People living with diabetes (DM) are at higher risk of developing periodontal disease than those without diabetes. This observation was first recorded in 1928. It is now believed that the risk is 3-4 times greater than for people without DM, and more for smokers. However, many doctors are not aware of this. DM and periodontal disease are bi-directionally linked, the one affecting the other and vice versa, although the mechanism is not fully understood. Periodontal disease has an adverse effect on glycaemic control. That improves when periodontitis is successfully treated. Doctors should consider periodontal disease when their patients have persistently high glycated haemoglobin (HbA1c) levels, and dentists should consider diabetes or pre-diabetes when they have patients with unstable periodontitis. Doctors and dentists, and their teams, need to share results. This paper considers what that shared information should be. A system of red, amber and green for both medical and dental risks is proposed. Until there are reliable methods of information exchanges and a paradigm shift in inter-professional working, patients should obtain their medical and dental results and share them with their respective advisors. Those patients who do not attend for dental care should be advised by their doctor about the potential benefits of dental screening for periodontitis.
{"title":"Diabetes mellitus and periodontal disease: education, collaboration and information sharing between doctors, dentists and patients","authors":"Chris Turner, P. Bouloux","doi":"10.15277/bjd.2023.403","DOIUrl":"https://doi.org/10.15277/bjd.2023.403","url":null,"abstract":"People living with diabetes (DM) are at higher risk of developing periodontal disease than those without diabetes. This observation was first recorded in 1928. It is now believed that the risk is 3-4 times greater than for people without DM, and more for smokers. However, many doctors are not aware of this.\u0000DM and periodontal disease are bi-directionally linked, the one affecting the other and vice versa, although the mechanism is not fully understood. Periodontal disease has an adverse effect on glycaemic control. That improves when periodontitis is successfully treated.\u0000Doctors should consider periodontal disease when their patients have persistently high glycated haemoglobin (HbA1c) levels, and dentists should consider diabetes or pre-diabetes when they have patients with unstable periodontitis.\u0000Doctors and dentists, and their teams, need to share results. This paper considers what that shared information should be. A system of red, amber and green for both medical and dental risks is proposed. Until there are reliable methods of information exchanges and a paradigm shift in inter-professional working, patients should obtain their medical and dental results and share them with their respective advisors.\u0000Those patients who do not attend for dental care should be advised by their doctor about the potential benefits of dental screening for periodontitis.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44821513","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Mirzababaei, Farideh Shiraseb, Sara Hajishizari, Mena Farazi, Hadith Tangestani, Leila Khorraminezhad, C. Clark, K. Mirzaei
Background and aims: We sought to examine the interaction between CRY1 genotypes and low carbohydrate diet (LCD) score and the effect on insulin resistance, insulin sensitivity, homeostasis model assessment of insulin resistance (HOMA- IR) and quantitative insulin sensitivity check index (ISQUKI). Methods: This cross-sectional study was conducted with a total of 228 overweight and obese women. The data related to anthropometric and biochemical measures were collected and a food frequency questionnaire (FFQ), with 147 items, was used to assess dietary intake. Based on the FFQ, we calculated an LCD score for each study participant, ranging from 0 to 70. Biochemical assessments, including TC, HDL, LDL, TG, FBS, insulin and HOMA-IR, were performed. Deoxyribonucleic acid (DNA) samples were assessed to be genotyped for the rs2287161, which was genotyped by the restriction fragment length polymorphism (PCR-RFLP) method. A generalised linear model was performed for interaction analysis. Results: The results of the study demonstrated that, after controlling for several confounders, increased adherence to an LCD (T3 vs. T1) in the interaction with one risk allele genotype (CG) increases ISQUKI level (β: 0.001, CI: 0.00, 0.002, p=0.041). Also, there was a marginally negative interaction between higher adherence to LCD and two risk alleles genotype (CC) on insulin level (β: -0.012, CI: 0-0.024, 0.001, p=0.054). Conclusions: This study revealed a negative interaction of CRY1 genotypes with two risk allele and higher LCD adherence on insulin level, and a positive interaction on ISQUKI. However, the mechanism of interaction between LCDs and CRY1 genotypes remains unclear.
