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Introduction: Adults represent over half of incident T1D cases but most studies on risk prediction focus on children. Methods: We studied 135,970 children (18 years old) and 99,795 adult relatives in the TrialNet Pathway to Prevention study screened for autoantibody positivity (AB+). Kaplan Meier curves and log rank tests compare T1D progression. We tested discrimination of existing metabolic risk scores: Index60 (I60) and DPT1 (DPTRS) using area under time dependent receiver operating characteristic curve (ROC AUC). Results: Adults had lower confirmed AB+ rates (adults 4.9% (n=4843); children 5.4% (n=7364), p 0.001), particularly for multiple AB+ (adults 0.9% (n=939); children 3% (n=4062), p 0.001). AB+ adults at all stages of disease exhibited lower 3 year progression risk compared to children (Table 1) but risk scores remained discriminative (DPTRS ROC AUC: adults 0.91 0.87 - 0.94, children 0.86 0.84 - 0.87; I60: adults 0.87 0.83 - 0.91, children 0.83 0.82 - 0.85). Conclusion: Key differences and similarities between children and adult relatives are highlighted: fewer adults presented with early stage T1D (multiple AB+), progression rates were lower in AB+ adults, and those at highest risk can be identified with metabolic risk scores. Large datasets of AB+ adults are needed to refine and calibrate T1D prediction models in adults. Disclosure E. Templeman: None. L.A. Ferrat: Consultant; Johnson Medtronic. Advisory Panel; Medtronic, Insulet Corporation. Speaker's Bureau; Insulet Corporation. Advisory Panel; Vertex Pharmaceuticals Incorporated, MannKind Corporation, StartUp Health T1D Moonshot, Bigfoot Biomedical, Inc., Cecelia Health. Speaker's Bureau; Zealand Pharma A/S. M.J. Redondo: None. C. Evans-Molina: Other Relationship; Bristol-Myers Squibb Company, Nimbus Therapeutics. Research Support; Lilly Diabetes, Astellas Pharma Inc. Advisory Panel; Avotres Inc., Neurodon, DiogenX, Isla Technologies. J. Sosenko: None. E.K. Sims: Consultant; Sanofi. Board Member; American Diabetes Association. Other Relationship; American Diabetes Association, Medscape. Consultant; DRI. R.A. Oram: Research Support; Randox R Provention Bio, Inc., Sanofi. Funding Randox Ltd
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