Welcome to our daily summary of type 1 diabetes (T1D) research highlights from the ADA’s 73rd Scientific Sessions! Each night, we will be posting summaries of notable sessions and presentations. Below are four relevant sessions from Saturday, June 22:
JDRF continues to place a high priority on discovering and developing immune therapies for T1D because they remain central to curing this disease. This session highlighted the challenges we all face in this endeavor. We are learning more and more about the detailed functioning of the human immune system, but it continues to resist our recent attempts to tame it. One thing is for sure, exciting reports of a T1D cure in mice, while an important step in the process, give little indication of what to expect when such therapies are studied in clinical trials of people with T1D.
A variety of clinical study results were reviewed today including those with IL2, IL2 plus rapamycin, alefacept, and anti-thymocyte globulin (ATG); all designed to target the T cells known to be key to the T1D autoimmune process. These studies generally produced the desired impact of rebalancing the “good” and “bad” T cells, but this did not translate into consistently improved beta cell functioning as measured by C-peptide or HbA1c levels. There were hints of benefits in some groups which may provide clues for better targeting the future testing of these agents. A study of the combination of ATG and GCSF is ongoing and will report results at the end of this year.
Many believe that the complexities of the T1D autoimmune process will require a multidrug approach to improve success; as was eventually found in other challenging diseases like cancer. JDRF remains optimistic about the potential of the T cell rebalancing concept as an immune therapy and is currently supporting multiple novel approaches to boost the proportion of a person’s “good” T cells to rebalance the immune system; these recently started clinical studies, however, were not discussed today.
This session consisted of four talks on continuous glucose monitoring (CGM) technology and its potential uses for pregnant women with T1D and newborns. Women with T1D whose blood sugar is not well-controlled during pregnancy are at higher risk for complications of pregnancy and delivery; they are more likely to deliver prematurely and more likely to have babies who weigh over 9 pounds and/or experience low blood sugar at birth.
In previous generations, women with T1D were often discouraged from having children, but medical consensus is much more optimistic these days and treatments for pregnant women with T1D continue to evolve.
Some of the treatment goals and challenges discussed during this session include:
- The need to establish what blood-glucose levels pregnant women with T1D should be aiming for. This is an area where CGM studies could assist tremendously, not only by tracking glucose levels in women with T1D, but in women without T1D, to establish baseline goals.
- The need for CGM technology that is both accurate and user-friendly.
- Determining the best ways to utilize constantly evolving CGM technology. In the study discussed by Elisabeth Mathiesen, M.D., from the Copenhagen Centre for Pregnant Women with Diabetes, CGM use by pregnant women with T1D did not reduce the incidence of large-sized newborns, which was the study’s primary goal. However, it was useful in reducing episodes of hypoglycemia during pregnancy.
- Determining how closed-loop technology in particular may become a feasible option for use in pregnancy. Helen Murphy, M.D., from the University of Cambridge, conducted a study that showed that the use of closed-loop technology overnight was safe and accurate, but was not yet a feasible option for preventing high blood sugar without additional bolus doses of insulin before meals.
- Determining how CGM may be used to monitor hypoglycemia in newborns.
Recognizing the need for more work in this field, JDRF is currently funding a new study on the benefits of CGM use in women with T1D who are pregnant or planning to become pregnant. The study is called CONCEPTT (Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial).
The main takeaway from this session is that a great deal of progress has been made in better treating complications of diabetes, such as retinopathy (eye disease), nephropathy (kidney disease), and neuropathy (nerve disease). We now have treatments on the market, such as anti-VEGF (which was developed with JDRF support), which can restore vision in people with diabetic macular edema (DME, a form of eye disease). At the same time, there is still vast room for improvement in treating complications, and ongoing trials are providing new knowledge that may lead to better treatments.
In the session, Anthony Keech, M.D., Ph.D., professor of medicine, cardiology, and epidemiology at the University of Sydney, discussed the FIELD and ACCORD Eye studies, which showed that treatment including a fibrate drug could slow the progression of retinopathy. Paul Fernyhough, Ph.D., professor of pharmacology and therapeutics and physiology and director of the division of neurodegenerative disorders at the University of Manitoba, presented his findings about the underlying similarities and differences between diabetic neuropathy and retinopathy, as well as his JDRF-funded research that has been successful in reversing fiber loss in rodents with neuropathy and should be in human trials soon. George King, M.D., professor of medicine at Harvard Medical School and director of research at Joslin Diabetes Center, shared results from the Medalist Study, partially supported by JDRF, which involves more than 850 people who have lived with T1D for over 50 years. His research shows that many of these individuals have protective factors that stop the progression of retinopathy and other complications, and the next steps will be to analyze organ and tissue samples to better determine what they may be. Interestingly, Dr. King has not found common potential protective factors for retinopathy and nephropathy, suggesting diabetic eye disease and kidney disease might have different pathways. Finally, Arup Das, M.D., Ph.D., chief of ophthalmology at the University of New Mexico, provided details about a number of clinical studies seeking novel uses of existing therapies such as anti-VEGF or combinations of multiple therapies to provide even more effective treatment for diabetic retinopathy.
China is increasingly in the global headlines on multiple fronts these days, to which we can also add news about diabetes. This session included presentations from Chinese researchers who are working to crystalize the details about the basic epidemiology of diabetes in their country.
Not surprisingly given the population of China, it is home to the largest population of people with type 2 diabetes (T2D): an estimated at nearly 100 million individuals. Zhiguang Zhou, M.D., Ph.D., from the Institute of Metabolism and Endocrinology at Central South University in Changsha, China, reviewed his study to estimate the frequency of latent autoimmune diabetes of adults (LADA) among those diagnosed with T2D in China. Frequently misdiagnosed, the NIH defines LADA as a condition in which T1D develops in adults. These individuals have at least one T1D autoantibody but may not yet be insulin dependent. Dr. Zhou reported that nearly 6% of those studied with T2D were positive for at least one autoantibody, suggesting there are about 6 million Chinese with LADA. Studies of LADA in other countries found rates around 10%.
The picture of T1D in China is emerging based on a study reported by Jin Li, M.D., Ph.D., from Guangzhou, China, but more work remains to be done. His pilot registration study in Guangdong province surprisingly found few individuals who have lived with T1D for long creating new questions for future study about why this might be. He did report a higher incidence of severe hypoglycemia and higher morbidity from diabetic ketoacidosis than reported in western countries. There remains much to be learned about T1D in China.