Counsel Patients with Type 1 Diabetes on Risks for Developing Autoimmune Thyroid Disease
Compared to the general population, children and adolescents with type 1 diabetes are up to four times more likely to develop autoimmune thyroid disease in the form of Hashimoto’s thyroiditis or Graves’ disease. Adding hypo- or hyperthyroidism to the mix significantly affects the overall health of all patients with type 1 diabetes and impacts the dose of insulin needed to maintain normal blood glucose.
When pharmacists fill insulin prescriptions, it’s vital to counsel parents and caregivers about the risks for developing autoimmune thyroid disease and to offer compassionate support for the challenge of getting pediatric patients to adhere to the treatment regimen.
Type 1 Diabetes and Comorbid Autoimmune Disease
Type 1 diabetes (T1D) occurs in roughly 1 out of every 400 to 600 children and represents 5 percent of all cases of diabetes.1 To make matters worse, there’s an upward trend, with T1D cases increasing at the rate of 3 to 5 percent every year. These numbers represent a lot of patients with T1D, who also face the risk of developing one or more additional autoimmune diseases (AID), thanks to shared genetic susceptibility.
In September 2016, the Journal of Clinical Endocrinology and Metabolism published a study that was the first to fully characterize the prevalence and predictive factors for T1D and autoimmune comorbidities across age groups. The researchers reviewed clinical data of 25,759 participants with T1D who were enrolled in the T1D Exchange Registry.2 Their results offer some insight into patient demographics:
- 27 percent had at least one autoimmune disease in addition to T1D.
- Risk for two or more autoimmune diseases was 4 percent in those aged 13 and under.
- Risk for two or more autoimmune diseases increases to 10 percent in T1D patients aged 50 and older.
- Women, non-Hispanic whites, and older patients are at increased risk for one or more AIDs.
- Autoimmune thyroid diseases were the most common, occurring in 24 percent of participants.
- Autoimmune gastric disease was second most common, found in 6 percent, and collagen vascular diseases accounted for 2 percent.
Autoimmune Thyroid Disease in Type 1 Diabetes
Autoimmune thyroid disease is seldom diagnosed prior to T1D, but patients should receive thyroid function and autoantibody tests at the time of diagnosis. Tests should be repeated every two years if initial results were normal, or every 6 to 12 months if autoantibodies are detected or thyroid symptoms appear
Hashimoto’s thyroiditis is the most common thyroid disorder diagnosed in those with T1D. However, up to 7 percent of T1D patients develop Graves’ disease.3 The most important point to remember is that each type of thyroid disease impacts the amount of insulin needed to maintain normal blood glucose.
- Hashimoto’s thyroiditis: Insulin requirements decrease in patients with hypothyroidism because Hashimoto’s impairs glucose absorption, delays gluconeogenesis and slows down glucose metabolism.4 Loss of appetite caused by hypothyroidism may also reduce insulin dosage. As hypothyroidism is corrected, changes in insulin must be titrated. These patients should subsequently be monitored for pituitary or adrenal failure.
- Graves’ disease: Thyroid hormones enhance glucose absorption, increase hepatic glucose output, and boost glycogenolysis and gluconeogenesis. As a result, hyperthyroidism worsens insulin resistance and increases insulin requirements. Hyperthyroidism also raises the risk of diabetic ketoacidosis. On the flip side, T1D patients who go into ketoacidosis should be screened for hyperthyroidism. In addition to ketoacidosis, comorbid hyperthyroidism is associated with arterial hypertension, even in children.
