Role of Pharmacists in Latent Autoimmune Diabetes in Adults Care Transitions

IRB Statement

Institutional Review Board Statement: This research was approved by the BILH Institutional Review Board (IRB) as not human subject research. Protocol Number: 2024D000692

Informed Consent Statement: Written informed consent was waived by the IRB.

Abstract

Objective

To describe a case of collaborative transitions of care for a patient with newly diagnosed latent autoimmune diabetes in adults (LADA), highlighting the roles of pharmacists at an academic medical center to optimize patient care.

Case Summary

A 40-year-old White man with no significant medical history presented to the emergency department with symptoms of polyuria, polydipsia, and altered mental status. Laboratory evaluation confirmed a diagnosis of LADA. The patient was admitted to the intensive care unit for diabetic ketoacidosis, then transferred to an acute care floor. During hospitalization, the patient’s medication regimen was managed by critical care and acute care internal medicine pharmacists. During interdisciplinary acute care rounds, the internal medicine pharmacist recommended initiating continuous glucose monitoring (CGM) and referring the patient to the hospital’s ambulatory care pharmacist. Prior to discharge, the ambulatory care pharmacist provided CGM initiation and education. The patient was discharged 2 days later with a scheduled follow-up with the ambulatory care pharmacist to optimize management of the newly diagnosed LADA.

Practice Implications

LADA is the most prevalent subtype of autoimmune diabetes, but it is frequently misdiagnosed as type 2 diabetes, which can complicate management. This case highlights the value of pharmacist collaboration across care settings to ensure continuity of care for patients with LADA during transition, improve patient outcomes, and improve the quality of diabetes management. Through this collaborative approach, pharmacists play a pivotal role in optimizing diabetes management and facilitating successful transitions of care for individuals with LADA.

Background

LADA is a slowly progressive autoimmune form of diabetes that typically manifests in adulthood. It was formally recognized as a subtype of type 1 diabetes in the American Diabetes Association (ADA) Standards of Care in Diabetes-2025.¹ In clinical practice, LADA is often referred to as type 1.5 diabetes because of its overlapping characteristics with both type 1 and type 2 diabetes.² Despite being the most prevalent subtype of autoimmune diabetes, LADA remains underrecognized and frequently misdiagnosed as type 2 diabetes. Currently, there is no standardized diagnostic criterion for LADA; however, it is generally diagnosed based on 3 criteria: onset after age 30, the presence of autoantibodies to pancreatic islet β cells, and initial insulin independence for at least 6 months following diagnosis.³ Compared with type 1 diabetes, LADA exhibits a more gradual autoimmune-mediated destruction of β-cell function.⁴ Early detection of this progression is critical, as timely diagnosis and intervention may help preserve β-cell function, delay insulin dependence, and reduce diabetes-related complications, as emphasized in the ADA standards of care.¹

The Joint Commission has identified transitions of care as a vulnerable period for patients—particularly those with complex medication regimens or high-risk treatments—due to an increased risk of medication-related adverse events. Pharmacists play a critical role during these transitions of care through activities such as patient counseling and medication reconciliation.^5,6 Evidence suggests that pharmacist-led transitions of care programs are associated with reduced hospital readmission rates and improved medication safety.^5,6

In the inpatient setting, pharmacists participate in interdisciplinary rounds, make medication interventions, and document therapeutic adjustments. They may also conduct medication reconciliation and discharge counseling. In contrast, ambulatory care pharmacists provide postdischarge follow-up in the outpatient setting, addressing medication adherence and managing chronic conditions. Additionally, they provide education on diabetes self-management, empower patients to track their glycemic control, and recommend appropriate lifestyle or medication regimen adjustments when necessary.

Pharmacists can exchange essential information with other health care providers both within and outside pharmacy, provide medication education, promote medication adherence, and help empower patients to take an active role in their own health. Effective collaboration between the inpatient and ambulatory care pharmacists enhances continuity of care. This collaboration enables real-time information sharing beyond what is captured in the electronic health record and fosters well-informed, coordinated decision-making. Introducing the ambulatory care pharmacist to the patient during hospitalization can help establish a trusting patient-pharmacist relationship and facilitate early outpatient care. Such early integration may lead to improved care continuity, greater patient empowerment, and better outcomes during the transition from inpatient to outpatient settings.

Case Summary

A 40-year-old White man with no known medical history presented to the emergency department with symptoms of polyuria, polydipsia, and altered mental status. Laboratory results revealed a markedly elevated blood glucose level of 600 mg/dL, a pH of 6.7, an anion gap of 28, an elevated CO2 level of 29 mmol/L, and a lactic acid level of 4.3 mmol/L—findings consistent with diabetic ketoacidosis. The patient reported that his last physician visit was approximately 20 years ago and noted an unintentional weight loss of nearly 80 lb over the past 6 months. His hemoglobin A_1c (HbA_1c) was 15.1%, and autoimmune markers were positive for both anti-GAD and anti-IA2 antibodies, confirming a diagnosis of latent LADA.

