From survival to freedom: redefining success in type 1 diabetes.

Abatacept is a CTLA4-Ig fusion protein that blocks CD80/CD86-dependent T-cell co-stimulation. When administered, Abatacept limits, to a variable degree, loss of stimulated C-peptide secretion in patients with newly-diagnosed type 1 diabetes (T1D), while reducing both circulating memory CD4+ T-cells and T follicular helper (Tfh) cells; however, its precise mechanism of action is not known. To investigate this effect, we studied 12 patients, using multi-parameter flow cytometry, who each self-administered Abatacept in subcutaneous formulation for 6 months within 100days of diagnosis. Abatacept treatment impacted the CD4+ T cell memory compartment, inducing a reduction in T-effector cells across both conventional (Tconv) and regulatory (Treg) sub-populations. A reduction in activated Tfh cells (CXCR5+PD1+ICOS+), previously described with intravenous therapy, was replicated and extended. An integrated baseline immunological phenotype predicted Abatacept-induced preservation of C-peptide.

Introduction and Objective: AVT001 is an autologous dendritic cell therapy to address correctable dysfunction of HLA-E restricted CD8+ T regulatory pathway in autoimmune diseases. AVT001 treatment demonstrated C-peptide preservation in type 1 diabetes (T1D) at Days 150 and 360. Continued effects through 2 years are reported. Methods: In a phase 1/2, randomized, double-blind, placebo-controlled trial of subjects at least 16 years old, within one year of T1D diagnosis, and with a correctable defect in HLA-E restricted CD8+ T regulatory function, AVT001 (n=16) or placebo (n=9), was administered in three-monthly intravenous infusions. The primary endpoint was safety; efficacy endpoints included C-peptide area under the curve (AUC) during a 4-hour mixed meal, HbA1c and insulin dose. Results: Baseline characteristics were similar between groups. No serious adverse events were reported through D720. C-peptide AUC remained significantly greater in AVT001 versus control through D360 but not at D540/D720. Younger age, lower BMI, higher C-peptide, and lower insulin requirements were associated with C-peptide preservation with AVT001. There was no difference in HbA1c or insulin dose with treatment at any timepoint. Measured T regulatory function improved by D150 after AVT001 and persisted through D720 while regulatory function worsened in the placebo group over time. Conclusion: AVT001 was safe without dose limiting adverse events and treatment was associated with preserved endogenous insulin secretion at D150, but efficacy waned over time. The disconnect between C-peptide and regulatory effects over time warrants further investigation. Future trials are planned to utilize a booster strategy to prolong efficacy. ClinicalTrials.gov number, NCT03895996. Disclosure J.L. Gaglia: Consultant; Vertex Pharmaceuticals Incorporated. Stock/Shareholder; Vertex Pharmaceuticals Incorporated. Consultant; Avotres Inc. Research Support; Avotres Inc. Consultant; Kriya Therapeutics, Imcyse, Diamyd Medical AB. Research Support; Diamyd Medical AB, Sanofi, Biomea Fusion. H.L. Daley: None. N. Bryant: None. D.Y. Kim: None. J. Ritz: Research Support; Gilead Sciences, Inc, Novartis Pharmaceuticals Corporation, Oncternal. Advisory Panel; Astraveus, Garuda Therapeutics, LifeVault Bio, Smart Immune, Tolerance Bio, TriArm Therapeutics. E.E. Fan: None. T. Dong: None. A. Li: Employee; Avotres Inc. J.S. Skyler: Advisory Panel; 4 Immune. Consultant; AbbVie Inc. Advisory Panel; Abvance Therapeutics. Consultant; ActoBiotics. Advisory Panel; ADOCIA. Consultant; AiTA. Board Member; Applied Therapeutics. Advisory Panel; Avotres Inc., Bayer Pharmaceuticals, Inc, Biomea Fusion. Consultant; COUR Pharmaceuticals. Board Member; Dexcom, Inc. Consultant; Eli Lilly and Company. Advisory Panel; Kriya Therapeutics, Levicure. Consultant; Novo Nordisk A/S, Quell Therapeutics. Board Member; SAB Biotherapeutics, Inc. Consultant; Sanofi, Shoreline Biosciences. Advisory Panel; Signos. Consultant; Vertex Pharmaceuticals Incorporated, vTv Therapeutics. Advisory Panel; WiNK. H. Jiang: Employee; Avotres Inc. Funding Avotres Inc.

