Challenges in Managing Type 1 Diabetes and Pressing Need for New Therapies

Natalie Bellini, DNP, FNP-BC: One of the things I think we should revisit in this discussion is the staging of diabetes. 10 or 20 years ago, there wasn't really staging at all. Either you didn't have type 1 or you did have type 1 diabetes. We asked Dr Sims to revisit that when she discussed it too. Type 1 staging is where you're antibody positive, but there are no symptoms, but there's also no change in blood sugar fluctuation. If you give someone a glucose tolerance test, they produce plenty of insulin still, but the antibodies are doing their magic and working against those beta cells. And then we have stage 2 where the antibodies are positive and yet during a glucose tolerance test that those blood sugars start to rise. And that was that first phase insulin response that she was discussing. That's the hardest time that you need the most insulin is when you eat carbohydrates. If you think about that as a clinician, that makes the most sense is that that would fail first and not the fasting blood sugar. When you think about fasting, the patient has had all night to make enough insulin to get that blood sugar down when you check it.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Can you tell us, I know when someone has 2 or more auto antibodies, what's the chance that they're going to develop type 1 diabetes?

Natalie Bellini, DNP, FNP-BC: Almost 100% in their lifetimes. And in the beginning, we thought about diabetes as something that came on as a child. It was juvenile onset for so many years. We have lots of patients who get it as a child, but we also have lots of people who get it as an adult. And you and I both have had patients in their 60s, 70s, 80s develop type 1 diabetes. How do we know how long they were antibody positive? We don't. But you have a 100% chance or close to it if you have two or more antibodies positive.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Yes. The staging system is interesting. There's not a ton of awareness about it. It's in the ADA standards of care, but I don't think a lot of people are aware of it. And especially in adults where type 1 diabetes tends to be more slow progressing, The staging is very helpful. For example, a common, I guess it's not so common, but I've experienced it in a number of my patients where a woman is diagnosed with gestational diabetes, right? And then come to find out, she actually has the auto antibodies. And I've seen several cases where the endocrinologist, someone thought hey, let's, you didn't seem like a person, you didn't have the characteristics that might put you at higher risk of developing gestational diabetes. Let's go ahead and check those auto antibodies. And sure enough, they've had them. But the neat thing about it is we've been able to catch it so early that in terms of the treatment, often we don't have to go straight to needing basal bolus insulin or using an insulin pump. When you catch it early, especially in adults where it's slower progressing, we can start off sometimes with even other therapies like with using metformin, but often maybe just with a long-acting insulin and not requiring mealtime insulin. It's interesting. There's a lot of benefits to this staging and to early detection.

Natalie Bellini, DNP, FNP-BC: Yes, and think about, when you think about diabetes, type 1 diabetes and the burden that comes with the management, the day-to-day management, every time you look at food, every time you think about how far is the gate that I walk to at the airport? Is that going to drop my blood sugar? What's going to happen next? There is a real burden that comes with this disease. Knowing ahead of time and using therapies as quickly as possible and addressing them as opposed to waiting will be a real option for patients.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I'm curious your thoughts on this. Of course there is a burden, but now we do have so many better tools, so many better technologies. We've got all these automated insulin delivery systems. I mean, I've got several patients that are easily able to get that 70-80% time in range. What do you think with all the new technologies, is it still as much of a burden? Do we still, should prevention or should cure? Is it still important?

Natalie Bellini, DNP, FNP-BC: I think it is. And some of the reasons are that we don't know. It's very hard sometimes. We can all talk about the patient, the person with diabetes who's had an A1C of 12 and they end up with eye disease, right? And those people that suffer and that they're trying to just get food on the table and trying to get their heat turned on a regular basis, their blood sugar sometimes can reflect those challenges in their lives. The social determinants of health when you, with type one diabetes are very similar to the social determinants of health with type 2 diabetes and the management of it all and the overwhelming feeling. So AID, automated insulin delivery, is still not for everyone. And I certainly, I have amazing patients who do very, very well. But I also have a lot of patients who really struggle, even with amazing technology that wasn't here 20 years ago, to get to goal and not feel like that's all they do every day. There is a place for delaying the onset. You could choose not to use the medication. We always want to provide a fair and balanced discussion. And this is a harder one because if you don't use the drug, there isn't another drug option. But you could just wait for the diabetes to come. And I don't know that we can always pick the patient that will suffer or have higher burden from the disease than other people. Because you and I both have those, we have both patients who seem to suffer a lot and who just struggle with the management, the daily management, and others who don't have that same challenge with it. They don't like it. They never wake up and say, there's a great diabetes day. But they also don't have the depression and some of the other things that kind of come with that wear and tear of diabetes daily.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Yes, I'm with you. I mean, I'm thrilled with all the different tools and the technologies we have. And I do tell my patients, I'm like, this is, if you must develop diabetes, this is the best time in history to have it because we have all these tools. But the reality is for automated insulin delivery currently, it does require wearing 2 sites. Your pump, you have your CGM, maybe at some point it'll be consolidated into one, but it's still wearing something all the time. And when you wear something, it's you have something on your body. If it falls off, that's a problem, right? You're not getting what you need. I agree with you. I think the cure, the prevention should still be a major focus. And I'm very excited to see that we are finally moving the needle on this. I mean, how many times have you heard a cure is five years away?

Natalie Bellini, DNP, FNP-BC: 50 years now. Right? We've been hearing it for our whole careers. Right.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Right, and I don't know if the cure is 5 years away, but I know that we have gotten a lot closer. The fact that we can delay diabetes by a few years. And even the thing is, it's not just the delay. Because it's also the preservation of those beta cells. Even if you say, ok, well, the person got 2 or 3 extra years of not having type 1 diabetes, well, when they did get it, what were those first few years like? Maybe they were a lot easier. Maybe they were able to be managed on initially a long, or just a little bit, a tiny bit of insulin. They weren't having these wide fluctuations in glucose levels. If we've improved their quality of life for several years, that is something.

Natalie Bellini, DNP, FNP-BC: Have we not done, right?

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: That's something big.

Natalie Bellini, DNP, FNP-BC: I agree with you wholeheartedly. I also loved her discussion around adding other drugs. This is not going to be the 1 and only drug that is ever going to be used to delay the onset of all kinds of autoimmune diseases. They're looking at Crohn disease, they're looking at, other groups are looking, other companies are looking, right? And that's important too. Is there going to be where we say, you have these 3 antibodies, but you don't have this one. Can we make that person a cocktail in the future to delay the onset longer, to prevent, what if you could get to 10 years? Would you do that? Those are the discussions in the future that we can have.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Yes, it's definitely very exciting. Well, thank you for this very rich and informative discussion, and thanks to our audience for tuning in. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming MedCast® episodes and other great content in your inbox.

Transcript Edited for Clarity