Diabetes Treatments of the Future
Research and the future
New developments and improvements in existing treatments can occur only through research; therefore research is vital to every person with diabetes. In the UK, Diabetes UK spends large sums each year (more than £4.9 million in 2000) on research into diabetes; similar large amounts of money are contributed by the Medical Research Council, the Wellcome Trust and other grant giving bodies. The more money that is raised for research into diabetes, the greater the benefits to the population with diabetes. At the time of writing, it costs about £40,000 to support a relatively junior research worker for just 1 year. The discovery of insulin was made by a doctor and a medical student (Banting and Best) doing research together for just one summer (1921). There have been many important but less dramatic discoveries since then, each in some way contributing to our understanding of diabetes and many improving the available treatment.
Searching for causes and cures
Do you think that diabetes will ever be cured?
This question cannot be answered yet. We must always try to take an optimistic view, however, and, if diabetes cannot yet be cured, it is not for want of research. Not only does Diabetes UK have meetings to discuss research and progress, but there is also an annual European Association for the Study of Diabetes meeting and an International Diabetes Federation congress which meets every third year. In addition there are also a great many national organizations that meet regularly. More has been discovered during the last 30 years about the cause of diabetes than ever before, and during the same period there have been important advances in treatment. This is therefore a very exciting period in diabetes research and we can continue to look forward to improvements in our understanding of the disease even if, for the moment, a cure is a little too much to hope for.
I have a friend who has been treated with insulin for 12 years. He recently came off insulin altogether after having had an operation on his adrenal gland. He now tells me that his diabetes has been cured. I thought there was no cure for diabetes.
It sounds as if your friend was one of the very few people in whom the diabetes was secondary to some other condition. In his case the other condition was an adrenal tumour. When this was eventually diagnosed and appropriately treated by an operation, it resulted in a cure for his diabetes. This result has been recorded in two forms of adrenal tumour. One is called a ‘phaeochromocytoma’, where the tumour produces adrenaline and noradrenaline, both of which inhibit insulin secretion by the pancreas. The other adrenal tumour is one producing excess of adrenal steroids and cortisone, which again produces a form of diabetes reversible on removal of the tumour.
There are a number of other rare conditions often associated with disturbances of other hormone-producing glands in the body. In these cases cure of diabetes is possible after appropriate therapy of the hormonal disturbance. Unfortunately, less than 1% of all people with diabetes, who have such a hormonal imbalance, are suitable for surgery. Specialists are always on the lookout for these causes since the benefits from an operation are so tremendous.
Will it ever be possible to prevent diabetes with a vaccine?
There is some evidence to suggest that certain virus infections can cause diabetes but we are not clear how often this happens: it is probably very infrequently. If a virus were isolated, which was found to cause diabetes, it would then be possible to produce a vaccine that could be given to children like the polio vaccine, to prevent them from developing diabetes later in life. At present this possibility seems rather remote.
Genetics
I gather that it is possible to identify people by looking at special blood tests within a family who are at high risk of developing diabetes. This sounds like an exciting development, as presumably children who have inherited an increased risk of diabetes will be those most in need of vaccination should a vaccine become available.
Yes, you are quite right. Studies of the so-called HLA tissue antigens in families in whom there appears to be a lot of diabetes, indicate that certain patterns of inherited antigens carry with ‘phaeochromocytoma’, where the tumour produces adrenaline and noradrenaline, both of which inhibit insulin secretion by the pancreas. The other adrenal tumour is one producing excess of adrenal steroids and cortisone, which again produces a form of diabetes reversible on removal of the tumour.
There are a number of other rare conditions often associated with disturbances of other hormone-producing glands in the body. In these cases cure of diabetes is possible after appropriate therapy of the hormonal disturbance. Unfortunately, less than 1% of all people with diabetes, who have such a hormonal imbalance, are suitable for surgery. Specialists are always on the lookout for these causes since the benefits from an operation are so tremendous.
With these tissue markers (discovered by using blood tests) it should be possible to identify the children who are likely to benefit most from a vaccine or an effective form of preventive treatment should one become available in the future. It will be in these susceptible individuals that the first clinical trials will need to be done.
Is it true those studying families who have several members with diabetes can help find a cure for the condition?
Family studies are very important for helping to understand the inheritance of diabetes. In some families there is a clear association between a certain genetic background and the development of diabetes. Some members who have not yet developed diabetes may have the ‘markers’ described in the answer to the previous question, indicating that they are at increased risk of developing the condition.
Is it possible to prevent diabetes in these high-risk people?
Diabetes has a genetic link and close relatives of people with the condition have an increased chance of developing it, i.e. they are ‘high risk’. There is a trial taking place in the USA and Canada called the Diabetes Prevention Trial-Type 1, which is looking at people who are at high risk for Type 1 diabetes, and seeing if intervention can prevent or delay Type 1 diabetes. The participants have a test to see if their blood contains islet cell antibodies (ICA), the antibodies that destroy the insulin-producing cells, and, if they do, they are possible recruits for the trial. Over a 5-year period, these individuals either inject low doses of insulin twice a day, or take insulin orally in the form of a capsule (or are part of a control group where no insulin is given). The insulin capsules are made up of insulin crystals, which are thought to be effective against the islet cell antibodies, but are not effective for controlling the condition after onset. Animal research and studies in humans have suggested that diabetes can be delayed in those at high risk when they are given small doses of insulin. The results of the trial should be interesting.
I have heard that there is a new programme called DAFNE. What does it involve? Could I take part?
DAFNE stands for Dose Adjustment For Normal Eating. It is an educational programme, first developed in Germany, aimed at people with Type 1 diabetes, which teaches them how to adjust their insulin injections to fit their life and food patterns, rather than the other way around. The intensive course takes place over a 5-day period, and is run by specialist diabetes nurses and dietitians, and about eight people with diabetes take part. They have to take several insulin injections a day, as well as monitoring blood glucose levels at least four times a day. It teaches them how to count carbohydrate units and to adjust their insulin to their individual lifestyle, whilst keeping their blood glucose levels controlled. Results suggest that, for the right sort of person, DAFNE is a liberating experience and that the freedom to eat what you want improves the enjoyment of life. As DAFNE develops, more centres will be involved. A similar lifestyle programme for Type 2 diabetes, DESMOND, is under development. For further information speak to a member of your diabetes team, or contact the Careline.