Introduction and Objective: Regulatory T cells (Tregs) are critical for immune homeostasis. In T1D, inflammation and IL-2 scarcity in the pancreas can result in Treg instability and dysfunction. Autologous expanded polyclonal Tregs have improved c-peptide preservation in some recently diagnosed T1D patients. Antigen-specific Tregs are more effective in preventing T1D onset preclinically. GNTI-122 is an autologous engineered regulatory T (EngTreg) cell therapy designed to prevent progression of recently diagnosed T1D by targeting islet antigens and addressing Treg instability and IL-2 scarcity. Methods: Clinical scale GNTI-122 was produced from bulk CD4+ T cells gene edited at the TRAC and FOXP3 loci, with targeted insertions via two AAV6 donor templates. The resulting cell product was characterized by flow cytometry, cytokine secretion assays, and suppression assays. Results: GNTI-122 purity exceeded 90% dual-edited product, with a monoclonal TCR directed at an islet-specific antigen (IGRP), and cell yields of >3X109 with high viability. The cell product displays characteristic Treg markers: FOXP3, CD25, low CD127, CTLA4, EOS, TNFRII, CD27, and low CD70. Upon stimulation, the cells have elevated LAP and GARP expression, characteristic of an immune suppressive profile, with reduced expression of pro-inflammatory cytokines (IL-2, TNF-α, and IFN-γ). GNTI-122 demonstrates pSTAT5 signaling with IL-2 or through the engineered chemically induced signaling complex (CISC), activated by rapamycin. GNTI-122 demonstrates potent suppression of T conventional cells (Tconv). Conclusion: We have demonstrated a robust clinical scale manufacturing process, Treg phenotype and activity profile. GNTI-122 represents a promising therapeutic to halt progression of recently diagnosed T1D. Finally, GentiBio has designed the Polaris study, a Phase 1 study to test this novel cell therapy in recently diagnosed adult T1D participants starting in the 2H2025. Disclosure M. Gose: None. P. Sharma: None. A.K. Meiners: None. S.J. Albertson: None. P. Saikumar lakshmi: None. G.I. Uenishi: Employee; GentiBio. C. Patel: None. T.F. Chen: Employee; GentiBio. B.R. Christin: None.

Background Type 1 diabetes is an autoimmune disease affecting over 400,000 children and adults in the United Kingdom for which currently the only available therapy is insulin. Objective(s) To determine the efficacy and safety of the monoclonal antibody ustekinumab targeting the interleukin 12/interleukin 23 immune pathway that generates T helper 1/T helper 17 T cells to slow down the autoimmune process and preserve beta cell production in type 1 diabetes. Design Randomised, double-blind, placebo-controlled, parallel-group phase II trial. Setting Paediatric and young adult diabetes clinics across 16 sites in the United Kingdom. Participants Newly diagnosed with type 1 diabetes and aged 12–18 years. Eligibility criteria Type 1 diabetes confirmed by islet autoantibody testing, within 100 days of first insulin injection, and with residual beta cell function (stimulated C-peptide level > 0.2 nmol/l). Interventions Ustekinumab at the highest approved doses or control (saline) subcutaneously at weeks 0, 4 and 12 and subsequently every 8 weeks to week 44 (seven doses). Main outcome measures Preservation of Mixed Meal Tolerance Test stimulated 2-hour insulin C-peptide area under the curve at week 52 as compared to control (saline) treatment by analysis of covariance adjusted for baseline parameters. Randomisation 2 : 1 Remote computerised randomisation with minimisation by age and baseline C-peptide groups. Blinding Blinding of participants, investigators, laboratory and trial staff. Numbers randomised Seventy-two participants were randomised, 60% male, 18% aged 16–18 years. Recruitment Two hundred and eight potentially eligible patients were approached, and 88 patients were screened. Four participants were lost to follow-up (6%). Four participants withdrew from the treatment but attended the primary end-point assessment. Numbers analysed Six participants were missing baseline data for the primary analysis. The final analysable sample was n = 62. Outcome Ustekinumab was associated with a 49% higher endogenous stimulated insulin production than control at week 52 after adjustments for baseline factors [geometric ratio of ustekinumab to control was 1.49 (95% confidence interval 1.08 to 2.06; p = 0.02)]. Secondary analyses showed no difference in C-peptide at week 28 suggesting that the effect was ‘late’ or ‘delayed’. Ancillary analysis showed a significant reduction in activated T helper 17.1 T cells (p < 0.001) in the treatment group which was associated with C-peptide preservation from week 28 to week 52. Harms No severe adverse events were reported and there were no differences between ustekinumab and control groups in the proportion of participants overall experiencing mild (87% vs. 88%) or moderate (32% vs. 32%) events. Limitations Sensitivity analysis showed the primary end point to be robust to exclusion of small numbers of participants with some protocol deviations and extreme values in key covariates, but not to imputation of all missing data. Conclusions Ustekinumab appears to slow down the autoimmune process providing the first clinical trial evidence that interleukin 17-secreting T cells play a pathogenic role in type 1 diabetes. Alone, it is insufficient to halt the autoimmune process. Future work Replication of this result is ongoing in a trial with a similar design in Canada. If confirmed, consideration may be given to testing other drugs targeting the interleukin 17 pathway, using ustekinumab in combination with other agents or using it earlier in the disease pathway (preclinical disease) since it is so well tolerated and simple to use. Study registration Current Controlled Trials ISRCTN14274380. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme (NIHR award ref: 16/36/01) and is published in full in Efficacy and Mechanism Evaluation; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Immunotherapy targeting the autoimmune process in type 1 diabetes (T1D) can delay the loss of β-cells but needs to have minimal adverse effects to be an adjunct to insulin in the management of T1D. Ustekinumab binds to the shared p40 subunit of interleukin (IL)-12 and IL-23, targeting development of T helper 1 cells and T helper 17 cells (TH1 and TH17 cells) implicated in the pathogenesis of T1D. We conducted a double-blind, randomized controlled trial of ustekinumab in 72 adolescents aged 12–18 years with recent-onset T1D. Treatment was well tolerated with no increase in adverse events. At 12 months, β-cell function, measured by stimulated C-peptide, was 49% higher in the intervention group (P = 0.02), meeting the prespecified primary outcome. Preservation of C-peptide correlated with the reduction of T helper cells co-secreting IL-17A and interferon-γ (TH17.1 cells, P = 0.04) and, in particular, with the reduction in a subset of TH17.1 cells co-expressing IL-2 and granulocyte–macrophage colony-stimulating factor (IL-2+ GM-CSF+ TH17.1 cells, P = 0.04). A significant fall in β-cell-targeted (proinsulin-specific) IL-17A-secreting T cells was also seen (P = 0.0003). Although exploratory, our data suggest a role for an activated subset of TH17.1 cells in T1D that can be targeted with minimal adverse effects to reduce C-peptide loss, which requires confirmation in a larger study. (International Standard Randomised Controlled Trial Number Registry: ISRCTN 14274380).

