blood pressure and high cholesterol for years, all of
which can lead to a heart attack.
Response from Dr. Bonnevie-Nielsen
A: The first patient I diagnosed as medical student was exactly similar to this example. Hidden diabetes, leading to coronary arterial disease, infarction, stress and deadly keto-acidosis.
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Q: Are rheumatoid arthritis patients prone to diabetes because it's also an autoimmune disorder?
Response from Dr. Metzger
A: People with autoimmune diseases such as rheumatoid arthritis are indeed more likely to get type 1 diabetes, particularly if they have another autoimmune endocrine disease (such as hypothyroidism). But the overall risk is still <1-2%.
Response from Dr. Bonnevie-Nielsen
A: Type 1 diabetes and Rheumatoid Arthritis are seen together as they both are associated with "autoimmune" HLA-DR4 genotype. Different frequencies have been reported.
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Q: Are there any animal studies comparing the severity of Beta cell destruction in mice with diabetes vs mice with diabetes and an autoimmune disease such as rheumatoid arthritis?
Response from Dr. Tan
A: Not that I know of. All animal models are very specific for their disease and may not accurately reflect what happens in humans. It is possible that mice with one autoimmune disease such as rheumatoid arthritis (RA) have a higher incidence of diabetes but I'm not aware of this. It would probably not be likely because such a large number (>20) of specific gene mutations are needed to produce diabetes and the chances are that the RA mouse model would not have these mutations. Non-obese diabetic (NOD) mice have a higher susceptibility to some other autoimmune diseases such as inflammatory bowel disease and thyroiditis, but I don't believe RA is one of them.
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Q: If prednisone or corticosteroids are related to Type 1 diabetes, then are there any data indicating that asthma patients have a higher rate of diabetes occurence? What about anyone looking to see if there is beta cell destruction of any sort in the pancreas?
Response from Dr. Metzger
A: rednisone and corticosteroids are not really associated significantly with the risk of developing type 1 diabetes, but in high doses, they can cause insulin resistance and precipitate type 2 diabetes, although this is often transient in children. Children with asthma may be slightly more likely than their friends to get type 1 diabetes, but the risk is still <1%.
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Q: Are there any data on incidence of Type 1 diabetes developing in kids with HIV vs an adult HIV population?
Response from Dr. Tan
A: Again I'm not aware of any of these studies. For starters, pediatric HIV is primarily a disease of Africa and India and other places where the incidence of type 1 diabetes is low. Secondly, HIV causes immune dysfunction and therefore is likely to *reduce* the incidence of type 1 diabetes. Perhaps, that's what the questioner is hypothesizing. The numbers of children with HIV in countries where T1D is prevalent are too small to facilitate these sorts of studies.
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Q: Interferons are higher in diabetes. What about the use of interferons in treatment of Hep C patients? Do these patients develop diabetes more or have pancreas problems?
Response from Dr. Tan
A: Interferon-alpha is used in the treatment of hepatitis C virus (HCV) infections and can be quite effective. I don't know that anyone has looked to see what the incidence of type 1 diabetes in patients treated with IFN-alpha. First, it is usually necessary to have all the genetic risk factors, those 20 or more gene mutations, to get type 1 diabetes. Second, IFN therapy for HCV infection has not been around that long and the numbers of people receiving it have not been that large. So study of the occurrence of T1D which has an incidence of less than 1% of the population in this other small group (people with HCV treated if IFN) would be difficult. In theory, IFN-alpha might accelerate disease but that's just conjecture. If we ever were able to do those experiments, we might find that IFN-alpha prevents disease! Hence, the necessity for science!
Response from Dr. Bonnevie-Nielsen
A: Interferon-alpha used in treatment of Hepatitis C is able to induce auto-antibodies against beta-cells and also Type 1 Diabetes, although with low frequencies. It is recommended that before treatment with Interferon-alpha, the HLA-genotype of the patient should be determined to rule out any pre-disposition to Type 1 diabetes.
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