Delaying Onset of T1D

Robert Busch, MD: How do we delay the onset of type 1 diabetes? We talked about the antibodies that can be done. Dr Quattrin, can you discuss the significance of delaying the onset of type 1 diabetes? It usually presents with ketoacidosis, which is very life-threatening. How do we prevent that?

Teresa Quattrin, MD: Despite technological advancements, I still check … But now we have much more. There’s evidence that type 1 diabetes is still an extreme burden for families. Whether we like to admit it or not, despite all the advancements, only 21% of adults in studies achieved hemoglobin A1C [glycated hemoglobin] at the target of less than 7%. It’s important to realize that even with all the technological advances, data from the T1D Exchange—another very large registry of patients around the world, along with TrialNet—show that hemoglobin A1C worsened. The importance of delaying lies in being able to have endogenous insulin production for a longer time. When you think about the 2 peaks of diagnosis—in very young patients and adolescents—these are both very critical times. If we can delay the onset and prolong the partial remission of the beta cell—it used to be called a honeymoon period, which isn’t the best way to refer to it—that’s extremely important because glycemic control and the dietary management are easier.

Dr Simmons raised the point that if one can control the situation where a patient gradually gets to a small amount of beta-cell functioning requiring insulin, then you prevent DKA [diabetic ketoacidosis]. This has implications in potential effect—acute and chronic, especially in young children’s development—but there are also clear data showing that the control is worse. The ability to delay by a median of even 3 years, and control this progression, is very relevant. I talked about the partial remission period. We also see that the abrupt increases, the highest insulin doses, more hypoglycemia, and parents fear of glycemic control. There are many other efforts in type 1 diabetes. The hope is that by delaying and by preserving some of the beta-cell function, these individuals with type 1 diabetes can benefit from these additional interventions.

Kimberly Simmons, MD, MPH/MSPH: The prevention of metabolic complications that was just discussed is important in the prevention of hypoglycemia. Another thing to think about is that for these patients and families, if you have a year without diabetes, then you have almost 1500 fewer injections, almost 2000 fewer finger pokes, or 40 fewer CGM [continuous glucose monitor] insertions. Individuals with diabetes make almost 200 additional decisions a day. When you put it in context like that, beyond the metabolic consequences, which are important, you have the burden, which is extremely important.

Robert Busch, MD: DCCT [Diabetes Control and Complications Trial] came out and then the long-term extension for the legacy effect. But I wonder if they’ll look at patients for whom you delayed type 1 diabetes, so you had normal glycemia. Will that cast an even longer shadow in the long run?

Teresa Quattrin, MD: Data from the DCCT show that those who had residual beta cell did better than other patients. The other point is that even newer data are showing that patients with diabetes feel that stigma. We think about the pump as something easy—you can push your dose—but our patients don’t feel that way. They don’t want to do it in front of their peers. It’s a very difficult, burdensome disease.

Transcript Edited for Clarity