Therapy of type 1 diabetes mellitus

Abstract

People with type 1 diabetes have distinct needs and challenges for their management and recent advances have made it even more important to understand the diagnosis and treatment of this disease, distinct from type 2 diabetes. Historically, the guidelines for treating type 1 diabetes and type 2 diabetes were the same, but recent advances in the field of type 1 diabetes have led to a greater understanding of its uniqueness, as well as of the fact that both children and adults, of all ethnicities, can develop type 1 diabetes (Bruno et al. Act Diabetol, 2016). In recent years, we have learned a great deal about the natural history of type 1 diabetes and its treatments (Sosenko et al. Diabetes Care 38:271-276, 2015; Laugesen et al. Diabet Med 32:843-852, 2015). We know, for instance, that the average blood glucose/hemoglobin A1C level in adults with type 1 diabetes in the T1D Exchange, a large registry of individuals with type 1 diabetes, is ~7.7% (Sosenko et al. Diabetes Care 38:271-276, 2015; Laugesen et al. Diabet Med 32:843-852, 2015) which is well above the target of <7%. Therefore, it is clear that the treatment we have for type 1 diabetes - use of exogenous insulin - still falls far short of its goal in many patients even though it is lifesaving for those who do not make any insulin of their own (Heller et al. Diabetes Res Clin Pract 78:149-158, 2007). Recently, we have expanded the insulin options for people with type 1 diabetes (Postgrad Med J 92:152-164, 2016). Newer insulins and more concentrated (U200 and U300) insulin analogues have come on the market, as well as a new form of inhaled insulin and biosimilar insulin analogues. Noninsulin therapies, metformin, pramlintide, GLP-1 receptor agonists, and SGLT-2 inhibitors, have been studied, with variable results. Insulin delivery devices, from pens to pumps, provide more options for patients. Monitoring technology, with easy to use glucose meters and continuing glucose sensing, makes it easier to follow blood sugar levels and react to trends in glucose levels. None of this approaches the functionality of the human beta cell, however, and it will be our ability to restore and maintain beta cell mass that will truly treat (and potentially cure) type 1 diabetes. This review will focus on the treatments that are currently available, the evolving area of continuous glucose monitoring and possible cures for type 1 diabetes.