Symptoms of the two autoimmune thyroid diseases include:
- Weight gain
- Sensitivity to cold
- Dry skin
- Weight loss
- Chest pain or palpitations
- Shortness of breath
- Muscle weakness
Pharmacist Counseling Tips for Type 1 Diabetes
Type 1 diabetes is difficult for everyone to manage, but pharmacists should be especially alert to helping parents and caregivers of pediatric patients. Chances are the physician referred them to a diabetes educator, but be sure to ask if they’ve gone for a consultation. If not, encourage them to follow through with their referral. If they don’t know where to turn, offer a list of local programs or suggest they go to the American Association of Diabetes Educators website to find the nearest accredited diabetes education program.5
Here are some other key concerns to consider as you have the opportunity to talk with T1D patients and parents of children with T1D:
- Medication counseling: When filling prescriptions, make it a point to ask if they have any problems with the regimen, because lack of adherence is a critical concern. When you fill the first prescription, ask whether thyroid tests were performed. Be sure to talk about the risks for thyroid disease and teach about symptoms.6
- Smoking cessation: People with T1D and parents of pediatric patients should not smoke. Teens with T1D who smoke have higher A1C, triglycerides and cholesterol, as well as an increased risk for diabetic nephropathy, retinopathy and neuropathy.7 Be prepared to recommend a local smoking cessation program.
- Lifestyle habits: While diabetes educators cover lifestyle concerns, more than one-third of children with T1D are overweight and have a nutritional deficit, so it’s important to talk about the most basic issues. In addition to foot and skin care, patients with T1D should maintain a healthy body weight, get enough protein, and eat a diet filled with vegetables, fruits, whole grains, unsaturated fats and lean protein.
- Hypoglycemia symptoms: T1D patients should be aware of hypoglycemia symptoms, such as shakiness, dizziness, sweating, headache and hunger. Parents must diligently watch for symptoms because children may not be able to communicate the problem. Hypoglycemia in young children may cause mood or behavior changes, they may become irritable, or cry for no apparent reason.8
There are also a number of concerns unique to adolescents with T1D: Compared to other pediatric age groups, adolescents with T1D are less likely to adhere to the treatment plan, which puts them at risk of poor glycemic control, morbidity and premature mortality.9 The onset of puberty often affects insulin resistance, plus these young patients face normal pressures, such as the desire to be accepted by their peer group and increasing independence from parents, that may influence adherence. Pharmacists can alert parents that T1D makes an already difficult developmental phase even more of a challenge and recommend interventions like using technology for medication reminders (rather than parent nagging) and finding a support group for teens.
Proactive Partner in the Outpatient Health Care Team
Patients with type 1 diabetes and autoimmune thyroid disease truly depend on a diverse health care team to help them live long and happy lives. Parents and caregivers need all the education and support they can find to support their children and adolescents on this often overwhelming journey. Pharmacists who take their part on the community team stand to make the essential difference by monitoring medication adherence, making timely referrals and offering encouragement.
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- “Type 1 Diabetes Mellitus,” September 2016, http://emedicine.medscape.com/article/117739-overview ↩
- “Autoimmune Diseases in Children and Adults with Type 1 Diabetes From the T1D Exchange Clinic Registry,” September 2016, http://press.endocrine.org/doi/10.1210/jc.2016-2478 ↩
- “Effect of Associated Autoimmune Diseases on Type 1 Diabetes Mellitus Incidence and Metabolic Control in Children and Adolescents,” July 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971288/ ↩
- “The Interface Between Thyroid and Diabetes Mellitus,” 2011, http://www.medscape.com/viewarticle/745282_1 ↩
- “Find a Diabetes Educator in Your Area,” 2016, https://www.diabeteseducator.org/patient-resources/find-a-diabetes-educator ↩
- “All Thyroid Diseases,” accessed November 2016, http://www.endocrineweb.com/conditions/thyroid/all ↩
- “Type 1 Diabetes: Its Problems and Solutions,” October 2016, http://www.pharmacytimes.com/publications/issue/2016/october2016/type-1-diabetes-its-problems-and-solutions ↩
- “Hypoglycemia and Low Blood Sugar: Symptoms and Causes,” accessed November 2016, http://www.childrenshospital.org/conditions-and-treatments/conditions/hypoglycemia-and-low-blood-sugar/symptoms-and-causes ↩
- “Adherence Challenges in the Management of Type 1 Diabetes in Adolescents: Prevention and Intervention,” August 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159529/ ↩