We reached out to Margaret Eckert-Norton RN, PhD, FNP-BC, CDE to ask few diabetes questions and here is what she had to say.
What new medicines or therapies seem promising on the horizon, and how will they help PWDs?
In reviewing peer reviewed literature for this commentary, I found reports about pancreatic cell “plasticity” 1, 2. These reports discuss experiments being done in mice, so human application may be a long way off. The concepts is that despite autoimmune destruction of insulin producing beta cells, the neighboring pancreatic alpha and/ or delta cells may be able to be genetically manipulated to produce insulin. The alpha cells generally produce glucagon and delta cells usually produce a hormone called somatostatin. These intriguing observations may indicate that mammalian pancreatic cells could be genetically reprogrammed potentially yielding a new path to cell-replacement based therapies for persons with diabetes 1, 2 .
There has been extensive research in the use of anti-vascular endothelial growth factor inhibitors (anti-VEGF) drugs for the treatment of diabetic retinopathy(DR) 3,4,5,6. The results of these studies are mixed with some study participants responding well while others do not. In this area everything old is new again. Early intervention in DR and excellent glycemic and blood pressure control are critical to reducing the impact of DR. There is emerging evidence of cellular “memory” of hyperglycemia (high blood sugar) which can occur after prolonged periods of poor glucose control 7. This finding further highlights the need for early intervention in DR and ongoing control of blood sugar and blood pressure.
To that end, there are multiple reports of enhanced diabetes control with technology. Smart phone applications and video games can help PWD stay on course while role-modelling use of cutting edge technology for family, friends and clinicians 8-12.
In 2017, when the artificial or bionic pancreas comes on the market, how do you anticipate this will change your endocrinology practice and the lives of PWD?
There are several prototypes of a “bionic pancreas” underdevelopment development. Each includes a continuous glucose monitoring (CGM) system and insulin delivery system. While there can be benefit from insulin only devices with CGM capability, the bi-hormonal pancreas also includes a glucagon delivery system. The glucagon delivery helps to defend against low-blood sugar and has demonstrated smoother control of blood sugar in children and adults with type 1 diabetes 13-19.
The bi-hormonal device is still in final clinical trials and it is likely to be submitted for FDA approval for 2018. In 2017, it is likely that one or two insulin only devices may be approved. Initial approval will be for persons with Type 1 diabetes. The impact of these devices on endocrine practice will largely be determined by the coverage provided by insurance companies. As these devices will initially be expensive, having them covered will be critical to their use and sustainability as an intervention.
How would early monitoring/recognition of symptoms help change the course of treatment for children with diabetes? (For example, a urine test at a well checkup detects the child is spilling ketones and glucose in their urine, but no recognizable symptoms are present yet.
This is a challenging question. I could not find reliable medical literature to support checking for ketone and or glucose in urine as early detection method for type 1 diabetes (T1D). Although clinical type 1 diabetes can be preceded a period without symptom, the only way to assess risk for developing diabetes is by blood tests for autoantibodies. The problem with urine testing is partly due to the relative variability of the blood sugar threshold for spilling sugar in the urine. Renal threshold for glucosuria (spilling sugar in the urine) varies by age and genetic predisposition 20.
The Environmental Determinants of Diabetes in the Young (TEDDY) study is designed to identify environmental triggers for the development of islet autoimmunity and type 1 diabetes ( T1D) in genetically high-risk children 21. Autoantibodies to glutamic acid decarboxylase (GADA), insulinoma-associated protein 2 ( IA-2) and insulin ( IAA) were analyzed in the first 100 children from 3 months of age with genetic risk for T1D. Children with all three autoantibodies had the most rapid development of T1D ( HR = 4.52, p = 0.014), followed by the combination of GADA and IAA ( HR= 2.82, p < 0.0001). This study suggests follow-up of infants and children with antibody levels most reliably provides early detection of T1D. We must continue to be vigilant with our children at risk for T1D. Unfortunately to date there is no reliable method to assess risk for T1D with urine tests. Only blood test and medical history can do this for now 22.