Introduction & Objective: Endogenous insulin production in T1D, as measured by detectable C-peptide, is associated with lower HbA1c and insulin dose, as well as lower hypoglycemia and retinopathy risk. We aimed to determine if detectable C-peptide is also associated with decreased risk of DKA. Methods: We accessed data from the Diabetes Control and Complications Trial (DCCT) from the NIDDK central repository to investigate the effects of detectable stimulated C-peptide measured annually (≥0.2 pmol/ml, exposure) on DKA incidence (outcome) over mean 6.5-year trial follow-up. Analysis was conducted using the Andersen-Gill model for recurrent DKA events with time-varying covariates; crude unadjusted models and models adjusted for age, sex, diabetes duration, and trial assignment (intensive vs. conventional) were fit. Sensitivity analysis also adjusted for HbA1c. Results: Of the 1441 participants with a median age of 27 years and median duration of diabetes of 49 months, 53% were male, 21% had detectable C-peptide levels (>0.2 pmol/ml) at baseline, and the median HbA1c level was 8.8%. During the trial, 129 participants (9%) had 180 DKA events. Only 1 of these 129 DKA events occurred in an individual with detectable C-peptide, while 128 events occurred in individuals after C-peptide became undetectable. In crude analysis, detectable C-peptide level had a 93% reduction in the hazard for recurrent DKA [hazard ratio (HR) 0.07, 95% CI 0.01 to 0.48, p=0.007]. Results were similar in the first adjusted model (HR 0.06, 95% CI 0.01 to 0.44, p=0.006) and in the final adjusted model (HR 0.08, 95% CI 0.01 to 0.60, p=0.012). Conclusion: In addition to previously identified clinical benefits, this analysis demonstrates that endogenous insulin production dramatically lowers the risk of DKA in T1D. This implies that therapies that may preserve insulin production - such as immune, cell-based, or other therapies - are likely to reduce the burden of DKA. Disclosure M.I. Abuabat: None. D.R. Budhram: None. P. Bapat: None. A.M.K. Bakhsh: None. N. Verhoeff: None. D. Mumford: None. A. Orszag: None. M. Fralick: Consultant; singal1, proofdx. A. Weisman: None. L. Lovblom: None. B.A. Perkins: Advisory Panel; Abbott. Other Relationship; Novo Nordisk. Advisory Panel; Insulet Corporation, Nephris. Other Relationship; Medtronic. Advisory Panel; Sanofi, Vertex Pharmaceuticals Incorporated, Dexcom, Inc. Funding Diabetes Canada (Operating Grant OG-3-21-5572-BP)