The patient was admitted to the intensive care unit and treated with a continuous insulin infusion for 2 days. He was then transferred to an acute care floor for further management. Throughout his hospitalization, the patient’s medication regimen was managed by critical care and acute care internal medicine pharmacists. During multidisciplinary acute care rounds, the providers discussed that the patient was adjusting his meal choices based on his finger-stick blood glucose levels. The internal medicine pharmacist recommended that the patient might benefit from continuous glucose monitoring (CGM), as well as consultation with the ambulatory care pharmacist at the hospital for continued outpatient support. After consulting with the internal medicine pharmacist, the ambulatory care pharmacist provided the patient with a FreeStyle Libre 3 CGM (Abbott Diabetes Care Inc) and education prior to discharge. He was discharged 2 days later on a basal-bolus insulin regimen: insulin glargine 40 units subcutaneous every morning and insulin lispro 9 units subcutaneous 4 times a day before each meal, along with an insulin sliding scale. A follow-up appointment with the ambulatory care pharmacist was scheduled.

At the 2-week follow-up visit with the ambulatory care pharmacy team, CGM data revealed significant improvement. The patient’s ambulatory glucose profile showed an average glucose of 125 mg/dL—a glucose management indicator (GMI)—an expected HbA_1c of 6.3%, and 90% time in range. However, persistent nocturnal hyperglycemia prompted further adjustment to the insulin regimen. Basal insulin (glargine) was reduced to 20 units and rescheduled to bedtime to better address nocturnal hyperglycemia. Bolus insulin (lispro) was modified to 2 to 4 units 3 times a day before meals, with correctional doses tailored to carbohydrate intake.

At the follow-up visit 2 weeks later, the patient’s glycemic control had further improved, with an average blood glucose level of 104 mg/dL and a GMI of 5.8%, with no hyperglycemic excursion; however, the patient reported an increase in hypoglycemic events. He admitted to self-adjusting his basal insulin dose up to 22 to 24 units and administering additional bolus doses up to 5 times daily to manage postprandial hyperglycemia.

The pharmacist provided targeted education on insulin pharmacokinetics, emphasizing the importance of maintaining a consistent basal insulin dose and advised limiting additional bolus corrections to 1 unit only if the postprandial blood glucose remained above 180 mg/dL 2 hours after a meal. These recommendations helped reduce the frequency of hypoglycemic events.

Overall, the patient reported significant improvement and increased energy levels after a prolonged period of hyperglycemia. This case underscores the value of collaborative transitions of care and pharmacist-led outpatient follow-up in optimizing diabetes management for patients with newly diagnosed LADA.

Practice Implications

Collaboration between inpatient and ambulatory care pharmacists is essential to ensuring seamless continuity of care for patients with LADA during their transition from hospital to outpatient management. Effective communication between these pharmacy teams contributes to improved clinical outcomes and enhances the overall quality of patient care. This coordinated approach enables comprehensive transfer of critical information, including any modifications or adjustments to the medication regimen during the hospital stay, thereby reducing the risk of therapeutic gaps or inconsistencies in the treatment plan. By establishing a strong foundation of shared knowledge, pharmacists facilitate the exchange of essential clinical information, promote medication adherence, and empower patients with LADA to take an active role in managing their disease. Through this collaborative model, pharmacists play a pivotal role in optimizing diabetes care and supporting successful transitions across care settings.

REFERENCES

1. American Diabetes Association Professional Practice Committee. 2: diagnosis and classification of diabetes: standards of care in diabetes–2025. Diabetes Care. 2025;48(suppl 1):S27-S49. doi:10.2337/dc25-S002

2. Rajkumar V, Levine SN. Latent autoimmune diabetes. In: StatPearls. StatPearls Publishing; 2022-.

3. O’Neal KS, Johnson JL, Panak RL. Recognizing and appropriately treating latent autoimmune diabetes in adults. Diabetes Spectr. 2016;29(4):249-252. doi:10.2337/ds15-0047.

4. Carlsson S. Etiology and pathogenesis of latent autoimmune diabetes in adults (LADA) compared to type 2 diabetes. Front Physiol. 2019;10:320. doi:10.3389/fphys.2019.00320

5. Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during care transitions on patient hospital readmission: a systematic review. J Am Pharm Assoc (2003). 2022;62(5):1477-1498.e8. doi:10.1016/j.japh.2022.05.017

6. Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493