Elaine M. Apperson, MD

Getting to know families and patients with diabetes has been a real privilege and honor in the scope of my practice. More than anything, you begin to realize that they have no option but to get up every day and face their diabetes, knock it down for the day, go to bed, and do it all over again. Whatever their effort was yesterday, they don’t really get to bank that and skate on the next day. They really have to do it all over again. Because of that, you don’t want any other members of the family, or they themselves to have to do that day after day.

Through antibody screenings, we want to prevent diabetes as much as possible. That is a complex endeavor. For decades we’ve been trying to cure diabetes, and for decades we’ve tried to prevent diabetes. The immune system has a definite mind of its own. I think of it like a military. A military has many divisions and doesn’t use just 1 division to come at you from 1 angle. With research, we are able to look at different ways that the immune system attacks the beta cell, and we have come up with various angles to try to prevent the immune system from attacking the beta cell from various angles. Thus far, unfortunately, we don’t have something widely available that prevents all the ways in which the immune system can attack the beta cell. We are definitely trying, but as yet nothing has been totally successful. It could be that in the future, there are going to be several different agents that will need to be used to shut down that attack.

Other ways that we think about how we can get a child to continue to have functioning beta cells is by infusing those cells or creating those cells. One of the challenges there is to, if we create those cells, we want to make sure that those cells can make insulin, but we don’t want them to make insulin all the time. Obviously, we only want them to make insulin when the blood sugar is at a certain level, and we want them to stop making insulin when the blood sugar starts to fall, just like our own insulin cells do in such a miraculous way all of the time. This has been a decades-long process, and the number of people who are dedicated to making this work are boundless. Many of them have diabetes or they know someone who has diabetes, and this is their life’s work and passion. We are so lucky to have them working day and night on this cause.

As they do that work, we still want the best quality of life for those patients we see and their families. We want them to be able to carry on playing softball and T-ball, going to school, going to parties, going on field trips, doing everything they want to do, and just incorporating diabetes into their lives. So, one of the exciting things we’ve witnessed as providers is technology evolving to help them do those things. Many of our patients here have not checked a finger-stick blood sugar level in a very long time, and they have not given themselves a shot in a very long time. They wear a continuous glucose sensor and an insulin pump, and over the past year to year and a half, those devices, the sensor and the pump, have been talking to one another and delivering insulin on an automated basis. That has provided a great improvement in glucose control for those patients. The complications that we mentioned earlier are becoming less common, and we love to see that.

We won’t ever drop our pursuit of a complete, 100% cure, but a lot of work is going on in a lot of avenues, and we hope it all works because that’s what we do, and that’s what we’re here to do. In the meantime, we’ll take care of these patients one by one and ensure that we do our best for them. They didn’t ask for this, and as soon as we can rid them of this burden, the better off they will all be, and we’ll all be very happy for them.

On occasion, diabetes can be a great pretender. A child might show up to your office just with complaints of abdominal pain, or with a complaint of fatigue. A child doesn’t always show up with classic symptoms of weight loss, increased thirst, and increased urination. If the complaint seemed vague, and you aren’t really sure what’s going on, but the child just has a bit of malaise, it is never a bad idea to get a finger stick for blood sugar and a urinalysis. The urinalysis will show you whether there are any ketones, and if the child’s spilling blood sugar. The glucose test will show you whether there’s any hyperglycemia. With those tools, you can rule out whether the abdominal pain, if there is such, is a product of ketosis. You can also see whether the blood sugar has been over 200 mg/dL and the child is spilling glucose in their urine, and obviously, the point-of-care glucose test shows you whether they are hyperglycemic. Those 2 simple points-of-care tests will give you a wealth of information and will essentially rule out new onset diabetes for you with each child who has vague complaints.

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Dr Elaine M. Apperson shares diabetes prevention strategies and mitigating disease complications in the pediatric population as well as advice for health care practitioners managing the disease.