We sought to determine whether the type 1 diabetes genetic risk score-2 (T1D-GRS2) and single nucleotide polymorphisms are associated with C-peptide preservation before type 1 diabetes diagnosis. We conducted a retrospective analysis of 713 autoantibody-positive participants who developed type 1 diabetes in the TrialNet Pathway to Prevention Study who had T1DExomeChip data. We evaluated the relationships of 16 known single nucleotide polymorphisms and T1D-GRS2 with area under the curve (AUC) C-peptide levels during oral glucose tolerance tests conducted in the 9 months before diagnosis. Higher T1D-GRS2 was associated with lower C-peptide AUC in the 9 months before diagnosis in univariate (β = -.06, P < .0001) and multivariate (β = -.03, P = .005) analyses. Participants with the JAZF1 rs864745 T allele had lower C-peptide AUC in both univariate (β = -.11, P = .002) and multivariate (β = -.06, P = .018) analyses. The type 2 diabetes-associated JAZF1 rs864745 T allele and higher T1D-GRS2 are associated with lower C-peptide AUC before diagnosis of type 1 diabetes, with implications for the design of prevention trials.

CD4+CD25hiCD127lo/-FOXP3+ regulatory T cells (Tregs) play a key role in preventing autoimmunity. In autoimmune type 1 diabetes (T1D), adoptive transfer of autologous polyclonal Tregs has been shown to be safe in adults in phase 1 clinical trials. We explored factors contributing to efficacy of autologous polyclonal expanded Tregs (expTregs) in a randomized phase 2 multi-center, double-blind, clinical trial (Sanford/Lisata Therapeutics T-Rex phase 2 trial, ClinicalTrials.gov NCT02691247). One hundred ten treated children and adolescents with new-onset T1D were randomized 1:1:1 to high-dose (20 × 106 cells/kilogram) or low-dose (1 × 106 cells/kilogram) treatments or to matching placebo. Cytometry as well as bulk and single-cell RNA sequencing were performed on selected expTregs and peripheral blood samples from participants. The single doses of expTregs were safe but did not prevent decline in residual β cell function over 1 year compared to placebo (P = 0.94 low dose, P = 0.21 high dose), regardless of age or baseline C-peptide. ExpTregs were highly activated and suppressive in vitro. A transient increase of activated memory Tregs was detectable 1 week after infusion in the high-dose cohort, suggesting effective transfer of expTregs. However, the in vitro fold expansion of expTregs varied across participants, even when accounting for age, and lower fold expansion and its associated gene signature were linked with better C-peptide preservation regardless of Treg dose. These results suggest that a single dose of polyclonal expTregs does not alter progression in T1D; instead, Treg quality may be an important factor.

Mixed-meal tolerance test-stimulated area under the curve (AUC) C-peptide at 12-24 months represents the primary end point for nearly all intervention trials seeking to preserve β-cell function in recent-onset type 1 diabetes. We hypothesized that participant benefit might be detected earlier and predict outcomes at 12 months posttherapy. Such findings would support shorter trials to establish initial efficacy. We examined data from six Type 1 Diabetes TrialNet immunotherapy randomized controlled trials in a post hoc analysis and included additional stimulated metabolic indices beyond C-peptide AUC. We partitioned the analysis into successful and unsuccessful trials and analyzed the data both in the aggregate as well as individually for each trial. Among trials meeting their primary end point, we identified a treatment effect at 3 and 6 months when using C-peptide AUC (P = 0.030 and P < 0.001, respectively) as a dynamic measure (i.e., change from baseline). Importantly, no such difference was seen in the unsuccessful trials. The use of C-peptide AUC as a 6-month dynamic measure not only detected treatment efficacy but also suggested long-term C-peptide preservation (R2 for 12-month C-peptide AUC adjusted for age and baseline value was 0.80, P < 0.001), and this finding supported the concept of smaller trial sizes down to 54 participants. Early dynamic measures can identify a treatment effect among successful immune therapies in type 1 diabetes trials with good long-term prediction and practical sample size over a 6-month period. While external validation of these findings is required, strong rationale and data exist in support of shortening early-phase clinical trials.

