Diabetes Update: Type 1 Breakthrough & Type 2 Setback

Can Type 1 Diabetes Onset Be Delayed?

Bad outcomes happen to other people — this is the typical mindset of the average patient that Jane S. Davis, CRNP, DNP, sees in her nephrology practice. As naïve as that mentality might be, especially for patients who have been diagnosed with diabetes and will certainly face the consequences of ill health, including disability and death, if they do not actively manage their condition, Davis is still reluctant to use what she describes as “scare tactics” to help patients live their healthiest life. It’s a method of caring for and providing education to her patients that have proven successful despite the ongoing and alarming trend of younger patients (defined as early teens) being diagnosed with type 2 diabetes and more likely to have serious diabetes-associated complications by their mid-20s. According to the second “Treatment Options for Type 2 Diabetes in Adolescents and Youth” (TODAY 2) study sponsored recently by the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, young patients are experiencing a more aggressive disease progression today as compared to the past and are more likely to die from their disease due to a variety of comorbid complications, including heart attack and renal failure. The disease may be aided by what has become a generally unhealthy set of lifestyle habits among today’s youth, said Davis, including environmental factors that may not be entirely their fault or within their opportunities to control. 

“Young kids have poor diets and are inactive,” she said. “Schools have eliminated physical education [classes] and those that have it, often do not use it effectively. “Parents are buying muffins and doughnuts for breakfast for their children, and children are more likely to get a ride most places today. I realize that this is also safety-related [from a society perspective].”

Where they can have control, despite their age, however, is in the healthcare provider’s office. That is, if the healthcare provider is well informed and willing to help accommodate this patient population, according to Davis, who said she likes to empower her patients not by using scare tactics but by trying to get to know them as best as possible on a personal level and then tailoring her communication to their lifestyle and habits. She estimates that about 40 percent of her patients who start dialysis have been diagnosed with diabetes and that 30 percent have hypertension (and most have both).  

“This approach takes time, and we are often pushed to see more patients in a shorter timeframe, but when I have a new patient I always ask about their life. I ask about their work, their family. That way I can tailor my explanations to something to which that patient can relate to.” As an example, she described an instance with a young male patient who had also been diagnosed with developmental delays who was on staff in a hospital kitchen. Davis limited his education to renal replacement modalities such as hemodialysis, peritoneal dialysis, transplantation, and medical management), and she explained how important hand washing and maintaining a clean environment would be for patients living with his type of circumstances to help to give him a sense of control over his environment and his health.

“Putting the patient in charge is a positive approach,” she said. “I also tell them there are few decisions that can’t be reversed or changed but that they have to want to be in control. Putting patients in control of their own health makes them responsible. Scare tactics don’t always work because if, for example, I tell patients they will damage their kidneys if they don’t control their blood sugars and they continue with an A1c of between 8 and 10 and their kidney function is not affected, then I am ‘wrong’ and they may continue on their [poor] path. For many, if they had taken a different path they would not be where they are. Often, it is a lack of resources and not totally their fault that they are unhealthy, but, as a provider, I take patients where they are and go from there. I see no value in dwelling on past missteps that my patients may have taken.”
Of the more than 500 young participants involved in the TODAY study, five died of various causes, mostly related to their diabetes, within about 7.5 years of being diagnosed, according to those who led the study.

“Cardiovascular risk factors are highly prevalent in the population, target organ damage is evident, and serious cardiovascular events are occurring at rates unexpected for age [around mid-20s],” said lead investigator Philip S. Zeitler, MD, PhD, professor of pediatrics-endocrinology, University of Colorado School of Medicine, Aurora, during a press briefing this summer during the American Diabetes Association’s 2019 Scientific Sessions.1

The studies researchers suggest that a very rapid loss of glycemic control is partly to blame for a need for more aggressive management in today’s youth than many adults with type 2 diabetes. Still, more research is needed to better understand the reasons for the more serious trajectory in youth-onset type 2 diabetes, according to the TODAY 2 authors. The full results can be found through the National Institutes of Health.2

Yale Research Claims Type 1 Diabetes Onset Can Be Delayed

The use of teplizumab, an investigational anti-CD3 monoclonal antibody monoclonal antibody that is being evaluated for treatment and prevention of type 1 diabetes by the biopharmaceutical company Provention Bio, Tewksbury, NJ, has become the first drug to produce a delay in the onset of type 1 diabetes, according to results of a trial that included high-risk participants (pediatrics and adult relatives of patients diagnosed with type 1). According to a recent report, phase 2 of the randomized, placebo-controlled trial of nearly 80 people who all had two or more autoantibodies and subclinical abnormal glucose tolerance, and who received teplizumab infusions for 14 days, saw delayed development of type 1 diabetes by 2 years compared to placebo, without major adverse events.3    

The drug company is now reportedly evaluating a regulatory path forward for the drug for at-risk individuals while another newly begun trial will be assessing teplizumab in newly diagnosed type 1 patients. Although the delay in diagnosis among those who did eventually develop type 1 diabetes with teplizumab was only 2 years, that duration of not living with the condition “makes a big difference,” according to researchers, who hail the findings as very clinically significant, especially among pediatric patients.3 The NIH offers more findings online.4

References

  1. Busko M. ‘Alarming’ Complications in 20-Year-Olds With Type 2 Diabetes. Medscape. 2019. Accessed online: www.medscape.com/viewarticle/914141
  2. TODAY2 Phase 2 Follow-up (T2P2). NIH. 2019. Accessed online: https://clinicaltrials.gov/ct2/show/NCT02310724
  3. Tucker ME. Game Changer: Antibody First to Delay Type 1 Diabetes Onset in TrialNet. Medscape. 2019. Accessed online: https://www.medscape.com/viewarticle/914171
  4. Recent-Onset Type 1 Diabetes Trial Evaluating Efficacy and Safety of Teplizumab (PROTECT). NIH. 2019. Accessed online: https://clinicaltrials.gov/ct2/show/NCT03875729

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