A new look at brittle diabetes

Pharmacotherapy of type 1 diabetes - part 1: yesterday

INTRODUCTION

Type 1 diabetes is a unique autoimmune attack on the β cell of the pancreatic islet resulting in progressive destruction of these cells and as a result the ability of the body to maintain insulin production. The consequences of insulin deficiency are very severe, and the disease was fatal prior to the ability to extract insulin from animal pancreas in 1921. We review progress in the treatment of childhood type 1 diabetes over the past 100 years.

AREAS COVERED

We used PubMed and standard search engines to search for the evolution of diagnosis and treatment of type 1 diabetes.

EXPERT OPINION

Insulin replacement proved lifesaving for children afflicted with type 1 diabetes. However, it was observed that these children suffered from microvascular and large vessel disease. The Diabetes Control and Complications Trial (DCCT) with its extension Epidemiology of Diabetes Interventions and Complications Trial (EDIC) proved that control of blood glucose as close to normal as possible could prevent these diabetes-related conditions. Many formuations of insulin with varying onset and duration of action have been developed; yet normalization of glucose levels is difficult due to hypoglycemic events. There is continued progress toward that goal.

Automated insulin delivery systems in elderly patients with brittle type 2 diabetes

PURPOSE

Geriatric diabetes is complicated by the frailty of this population, and hypoglycemia with insulin is not uncommon in these patients. Automated Insulin Delivery (AID) systems may provide better glycemic control in elderly patients with brittle type 2 diabetes.

METHODS

Thirty-four patients (≥ 60 years) including cancer patients with brittle diabetes were switched to an AID system from multiple-dose insulin (MDI) treatment. HbA1c level, weight, total daily insulin requirement, and C-peptide, creatinine, and lipids were followed for at least six months.

RESULTS

There were 34 patients (14 male, 41.2 %) with a median age of 67 (IQR 63.0-75.5). Six patients (17.6 %) were on chemotherapy and/or steroids (Ch/S). The patients' initial median HbA1c % was 9.3 (IQR 7.6-11.0), c-peptide level was 0.9 (IQR 0.5-2.2) ng/mL, and median total daily insulin dose was 41 IU (IQR 32-53). Six months after the patients were switched to an AID system their HbA1c % decreased to 7.1 (IQR 6.5-8.1), p < 0.001 and c-peptide increased to 1.21 (IQR 0.2-1.7) ng/mL, p = 0.878. Total insulin dose decreased with AID systems [32 IU (IQR 23.9-37.8)), p < 0.001]. There was a decrease in median HbA1c % in patients on Ch/S [8.7 (IQR 7.0-11.5) to 6.9 (IQR 6.3-9.2)] however it didn't reach statistical significance p = 0.225. Total insulin dose also decreased without statistical significance [33 IU (IQR 41-28) to 28 (IQR 23-35), p = 0.173]. The mean time in range (TIR) percent of the patients with AID systems were as follows; <54 mg/dL was 0.5 %, 56-70 mg/dL was 1.3 %, 70-180 mg/dL was 64.8 %, >180 mg/dL was 26.7 % and > 250 mg/dL was 6.7 %.

CONCLUSION

Although AID systems are tested mostly in young type 1 patients our results show that elderly patients with brittle type 2 diabetes also benefit from an AID system. Even in very frail patients such as cancer patients, improvement can be seen.

Insights in Nutrition to Optimize Type 1 Diabetes Therapy

Nutrition is an essential part of therapy for type 1 diabetes and is constantly evolving, offering growing opportunities to prevent this disease, slow down its evolution, and mitigate it. An attempt was made to bring together the current state of knowledge. In the path from the preclinical phase of the disease to its clinical onset, there is a phase known as the "honeymoon period" or partial remission, where different possible dietary options for combatting this disease have been presented. The most commonly used dietary models were compared, and the most frequent co-existing pathologies, such as overweight, non-alcoholic fatty liver disease, dyslipidemia, celiac disease, and metabolic instability, were addressed from their nutritional and dietary perspectives to provide clinicians with an updated framework of knowledge and support researchers in further investigations into the topic. Finally, a glimpse into the possible interplay between nutrition and the gut microbiome, food security, and ultra-processed food is provided. It is hoped that clinicians treating people with type 1 diabetes will be provided with further opportunities for the daily management of their patients through personalized nutrition.

Stiff Person Syndrome and Brittle Type 1 Diabetes: Report of 2 Cases

Background/Objective

Stiff person syndrome (SPS) and type 1 diabetes (T1D) are heterogeneous disorders characterized by antibodies (Abs) against glutamic acid decarboxylase (GAD).