Rethinking Type-1 Diabetes Treatment: Emerging Medicines Based on AAT Therapy and C-peptide Preservation Therapy

Variation in the preservation of β cell function in clinical trials in type 1 diabetes (T1D) has emphasized the need to define biomarkers to predict treatment response. The T1DAL trial targeted T cells with alefacept (LFA-3-Ig) and demonstrated C-peptide preservation in approximately 30% of new-onset T1D individuals. We analyzed islet antigen-reactive (IAR) CD4+ T cells in PBMC samples collected prior to treatment from alefacept- and placebo-treated individuals using flow cytometry and single-cell RNA sequencing. IAR CD4+ T cells at baseline had heterogeneous phenotypes. Transcript profiles formed phenotypic clusters of cells along a trajectory based on increasing maturation and activation, and T cell receptor (TCR) chains showed clonal expansion. Notably, the frequency of IAR CD4+ T cells with a memory phenotype and a unique transcript profile (cluster 3) were inversely correlated with C-peptide preservation in alefacept-treated, but not placebo-treated, individuals. Cluster 3 cells had a proinflammatory phenotype characterized by expression of the transcription factor BHLHE40 and the cytokines GM-CSF and TNF-α, and shared TCR chains with effector memory-like clusters. Our results suggest IAR CD4+ T cells as a potential baseline biomarker of response to therapies targeting the CD2 pathway and warrant investigation for other T cell-related therapies.

Metabolic outcomes in type 1 diabetes remain suboptimal. Disease modifying therapy to prevent β-cell loss presents an alternative treatment framework but the effect on metabolic outcomes is unclear. We, therefore, aimed to define the relationship between insulin C-peptide as a marker of β-cell function and metabolic outcomes in new-onset type 1 diabetes. 21 trials of disease-modifying interventions within 100 days of type 1 diabetes diagnosis comprising 1315 adults (ie, those 18 years and older) and 1396 children (ie, those younger than 18 years) were combined. Endpoints assessed were stimulated area under the curve C-peptide, HbA1c, insulin use, hypoglycaemic events, and composite scores (such as insulin dose adjusted A1c, total daily insulin, U/kg per day, and BETA-2 score). Positive studies were defined as those meeting their primary endpoint. Differences in outcomes between active and control groups were assessed using the Wilcoxon rank test. 6 months after treatment, a 24·8% greater C-peptide preservation in positive studies was associated with a 0·55% lower HbA1c (p<0·0001), with differences being detectable as early as 3 months. Cross-sectional analysis, combining positive and negative studies, was consistent with this proportionality: a 55% improvement in C-peptide preservation was associated with 0·64% lower HbA1c (p<0·0001). Higher initial C-peptide levels and greater preservation were associated with greater improvement in HbA1c. For HbA1c, IDAAC, and BETA-2 score, sample size predictions indicated that 2-3 times as many participants per group would be required to show a difference at 6 months as compared with C-peptide. Detecting a reduction in hypoglycaemia was affected by reporting methods. Interventions that preserve β-cell function are effective at improving metabolic outcomes in new-onset type 1 diabetes, confirming their potential as adjuncts to insulin. We have shown that improvements in HbA1c are directly proportional to the degree of C-peptide preservation, quantifying this relationship, and supporting the use of C-peptides as a surrogate endpoint in clinical trials. JDRF and Diabetes UK.

