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Alhakim FR, AlKhayyat H. Two siblings with a rare type of maturity-onset diabetes of the young (MODY). BMJ Case Rep 2023; 16:e249362. [PMID: 36764736 PMCID: PMC9923254 DOI: 10.1136/bcr-2022-249362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Maturity-onset diabetes of the young (MODY) is a type of diabetes that does not entirely fit the usually encountered type 1 or type 2 diabetes. It is a monogenic, familial and non-autoimmune diabetes among children and young adults resulting from autosomal dominant gene mutations.MODY diagnosis is confirmed by molecular genetic testing, which is costly. Therefore, it is rarely done.Nearly 1%-6% of diabetes has a monogenic cause but this is frequently misclassified as type 1 diabetes mellitus due to the lack of genetic testing. Therefore, a correct diagnosis of MODY is crucial for determining the plan of management. Furthermore, having a patient with MODY in a family indicates screening other family members. In this case report, we highlight that paediatric diabetes cases are not always type 1 or type 2 diabetes mellitus since two siblings incidentally presented with hyperglycaemia and a confirmed diagnosis of MODY type 10 was ultimately made. Moreover, their mother who was previously labelled as a case of type 1 diabetes mellitus was diagnosed later as MODY after genetic testing.
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Affiliation(s)
| | - Haya AlKhayyat
- Pediatrics, Bahrain Defence Force Royal Medical Services, Riffa, Bahrain
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2
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Florez JC, Pearson ER. A roadmap to achieve pharmacological precision medicine in diabetes. Diabetologia 2022; 65:1830-1838. [PMID: 35748917 PMCID: PMC9522818 DOI: 10.1007/s00125-022-05732-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
Current pharmacological treatment of diabetes is largely algorithmic. Other than for cardiovascular disease or renal disease, where sodium-glucose cotransporter 2 inhibitors and/or glucagon-like peptide-1 receptor agonists are indicated, the choice of treatment is based upon overall risks of harm or side effect and cost, and not on probable benefit. Here we argue that a more precise approach to treatment choice is necessary to maximise benefit and minimise harm from existing diabetes therapies. We propose a roadmap to achieve precision medicine as standard of care, to discuss current progress in relation to monogenic diabetes and type 2 diabetes, and to determine what additional work is required. The first step is to identify robust and reliable genetic predictors of response, recognising that genotype is static over time and provides the skeleton upon which modifiers such as clinical phenotype and metabolic biomarkers can be overlaid. The second step is to identify these metabolic biomarkers (e.g. beta cell function, insulin sensitivity, BMI, liver fat, metabolite profile), which capture the metabolic state at the point of prescribing and may have a large impact on drug response. Third, we need to show that predictions that utilise these genetic and metabolic biomarkers improve therapeutic outcomes for patients, and fourth, that this is cost-effective. Finally, these biomarkers and prediction models need to be embedded in clinical care systems to enable effective and equitable clinical implementation. Whilst this roadmap is largely complete for monogenic diabetes, we still have considerable work to do to implement this for type 2 diabetes. Increasing collaborations, including with industry, and access to clinical trial data should enable progress to implementation of precision treatment in type 2 diabetes in the near future.
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Affiliation(s)
- Jose C Florez
- Center for Genomic Medicine and Diabetes Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of Harvard & MIT, Cambridge, MA, USA.
| | - Ewan R Pearson
- Department of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, Scotland, UK.
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Dusatkova P, Pavlikova M, Elblova L, Larionov V, Vesela K, Kolarova K, Sumnik Z, Lebl J, Pruhova S. Search for a time- and cost-saving genetic testing strategy for maturity-onset diabetes of the young. Acta Diabetol 2022; 59:1169-1178. [PMID: 35737141 PMCID: PMC9219402 DOI: 10.1007/s00592-022-01915-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022]
Abstract
AIMS Correct genetic diagnosis of maturity-onset diabetes of the young (MODY) is beneficial for person's diabetes management compared to no genetic testing. Aim of the present study was a search for optimal time- and cost-saving strategies by comparing two approaches of genetic testing of participants with clinical suspicion of MODY. METHODS A total of 121 consecutive probands referred for suspicion of MODY (Group A) were screened using targeted NGS (tNGS), while the other 112 consecutive probands (Group B) underwent a single gene test based on phenotype, and in cases of negative findings, tNGS was conducted. The study was performed in two subsequent years. The genetic results, time until reporting of the final results and financial expenses were compared between the groups. RESULTS MODY was confirmed in 30.6% and 40.2% probands from Groups A and B, respectively; GCK-MODY was predominant (72.2% in Group A and 77.8% in Group B). The median number of days until results reporting was 184 days (IQR 122-258) in Group A and 91 days (44-174) in Group B (p < 0.00001). Mean costs per person were higher for Group A (639 ± 30 USD) than for Group B (584 ± 296 USD; p = 0.044). CONCLUSIONS The two-step approach represented a better strategy for genetic investigation of MODY concerning time and costs compared to direct tNGS. Although a single-gene investigation clarified the diabetes aetiology in the majority of cases, tNGS could reveal rare causes of MODY and expose possible limitations of both standard genetic techniques and clinical evaluation.
