By Wendy S Lane, MD, Endocrinologist, Mountain Diabetes & Endocrine Center
Today, 1.5 million people in the United States alone are living with type 1 diabetes (T1D), a disease for which there is no cure.[i] Patients with T1D must carefully manage their blood glucose levels throughout their entire lives, which requires replacement insulin therapy and exacting attention to diet and exercise.
Although replacement insulin is essential for a patient with T1D’s survival, it is a treatment that can lead to life-threatening adverse events, the most dangerous of which is hypoglycemia (low blood sugar). Hypoglycemia can lead to neurological symptoms, cognitive dysfunction and death. Conversely, poor insulin management can lead to hyperglycemia, which, increases the risk of developing a variety of serious vascular diseases, and is associated with unwanted side effects including weight gain.
Honest and compassionate communication between patients with T1D and their healthcare providers is essential for effectively managing blood glucose levels and achieving optimal health outcomes. Unfortunately, such communication is often hindered by blame and shame resulting from misconceptions – among patients and physicians – that improper glycemic control results from poor self-management and/or failure to adhere to therapy, rather than from the inherent limitations of T1D treatment regimens.
Patients and physicians need to keep in mind that while replacement insulin therapy provides the body with an essential hormone that it can’t produce on its own, it does not come close to replicating how insulin is normally regulated and distributed throughout the body. In individuals without T1D, insulin travels directly to the liver and interacts specifically with cells designed to regulate glucose levels. In contrast, replacement insulin is administered systemically and travels throughout the body. As a result, it impacts cells that would not normally be exposed to insulin, which can have negative effects on those cells and on overall glucose regulation. Under normal conditions insulin production is tightly coupled to glucose levels to maintain blood sugar within a healthy range. This coupling cannot be achieved when insulin is administered systemically. Taken together, the differences between naturally occurring and replacement insulin create significant barriers to successful glucose control, even for the most adherent and conscientious patients.
Yet, while effective management of T1D is challenging, new technologies and therapeutic advances hold great promise to enable improved treatment outcomes. New pump technologies that can sense decreases in glucose and reduce or halt insulin delivery before blood sugar levels become too low are helping to improve insulin therapy, as are advanced forms of insulin that last longer or are easier to administer. Investigational adjunctive therapies that could be used to reduce the amount of insulin needed and/or to improve time in range may also provide new options for managing T1D.
Optimum health outcomes for patients with T1D can only be achieved when they and their physicians are educated about available options – including approved and investigational therapies – and understand how these options fit with an individual patient’s needs, goals and abilities. The following topics can provide a strong foundation on which to have candid conversations between patients with T1D and their physicians and may foster partnerships that can improve patients’ day-to-day lives and their longer-term health outcomes.
What types of replacement insulin therapy are available, and am I using the type that is best for me?
Patients who don’t comply with treatment because they find it difficult or unpleasant to inject replacement insulin several times a day may wish to explore the possibility of switching to a long-acting insulin formulation or an insulin pump.
I know that keeping my glucose in range is important, but I’m afraid of becoming hypoglycemic, and changes in my glucose levels are unpleasant
The vast majority of physicians who care for patients with T1D don’t have the disease and patients may need to educate their care providers about how they experience their disease. Not only is it okay to tell your care provider what you find unpleasant, uncomfortable or scary about managing your glucose level, it’s essential to building a trusting relationship that can help you achieve your long-term health goals.
Sometimes I get tired of having to watch what I eat, and I just want to be able to eat and drink like my friends and family do
Effectively managing T1D is a 24/7 job, and patients and care providers need to acknowledge how demanding this is and the effects it has on patients’ ability to socialize and their mental health status. Effectively managing T1D requires more than insulin, and care providers should be prepared to refer patients to appropriate support resources that can help them holistically incorporate their T1D regimen into their lives. No patient with T1D should feel that they are defined by his or her disease.
Is there anything new on the T1D treatment horizon?
Researchers and clinicians are continuing to advance new approaches to treating T1D. Additional long-acting insulin formulations are currently being evaluated in clinical trials, as are novel systems for administering insulin. As noted above, novel pump technologies that can sense and respond to changing glucose levels may reduce the need for frequent self-monitoring of glucose levels. Additionally, clinical studies of adjunctive therapies that would be used in conjunction with insulin, including an investigational therapy known as TTP399, may also lead to new approaches to T1D therapy. TTP399 is not insulin. Instead, it activates the body’s key glucose sensing mechanism (glucokinase) specifically in the liver. Recently presented clinical data suggest that TTP399 improved time in range and reduced daily bolus insulin use compared with placebo, with no diabetic ketoacidosis, no incidence of severe hypoglycemia, and fewer symptomatic hypoglycemic episodes.
With multiple innovative T1D therapies in clinical development, patients interested in exploring investigational options should speak with their care providers about clinical trials for which they may be eligible.
In conclusion, acknowledging and accepting the challenges inherent to managing T1D is essential for building patient-physician relationships that enable more effective solutions.
[i] Global Data. Type 1 diabetes: epidemiology forecast to 2026. April 2019.