Type 1 Diabetes in Focus: Optimizing With Early Interventions | Written Recap

Kimber Simmons, M.D., M.S., is an associate professor at the University of Colorado School of Medicine who specializes in the genetic, metabolic and immunologic diversity of autoimmune diseases, with a primary focus on Type 1 diabetes. In this Managed Healthcare Executive K-Cast video series, Simmons discusses the epidemiology of Type 1 diabetes, its causes, screening and early detection, treatment and future research.

A ‘silent’ disease

Type 1 diabetes is one of the most common chronic conditions in childhood, said Simmons, adding that the estimated prevalence is 1 in 300 people. But it is not just a pediatric disease, she noted, and approximately half of Type 1 diabetes cases are diagnosed in adulthood.

Simmons said Type 1 diabetes is an autoimmune disease that targets the insulin-producing beta cells in the pancreas. Although there are approximately 50 genes that can confer risk for the disease, the genes are not the sole cause, she said, adding that still-unknown nongenetic triggers may be involved, such as certain viral infections. Autoimmune destruction of pancreatic cells leads to lower insulin levels, which leads to higher blood glucose levels, Simmons explained. But well before people with Type 1 diabetes meet the diagnostic criteria for diabetes by virtue of high blood glucose levels, the autoimmune process that attacks beta cells is already occurring, she said.

“For the most part, Type 1 diabetes is a silent disease that can be happening for years before a patient has clinical symptoms,” Simmons said. Yet most patients are identified when they have clinical symptoms, she added. They sometimes can be ill enough to seek care in an emergency room or be admitted to a hospital for treatment of diabetic ketoacidosis.

C-peptide, autoantibodies and early detection

C-peptide is involved in the production of insulin by beta cells, and Simmons explained that C-peptide levels are an important indicator of whether someone’s pancreatic beta cells are producing insulin as they should. She said C-peptide is an important marker when people are being treated for diabetes, but it is less helpful in detecting Type 1 diabetes. “When patients have early stages of Type 1 diabetes, they can make good amounts of C-peptide, so it becomes really hard to tell if someone is developing Type 1 diabetes by just looking at C-peptide. That is why measuring autoantibodies is so important,” Simmons said. Stage 1 of
Type 1 diabetes is characterized by elevated autoantibodies and normal blood glucose levels, she noted.

Simmons stressed the importance of early detection of Type 1 diabetes. “If patients know that they’re developing Type 1 diabetes, they can set themselves up for success by planning to have appropriate care options when they need insulin. They also have options earlier, if there are treatments available to delay the onset of diabetes, or if they want to enroll in any clinical prevention trials, they have the opportunity to learn about those. So it’s really important for patients to be able to have that shared decision-making and have control of their own health, and by doing that, we really hope that then the long-term outlook for those patients is better,” she said.

Autoantibody screening

Screening for elevated autoantibodies is important because it’s the only way Type 1 diabetes can be identified before symptoms develop, Simmons stressed. “If you wait until symptoms develop, you are missing out on valuable time to allow patients to have more control over their health and let them have conversations with healthcare providers about how to best protect their health,” Simmons said. She added that there’s no question that people who have a family history of Type 1 diabetes should be screened. Approximately 1 in 20 people with a family history of Type 1 diabetes will develop the disease, according to Simmons.

Simmons noted, though, that 90% of people with Type 1 diabetes don’t have a family history, so screening only those with a family history means missing out on early detection in the majority of cases. The lower incidence in the general population means the yield of positive tests is going to be much lower, Simmons acknowledged, but she expects screening programs to gain momentum. “The only way that we’re ever going to prevent Type 1 diabetes is by identifying patients early so that we can learn more and so we can enroll them in clinical trials. This is the only way we’re going to put an end to people needing insulin and being at risk from all the long-term complications from Type 1 diabetes.”

Misdiagnosis

Type 1 diabetes develops quickly in children, so it becomes readily apparent that they have the disease and need insulin, Simmons said. In adults, the disease develops more slowly, so there may not be an acute episode for months or even every year. As a result, misdiagnosis among adults in the early stages of Type 1 diabetes is common, she said. Measuring C-peptide is very useful clinically because it can signal that people need to take action to combat insulin resistance. However, Simmons cautioned against depending on C-peptide for early detection.

“You’re not going to get the full picture,” she said, “because patients who are developing Type 1 diabetes can still make a good amount of their own insulin, especially adults. But if they have autoantibodies present, you know there’s an autoimmune process that is eventually going to lead them to not making enough insulin.”

Beta cells

Simmons said researchers are investigating ways to preserve pancreatic beta cells so they make insulin longer. Blunting or even eliminating the immune system’s attack on the beta cells is one way of protecting pancreatic beta cells, said Simmons, noting that there have been more than 10 immune-modifying medications shown to have a positive effect on the production of insulin in people newly diagnosed with Type 1 diabetes. Now, there is a question of whether some of those medications might be used to treat patients earlier in the course of the disease, she said. Another treatment strategy for Type 1 diabetes involves medications that target the beta cells, and combining the two approaches would likely have a greater effect, Simmons said.

Technology

Technology, such as continuous glucose monitoring, has helped people with Type 1 diabetes with the management of the disease, improving glycemic control and reducing the burdens from the disease. But Simmons also sounded a note of caution. “Technology has problems. Technology comes with its own issues, such as skin reactions, so although technology is critical for patients living with Type 1 diabetes, it is also not a cure.”

Difficulties

Simmons observed that despite technological advances in treatment, people with Type 1 diabetes still must cope with a chronic disease. “There are many times, especially during the teenage years, when patients are burdened and burnt out and have trouble performing the daily care tasks that we know are really important to keep them healthy,” she said. “The hard part about that is that we don’t have a medication we can give them or a magical fix for that, and it requires a lot of time with patients and a lot of empathy and a lot of understanding. But, eventually, patients usually will start to take more ownership over their health.”

Future direction

Simmons stressed the importance of people with Type 1 diabetes having access to treatment and staying involved in their healthcare decisions. She said identifying the disease early can help avoid complications that increase healthcare utilization and costs.

“The field is shifting by trying to identify people early, and my hope is that we have more and more therapies to offer people so that we can have a preventive cure,” said Simmons, “and then, by replacing beta cells in some people, we can offer a cure to people already living with Type 1 diabetes.”