Pharmacological therapies to address obesity in type 1 diabetes

Impact of tirzepatide in a patient with type 1 diabetes and obesity: A case report

BACKGROUND

The purpose of this case report is to describe the use of tirzepatide, a glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 receptor agonist, in a patient with type 1 diabetes mellitus (T1DM) and obesity.

CASE SUMMARY

A 23-year-old female with T1DM since the age of 10 years was referred to an endocrinology clinic for specialized diabetes care with a pharmacist owing to increasing insulin requirements and resistance. At baseline, the patient weighed 195 pounds (86.64 kg), which had increased significantly by approximately 40 pounds in the last year, and had a body mass index of 38 kg/m2 and hemoglobin A1c (HbA1c) level of 7.4%. She used hybrid closed loop insulin pump technology with continuous glucose monitoring in 100% automation mode. The patient used on average 55.4 units of basal insulin and 26.5 units of bolus per day (total daily dose, 81.9 units) with a time in range (TIR) of 31%. The patient was started on tirzepatide 2.5 mg weekly and titrated to 7.5 mg weekly with 4-week dose titrations. After 12 weeks, the patient's TIR had doubled to 61% with improvements in glucose variability, insulin requirements had decreased to 57.6 units per day, HbA1c had decreased to 6.9%, daily carbohydrates had decreased by approximately 24%, and weight had decreased to 188 pounds (-7 lbs).

PRACTICE IMPLICATIONS

With additional studies, tirzepatide may be a safe and effective option for patients with T1DM and obesity to improve glycemic control, reduce insulin requirements, and promote weight loss.

Differential Effects of Aromatic Residues on Amyloid Formation and Cytotoxicity of Human IAPP

Islet amyloid polypeptide (IAPP) is a 37-residue polypeptide hormone secreted by the pancreatic β-cells. IAPP plays a role in glycemic regulation, but in the pre-type-2 diabetic state, it aggregates to form an islet amyloid. The process of islet amyloid formation contributes to β-cell dysfunction and disease progression. The features of the IAPP sequence that modulate amyloid formation are still not understood. Human IAPP contains three aromatic residues, F15, F23, and Y37. F15 and Y37 are highly conserved, while F23 is more commonly a Leu or Ile in other species. The role of the aromatic residues in modulating the time course of amyloid formation and the cytotoxicity was examined using aromatic to Leu mutations. All three single and double mutants and the triple mutant were studied. F23 plays a dominant role in both amyloid formation and toxicity. An F15L mutant accelerated amyloid formation, a Y37L mutant had little effect, while an F23L replacement slowed amyloid formation by a factor of 2.6. Double mutants, which contained an F23L replacement, had a larger effect than those that did not, and there are non-additive effects between pairs of aromatic residues. F23 also plays a key role in toxicity. Single or multiple mutants that contain the F23L replacement were noticeably less toxic than the wild-type or mutants which did not include the F23L substitution. In contrast, the F15L mutant was more toxic than the wild-type one. The implications for IAPP amyloid formation and for the design of non-aggregating analogues of IAPP are discussed.

Pramlintide: A Novel Therapeutic Approach for Osteosarcoma through Metabolic Reprogramming

Despite aggressive combination chemotherapy and surgery, outcomes for patients with osteosarcoma have remained stagnant for more than 25 years, and numerous clinical trials have identified no new therapies. p53 deletion or mutation is found in more than 80% of osteosarcoma tumors. In p53-deficient cancers with structurally altered p63 and p73, interfering with tumor cell metabolism using Pramlintide (an FDA-approved drug for type 2 diabetes) results in tumor regression. Pramlintide response is mediated through upregulation of islet amyloid polypeptide (IAPP). Here, we showed that osteosarcoma cells have altered p63, p73, and p53, and decreased IAPP expression but have the two main IAPP receptors, CalcR and RAMP3, which inhibit glycolysis and induce apoptosis. We showed that in osteosarcoma cells with high- or mid-range glycolytic activity, Pramlintide decreased cell glycolysis, resulting in decreased proliferation and increased apoptosis in vitro. In contrast, Pramlintide had no effect in osteosarcoma cells with low glycolytic activity. Using a subcutaneous osteosarcoma mouse model, we showed that intratumoral injection of Pramlintide-induced tumor regression. Tumor sections showed increased apoptosis and a decrease in Ki-67 and HIF-1α. These data suggest that in osteosarcoma cells with altered p53, p63, and p73 and a high glycolytic function, Pramlintide therapy can modulate metabolic programming and inhibit tumor growth.

Association of Insulin Regimen and Estimated Body Fat Over Time among Youths and Young Adults with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

AIMS

To explore how changes in insulin regimen are associated with estimated adiposity over time among youths and young adults with type 1 diabetes and whether any associations differ according to sex.

MATERIALS AND METHODS

Longitudinal data were analyzed from youths and young adults with type 1 diabetes in the SEARCH for Diabetes in Youth study. Participants were classified according to insulin regimen categorized as exclusive pump ("pump only"), exclusive injections ("injections only"), injection-pump transition ("injections-pump"), or pump-injection transition ("pump-injections") for each follow-up visit completed. Estimated body fat percentage (eBFP) was calculated using validated equations. Sex-specific, linear mixed effects models examined the relationship between the insulin regimen group and change in eBFP during follow-up, adjusted for baseline eBFP, baseline insulin regimen, time-varying insulin dose, sociodemographic factors, and baseline HbA1c (≥9.0% vs. <9.0%).