{"title":"CRY1 polymorphism may influence the association of low carbohydrate diet (LCD) score on glucose homeostasis in overweight and obese women","authors":"A. Mirzababaei, Farideh Shiraseb, Sara Hajishizari, Mena Farazi, Hadith Tangestani, Leila Khorraminezhad, C. Clark, K. Mirzaei","doi":"10.15277/bjd.2023.402","DOIUrl":"https://doi.org/10.15277/bjd.2023.402","url":null,"abstract":"Background and aims: We sought to examine the interaction between CRY1 genotypes and low carbohydrate diet (LCD) score and the effect on insulin resistance, insulin sensitivity, homeostasis model assessment of insulin resistance (HOMA- IR) and quantitative insulin sensitivity check index (ISQUKI).\u0000Methods: This cross-sectional study was conducted with a total of 228 overweight and obese women. The data related to anthropometric and biochemical measures were collected and a food frequency questionnaire (FFQ), with 147 items, was used to assess dietary intake. Based on the FFQ, we calculated an LCD score for each study participant, ranging from 0 to 70. Biochemical assessments, including TC, HDL, LDL, TG, FBS, insulin and HOMA-IR, were performed. Deoxyribonucleic acid (DNA) samples were assessed to be genotyped for the rs2287161, which was genotyped by the restriction fragment length polymorphism (PCR-RFLP) method. A generalised linear model was performed for interaction analysis.\u0000Results: The results of the study demonstrated that, after controlling for several confounders, increased adherence to an LCD (T3 vs. T1) in the interaction with one risk allele genotype (CG) increases ISQUKI level (β: 0.001, CI: 0.00, 0.002, p=0.041). Also, there was a marginally negative interaction between higher adherence to LCD and two risk alleles genotype (CC) on insulin level (β: -0.012, CI: 0-0.024, 0.001, p=0.054).\u0000Conclusions: This study revealed a negative interaction of CRY1 genotypes with two risk allele and higher LCD adherence on insulin level, and a positive interaction on ISQUKI. However, the mechanism of interaction between LCDs and CRY1 genotypes remains unclear.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2023-03-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41731475","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
While it is difficult to predict the next 100 years of development, the current Medtronic product innovation pipeline is changing the lives of people with diabetes. The MiniMedTM 780G system with GuardianTM 4 sensor and extended wear infusion set is the advanced hybrid closed-loop pump system currently available in the UK from Medtronic. It has been clinically proven to achieve >70% time in range and to lower HbA1c levels in people with diabetes. Medtronic continues to innovate in the hybrid closed-loop and insulin pump and sensor area. The company is developing new sensor technology and personalised closed-loop options for future patients. Medtronic recognises that not all people with diabetes will want to use an insulin pump and therefore is launching a Smart MDI system for people looking for more from MDI therapy. The Smart MDI system brings together a collection of tools that provides real-time insights and comprehensive reports. These make it easier for people with diabetes to manage life on multiple daily injections. The system combines predictive glucose management with the GuardianTM 4 sensor, with no finger pricks and personalised high and low alerts up to 60 minutes in advance. Personalised insulin management with the inpen device allows informed insulin dosing with integrated real-time glucose data trends and shareable insight reports. The Medtronic extended-wear infusion set is due to launch in the UK soon. It is focused on improving user experience. It is the only infusion set approved for longer wear (with a wear twice as long as standard infusion sets) without compromising comfort, safety or insulin delivery. This new set will also reduce traditional infusion set plastic waste by half.
{"title":"Gazing into the future. The next 100 years: the Medtronic perspective","authors":"D. Turner","doi":"10.15277/bjd.2022.376","DOIUrl":"https://doi.org/10.15277/bjd.2022.376","url":null,"abstract":"While it is difficult to predict the next 100 years of development, the current Medtronic product innovation pipeline is changing the lives of people with diabetes. The MiniMedTM 780G system with GuardianTM 4 sensor and extended wear infusion set is the advanced hybrid closed-loop pump system currently available in the UK from Medtronic. It has been clinically proven to achieve >70% time in range and to lower HbA1c levels in people with diabetes. Medtronic continues to innovate in the hybrid closed-loop and insulin pump and sensor area. The company is developing new sensor technology and personalised closed-loop options for future patients. Medtronic recognises that not all people with diabetes will want to use an insulin pump and therefore is launching a Smart MDI system for people looking for more from MDI therapy. The Smart MDI system brings together a collection of tools that provides real-time insights and comprehensive reports. These make it easier for people with diabetes to manage life on multiple daily injections. The system combines predictive glucose management with the GuardianTM 4 sensor, with no finger pricks and personalised high and low alerts up to 60 minutes in advance. Personalised insulin management with the inpen device allows informed insulin dosing with integrated real-time glucose data trends and shareable insight reports. The Medtronic extended-wear infusion set is due to launch in the UK soon. It is focused on improving user experience. It is the only infusion set approved for longer wear (with a wear twice as long as standard infusion sets) without compromising comfort, safety or insulin delivery. This new set will also reduce traditional infusion set plastic waste by half.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43976330","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hybrid closed-loop systems are transforming the clinical management of T1DM. Large randomised controlled trials of hybrid closed-loop systems have demonstrated safety and efficacy, with significant improvements in glycaemic control compared to control therapy, and there are now several commercially approved hybrid closed-loop systems available in the UK. There is also a growing body of evidence demonstrating the quality of life benefits associated with hybrid closed-loop systems, both for users and also for parents/caregivers and other family members. We review the clinical evidence supporting currently available hybrid closed-loop systems in the UK and also new systems on the horizon. We discuss the emerging evidence for associated psychosocial benefits of hybrid closed-loop therapy. We also address future challenges around healthcare professional readiness to deliver closed-loop technology and ensuring equitable access across the UK.