Background: Despite advances in insulin therapy, metabolic outcomes in T1D remain suboptimal. Immunotherapy to preserve beta cell function has enormous potential but the metabolic benefits and the size of trial needed to demonstrate them remain unclear, hindering drug development. Methods: Our dataset comprised 1315 adults and 1396 children enrolled in 20 immunotherapy intervention trials within 100 days of diagnosis. End points assessed were AUC c-peptide, HbA1c, IDAAC, Beta-2 Score and hypoglycemia. Differences in outcomes between active and control arms in positive and negative studies were assessed using the Wilcoxon rank test. Results: C-peptide preservation in positive studies resulted in greater improvements in HbA1c within 3 months of beginning therapy. Beyond the initial 3 month “honeymoon” period, 20% greater preservation of C-peptide in active versus placebo subjects was associated with a 0.5% lower HbA1c. Higher initial C-peptide levels and greater C-peptide preservation were associated with better glycemic outcomes. Sample size for HbA1c, IDAAC, and Beta-2 Score required 2-3 times as many subjects per armto demonstrate a difference at 6 months as compared to C-peptide. Smaller samples sizes were required in children. Longer studies are required to demonstrate durability but not efficacy. Hypoglycaemia rates required substantially larger sample sizes and more than 1 year follow-up. Conclusion: Immunotherapy to preserve beta cell function is effective at improving metabolic outcomes in new-onset T1D. Beyond the initial 3 month period, improvements in HbA1c are proportional to C-peptide preservation. Early intervention and sustained high C-peptide levels are required for ongoing benefits. Disclosure P.Taylor: None. M.Rigby: None. P.Gottlieb: Advisory Panel; ViaCyte, Inc., Board Member; ImmunoMolecular Therapeutics, Research Support; Imcyse, Hemsley Charitable Trust, Novartis, National Institute of Diabetes and Digestive and Kidney Diseases, Precigen, Inc., Dompé, Nova Pharmaceuticals, Provention Bio, Inc. C.Dayan: Advisory Panel; AstraZeneca, Consultant; Provention Bio, Sanofi, Avotres Inc., Other Relationship; Dompé, Merck &amp; Co., Inc. K.S.Collins: None. S.Karpen: None. E.Atabakhsh: None. S.Ahmed: None. M.Marinac: None. E.Latres: None. A.Lam: None. P.A.Senior: Advisory Panel; Novo Nordisk Canada Inc., Consultant; Novo Nordisk Canada Inc., Bayer Inc., Viatris Inc., Vertex Pharmaceuticals Incorporated, ViaCyte, Inc., Insulet Corporation. Funding JDRF; Diabetes UK

Autoimmune loss of beta-cell function (measured by C-peptide) is the hallmark of type 1 diabetes (T1D) targeted by interventions that aim to prevent T1D or its progression after onset. We sought to determine whether T1D genetic risk score-2 (T1D-GRS2) and single nucleotide polymorphisms (SNPs) that have been previously associated with C-peptide preservation after T1D diagnosis (e.g., SNPs in CLEC16A, G6CP2, INS, JAZF1, PTPN22, SLC30A8 and TCF7L2) influence C-peptide levels before diagnosis. We studied islet autoantibody (Ab)-positive participants in the TrialNet Pathway to Prevention Study who had T1DExomeChip data and assessed the influence of these 12 SNPs and the T1D-GRS2 on area under the curve (AUC) C-peptide levels during oral glucose tolerance tests conducted between 0-9 months prior to the diagnosis of T1D. Participants (n=702) had a mean age of 13.5±10.3 years, 47% were female, mean BMI was 20.7±6.0 kg/m2, and mean HbA1c 5.4±0.4%. The T1D high-risk HLA-DR3-DQ2 haplotype was present in 47% and the high-risk HLA-DR4-DQ8 haplotype was present in 67% of participants. We performed univariate and multivariate analyses adjusting for BMI, age, sex, number of positive Ab, and the first 3 principal components of ancestry. A higher T1D-GRS2 was associated with lower C-peptide AUC 0-9 months prior to T1D diagnosis in univariate (β=-0.06, P&amp;lt;0.0001) and multivariate (β=-0.03, p=0.008) analyses. Participants with the JAZF1 rs864745 G allele had lower C-peptide AUC 0-9 months prior to T1D diagnosis in univariate (β=-0.10, p=0.003) and multivariate (β=-0.05, p=0.047) analysis. In conclusion, the JAZF1 rs864745 G allele (which has also been associated with type 2 diabetes risk) and higher T1D-GRS2 predict lower C-peptide AUC prior to the diagnosis of T1D. Studies on their effect on response to trials to prevent or delay T1D onset are warranted. Disclosure T. M. Triolo: None. S. S. Rich: None. A. Steck: None. M. J. Redondo: None. H. M. Parikh: None. M. Tosur: Advisory Panel; Provention Bio, Inc. L. A. Ferrat: Consultant; Johnson &amp; Johnson. L. You: None. P. Gottlieb: Advisory Panel; ViaCyte, Inc., Board Member; ImmunoMolecular Therapeutics, Research Support; Imcyse, Hemsley Charitable Trust, Novartis, National Institute of Diabetes and Digestive and Kidney Diseases, Precigen, Inc., Dompé, Nova Pharmaceuticals, Provention Bio, Inc. R. A. Oram: Consultant; Janssen Research &amp; Development, LLC, Research Support; Randox R &amp; D. S. Onengut-gumuscu: None. J. Krischer: None. Funding National Institutes of Health (R01DK121843, R01DK124395)

