For over a century, type 1 diabetes means one thing. It's the lifetime of administering insulin.
However, science is not about breaking that paradigm for the first time, managing the disease, but by intercepting it before symptoms appear.
When the UK's first patients begin receiving the groundbreaking new treatment, teprizumab, they are developing a method to identify who may benefit from a drug that only works if given before symptoms appear.
The Royal Devon NHS is currently treating Hannah Robinson, the UK's first adult. Hannah Robinson was discovered by chance to suffer from type 1 diabetes during her daily pregnancy screening.
Related: New treatments could cure severe type 1 diabetes, research finds
Approximately 10% of people with diabetes are Type 1, while the remaining 90% have Type 2. This is a condition associated with lifestyle factors where insulin is still being produced but not functioning properly.
Type 1 diabetes is an autoimmune state that leads to the complete loss of insulin production from the pancreas. Without insulin, blood sugar levels are at risk, increasing the risk of blindness, kidney failure and early death.
Although type 1 is often considered a childhood illness, a study from the University of Exeter highlights that more than half of all new cases occur in adults.
For millions of people around the world who live with type 1 diabetes, treatments to reduce blood sugar refer to lifelong daily insulin. However, insulin use has its own risks.
If blood glucose is low too much, it can cause hypoglycemia or “hypochemia,” and in severe cases it can lead to seizures and death. It's no surprise that constant balancing between hyperglycemia and hypoglycemia can be a major blow to both physical and mental health. During her pregnancy, Robinson needed insulin and saw firsthand that “life fully unfolds the balance of blood glucose.”
Teprizumab offers a completely different approach. Instead of simply replacing insulin, it targets immune attacks that cause type 1 diabetes.
Our immune system is usually good at communicating our friends from enemies to friends, keeping our own organs alone, protecting us from infection and cancer. But sometimes, for reasons that are not yet fully understood, this balance breaks down in a process known as autoimmunity.
In type 1 diabetes, the immune system accidentally attacks the pancreas and destroys insulin-producing cells.
Teprizumab works by retraining the immune system and dialing down specific cells targeting the pancreas. Research has shown that mild side effects in general may delay the illness and the need for insulin therapy for two to three years.
For Robinson, who is well-known from his full-time job living with pregnancy and type 1 diabetes, the possibilities for years without insulin were really important.
The drug has already been approved in the US, and several UK children and teenagers have also received it through special access programs, but is currently under review for daily use of the NHS.
Find people quickly
There's a catch. By the time you develop symptoms of type 1 diabetes, such as thirst, weight loss, and fatigue, more than three-quarters of your insulin production ability have already been destroyed.
Similar treatments to teprizumab must be given before symptoms appear, while blood glucose levels are still normal. This means that these treatments are not an option for people who have already established type 1 diabetes.
So how do you find people in this early stage? Fortunately, it is possible to detect the onset of an autoimmune attack several years before symptoms are displayed using a simple blood test that measures immune markers called pancreatic autoantibodies.
Only a few drops from a finger prick can reveal whether the immune system has begun to target the pancreas. Finding people early not only provides an opportunity to slow the progression of the disease, but also helps avoid life-threatening emergencies that can accompany initial diagnosis such as diabetic ketosidosis.
With type 1 diabetes affecting about one in 200 people, there is still a question of who should test it. Not everyone has the same risk. Given hereditary diseases, we often imagine conditions caused by single genetic changes, such as cystic fibrosis.
Type 1 diabetes has a genetic component, but each contains many different genes that fine-tune a person's risk up and down. Having just a genetic risk is not enough, and unknown environmental factors are required to help balance.
Nine out of ten people who develop type 1 diabetes have no family history. Testing relatives in type 1 people is a logical first step, but a study at the University of Exeter suggests that combining all these genetic factors into a single risk score will help predict who develop the disease and identify babies who need to be monitored more closely.
This could be an important tool as you move towards wider genomic screening.
It's still early on, but there are fundamental changes in how we approach type 1 diabetes. For over a century, treatment has meant that patients are causing the daily burden of replacing insulin.
Now the focus is on treatments that address the immune problem that is at its source, hoping to stop the disease and open the door to an insulin-free future before it fully develops.
Richard Oram, Clinical Lecturer, University of Exeter, Nicholas Thomas University, Professor Richard Oram, Diabetes and Endocrinology, University of Exeter
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