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Letters

Atypical diabetes: clarifying the muddy waters

Elizabeth Sellers, Seth Marks, Celia Rodd, Randy Wicklow and Heather Dean
CMAJ December 09, 2014 186 (18) 1397; DOI: https://doi.org/10.1503/cmaj.1140088
Elizabeth Sellers
Section of Pediatric Endocrinology and Metabolism (Sellers, Marks, Rodd, Wicklow, Dean), Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.
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Seth Marks
Section of Pediatric Endocrinology and Metabolism (Sellers, Marks, Rodd, Wicklow, Dean), Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.
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Celia Rodd
Section of Pediatric Endocrinology and Metabolism (Sellers, Marks, Rodd, Wicklow, Dean), Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.
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Randy Wicklow
Section of Pediatric Endocrinology and Metabolism (Sellers, Marks, Rodd, Wicklow, Dean), Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.
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Heather Dean
Section of Pediatric Endocrinology and Metabolism (Sellers, Marks, Rodd, Wicklow, Dean), Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.
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We are writing this letter in response to Steenkamp and collegues’ recent review article.1 We have several concerns about the content of this review particularly in the context of the Canadian diabetes landscape.

There is no discussion in the review around the controversy that surrounds the diagnoses of ketosis-prone diabetes and latent-autoimmune diabetes of adulthood (LADA). Many clinicians believe these are not separate entities but are within the spectrum of type 2 diabetes and type 1 diabetes, respectively. There is no mention of the occurrence of diabetic ketoacidosis in both adults and children with type 2 diabetes. This has been well published over the last two decades in both adults and children.2–4

The authors use somewhat dated terminology, such as “the classic juvenile form of diabetes.” Both the Canadian Diabetes Association and the American Diabetes Association discontinued the use of this terminology more than 15 years ago.

The Canadian Diabetes Association has worked hard to provide useful age-specific definitions and management guidelines; these are available online for health care providers.5

The authors state that metformin is first line therapy for most patients with type 2 diabetes. This is not consistent with the Canadian Diabetes Association Clinical Practice Guidelines where lifestyle modification is first line therapy in children and also in adults. Perhaps it should have been clarified that metformin would be the first-line pharmacotherapeutic agent.

Mention of the polymorphism of the HNF 1 α gene found in the Oji–Cree of northeastern Manitoba and northwestern Ontario is warranted. This polymorphism contributes to the development of type 2 diabetes in the Oji–Cree, who have among the highest reported rates of type 2 diabetes in both adults and youth.6,7 Regional differences are important to reinforce to ensure optimal diagnoses and intervention.

References

  1. ↵
    1. Steenkamp DW,
    2. Alexanian SM,
    3. Sternthal E
    . Approach to the patient with atypical diabetes. CMAJ 2014;186:678–84.
    OpenUrlFREE Full Text
  2. ↵
    1. Newton CA,
    2. Raskin P
    . Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus. Arch Intern Med 2004;164:1925–31.
    OpenUrlCrossRefPubMed
    1. Rewers A,
    2. Klingensmith G,
    3. Davis C,
    4. et al
    . Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics 2008;121:e1258–66.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Amed S,
    2. Dean HJ,
    3. Panagiotopoulos C,
    4. et al
    . Type 2 diabetes, medication-induced diabetes and monogenic diabetes in Canadian children: a prospective national surveillance study. Diabetes Care 2010;33:786–91.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    Clinical practice guidelines. Toronto: Canadian Diabetes Association; 2014. Available: www.diabetes.ca/clinical-practice-education/clinical-practice-guidelines (accessed 2014 Nov. 13).
  5. ↵
    1. Hegele RA,
    2. Zinman B,
    3. Hanley AJ,
    4. et al
    . Genes, environment and Oji-Cree type 2 diabetes. Clin Biochem 2003;36:163–70.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Dean HJ,
    2. Young TK,
    3. Flett B,
    4. et al
    . Screening for type-2 diabetes in aboriginal children in northern Canada. Lancet 1998;352:1523–4.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 186 (18)
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Vol. 186, Issue 18
9 Dec 2014
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Atypical diabetes: clarifying the muddy waters
Elizabeth Sellers, Seth Marks, Celia Rodd, Randy Wicklow, Heather Dean
CMAJ Dec 2014, 186 (18) 1397; DOI: 10.1503/cmaj.1140088

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Atypical diabetes: clarifying the muddy waters
Elizabeth Sellers, Seth Marks, Celia Rodd, Randy Wicklow, Heather Dean
CMAJ Dec 2014, 186 (18) 1397; DOI: 10.1503/cmaj.1140088
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