Tina Q Tan, MD, FAAP, FIDSA, FPIDS

What resources would you direct pediatricians to that they can share with their patients regarding type 1 diabetes [T1D] and the screening for the condition?

I think for screening for type 1 diabetes, there are a couple of places to go toget great information. I think the Juvenile Diabetes Research Foundation [JDRF] in New York, New York has a lot of information with their T1 Detect program, which helps people understand what screening means and where to get screened. Again, our Ask the Experts programs at the University of Colorado in Aurora, Colorado, have really similar information to JDRF, is another place that people could go to get information and resources and support. I think those are the 2 places I might start with. But we have links on both of those websites to other organizations and other research programs that also have really valuable information.

What are some takeaway points that you feel are important that those individuals that are watching know regarding what we’ve been discussing?

I think it’s important to know that you do not need to have a family history of type 1 diabetes to develop type 1 diabetes. And that the majority of people that develop type 1 diabetes are completely healthy and don’t seem to have any underlying risk factors. So, whether you have a family history where your risk is increased a little bit, or you’re somebody who doesn’t, it is a possibility for you to get screened for type 1 diabetes and to know whether you’re at risk. And screening is a simple test. It’s a blood draw or a finger poke, and it is widely available. So, families need to decide if that’s the information that they want. If they do want that information, then it is something they have access to. I think that’s really one important part.

Then I think the other important thing for pediatricians, and other physicians and providers, is that you should always have type 1 diabetes on your differential. Because it really can happen in any kid, and it masks quite often as a stomach bug or a growth spurt or some other sickness during the viral season. It’s really easy to miss because of all the respiratory stuff going around, and somebody is a little fatigued and maybe breathing not quite normally. So, it’s always a good idea to go ahead and check urine for glucose or check blood glucose levels and roll it off the differential. And then for families who know that they’re antibody positive, it’s really important to always be monitoring for symptoms and to not just attribute it to a growth spurt or an illness but to always reach out if they’re noticing any of those symptoms.

Should pediatricians incorporate type 1 diabetes screenings into their routine visits for kids of specific ages?

I think that almost all the criteria is there for having T1D be a screening test that’s recommended clinically. I think the one thing that’s still being worked out is the cost-benefit analysis, but I think it would be wonderful from almost every perspective to have it included in the normal guidelines where kids have their vaccinations, their blood and hemoglobin test.

Kimberly, thank you so much for this very rich and informative discussion. I learned a lot about type 1 diabetes and type 1 diabetes screening. I want to thank our viewing audience for tuning in. And if you enjoyed the content of this discussion, please subscribe to our e-newsletters to receive upcoming peers and prospective program announcements and other great content in your inbox.

Videos

Kimberly Simmons, MD, provides resources for patients with T1D, and key takeaways for pediatricians screening for and diagnosing T1D in pediatric patients.

Key Takeaways for Screening and Diagnosis of T1D

Can you talk a little bit about the monitoring of individuals who have type 1 diabetes [T1D]? For the longest time, people were doing finger sticks to heck their glucose levels and now there are glucose monitors. Is there anything else coming down the pike that would make it easier for these individuals to get a better idea of what their glucose levels are at any point in time?

Yes, and are we talking about patients in stage 3 type 1 diabetes?

Correct. Someone who already has type 1 diabetes.

This is an area that’s also really exciting, and for people with type 1 diabetes, it’s been life-changing over the last few years. There are now several continuous glucose monitors available, and there are 2 that are available that you do not have to do finger sticks to calibrate. So, you insert the device and the sensors under your skin, and they last from 7 to 14 days based on all 3 that are available. So that’s exciting and really nice for kids when they realize they don’t have to check their fingers 6 to 10 times a day to meet their glycemic targets. They’re very excited to wear these devices. I think that’s been very great.

Then the other thing with diabetes management that’s been really wonderful is hybrid closed-loop artificial pancreas systems. There are several pumps that integrate with the continuous glucose monitors, and there’s some automation of insulin delivery to try to keep glucose levels from going too low or too high. And I think that not only has glycemic control really improved in patients, but we’ve also seen the burden of diabetes decrease, which is very important.

And with these monitoring systems, are there specific areas of the body where people are supposed to insert them, or can it be worn anywhere?

When you look at where on the body each sensor is approved to use, it’s based on how they did it during their study. The sites that have been tested in studies are typically the arms, upper buttocks, or abdomen. But, in general, what we see in clinical practice is that you can insert a sensor anywhere where there’s adequate subcutaneous tissue.

You said that you change the sensor every 7 to 14 days. Is there anything in the works where you don’t have to change the sensor that often? That it can be there a month or 2 months? Because in kids, sometimes it’s really difficult to get them to cooperate when every 1 to 2 weeks they’re getting poked to put this thing back in.

Yes, so I think the reason that something external can’t stand for longer than a couple of weeks is because the adhesive can’t last any longer, or it’s irritating. I think that’s really the major limitation of having something external. There is a continuous glucose monitor company that’s working on doing implantable sensors. So, there may be something in the future available in the pediatric population that wouldn’t be external, but right now, even the one that’s implanted still has something that’s external on the outside that you wear.

Are there any activities that kids are not supposed to participate in if they have one of these glucose monitors?

No. Kids should and can participate in any activity with these glucose monitors. Occasionally, if the activity is contact-related, one could get ripped out, but then you just replace it. We have ways of trying to secure devices and make sure that things are padded, but the device companies have great warranties and can really support families if something were to happen.

And they can swim with these glucose monitors? Because that’s a question we get all the time. If someone has a line or they have some other external device in place, the big questions are, “Can I take a shower? and “Can I go swimming?”