Case Report

We describe 2 patients with T1D and autoimmune thyroid disease who presented with muscle rigidity and intermittent spasms that affected gait and with elevated circulating anti-GAD titers. Classic SPS and stiff limb syndrome were diagnosed, respectively. Muscle spasms resolved with immunotherapy and muscle relaxants in both patients, and the ability to ambulate without an assistive device was restored in 1 patient. Patients also had brittle diabetes with high glycemic variability, requiring the use of flash glucose monitoring with an insulin pump and a second-generation basal insulin analog, respectively.

Discussion

GAD Ab-associated syndromes include SPS, T1D, and other endocrinopathies. The clinical heterogeneity implies variable susceptibility of γ-aminobutyric acid-ergic neurons and pancreatic beta cells to anti-GAD or other autoantibodies.

Conclusion

Our case series represent the heterogeneity in natural history, clinical course, and response to therapy in patients with Abs against GAD-spectrum disorders.

Assessment of the Impact of Subcutaneous Catheter Change on Glucose Control in Patients with Type 1 Diabetes Treated by Insulin Pump in Open- and Closed-Loop Modes

Introduction: Most continuous subcutaneous insulin infusion (CSII) catheters (KT) are changed every 3 days. This study aims at evaluating whether KT changes impact glucose control while under open-loop (OL) or automated insulin delivery (AID) modes. Methods: We included patients with type 1 diabetes who used Tandem t:slim x2 insulin pump and Dexcom G6 glucose sensor for 20 days in OL, then as AID. CSII and sensor glucose data in OL and for the past 20 days of 3-month AID were retrospectively analyzed. The percentage of time spent with sensor glucose above 180 mg/dL (%TAR180) was compared between the calendar day of KT change (D0), the next day (D1), and 2 days later (D2). Values were adjusted for age, gender, body mass index (BMI), hemoglobin A1c (HbA1c) at inclusion, and %TAR180 for the 2 h before KT change. Results: A total of 1636 KT changes were analyzed in 134 patients: 72 women (54%), age: 35.6 ± 15.7 years, BMI: 25.2 ± 4.7 kg/m2, and HbA1c: 7.5 ± 0.8%. %TAR180 in the 2 h before the KT change was 51.3 ± 37.0% in OL and 33.2 ± 30.0% in AID mode. In OL, significant absolute increases of %TAR180 at D0 versus D1 (+6.9%; P < 0.0001) or versus D2 (+6.8%; P < 0.0001) were observed. In AID, significant absolute increases of %TA180R at D0 versus D1 (+4.8%; P < 0.0001) or versus D2 (+4.2%; P < 0.0001) were also observed. Conclusion: This study shows an increase in time spent in hyperglycemia on the day of the KT change both in OL and AID modes. This additional information should be taken into account to improve current AID algorithms. ClinicalTrials.gov: NCT04939766.

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.

Revolutionizing pancreatic islet organoid transplants: Improving engraftment and exploring future frontiers

Type-1 Diabetes Mellitus (T1DM) manifests due to pancreatic beta cell destruction, causing insulin deficiency and hyperglycaemia. Current therapies are inadequate for brittle diabetics, necessitating pancreatic islet transplants, which however, introduces its own set of challenges such as paucity of donors, rigorous immunosuppression and autoimmune rejection. Organoid technology represents a significant stride in the field of regenerative medicine and bypasses donor-based approaches. Hence this article focuses on strategies enhancing the in vivo engraftment of islet organoids (IOs), namely vascularization, encapsulation, immune evasion, alternative extra-hepatic transplant sites and 3D bioprinting. Hypoxia-induced necrosis and delayed revascularization attenuate organoid viability and functional capacity, alleviated by the integration of diverse cell types e.g., human amniotic epithelial cells (hAECs) and human umbilical vein endothelial cells (HUVECs) to boost vascularization. Encapsulation with biocompatible materials and genetic modifications counters immune damage, while extra-hepatic sites avoid surgical complications and immediate blood-mediated inflammatory reactions (IBMIR). Customizable 3D bioprinting may help augment the viability and functionality of IOs. While the clinical translation of IOs faces hurdles, preliminary results show promise. This article underscores the importance of addressing challenges in IO transplantation to advance their use in treating type 1 diabetes effectively.

Donislecel-the first approved pancreatic islet cell therapy medication for type 1 diabetes: a letter to the editor

Type 1 diabetes is an autoimmune disorder which is caused due to T-cell mediated destruction of β cells of pancreas leading to insulin deficiency and hyperglycemia. The prevalence has been increasing in many countries especially Europe and America. The exogenous therapy which includes insulin administration is not sufficient in maintaining the glucose levels especially in patients with brittle T1D. Therefore, endogenous production of insulin via islet cell therapy has been a center of research for many years and results have largely supported the idea. The US. FDA approved the first cell therapy drug, Donislecel for brittle T1D which may be a crucial achievement in treatment of the autoimmune disorder.

