For almost a hundred years, the treatment of type 1 diabetes has not advanced beyond insulin replacement. However“insulin does not provide satisfactory glycemic control in most people and there remains a significant unmet need for new treatments for type 1 diabetes (DT1)”as he recently acknowledged in an article* Colin M. Dayan that, together with Danijela Tatovic, assures that “preserving beta cell function with immunomodulation offers the possibility of facilitating insulin treatment and/or preventing the need for insulin, particularly when it comes to new low-risk immunotherapies”.
The doctor. Colin Dayanfrom the Group of Diabetes and Autoimmunity of the Faculty of Medicine of Cardiff University (United Kingdom), is today responsible for the inaugural conference of the XXXV National Congress of the Spanish Diabetes Society (SED), where he summarizes the results of the main ongoing trials focused on the prevention of T1D. The Welsh expert defends the need to change the management of this disease through the use of low-risk immunotherapy, with the aim of preserving the endogenous function of beta cells and substantially facilitating metabolic control. In this way, he assures, “insulin and/or beta cell replacement (stem cells or transplant) should be considered in the future as rescue therapies reserved for late presentations”.
T1D, a disease that is more autoimmune than metabolic
As anticipated, “In my talk I will try to explain that T1D is an autoimmune disease rather than a metabolic one, identifying the risks and advantages of treating it with immunotherapy instead of insulin”.
In this sense, it shows “excited about the recent approval of the drug teplizumab to delay the need for insulin by 2 to 3 years”, especially because it is the beginning of a new era; in fact“there are at least seven other drugs that also have beneficial effects and should be able to prolong this period even more”. In his opinion, “no doubt it is now possible to delay the loss of insulin-producing cells with low risk for patients and also, now we can extend this ‘insulin-free T1D’ period for longer and longer”says the expert from the University of Wales.
According to the results that are becoming known from these studies, new and revolutionary trends in the prevention of type 1 diabetes are pointed out. “We must think about how to evaluate first-degree relatives of people with T1D (who have a 10-fold increased risk), and later to the general population, to detect preclinical type 1 diabetes (using islet autoantibodies), before too many insulin-producing cells are lost.advises Prof. Colin.
More prevention and control
Currently, like most other autoimmune diseases, T1D can be managed for many years without the need for insulin, although ongoing treatment may be necessary. “If we understand the stages of the disease, we can move towards ‘insulin-free T1D’”highlights the lecturer.
Apart from the advances in therapies aimed at preventing the disease through immunotherapy (already with a available drug that can delay the diagnosis of T1D a median of 2 years in high-risk people), “Are developing new insulins and delivery systems that facilitate this treatment in people with type 1 diabetes”highlights Dr. Antonio Pérez Pérez, president of the SED.
In the same way, according to the head of the SED, there is improving the accuracy and precision of continuous glucose monitoring systems and in what are known as artificial pancreas systems or automated insulin infusion systems, incorporating an insulin pump (a real-time continuous interstitial glucose sensor and an algorithm that determines the amount of insulin that the pump should infuse based on the readings made by the sensor).
Progress in T2D
Already among the main improvements in the approach to people with type 2 diabetes, Dr. Pérez points out “the incorporation of technology (essentially continuous glucose monitoring) for the management of patients treated with insulinand the extraordinary development of new oral and injectable drugs (GLP1 receptor agonists, dual GLP1/GIP agonists and SGLT2 inhibitors) for the treatment of hyperglycemia and comorbidities associated with diabetes”.
These drugs have greatly modified the treatment strategies of patients with type 2 diabetes since, in addition to their effect on glycemic control without increasing the risk of hypoglycemia, reduce body weight and have beneficial effects on cardiovascular and kidney protection. Besides, “In the case of GLP1 receptor agonists and dual GLP1/GIP agonists, due to their effect on weight, we can talk about the possibility to achieve long-term disease remission”assures the president of the SED.
But the threat continues
All these progress are not incompatible with a threatening reality. On the one hand, today Type 2 diabetes is a true epidemic throughout the world. In Spainaccording to data from the Network Biomedical Research Center for Diabetes and Associated Metabolic Diseases (CIBERDEM), The total prevalence of type 2 diabetes is now 13.8% of the population, a figure that becomes truly alarming if we consider that 6% of the population has diabetes and is unaware of it., and that more than 10% of the adult population is at risk of developing diabetes. Besidestype 1 diabetes accounts for between 10 and 15% of total cases and it is one of the most common chronic diseases in childhood.
Besides the high prevalenceas recognized by Dr. Pérez, who works in the Endocrinology and Nutrition Service of the Hospital de la Santa Creu i Sant Pau (Barcelona), “diabetes is a complex disease in which the long-term health problems it causes are more important than the acute episodes (such as hyperglycemia or hypoglycemia), and represents a significant overload for the person who suffers from it and for the health system”.
But there are other aspects that particularly worry the president of the SED, who remembers that “Equity is a fundamental value of our health system and innovation in medicines, procedures and digitalization are also important to continue improving the health and quality of life of patients with diabetes”. However, as reported, “Currently, the incorporation of new medications or tools into clinical practice is limited.among other factors, due to regulatory aspects of the prescription (such as visas, which frequently obey economic criteria without considering the added value of the drug)”.
Precisely because these are non-scientific criteria, the application of restrictions is very heterogeneous between countries around us and between the different autonomous communities from Spain. Added to this is the publication of guides, and above all recommendations and consensus, with differences in fundamental aspects and without a clear distinction as to whether the indications are based on the technical sheet, scientific evidence or the opinion of the authors. “All this may lead to confusion more than driving, since promote lack of equity”says the president of the SED.
References:
* Danijela Tatovic, Colin M Dayan. Replacing insulin with immunotherapy: Time for a paradigm change in Type 1 diabetes. Diabet Med 2021 Dec;38(12):e14696
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