{"title":"#We don't have to wait any more Closed-loop systems: transforming the landscape","authors":"C. Boughton, R. Hovorka","doi":"10.15277/bjd.2022.374","DOIUrl":"https://doi.org/10.15277/bjd.2022.374","url":null,"abstract":"Hybrid closed-loop systems are transforming the clinical management of T1DM. Large randomised controlled trials of hybrid closed-loop systems have demonstrated safety and efficacy, with significant improvements in glycaemic control compared to control therapy, and there are now several commercially approved hybrid closed-loop systems available in the UK. There is also a growing body of evidence demonstrating the quality of life benefits associated with hybrid closed-loop systems, both for users and also for parents/caregivers and other family members.\u0000We review the clinical evidence supporting currently available hybrid closed-loop systems in the UK and also new systems on the horizon. We discuss the emerging evidence for associated psychosocial benefits of hybrid closed-loop therapy. We also address future challenges around healthcare professional readiness to deliver closed-loop technology and ensuring equitable access across the UK.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44418737","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"100 years of insulin; 50 years of diabetic life*","authors":"Maggie Loughran","doi":"10.15277/bjd.2022.379","DOIUrl":"https://doi.org/10.15277/bjd.2022.379","url":null,"abstract":"","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46529728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The UK Prospective Diabetes Study (UKPDS) epidemiological findings confirmed that T2DM is not a “mild” disease, with roughly 50% of patients having clinically evident complica- tions at diagnosis, emphasising the need for its early detection and treatment. Hyperglycaemia was identified as an independent coronary heart disease risk factor, with progressive hyperglycaemia shown to be a major pathophysiological feature of T2DM, driven by declining beta-cell function. People with T2DM and hypertension were found to be at double jeopardy for any diabetes endpoint, and worsening kidney function was shown to increase the risk of death substantially. The UKPDS 20-year trial results were the first to demon- strate that diabetic complications are not inevitable but can be prevented by more intensive blood glucose control and by metformin therapy, changing T2DM management guide- lines worldwide. The UKPDS also showed that tighter blood pressure control prevents diabetic complications; the benefits of the glucose and blood pressure interventions are additive. The UKPDS 10-year post-trial monitoring study was the first to identify the T2DM glycaemic and metformin legacy effects, with early more intensive therapy having continuing benefits long after the trial terminated. The trial demon- strated the need to achieve good glycaemic control as early as possible to minimise the risk of future complications.