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Affiliation(s)
- Petra Dusatkova
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic.
| | - Marketa Pavlikova
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University, Sokolovska 83, 18675, Prague, Czech Republic
| | - Lenka Elblova
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Vladyslav Larionov
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Klara Vesela
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Katerina Kolarova
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Jan Lebl
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Stepanka Pruhova
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
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Tatovic D, Dayan CM. Replacing insulin with immunotherapy: Time for a paradigm change in Type 1 diabetes. Diabet Med 2021; 38:e14696. [PMID: 34555209 DOI: 10.1111/dme.14696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022]
Abstract
For almost a hundred years, the management of Type 1 diabetes has not advanced beyond insulin replacement. However, insulin does not provide satisfactory glycaemic control in the majority of individuals and there remains a major unmet need for novel treatments for Type 1 diabetes. Immunomodulation to preserve beta-cell function offers the prospect of making treatment with insulin easier and/or preventing the need for insulin, particularly when it comes to novel low-risk immunotherapies. Led by the concept that the best insulin-producing cell is a patient's own beta-cell, the Type 1 diabetes scientific community has a challenging task ahead-to fundamentally change the management of this devastating disease by using low-risk immunotherapy to preserve endogenous beta-cell function and make metabolic control substantially easier. In that way, insulin and/or beta-cell replacement (stem cell or transplantation) should in the future be considered rescue therapies reserved for delayed presentations.
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Affiliation(s)
- Danijela Tatovic
- Diabetes and Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Diabetes and Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, UK
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Todd JN, Kleinberger JW, Zhang H, Srinivasan S, Tollefsen SE, Levitsky LL, Levitt Katz LE, Tryggestad JB, Bacha F, Imperatore G, Lawrence JM, Pihoker C, Divers J, Flannick J, Dabelea D, Florez JC, Pollin TI. Monogenic Diabetes in Youth With Presumed Type 2 Diabetes: Results From the Progress in Diabetes Genetics in Youth (ProDiGY) Collaboration. Diabetes Care 2021; 44:dc210491. [PMID: 34362814 PMCID: PMC8929184 DOI: 10.2337/dc21-0491] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/01/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Maturity-onset diabetes of the young (MODY) is frequently misdiagnosed as type 1 or type 2 diabetes. Correct diagnosis may result in a change in clinical treatment and impacts prediction of complications and familial risk. In this study, we aimed to assess the prevalence of MODY in multiethnic youth under age 20 years with a clinical diagnosis of type 2 diabetes. RESEARCH DESIGN AND METHODS We evaluated whole-exome sequence data of youth with a clinical diagnosis of type 2 diabetes. We considered participants to have MODY if they carried a MODY gene variant classified as likely pathogenic (LP) or pathogenic (P) according to current guidelines. RESULTS Of 3,333 participants, 93 (2.8%) carried an LP/P variant in HNF4A (16 participants), GCK (23), HNF1A (44), PDX1 (5), INS (4), and CEL (1). Compared with those with no LP/P variants, youth with MODY had a younger age at diagnosis (12.9 ± 2.5 vs. 13.6 ± 2.3 years, P = 0.002) and lower fasting C-peptide levels (3.0 ± 1.7 vs. 4.7 ± 3.5 ng/mL, P < 0.0001). Youth with MODY were less likely to have hypertension (6.9% vs. 19.5%, P = 0.007) and had higher HDL cholesterol (43.8 vs. 39.7 mg/dL, P = 0.006). CONCLUSIONS By comprehensively sequencing the coding regions of all MODY genes, we identified MODY in 2.8% of youth with clinically diagnosed type 2 diabetes; importantly, in 89% (n = 83) the specific diagnosis would have changed clinical management. No clinical criterion reliably separated the two groups. New tools are needed to find ideal criteria for selection of individuals for genetic testing.