Those are great questions. For the continuous glucose monitors, yes, they can be in showers, they can be in the water. For the insulin pumps, there’s a variety, and some are water-resistant but not waterproof. So, for some of them, they have to disconnect them when they go swimming and then reconnect them when they come back out. The other thing is that patients who have waterproof pumps have to also be careful if they’re going in a hot tub, for example, because the insulin, if it gets too hot, cannot work.

Tina Q. Tan, MD, and Kimberly Simmons, MD, discuss improved methods of monitoring blood glucose levels in patients with type 1 diabetes.

Blood Glucose Monitoring in T1D

What treatments are currently available, or what treatments are in development, to try to slow the progression of type 1 diabetes [T1D]?

 Currently, there’s only 1 medication that has been approved, and that was approved on November 17, 2022, for delaying the onset of stage 3 type 1 diabetes. That drug is called teplizumab. That medication is a drug that is given via IV [intravenous therapy] infusion. The IV infusion takes about a half an hour, and it’s given for 14 days in a row. A TrialNet study that it was tested in showed that there was an average delay to the onset of type 1 diabetes of 3 years in people who received that medication. It’s exciting that we have something to offer patients, and it has opened the door. And that’s probably the most important thing, to add to that arsenal of medications over the next 5 to 10 years. There are other medications that are being tried within both industry and TrialNet initiatives to see if type 1 diabetes can be delayed. And maybe one day it can be prevented by figuring out the right way to administer all of these.

How young can this medication be given?¼

 Eight years of age and older is what the current indications are. TrialNet is working on designing a study that would be for kids younger than that, but right now it would be prescribed to kids ages 8 and older.

A question that people always ask is: Is this covered by insurance and by Medicaid?

 I think we have yet to determine what insurance coverage will look like. I’m hopeful that it will be covered, and Medicaid usually does a really great job in Colorado of coming on board with things that have great therapeutic potential. But that varies from state to state. We’ll have to see how that all plays out. And the other thing that’s important is, I’m speaking as a pediatrician, but the drug is approved for adults, too. So, I say 8 and older kids, but also adults that have ILA [lymphocyte activation] autoantibodies and dysglycemia.

What are some other emerging therapies that are coming out or are just released for treating type 1 diabetes?

When we’re talking in terms of immunotherapy, there hasn’t been anything submitted to the FDA as an example. A lot of the studies are just starting, so it will take time to enroll and to see what the clinical end points show and then submit to the FDA. I think probably in the next 10 years we’ll see some things. Antithymocyte globulin is a study that we’ll be starting in people who are in stage 2 type 1 diabetes through TrialNet. In the next few months, TrialNet will probably have people enrolled. A lot of the other studies are still in pretty small safety and efficacy trials.

Can you talk a little bit about the clinical trials, if they’re even in humans now, for beta cell regeneration?

That is an area of great interest, because if we can regenerate beta cells, then that makes these therapies that are being approved potentially useful for people that already have type 1 diabetes. I think it’s a very exciting area of research. It’s outside of my direct research expertise, but I do know that there’s been a lot of promise recently and that the people we have at our center working on beta cell regeneration have really provided a lot of hope compared to what we’ve seen in the past. We do know that the challenge really is still how do you get those cells to survive without having immunosuppressants on board. That’s something where there are a lot of different methods being looked at to try to make that happen. That’s another area where I think we’ll see some development in the next 5 to 10 years.

 What’s the role for stem cell transplantation in individuals that have severe type 1 diabetes? Or is there a role for stem cell transplantation?

Clinically there’s not a role yet for stem cell transplantation. Again, I think that’s in the very early stages of trying to bring that in clinical trials to see what happens. There’s been success in 1 individual using stem cell transplantation that has led to people being really excited about it and trials moving forward. It still becomes, how do you grow those stem cells into islet cells. And that’s been really hard to do. We have great researchers working on how you can make those stem cells turn into the cells that we want. And then how to keep those cells alive once they’re in the body that has an autoimmune process going.

Emerging Treatments in T1D

One thing is that if a patient has a family history of type 1 diabetes [T1D] and the pediatrician decides they’re going to send off a screening test and the autoantibodies come back negative, how often should this patient be rescreened to monitor them for the potential development of type 1 diabetes?

 I think that is a question we don’t know the exact answer to. I think the study that I referenced earlier was looking at relatives mostly, and so, what are those time buckets where you’re going to catch most people? But you’re going to have patients that screen negative, and if you don’t plan to screen them for 3 more years, they’re going to become positive the next year. That’s part of what happens. Islet autoantibodies and that trigger can really happen at any time, and we don’t have enough understanding to say when the exact right time is to repeat testing. So, if resources are not limited, if somebody has a family history, you could say that maybe a yearly screen is OK. But if resources are limited, and to be more cost-effective, we probably need to think about what specific time points are most important.

And if a pediatrician is screening 1 sibling, and that sibling comes back with potential positive autoantibodies, should they be screening all the other siblings? Because that’s a question that comes up frequently: How many of the siblings should be screened, and how often should all of them be screened?

My thought would be: yes, if a sibling has islet autoantibodies, then their siblings are probably at risk, just as they would be at risk if they already had clinical type 1 diabetes. And part of that is because they share genetics, and part of that is because they share environment. We don’t know exactly why, but we know that their risk is higher, so it would make sense to screen the siblings of someone who is, really, in any stage of type 1 diabetes.

Experts consider how often a patient with a family history of type 1 diabetes needs to be retested.

Approaching T1D Screening Retesting

Tina Q Tan, MD, and Kimberly Simmons, MD, discuss lifestyle changes such as a balanced diet and glucose monitoring in the management of pediatric T1D.

Lifestyle Management in T1D

Tina Q Tan, MD, and Kimberly Simmons, MD, comment on early screening for pediatric T1D, screening options, and next steps once a child has tested positive for 2 or more autoantibodies.