{"title":"brief history of the UK Prospective Diabetes Study","authors":"R. Holman","doi":"10.15277/bjd.2022.359","DOIUrl":"https://doi.org/10.15277/bjd.2022.359","url":null,"abstract":"The UK Prospective Diabetes Study (UKPDS) epidemiological findings confirmed that T2DM is not a “mild” disease, with roughly 50% of patients having clinically evident complica- tions at diagnosis, emphasising the need for its early detection and treatment. Hyperglycaemia was identified as an independent coronary heart disease risk factor, with progressive hyperglycaemia shown to be a major pathophysiological feature of T2DM, driven by declining beta-cell function. People with T2DM and hypertension were found to be at double jeopardy for any diabetes endpoint, and worsening kidney function was shown to increase the risk of death substantially.\u0000The UKPDS 20-year trial results were the first to demon- strate that diabetic complications are not inevitable but can be prevented by more intensive blood glucose control and by metformin therapy, changing T2DM management guide- lines worldwide. The UKPDS also showed that tighter blood pressure control prevents diabetic complications; the benefits of the glucose and blood pressure interventions are additive. The UKPDS 10-year post-trial monitoring study was the first to identify the T2DM glycaemic and metformin legacy effects, with early more intensive therapy having continuing benefits long after the trial terminated. The trial demon- strated the need to achieve good glycaemic control as early as possible to minimise the risk of future complications.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48656482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Reflections on 60 years of caring for people with diabetes","authors":"A. Wright","doi":"10.15277/bjd.2022.362","DOIUrl":"https://doi.org/10.15277/bjd.2022.362","url":null,"abstract":"","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47159379","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Although we have treated type 1 diabetes (T1DM) with insulin for more than 100 years, it has been apparent since the discovery of insulitis in the 1960s and islet cell antibodies in 1974 that T1DM is fundamentally an autoimmune disease, not a metabolic disease.1 Almost all other autoimmune diseases, from inflammatory bowel disease to rheumatoid arthritis, are treated with immunotherapy but not T1DM. In large part this is because of the discovery of insulin: unlike most other autoimmune diseases, a replacement therapy exists for T1DM. As a result, the discovery of insulin can be viewed as both a blessing and a curse. It is a “curse” because most of the major drug companies have developed their large immunotherapy portfolios of drugs for autoimmune diseases other than T1DM, including some such as psoriasis or alopecia areata that might be considered less life-threatening. And it is likely that diabetes practitioners are also partly to blame since they fear immunotherapy since it is a treatment with which they are not familiar. It is important to remind ourselves of the challenges of insulin therapy. It is not a drug without risk: deaths still occur from underdosage (DKA) and overdosage (hypoglycaemia). According to ONS data, in 2021 in England and Wales, 44 people under the age of 50 died of DKA and 154 died of hypoglycaemia.2 Set against this, even despite the introduction of CGM and insulin pumps, fewer than 30% of adults and children with diabetes achieve a target HbA1c < 7.0%, or 53 mmol/mol which obviates the risks of longterm complications.3 Furthermore, insulin management consumes millions of hours of patients and healthcare professional time in training, adjustments, testing and decision-making. Despite this, 36% of children and families continue to need psychological support more than five years after diagnosis (NPDA national audit 2018-2019,3 and up to 50% of adults with T1DM report significant diabetes-related distress. 4 There is a large and expanding world of highly selective immunotherapies that does not include the classic immunosuppressents (e.g. cyclosporin, tacrolimus) used in transplantation. Rather, it includes many drugs known as “biologics” that have been widely used and have been very well tolerated in other autoimmune diseases for more than 20 years. Many are monoclonal antibodies, but small molecule inhibitors such as JAK kinase inhibitors are being introduced.5 At least seven selective immunotherapies have shown efficacy in Phase 2 studies in preserving beta cell function from diagnosis compared to controls.6,7 These treatments reduce progression of the underlying disease process but do not cause regrowth of beta cells. In current clinical practice, T1DM is diagnosed at the time that insulin replacement is required. This is late in the disease course, when it is estimated that more than 80% of functional beta cells have been lost. When selective immunotherapy is given at this stage, some impact on insulin dose (and in some