Approaching Prevention and Management of Diabetes

Nothing has been approved by the FDA to use as an intervention. When you monkey around with giving something that would alter, be an immune modulator, you better have some long-term data showing safety. We don’t have that yet. The idea most likely is that it’s going to look something like chemotherapy where you have multiple immune modulators at the same time to thwart the immune system’s attack. By the time you’re showing signs of elevated blood sugar, you’ve lost about 90% of your beta cell function. That doesn’t leave you a whole lot of room to operate. So by the time you’re requiring insulin and that sick, you’ve only got a small margin of working beta cells. We don’t have anything that is out on the market to do anything at stage 1 or 2. That’s why we keep working.

Even when they tried to transplant pancreatic cells from cadavers, the immune system would tear those up. The hard part was shutting down the immune system and the morbidity from that. With immunosuppressant drugs the outcomes were terrible, and the immune system would, even if you tried suppressing it, the cells would not thrive. Patients could go sometimes insulin free or with very reduced insulin for a few years, but overall, in general, it was not a successful endeavor.

Right now, to be honest, where we are with hooking up sensors to insulin pumps and automating those systems where the sensor tells the pump how much insulin to deliver every 5 minutes, and having the patient put in the amount of carbohydrates they eat and having the insulin pump be programmed with their insulin needs for carbohydrates and for high blood sugar, and have that happen, essentially automatically like an external pancreas, is our quasi cure. And the good thing about technology is that you can press stop, you can take it off, and you haven’t monkeyed around with your physiology internally. That’s where we are, essentially, and it’s producing great outcomes. Would it be nice to have a biological cure right away? Sure, but in the meantime, 75% or more of our patients are on a pump, a CGM [continuous glucose monitor], or both, and they do pretty well.

Elaine M. Apperson, MD, addresses early intervention and technologies for monitoring type 1 diabetes for disease management.

Monitoring Type 1 Diabetes

Sometimes it takes a second or third visit to an urgent care or a PCP [primary care provider] office to recognize signs of type 1 diabetes. Buzzwords are important to have in a PCP’s ear. Fatigue and frequent urination, for example. Sometimes they hear frequent urination and they go right to UTI [urinary tract infection]; or polydipsia, nocturia, UTI. Additionally, unintentional weight loss and abdominal pain. Abdominal pain can occur if you’re having keto acids with fat burning.

I think they will never ever go wrong with doing a urinalysis and a fingerstick blood sugar test. If a patient is spilling glucose and has some ketones on their urinalysis and they get a blood sugar test done, they’re always going to find it. Sometimes I never get to see the blood sugar results, and there is no urinalysis. To me those tests are so easy because they have the ability to do that in every single office.

An expert pediatric endocrinologist discusses raising awareness among pediatricians about type 1 diabetes.

Awareness of Type 1 Diabetes

We discussed a little earlier about stages of developing type 1 diabetes, and we talked about how the immune system can start attacking beta cells, which are so necessary for glucose control. Generally, when a patient presents with full-blown diabetes they are referred to a pediatric endocrinologist. We know the sibling risk is about 5%. At a pediatric endocrinology visit where the child is being treated, at that point, the sibling or siblings of that patient are offered antibody screening. The reason is that we are working in research settings on trying to find some interventions that could thwart or postpone the onset of type 1 diabetes in patients before they develop it. We don’t have the 1-shot preventive treatment now, but we certainly are working toward possibly a few different interventions that could be used simultaneously to delay or even negate the onset of type 1 diabetes in patients who have not been diagnosed by working on immune system interventions.

We offer that screening in the pediatric endocrinology office to siblings, and if one of the siblings shows that they have 2 or more antibodies, they are eligible potentially for some of the trials we run across the country. Here in our office, we have just concluded 1 trial that we use for siblings. Additional trials are at different centers and are made available to families who wish to participate. It’s an ongoing process and a labor of love because it takes years to collect the data and figure out whether we’re making any impact at all. We definitely appreciate when our patient’s siblings choose to participate and parents choose to make the effort to help us do that work.

Dr Elaine M. Apperson provides insight on when to refer patients with type 1 diabetes to pediatric endocrinology and comments on offering sibling antibody screening.

Elaine M. Apperson, MD

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