Ask the doctors: Treating two autoimmune disorders simultaneously is tricky
Q: How often are multiple sclerosis (MS) and Type 1 diabetes seen in one individual? In my experience, MS specialists are not familiar with how to treat flares in people with both. I have been advised to get IV steroids to manage a flare, which would have spiked glucose. I find this lack of experience to be frightening.
A: In explaining your situation, you have outlined one of the major challenges to crafting a treatment plan for people living with more than one autoimmune condition. This is a phenomenon known as polyautoimmunity.
Some studies suggest that up to 30% of people with an autoimmune disease may develop at least one additional autoimmune condition over time. Risk factors include a family history of autoimmune disease and being female. Increased duration of the primary disease also raises the likelihood of developing another.
For those who are not familiar, an autoimmune disease occurs when the immune system mistakenly begins to target and damage the body’s own tissues. In Type 1 diabetes, certain white blood cells, including T cells, attack and destroy the insulin-producing cells in the pancreas. In multiple sclerosis, T cells and other immune cells target the protective coating around nerve fibers in the brain and spinal cord.
In autoimmune disease, a crucial state of balance has been disrupted. Known as homeostasis, this is when the body’s systems are operating properly and in harmony with one another. It is also at the heart of the dilemma doctors face when treating a person with polyautoimmunity. It often happens that a treatment used to manage a symptom, flare or complication in one disease will create an imbalance that worsens the coexisting condition.
In the case of your doctor prescribing IV steroids to manage an MS flare, they are following the standard of care. Steroids are highly effective at shutting down the inflammation associated with an MS flare. But as you point out, steroids raise blood glucose and interfere with insulin metabolism. For someone with Type 1 diabetes, this poses significant health risks.
These include diabetic ketoacidosis, a potentially deadly condition. Without enough insulin, the body begins to rapidly burn fat. This produces metabolic byproducts known as ketones, which make the blood dangerously acidic.
Faced with two dangerous outcomes, the challenge for the doctor becomes finding a point of balance. They need to suppress the immune attack that is driving the MS flare without disturbing the metabolic control needed to regulate blood sugar. For treatment with IV steroids, this would require a hospital setting with stringent monitoring of ketones and electrolytes, and vigilant adjustments to insulin during and after the treatment.
All of this explains why your situation feels so precarious and, understandably, frightening. Treating two autoimmune diseases at the same time amplifies the level of care needed to stay safe. With careful planning, including coordinated care for both conditions, vigilant glucose management before MS treatment, and clear guidance about warning signs, this risk can be managed.
• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.
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