The prevalence of obesity in general pediatric population increases without sparing children with T1D. We intended to find factors associated with the possibility of preserving endogenous insulin secretion in individuals with long-standing T1D. At onset, higher BMI is associated with higher C-peptide level, which may indicate to be one of the favorable factors involved in preserving residual β-cell function. The study determines the influence of BMI on C-peptide secretion in children newly diagnosed with T1D in two years observation. We assessed the possible relationship between selected pro- and anti-inflammatory cytokines, body mass at recognition and β-cell function status. 153 pediatric patients with newly diagnosed T1D were divided into quartiles according to BMI-SDS index. We separated a group consisted of patients with BMI-SDS >1. Participants were followed up for two years and examined for changes in body weight, HbA1c, and insulin requirement. C-peptide was assessed at baseline and after two years. We evaluated the patients' levels of selected inflammatory cytokines at baseline. Subjects with higher BMI-SDS presented higher serum C-peptide levels and lower insulin requirements at diagnosis than children with lower body weight. The two-year follow-up showed that C-peptide levels of obese patients dropped more rapidly than in children with BMI-SDS within normal limits. The group with BMI-SDS >1 showed the greatest decrease in C-peptide level. Despite statistically insignificant differences in HbA1c at diagnosis between the study groups, in the fourth quartile and BMI-SDS >1 groups, HbA1c as well as insulin requirements increased after two years. The levels of cytokines varied the most between BMI-SDS <1 and BMI-SDS >1 groups and were significantly higher within BMI-SDS >1 group. Higher BMI, associated with enhanced levels of inflammatory cytokines, relates to preservation of C-peptide at T1D recognition in children but is not beneficial in the long term. A decrease in C-peptide levels combined with an increase in insulin requirements and in HbA1c among patients with high BMI occur, which may indicate a negative effect of excessive body weight on the long term preservation of residual β-cell function. The process seems to be mediated by inflammatory cytokines.

GAD-alum given into lymph nodes to Type 1 diabetes (T1D) patients participating in a multicenter, randomized, placebo-controlled double-blind study seemed to have a positive effect for patients with DR3DQ2 haplotype, who showed better preservation of C-peptide than the placebo group. Here we compared the immunomodulatory effect of GAD-alum administered into lymph nodes of patients with T1D versus placebo with focus on patients with DR3DQ2 haplotype.MethodsGAD autoantibodies, GADA subclasses, GAD65-induced cytokine secretion (Luminex panel) and proliferation of peripheral mononuclear cells were analyzed in T1D patients (n=109) who received either three intra-lymphatic injections (one month apart) with 4 µg GAD-alum and oral vitamin D supplementation (2000 IE daily for 120 days), or placebo.ResultsHigher GADA, GADA subclasses, GAD65-induced proliferation and cytokine secretion was observed in actively treated patients after the second injection of GAD-alum compared to the placebo group. Following the second injection of GAD-alum, actively treated subjects with DR3DQ2 haplotype had higher GAD65-induced secretion of several cytokine (IL4, IL5, IL7, IL10, IL13, IFNγ, GM-CSF and MIP1β) and proliferation compared to treated individuals without DR3DQ2. Stratification of samples from GAD-alum treated patients according to C-peptide preservation at 15 months revealed that “good responder” individuals with better preservation of C-peptide secretion, independently of the HLA haplotype, had increased GAD65-induced proliferation and IL13 secretion at 3 months, and a 2,5-fold increase of IL5 and IL10 as compared to “poor responders”. The second dose of GAD-alum also induced a more pronounced cytokine secretion in “good responders” with DR3DQ2, compared to few “good responders” without DR3DQ2 haplotype.ConclusionPatients with DR3DQ2 haplotype had a distinct early cellular immune response to GAD-alum injections into the lymph node, and predominant GAD65-induced IL13 secretion and proliferation that seems to be associated with a better clinical outcome. If confirmed in the ongoing larger randomized double-blind placebo-controlled clinical trial (DIAGNODE-3), including only patients carrying DR3DQ2 haplotype, these results might be used as early surrogate markers for clinical efficacy.