RESULTS

The final sample included 284 females and 304 males, of whom 80% were non-Hispanic white with mean diagnosis age of 12.7 ± 2.4 years. In fully adjusted models for females, exclusive pump use over the study duration was associated with significantly greater increases in eBFP compared to exclusive use of injections (difference in rate of change = 0.023% increase per month, 95%CI = 0.01, 0.04). Injection-to-pump transitions and pump-to-injection transitions were also associated with greater increases in eBFP compared to exclusive use of injections (difference in rate of change = 0.02%, 95%CI = 0.004, 0.03, and 0.02%; 95%CI = 0.0001, 0.04, respectively). There was no relationship between the insulin regimen and eBFP among males.

CONCLUSIONS

Among females with type 1 diabetes, exclusive and partial pump use may have the unintended consequence of increasing adiposity over time compared to exclusive use of injections, independent of insulin dose.

Body mass index, basal insulin and glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system remain stable - 1-year prospective, observational, two-center study

BACKGROUND

Information on the influence of insulin treatment using advanced hybrid closed loop systems (AHCL) on body weight of young patients with type 1 diabetes (T1D) is scarce. The aim of this study was to observe whether there were any changes in body mass index (BMI) of children and adolescents with T1D treated using the Medtronic Minimed 780G AHCL after 1 year of follow up and to analyze potential associations between these changes and the insulin doses.

MATERIALS AND METHODS

For 50 children and adolescents (age 5.4-16.8 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system anthropometric and AHCL data were collected prospectively. BMI Z-scores and two-week AHCL records obtained after AHCL enrollment were compared with data after 6 months and also 1 year after starting AHCL.

RESULTS

The BMI Z-score of the patients at 1 year follow-up did not change from time of AHCL initiation (0.51 ± 2.79 vs 0.57 ± 2.85, p>0.05). There was a slight increase in total daily insulin per kg of body weight (0.67 ± 0.21 U/kg vs 0.80 ± 0.21 U/kg, p <0.001), but the percent of basal insulin was unchanged (34.88 ± 6.91% vs 35.08 ± 6.30%, p>0.05). We observed also no change (AHCL start vs after 1 year) in glycemic control parameters: average sensor glucose (131.36± 11.04 mg/dL vs 132.45 ± 13.42 mg/dL, p>0.05), coefficient of variation (34.99± 5.17% vs 34.06 ± 5.38%, p>0.05), glucose management indicator (6.45 ± 0.26% vs 6.48 ± 0.32%, p>0.05), and time spent in the range of 70-180 mg/dL (79.28 ± 8.12% vs 80.40 ± 8.25%, p>0.05).

CONCLUSION

During the 1 year of follow-up the BMI of children and adolescents with T1D treated with an AHCL system remained stable. Although there was a slight increase in the total daily insulin dose, the percent of basal insulin was unchanged. The patients maintained recommended glycemic control.

Multi-Faceted Influence of Obesity on Type 1 Diabetes in Children - From Disease Pathogenesis to Complications

The prevalence of overweight and obesity among youth patients with diabetes type 1 is increasing. It is estimated, that even up to 35% of young patients with this type of diabetes, considered so far to be characteristic for slim figure, are overweight or even obese. General increase of obesity in children's population complicates differential diagnosis of the type of diabetes in youths. Coexistence of obesity has clinical implications for all stages of diabetes course. It is confirmed that obesity is the risk factor for autoimmune diabetes, and is connected with the earlier onset of diabetes in predisposed patients. Many diabetic patients with obesity present additional risk factors for macroangiopathy, and are recognised to present metabolic syndrome, insulin resistance, and typical for diabetes type 2 - polycystic ovary syndrome, or non-alcoholic fatty liver disease. The prevalence of obesity rises dramatically in adolescence of diabetic child, more often in girls. It has negative impact on metabolic control, glycaemic variability and insulin demand. The risk for microangiopathic complications increases as well. The treatment is difficult and includes not only insulinotherapy and non-pharmacological trials. Recently treatment of insulin resistance with biguanids, and treatment with typical for type 2 new diabetes drugs like GLP-1 analogues, SGLT-2 receptor inhibitors, or even cases of bariatric surgery also has been reported.

The association between overweight/obesity and double diabetes in adults with type 1 diabetes; a cross-sectional study

BACKGROUND

Double Diabetes (DD), type 1 diabetes (T1DM) + insulin resistance (IR), is associated with increased risk of micro/macro-vascular complications and mortality. Obesity can contribute to the development of DD. This study explored the prevalence of overweight/obesity and their association with DD in adults with T1DM.

METHODS

Cross-sectional study of consecutive adults with T1DM attending diabetes clinics in a secondary care hospital (January-November 2019). Estimated glucose disposal rate (eGDR) was used as a marker of IR, and an eGDR < 8 was used to identify individuals with DD.

RESULTS

One hundred seven adults with T1DM were included; female/male: 51/56; age [median (inter-quartile range): 30.0 (23-51) years]; BMI 25.4 (22.8-30.0) kg/m². Overweight/obesity prevalence was 57/107 (53.3 %) [overweight: 30/107 (28 %); obesity: 27/107 (25.2 %)]. Compared to those with normal BMI, individuals with T1DM and overweight/obesity had longer diabetes duration; higher total daily insulin dose; and higher DD prevalence: 48/57 (84.2 %) vs. 14/50 (28 %) (p < 0.01); with similar HbA1c. BMI correlated with total daily insulin dose (rho = 0.55; p < 0.01). Individuals with DD were older, had longer duration of diabetes, higher HbA1c, and more adverse lipid profile and microalbuminuria compared to those without DD.

CONCLUSIONS

Overweight/obesity is very common in adults with T1DM, and is associated with double diabetes. BMI is positively associated with total insulin dose. Double diabetes is associated with adverse cardiovascular risk profile and is also common in lean individuals with T1DM. Further research is needed to examine the impact of overweight/obesity in people with T1DM and whether weight loss in this population can improve diabetes-related outcomes.