Key indices of glycaemic variability for application in diabetes clinical practice

Near normal glycaemic control in diabetes consists to target daily glucose fluctuations and quarterly HbA1c oscillations in addition to overall glucose exposure. Consequently, the prerequisite is to define simple, and mathematically undisputable key metrics for the short- and long-term variability in glucose homeostasis. As the standard deviations (SD) of either glucose or HbA1c are dependent on their means, the coefficient of variation (CV = SD/mean) should be applied instead as it that avoids the correlation between the SD and mean values. A CV glucose of 36% is the most appropriate threshold between those with stable versus labile glucose homeostasis. However, when near normal mean glucose concentrations are achieved a lower CV threshold of <27 % is necessary for reducing the risk for hypoglycaemia to a minimal rate. For the long-term variability in glucose homeostasis, a CVHbA1c < 5 % seems to be a relevant recommendation for preventing adverse clinical outcomes.

Diabetes and diabesity in the view of proteomics, drug, and plant-derived remedies

Diabetes and obesity are highly prevalent in the world. Proteomics is a promising approach to better understanding enzymes, proteins, and signaling molecules involved in diabetes processes which help recognize the basis of the disease better and find suitable new treatments. This study aimed to summarize the molecular mechanisms from the beginning of insulin secretion in response to stimuli to the pathology of the insulin signaling pathway and, finally, the mechanisms of drugs/chemicals remedies that affect this process. The titles and subtitles of this process were determined, and then for each of them, the articles searched in PubMed and ScienceDirect were used. This review article starts the discussion with the molecular basis of insulin biosynthesis, secretion, insulin's mechanism of action, and molecular aspect of diabetes and diabesity (a new term showing the relation between diabetes and obesity) and ends with the drug and plant-derived intervention for hyperglycemia.

Diabetes Mellitus in Pancreatic Cancer: A Distinct Approach to Older Subjects with New-Onset Diabetes Mellitus

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is associated with a very poor prognosis, with near-identical incidence and mortality. According to the World Health Organization Globocan Database, the estimated number of new cases worldwide will rise by 70% between 2020 and 2040. There are no effective screening methods available so far, even for high-risk individuals. The prognosis of PDAC, even at its early stages, is still mostly unsatisfactory. Impaired glucose metabolism is present in about 3/4 of PDAC cases.

METHODS

Available literature on pancreatic cancer and diabetes mellitus was reviewed using a PubMed database. Data from a national oncology registry (on PDAC) and information from a registry of healthcare providers (on diabetes mellitus and a number of abdominal ultrasound investigations) were obtained.

RESULTS

New-onset diabetes mellitus in subjects older than 60 years should be an incentive for a prompt and detailed investigation to exclude PDAC. Type 2 diabetes mellitus, diabetes mellitus associated with chronic non-malignant diseases of the exocrine pancreas, and PDAC-associated type 3c diabetes mellitus are the most frequent types. Proper differentiation of particular types of new-onset diabetes mellitus is a starting point for a population-based program. An algorithm for subsequent steps of the workup was proposed.

CONCLUSIONS

The structured, well-differentiated, and elaborately designed approach to the elderly with a new onset of diabetes mellitus could improve the current situation in diagnostics and subsequent poor outcomes of therapy of PDAC.

Association Between Intestinal Prevotella copri Abundance and Glycemic Fluctuation in Patients with Brittle Diabetes

Objective

Previous studies have demonstrated an association between gut microbiota composition and non-brittle type 2 diabetes (NBT2DM) pathogenesis. However, little is known about the correlation between the abundance of intestinal Prevotella copri and glycemic fluctuations in patients with brittle diabetes mellitus (BDM). In this context, we conducted a case-control study of BDM patients and patients with NBT2DM, aiming to determine and analyze the relationship between the abundance of intestinal Prevotella copri and glycemic fluctuations in patients with BDM.

Research Design and methods

We performed a metagenomic analysis of the gut microbiome obtained from fecal samples of 10 BDM patients, and compared their microbial composition and function to NBT2DM patients (1:1 ratio). Then further collected data including age, sex, BMI, glycated hemoglobin (HbA1c), blood lipids, and alpha diversity of the gut microbiota, which were comparable between the BDM and NBT2DM patients by t-test.

Results

A significant difference existed in the beta diversity of the gut microbiota between the two groups (PCoA, R² = 0.254, P = 0.0001). The phylum-level abundance of Bacteroidetes in the gut microbiota of the BDM patients was significantly lower, by 24.9% (P = 0.001), than that of the NBT2DM patients. At the gene level, the abundance of Prevotella copri was obviously reduced, Correlation analysis showed that the Prevotella copri abundance was inversely correlated to the standard deviation of blood glucose (SDBG) (r = -0.477, P = 0.034). Quantitative PCR confirmed that the abundance of Prevotella copri in the BDM patients in the validation cohort was significantly lower than that in NBT2DM patients, and was negatively correlated with SDBG (r = -0.318, P = 0.043). Glycemic variability in BDM was inversely correlated with the abundance of intestinal Prevotella copri.