- Bramswig, N. C., Everett, L. J., Schug, J., Dorrell, C., Chengyang, L., Yanping, L., & … Kaestner, K. H. (2013). Epigenomic plasticity enables human pancreatic α to β cell reprogramming. Journal Of Clinical Investigation, 123(3), 1275-1284. doi:10.1172/JCI66514
- Chera, S., Baronnier, D., Ghila, L., Cigliola, V., Furuyama, K., Thorel, F., & … Reimann, F. (2014). Diabetes recovery by age-dependent conversion of pancreatic δ-cells into insulin producers. Nature, 514(7523), 503-507. doi:10.1038/nature13633
- Gross, J. G., Glassman, A. R., Jampol, L. M., Inusah, S., Aiello, L. P., Antoszyk, A. N., & … Ferris, F. 3. (2015). Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy: A Randomized Clinical Trial. JAMA: Journal of The American Medical Association, 314(20), 2137-2146. doi:10.1001/jama.2015.15217
- Ning, C., Ian Y., W., & Tien Y., W. (2014). Ocular Anti-VEGF Therapy for Diabetic Retinopathy: Overview of Clinical Efficacy and Evolving Applications. Diabetes Care, 37(4), 900-905. doi:10.2337/dc13-1990
- Olsen, T. W. (2015). Anti-VEGF Pharmacotherapy as an Alternative to Panretinal Laser Photocoagulation for Proliferative Diabetic Retinopathy. JAMA: Journal of the American Medical Association, 314(20), 2135-2136. doi:10.1001/jama.2015.15409
- Ajlan, R. S., Silva, P. S., & Sun, J. K. (2016). Vascular Endothelial Growth Factor and Diabetic Retinal Disease. Seminars In Ophthalmology, 31(1/2), 40-48. doi:10.3109/08820538.2015.1114833
- Perrone, L., Matrone, C., & Singh, L. P. (2014). Epigenetic Modifications and Potential New Treatment Targets in Diabetic Retinopathy. Journal of Ophthalmology, 1-10. doi:10.1155/2014/789120
- St. George, S. M., Delamater, A. M., Pulgaron, E. R., Daigre, A., & Sanchez, J. (2016). Access to and Interest in Using Smartphone Technology for the Management of Type 1 Diabetes in Ethnic Minority Adolescents and Their Parents. Diabetes Technology & Therapeutics, 18(2), 104-109. doi:10.1089/dia.2015.0086
- Park, S., Burford, S., Nolan, C., & Hanlen, L. (2016). The role of digital engagement in the self-management of type 2 diabetes. Health Communication, 31(12), 1557-1565. doi:10.1080/10410236.2015.108946
- Theng, Y., Lee, J. Y., Patinadan, P. V., & Foo, S. B. (2015). The use of videogames, gamification, and virtual environments in the self-management of diabetes: A systematic review of evidence. Games For Health, 4(5), 352-361. doi:10.1089/g4h.2014.0114
- Swartwout, E., El-Zein, A., Deyo, P., Sweenie, R., & Streisand, R. (2016). Use of Gaming in Self-Management of Diabetes in Teens. Current Diabetes Reports, 16(7), 1-13. doi:10.1007/s11892-016-0754-2
- Garabedian, L., Ross-Degnan, D., Wharam, J., Garabedian, L. F., & Wharam, J. F. (2015). Mobile Phone and Smartphone Technologies for Diabetes Care and Self-Management. Current Diabetes Reports, 15(12), 1-9. doi:10.1007/s11892-015-0680-8
- El-Khatib, F. H., Russell, S. J., Magyar, K. L., Sinha, M., McKeon, K., Nathan, D. M., & Damiano, E. R. (2014). Autonomous and continuous adaptation of a bihormonal bionic pancreas in adults and adolescents with type 1 diabetes. Journal Of Clinical Endocrinology & Metabolism, 99(5), 1701-1711. doi:10.1210/jc.2013-4151
- Russell, S. J., El-Khatib, F. H., Sinha, M., Magyar, K. L., McKeon, K., Goergen, L. G., & … Damiano, E. R. (2014). Outpatient glycemic control with a bionic pancreas in type 1 diabetes. New England Journal Of Medicine, 371(4), 313-325. doi:10.1056/NEJMoa1314474
- Russell, S. J., Hillard, M. A., Balliro, C., Magyar, K. L., Selagamsetty, R., Sinha, M., & … El-Khatib, F. H. (2016). Day and night glycaemic control with a bionic pancreas versus conventional insulin pump therapy in preadolescent children with type 1 diabetes: a randomised crossover trial. The Lancet. Diabetes & Endocrinology, 4(3), 233-243. doi:10.1016/S2213-8587(15)00489-1
- Sifferlin, A. (2015). The Next Best Thing to a Cure. Time, 185(4), 42-46.
- Sifferlin, A. (2016). The Bionic Pancreas Is Getting Closer to Reality. Time.Com, 1.
- Sifferlin, A., & Tsai, D. (2015). Meet the Father and Son Behind a Diabetes Device With Life-Changing Potential. Time.Com, N.PAG.
- Weissberg-Benchell, J., Hessler, D., Polonsky, W. H., & Fisher, L. (2016). Psychosocial Impact of the Bionic Pancreas During Summer Camp. Journal of Diabetes Science and Technology, 10(4), 840-844. doi:10.1177/1932296816640289
- Bhimma, M.B., Langman, C.B. (ed.) (2015)Renal glucosuria: Background, pathophysiology, epidemiology. Medscape. Retrieved fromhttp://emedicine.medscape.com/article/983678
- Elding Larsson, H., Vehik, K., Gesualdo, P., Akolkar, B., Hagopian, W., Krischer, J., & … Haller, M. J. (2014). Children followed in the TEDDY study are diagnosed with type 1 diabetes at an early stage of disease. Pediatric Diabetes, 15(2), 118-126. doi:10.1111/pedi.12066
- Bonifacio, E. (2015). Predicting Type 1 Diabetes Using Biomarkers. Diabetes Care, 38(6), 989-996. doi:10.2337/dc15-0101