尽管我们用胰岛素治疗1型糖尿病（T1DM）已有100多年的历史，但自20世纪60年代发现胰岛炎和1974年发现胰岛细胞抗体以来，T1DM从根本上说是一种自身免疫性疾病，而不是代谢性疾病，用免疫疗法治疗，但不治疗T1DM。这在很大程度上是因为胰岛素的发现：与大多数其他自身免疫性疾病不同，T1DM有一种替代疗法。因此，胰岛素的发现可以被视为福与祸。这是一个“诅咒”，因为大多数主要制药公司都开发了针对T1DM以外的自身免疫性疾病的大型免疫疗法药物组合，包括一些可能被认为不那么危及生命的银屑病或斑秃。糖尿病从业者可能也要承担部分责任，因为他们害怕免疫疗法，因为这是一种他们不熟悉的治疗方法。提醒我们自己胰岛素治疗的挑战是很重要的。它不是一种没有风险的药物：剂量不足（DKA）和过量（低血糖）仍会导致死亡。根据英国国家统计局的数据，2021年，英格兰和威尔士有44名50岁以下的人死于DKA，154人死于低血糖。2与此相反，即使引入了CGM和胰岛素泵，仍只有不到30%的糖尿病成人和儿童达到目标HbA1c<7.0%，即53 mmol/mol，从而消除了长期并发症的风险。3此外，胰岛素管理消耗了数百万小时的患者和医疗保健专业人员在培训、调整、测试和决策方面的时间。尽管如此，36%的儿童和家庭在确诊后五年以上仍需要心理支持（NPDA 2018-2019年国家审计3，多达50%的T1DM成年人报告了严重的糖尿病相关痛苦移植相反，它包括许多被称为“生物制剂”的药物，这些药物已经被广泛使用，并且在20多年的其他自身免疫性疾病中耐受性很好。许多是单克隆抗体，但正在引入小分子抑制剂，如JAK激酶抑制剂。5与对照组相比，在2期研究中，至少有7种选择性免疫疗法在保护β细胞功能方面显示出有效性。6,7这些疗法可以减少潜在疾病过程的进展，但不会导致β细胞的再生。在目前的临床实践中，T1DM是在需要胰岛素替代的时候被诊断出来的。这是在病程后期，据估计，超过80%的功能性β细胞已经丧失。当在这个阶段给予选择性免疫治疗时，可以看到对胰岛素剂量的一些影响（在一些研究中，还可以看到HbA1c和低血糖率），但现在消除对胰岛素的需求已经太晚了。幸运的是，早期诊断T1DM是可能的。对T1DM患者亲属和普通人群的出生队列进行的多项研究表明，80-90%的无症状儿童如果被发现有两种或两种以上的胰岛自身抗体（包括抗GAD、抗IA-2、抗ZNT8或抗胰岛素），将继续发展为T1DM（图1）。一旦出现低血糖（相当于糖耐量受损），高血糖水平通信地址：Colin M Dayan教授临床糖尿病和代谢教授，加的夫大学，Heath Park，Cardiff，CF14 4XN，英国电子邮件：DayanCM@cardiff.ac.uk
{"title":"beginning of the end for insulin? – enter immunotherapy for T1DM","authors":"C. Dayan","doi":"10.15277/bjd.2022.369","DOIUrl":"https://doi.org/10.15277/bjd.2022.369","url":null,"abstract":"Although we have treated type 1 diabetes (T1DM) with insulin for more than 100 years, it has been apparent since the discovery of insulitis in the 1960s and islet cell antibodies in 1974 that T1DM is fundamentally an autoimmune disease, not a metabolic disease.1 Almost all other autoimmune diseases, from inflammatory bowel disease to rheumatoid arthritis, are treated with immunotherapy but not T1DM. In large part this is because of the discovery of insulin: unlike most other autoimmune diseases, a replacement therapy exists for T1DM. As a result, the discovery of insulin can be viewed as both a blessing and a curse. It is a “curse” because most of the major drug companies have developed their large immunotherapy portfolios of drugs for autoimmune diseases other than T1DM, including some such as psoriasis or alopecia areata that might be considered less life-threatening. And it is likely that diabetes practitioners are also partly to blame since they fear immunotherapy since it is a treatment with which they are not familiar. It is important to remind ourselves of the challenges of insulin therapy. It is not a drug without risk: deaths still occur from underdosage (DKA) and overdosage (hypoglycaemia). According to ONS data, in 2021 in England and Wales, 44 people under the age of 50 died of DKA and 154 died of hypoglycaemia.2 Set against this, even despite the introduction of CGM and insulin pumps, fewer than 30% of adults and children with diabetes achieve a target HbA1c < 7.0%, or 53 mmol/mol which obviates the risks of longterm complications.3 Furthermore, insulin management consumes millions of hours of patients and healthcare professional time in training, adjustments, testing and decision-making. Despite this, 36% of children and families continue to need psychological support more than five years after diagnosis (NPDA national audit 2018-2019,3 and up to 50% of adults with T1DM report significant diabetes-related distress. 4 There is a large and expanding world of highly selective immunotherapies that does not include the classic immunosuppressents (e.g. cyclosporin, tacrolimus) used in transplantation. Rather, it includes many drugs known as “biologics” that have been widely used and have been very well tolerated in other autoimmune diseases for more than 20 years. Many are monoclonal antibodies, but small molecule inhibitors such as JAK kinase inhibitors are being introduced.5 At least seven selective immunotherapies have shown efficacy in Phase 2 studies in preserving beta cell function from diagnosis compared to controls.6,7 These treatments reduce progression of the underlying disease process but do not cause regrowth of beta cells. In current clinical practice, T1DM is diagnosed at the time that insulin replacement is required. This is late in the disease course, when it is estimated that more than 80% of functional beta cells have been lost. When selective immunotherapy is given at this stage, some impact on insulin dose (and in some","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43790790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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