Conclusion

The decreased abundance of Prevotella copri in patients with BDM may be associated with glycemic fluctuation.

From islet of Langerhans transplantation to the bioartificial pancreas

Type 1 diabetes is a disease resulting from autoimmune destruction of the insulin-producing beta cells in the pancreas. When type 1 diabetes develops into severe secondary complications, in particular end-stage nephropathy, or life-threatening severe hypoglycemia, the best therapeutic approach is pancreas transplantation, or more recently transplantation of the pancreatic islets of Langerhans. Islet transplantation is a cell therapy procedure, that is minimally invasive and has a low morbidity, but does not display the same rate of functional success as the more invasive pancreas transplantation because of suboptimal engraftment and survival. Another issue is that pancreas or islet transplantation (collectively known as beta cell replacement therapy) is limited by the shortage of organ donors and by the need for lifelong immunosuppression to prevent immune rejection and recurrence of autoimmunity. A bioartificial pancreas is a construct made of functional, insulin-producing tissue, embedded in an anti-inflammatory, immunomodulatory microenvironment and encapsulated in a perm-selective membrane allowing glucose sensing and insulin release, but isolating from attacks by cells of the immune system. A successful bioartificial pancreas would address the issues of engraftment, survival and rejection. Inclusion of unlimited sources of insulin-producing cells, such as xenogeneic porcine islets or stem cell-derived beta cells would further solve the problem of organ shortage. This article reviews the current status of clinical islet transplantation, the strategies aiming at developing a bioartificial pancreas, the clinical trials conducted in the field and the perspectives for further progress.

Total pancreatectomy with intraportal islet autotransplantation for pancreatic malignancies: a literature overview

INTRODUCTION

'Brittle Diabetes' (BD) is a life-threatening metabolic complication after total pancreatectomy (TP). More than 500 Intraportal islet autotransplantation (IAT) have been performed to prevent this complication, with almost 70% insulin independence after 3 years. Even when insulin independence was not achieved, IAT successfully prevented severe hypoglycemia. Currently, preliminary results for oncologic situations are promising, but their oncological outcomes are still a matter of debate.

AREAS COVERED

We performed a bibliographic research of the last 25 years of data. Articles published in English in peer-reviewed journals were retained. In France, auto- and allo-islet transplantation was recently recognized as a valuable treatment for BD by the national health authority. While accepted for benign diseases, the risk of tumor spreading after IAT in oncologic situations is a source of concern.

EXPERT OPINION

Preliminary results of IAT in oncological situations are very encouraging. So far, there is no evidence of tumor dissemination. In our opinion, to overcome BD TP with IAT for resectable pancreatic malignancies in patients with a higher risk of postoperative pancreatic fistula and extended pancreatic cancers can be safely performed. Diagnosis of malignancy should not be considered as an exclusion criterion for IAT.

Human pluripotent stem-cell-derived islets ameliorate diabetes in non-human primates

Human pluripotent stem-cell-derived islets (hPSC-islets) are a promising cell resource for diabetes treatment^1,2. However, this therapeutic strategy has not been systematically assessed in large animal models physiologically similar to humans, such as non-human primates³. In this study, we generated islets from human chemically induced pluripotent stem cells (hCiPSC-islets) and show that a one-dose intraportal infusion of hCiPSC-islets into diabetic non-human primates effectively restored endogenous insulin secretion and improved glycemic control. Fasting and average pre-prandial blood glucose levels significantly decreased in all recipients, accompanied by meal or glucose-responsive C-peptide release and overall increase in body weight. Notably, in the four long-term follow-up macaques, average hemoglobin A1c dropped by over 2% compared with peak values, whereas the average exogenous insulin requirement reduced by 49% 15 weeks after transplantation. Collectively, our findings show the feasibility of hPSC-islets for diabetic treatment in a preclinical context, marking a substantial step forward in clinical translation of hPSC-islets.

Celiac Disease as a Cause of Anemia and Brittle Diabetes in Type 1 Diabetes Mellitus

Untreated celiac disease (CD) leads to an increased risk for hypoglycemia and diabetic complications. However, the diagnosis of CD can be challenging and some extra-gastrointestinal tract manifestations could be a presenting symptom. We report a case of a 29-year-old Indian male with brittle T1DM whose underlying CD was discovered from a work-up for anemia. After an introduction of a gluten-free diet, he gained 5 kgs in two months, was responsive to oral iron supplement, and had stable glycemic control with much less hypoglycemia. Even though this disease is rare in Asian populations, the diagnosis of celiac disease should always be kept in mind when people with T1DM present with unexplained microcytic anemia and/or unexplained hypoglycemia.