Diabetes

Type 1 diabetes

Common acute symptoms of type 1 diabetes are fatigue, nausea, increased thirst, frequent urination, abdominal pain, weight loss, and blurred vision. Patients that have severe insulin deficiency with uncontrolled hyperglycemia may experience breath that smells of acetone. These patients may have diabetic ketoacidosis, a condition that may be life-threatening and requires urgent medical care. Both newly diagnosed and patients with known diabetes can suffer from diabetic ketoacidosis.  

Type 2 diabetes

Type 2 diabetes patients more often have fewer symptoms at diagnosis, but some may experience symptoms that are similar to those listed above for type I diabetes. A significant proportion of patients admitted to the hospital for acute coronary syndromes or stroke are diagnosed with type 2 diabetes. 
There are MODY forms that, similar to type 2 diabetes, are associated with cardiovascular and microvascular complications, but MODY very rarely presents clinical symptoms as described for type 1 diabetes. 

The diagnosis of diabetes is straightforward: a plasma sugar level above 7.0 mmol/L after fasting for at least eight hours or a glucose level at or above 11.1 mmol/L two hours after an oral glucose tolerance test. Additional diagnosis criteria include symptoms of hyperglycemia and blood sugar at any time at or above 11.1 mmol/L or glycated hemoglobin (hemoglobin A1c) levels at or above 48 mmol/mol.

Type 1 Diabetes

Type 1 diabetes is an autoimmune disease that occurs when the insulin-producing beta cells in the pancreas are destroyed by immune cells. When insulin levels are low, glucose cannot enter the cells, and blood glucose levels rise. The disease usually develops in children or adolescents. The median age of diagnosis in Sweden is approximately 14 years. However, adults also can become affected by type 1 diabetes. The causes of the disease are many; both genetic and environmental factors have been shown to increase the risk of type 1 diabetes.    

Type 1 diabetes is characterized by the presence of a specific set of circulating autoantibodies. 

A person diagnosed with type 1 diabetes in youth or childhood has a risk for complications later in life. However, if risk factors such as lifestyle (for example smoking and diet) and high glucose levels/blood lipids, and hypertension can be controlled, the risk for diabetes-related complications will be markedly diminished.

Type 2 Diabetes

Type 2 diabetes is the predominant form of diabetes, and about 90% of all patients with diabetes have type 2 diabetes. Type 2 diabetes is characterized by dysregulated insulin production as well as a phenomenon called insulin resistance. Insulin resistance occurs when cells, mainly in muscle, liver, and fat, do not respond sufficiently to insulin. Factors that are linked to insulin resistance are obesity, inactive lifestyle, smoking, medication (for example steroids and antipsychotics), and sleep apnea. 

Both type 1 and type 2 diabetes increase the risk of microvascular (for example retinopathy, neuropathy, and nephropathy) and macrovascular (for example ischemic stroke, myocardial infarction, and peripheral arterial disease) complications. One of the severe complications of diabetes is foot ulcers, which can lead to amputation. With advanced care and self-care education, foot ulcers and amputation can be prevented. Karolinska has a large unit specializing in diabetic foot ulcers, and the unit has a diagnostic platform for performing investigations of peripheral circulation. 

Monogenic Diabetes  

Monogenic diabetes is underdiagnosed diabetes types that stem from mutations in a single gene. Maturity-onset diabetes of the young (MODY) and neonatal diabetes are specific subtypes of monogenic diabetes. Monogenic diabetes accounts for about 1-2% of all diabetes. Cases of MODY should be suspected when diabetes is diagnosed before the age of 25 and when there is a strong hereditary pattern of diabetes within a family.  

At Karolinska, we have developed a diagnostic platform with a panel for screening 50 gene variants to diagnose monogenic diabetes, and we meet in multidisciplinary conferences to improve the diagnosis and treatment of MODY.   

In addition to monogenic forms of diabetes, we also treat patients with diabetes associated with diseases such as cystic fibrosis and mitochondrial dysfunction, as well as diabetes induced by drugs such as glucocorticoids. 

Gestational Diabetes

Gestational diabetes is a temporary form of diabetes diagnosed during pregnancy that leads to excessively high blood sugar levels, which can compromise the baby's health. This form of diabetes usually develops during the second or third trimester and often goes away after the baby's birth. During pregnancy, regular checkups and blood tests are performed, making it possible to keep track of potential gestational diabetes. During this period, patients are followed by the obstetrics department, but Karolinska’s endocrinology unit works closely with obstetricians to offer pregnant women with gestational diabetes the best possible care.  

Irrespective of diabetes type, the treatment goals of each patient are individualized, and the patient is always involved in setting these goals.

Type 1 Diabetes

A person diagnosed with type 1 diabetes will not survive without insulin treatment. Therefore, all diagnosed patients need insulin treatment immediately. However, insulin is not a cure for diabetes – it is a treatment. To minimize the burden of hyperglycemia and the risk of diabetes-related complications, the person living with diabetes must monitor blood glucose multiple times daily and regard the number of carbohydrates ingested to calculate and optimize the insulin doses. Moreover, it is of great importance to improve other lifestyle factors, such as physical activity, as this helps control blood sugar levels and improves blood lipids and blood pressure.  

Multiple daily insulin injections are the most common treatment, while insulin pumps are used among one-third of patients diagnosed with type 1 diabetes. In the last decade, the evolution of technical devices such as continuous glucose monitoring (CGM) and hybrid closed-loop insulin pumps have improved patient outcomes for persons with type 1 diabetes. HybridClosed Loop insulin pumps are a technical system combining a CGM with an insulin pump that uses algorithms to predict glucose values and insulin doses. At the moment, there are several different systems available.  
At our unit, we strive to implement the most recent med-tech innovations soon after they are introduced to the market.

Type 2 Diabetes 

The purpose of type 2 diabetes treatment is not only to address high glucose levels but also to improve lifestyle and other risk factors such as being overweight, blood lipids, and high blood pressure. Furthermore, the ambition is to always improve quality of life through greater satisfaction with treatment and less distress from diabetes.  

For many years, the cornerstone pharmacological treatment in type 2 diabetes has been metformin. Metformin is a drug that decreases blood sugar levels without risk for low blood sugar (hypoglycemia). Insulin is also frequently used in the treatment of type 2 diabetes, albeit most commonly by daily injections of basal insulin in the evening. During the last two decades, new treatments for type 2 diabetes have emerged, and these glucose-lowering drugs have been shown to give patients significant benefits in the form of diminished risks for cardiovascular complications. Among these new drugs, SGLT-2 inhibitors (taken orally) and the GLP-1 receptor (GLP1R) agonists (taken both orally and by injection) have been, in large clinical studies, shown to reduce the risk for myocardial infarction, heart failure, stroke, and death. These two groups of antihyperglycemic drugs also reduce body weight significantly, where the effects of GLP1R-agonists can be particularly prominent. Moreover, new classes of antihyperglycemic and weight-reducing drugs are now being introduced to the market.  

Monogenic and other forms of diabetes 

These forms of diabetes require individualized treatments according to the specific mutation and/or disease of the patient.