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Affiliation(s)
- Jennifer N Todd
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Vermont, Burlington, VT
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Program in Medical and Population Genetics, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
| | - Jeffrey W Kleinberger
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Haichen Zhang
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Shylaja Srinivasan
- Division of Pediatric Endocrinology, University of California, San Francisco, San Francisco, CA
| | - Sherida E Tollefsen
- Department of Pediatrics, Saint Louis University Health Sciences Center, St. Louis, MO
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lorraine E Levitt Katz
- Children's Hospital of Philadelphia, Perelman School of Medicine of University of Pennsylvania, Philadelphia, PA
| | - Jeanie B Tryggestad
- Section of Diabetes & Endocrinology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Fida Bacha
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | | | - Jean M Lawrence
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Jasmin Divers
- New York University Langone Medical Center, New York, NY
| | - Jason Flannick
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Program in Medical and Population Genetics, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity & Diabetes (LEAD) Center, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jose C Florez
- Program in Medical and Population Genetics, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Diabetes Research Center, Diabetes Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Toni I Pollin
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
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Hyde C. Will better evidence on clinical utility bring about greater use of (genetic) tests? NPJ Genom Med 2021; 6:22. [PMID: 33664270 PMCID: PMC7933423 DOI: 10.1038/s41525-021-00187-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
Greater clarity on the nature of clinical utility is desirable. Of itself it may not bring about greater use of tests, including WGS (whole-genome sequencing), not least because clinical utility studies when performed may not confirm predicted changes in patient outcome. The notion that single “pivotal” clinical utility studies will achieve uptake needs to be questioned and that the evidence base for tests is likely to rely on patchworks of imperfect evidence embraced.
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Affiliation(s)
- Chris Hyde
- Exeter Test Group, Institute of Health Research, College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK.
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Riddle MC, Philipson LH, Rich SS, Carlsson A, Franks PW, Greeley SAW, Nolan JJ, Pearson ER, Zeitler PS, Hattersley AT. Monogenic Diabetes: From Genetic Insights to Population-Based Precision in Care. Reflections From a Diabetes Care Editors' Expert Forum. Diabetes Care 2020; 43:3117-3128. [PMID: 33560999 PMCID: PMC8162450 DOI: 10.2337/dci20-0065] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023]
Abstract
Individualization of therapy based on a person's specific type of diabetes is one key element of a "precision medicine" approach to diabetes care. However, applying such an approach remains difficult because of barriers such as disease heterogeneity, difficulties in accurately diagnosing different types of diabetes, multiple genetic influences, incomplete understanding of pathophysiology, limitations of current therapies, and environmental, social, and psychological factors. Monogenic diabetes, for which single gene mutations are causal, is the category most suited to a precision approach. The pathophysiological mechanisms of monogenic diabetes are understood better than those of any other form of diabetes. Thus, this category offers the advantage of accurate diagnosis of nonoverlapping etiological subgroups for which specific interventions can be applied. Although representing a small proportion of all diabetes cases, monogenic forms present an opportunity to demonstrate the feasibility of precision medicine strategies. In June 2019, the editors of Diabetes Care convened a panel of experts to discuss this opportunity. This article summarizes the major themes that arose at that forum. It presents an overview of the common causes of monogenic diabetes, describes some challenges in identifying and treating these disorders, and reports experience with various approaches to screening, diagnosis, and management. This article complements a larger American Diabetes Association effort supporting implementation of precision medicine for monogenic diabetes, which could serve as a platform for a broader initiative to apply more precise tactics to treating the more common forms of diabetes.
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Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes, & Clinical Nutrition, Oregon Health & Science University, Portland, OR
| | - Louis H Philipson
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine, The University of Chicago, Chicago, IL.,Kovler Diabetes Center, The University of Chicago, Chicago, IL
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Annelie Carlsson
- Department of Clinical Sciences, Lund University/Clinical Research Centre, Skåne University Hospital, Lund, Sweden
| | - Paul W Franks
- Harvard T.H. Chan School of Public Health, Boston, MA.,Lund University Diabetes Center, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Siri Atma W Greeley
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Department of Medicine, The University of Chicago, Chicago, IL.,Kovler Diabetes Center, The University of Chicago, Chicago, IL
| | - John J Nolan
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ewan R Pearson
- Division of Population Health and Genomics, Ninewells Hospital and School of Medicine, University of Dundee, Dundee, Scotland, U.K
| | - Philip S Zeitler
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
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