The Future of Type 1 Diabetes Management - Episode 1

Overview of Type 1 Diabetes (T1D)

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Robert Busch, MD, and Robin S. Goland, MD, review the prevalence and pathophysiology of type 1 diabetes.

Robert Busch, MD: Hello, and welcome to this HCPLive® Peer Exchange titled, “The Future of Type 1 Diabetes Management.” I’m Dr Bob Busch. I practice endocrinology, and I’m director of clinical research at the Albany Medical Center in Albany, New York. Joining me in this discussion are 3 of my colleagues. We’ll start with Dr Goland.

Robin S. Goland, MD: Hi, I’m Dr Robin Goland, I’m the Eastman professor of medicine in pediatrics at Columbia University and the codirector of the Naomi Berrie Diabetes Center in New York, New York.

Robert Busch, MD: Dr Simmons?

Kimberly Simmons, MD, MPH/MSPH: Hi, I’m Dr Simmons. I’m a pediatric endocrinologist who practices at the Barbara Davis Center for Diabetes Pediatric Clinic in Aurora, Colorado.

Robert Busch, MD: And Dr Quattrin?

Teresa Quattrin, MD: Hi, I’m Teresa Quattrin. I’m associated with the University of Buffalo and the Oishei Children’s Hospital in Buffalo, New York. I’m a distinguished professor at the University of Buffalo, an associate dean for research integration, and a pediatric endocrinologist.

Robert Busch, MD: Welcome to all of you. I’m thrilled to be with you. Our discussion will cover the diagnosis and screening for type 1 diabetes and current and emerging treatment options. We’ll discuss how newer treatments aimed at delaying the onset of type 1 diabetes are poised to make a difference in the management of this disease. We’ll also share data with recently approved anti-CD3 monoclonal antibodies and how this and other treatments are likely to change the treatment landscape of type 1 diabetes.

To start, what’s the prevalence and incidence of diabetes? Worldwide, the prevalence of type 1 is 8.4 million individuals; about 18% are below age 20, 18% are above age 60, and the rest are between 20 and 60. In the United States, about 1.6 million individuals have type 1 diabetes, and 187,000 of them are below age 18. The incidence is about 64,000 new patients per year, and 18,000 of these are under age 18. As an adult endocrinologist, I’m usually seeing the patient when we’re called to the emergency department with diabetic ketoacidosis. I’m very interested if our pediatric endocrinologists are making the diagnosis the same way. But before we get to that, we’ll talk about the path of physiology of type 1 diabetes. Dr Goland, you’ll be discussing the autoimmune aspects of that.

Robin S. Goland, MD: Type 1 diabetes is a disease that, in many cases—you’ll hear today how some data are aiming to change this—often lands in a family like a meteorite. Although it’s a classic genetic illness that is affected by the environment, it takes a gene on the mother’s side and a gene on the father’s side, and then it’s affected by some environmental factors that we’re not sure about. That leads to the development of this autoimmune assault on the beta cell. Data from a study that you’ll hear a lot more about, the NIH [National Institutes of Health] TrialNet study, has identified that even years before the patient comes down with clinical type 1 diabetes, or stage III diabetes, we can identify in a sibling, say—someone with type 1 diabetes—that this autoimmune assault has been ongoing. The patient starts with a genetic risk for the immune system, by mistake, to attack the beta cells. This goes unnoticed and is clinically not apparent to the patient. You can lose up to 50%, and even more of your beta cells, without your blood sugar rising. This brings up the possibility of intervening before the disease is apparent and the blood sugar goes up. What triggers the antibodies, or what’s at the heart of the problem, is the T-cell destruction of the beta cells. It’s linked to certain HLA [human leukocyte antigen] types. There are some protective alleles that, in our families, are lacking.

What’s triggering all this is under intense study for what we can do to intercede because type 1 diabetes is 1 of the few autoimmune diseases that we can identify before it’s clinically apparent. In data from 1 of the young investigators at Columbia, 6 months before we meet the patient in the emergency department, the insulin levels start to fall. Finally, we have the first approved drug, as you’ll also hear more about, which looks like it could intercede in this important process.

Robert Busch, MD: That’s a great overview. Thank you.

Transcript Edited for Clarity