Diabetes is classically categorized as Type 1 and Type 2. However, the prevalence of Type 2 diabetes in children is increasing and latent autoimmune diabetes in adults (LADA) is becoming a common variant of autoimmune diabetes. It’s also possible to have a mixed diabetic diagnosis making management more challenging. Most patients with autoimmune diabetes progress to insulin dependence within several years. We present a case of autoimmune diabetes with features of insulin resistance successfully managed without insulin for over a decade. A male patient in their 40s was diagnosed with Type 2 diabetes in 2011 after presenting with polyuria, polydipsia, and blurry vision. At diagnosis, BMI was 39 kg/m2 and hemoglobin A1C was 9.1% with a family history of Type 2 diabetes. At initial evaluation, low levels of insulin prompted further testing. C-peptide was found to be 3.9 ng/mL indicating insulin resistance; however, GAD autoantibodies were positive (>30 U/mL). This result led to the diagnosis of autoimmune diabetes. Despite autoantibodies, insulin therapy was deferred due to sufficient glucose level maintenance. Initial management included metformin, GLP-1 receptor agonist, and lifestyle modification. In 2015, a SGLT2 inhibitor was added. By 2019, A1C improved to 5.7% with 56 pounds of weight loss, allowing the discontinuation of metformin. At the most recent visit, the patient is on tirzepatide and a SGLT2 inhibitor, with a total weight loss of 61 pounds, BMI of 30.1 kg/m2 and A1C of 5.8%. For over 10 years, A1C has remained <7% without insulin, with no episodes of ketoacidosis, severe hypoglycemia, or microvascular complications. Although findings are limited to a single case, select patients with autoimmune diabetes and preserved endogenous insulin production may achieve glycemic control without insulin. An individualized approach to diabetic management is encouraged while integrating immunologic, pharmaceutic, and lifestyle modifications to help guide therapy and optimize outcomes.