This study focused on the cognitive function of women with type 1 diabetes in pregnancy. We investigated risk factors for a low cognitive score such as age, duration of Diabetes, BMI, subclinical hypothyroidism, cardiovascular autonomic neuropathy, the impact of hypo-/hyperglycemia, and C-peptide preservation. Material and methods. Seventy-eight pregnant women with type 1 diabetes (age 31.1 ± 5.4 years, diabetes duration 14.3 ± 8.9 years) were included in the study. Cognitive function was assessed in different domains, such as reasoning, memory, attention, coordination, and perception. Results. The cognitive test values ≥400 were considered high scores, and values <400 were considered low. Relative risks for low scores for general cognitive function were associated with increased BMI > 25 kg/m2 2.208 (95% CI 1.116–4.370), HbA1c > 6.5% RR 0.774 (95% CI 0.366–1.638), subclinical hypothyroidism RR 3.111 (95% CI 1.140–8.491), and impaired cardiovascular autonomic neuropathy RR 2.250 (95% CI 1.000–5.062). Pregnant women with a lower score for general cognitive function had higher BMI and higher leptin levels. Preserved C-peptide reduces the risk for cognitive impairment (RR 0.297 (95% CI 0.097–0.912)) in pregnant women with type 1 diabetes Conclusion. BMI > 25 kg/m2, subclinical hypothyroidism, and cardiovascular autonomic neuropathy are associated with increased risk, and postprandial C-peptide preservation with reduced risk for cognitive impairment in pregnant women with type 1 diabetes.

BackgroundRestoration of immune tolerance to disease-relevant antigens is an appealing approach to prevent or arrest an organ-specific autoimmune disease like type 1 diabetes (T1D). Numerous studies have identified insulin as a key antigen of interest to use in such strategies, but to date, the success of these interventions in humans has been inconsistent. The efficacy of antigen-specific immunotherapy may be enhanced by optimising the dose, timing, and route of administration, and perhaps by the inclusion of adjuvants like alum. The aim of our study was to evaluate the effect of an insulin peptide vaccine formulated with alum to prevent T1D development in female non-obese diabetic (NOD) mice when administered during late-stage pre-diabetes.MethodsStarting at 10 weeks of age, female NOD mice received four weekly subcutaneous injections of an insulin B:8-24 (InsB:8-24) peptide with (Ins+alum) or without Imject® alum (Ins) as adjuvant. Diabetes incidence was assessed for up to 30 weeks of age. Insulin autoantibodies and C-peptide concentrations were measured in plasma and flow cytometric analysis was performed on pancreatic-draining lymph nodes (PLN) and pancreas using an InsB:12-20-reactive tetramer.ResultsInsB:8-24 peptide formulated in alum reduced diabetes incidence (39%), compared to mice receiving the InsB:8-24 peptide without alum (71%, P < 0.05), mice receiving alum alone (76%, P < 0.01), or mice left untreated (70%, P < 0.01). This was accompanied by reduced insulitis severity, and preservation of C-peptide. Ins+alum was associated with reduced frequencies of pathogenic effector memory CD4+ and CD8+ T cells in the pancreas and increased frequencies of insulin-reactive FoxP3+ Tregs in the PLN. Of interest, insulin-reactive Tregs were enriched amongst populations of Tregs expressing markers indicative of stable FoxP3 expression and enhanced suppressive function.ConclusionAn InsB:8-24 peptide vaccine prevented the onset of T1D in late-stage pre-diabetic NOD mice, but only when formulated in alum. These findings support the use of alum as adjuvant to optimise the efficacy of antigen-specific immunotherapy in future trials.

Aim: The contemporaneous increase in type 1 diabetes (T1D) and obesity prevalence in children has led to conflicting reports regarding the effects of weight excess on beta-cell function and clinical manifestation of T1D. We aimed to analyze the association between body mass index (BMI) and beta-cell function in a large cohort of new-onset T1D youth. Material and Methods: This study included 204 consecutive children with T1D aged 1-18 years. We retrospectively reviewed the medical data. The preservation of C-peptide was defined as a C-peptide level ≥0.6 ng/mL. Comparisons of variables between groups were made using appropriate statistical procedures. Results: Eighteen percent of children were overweight or obese. Overweight/obesity was associated with significantly higher C-peptide levels at onset [0.57 (0.05-2.99) vs 0.41 (0.05-2.58) ng/ml, p=0.01]. Preservation of C-peptide levels was observed in 67% of patients. Patients with preserved C-peptide levels were older at onset [10.4 (1.9-16.5) vs 7.5 (1.1-17.3) yr, p<0.001], more likely to be pubertal (61.2% vs 22.6%, p<0.001) and had a higher BMI SDS (0.03±1.37 vs -0.67±1.47, p=0.001). The proportion of individuals with preserved C-peptide levels increased with increasing BMI, but the difference did not reach statistical significance (29.9% to 45.9%, p=0.06). While there was a positive correlation between BMI SDS and C-peptide levels (rs=0.24, p=0.001), HbA1c levels negatively correlated with BMI SDS (r=-0.16, p=0.025). Conclusion: Overweight/obesity was present in a significant proportion of the study population. Obese and overweight children had a greater residual beta-cell function at the onset of T1D. It could be speculated that they were diagnosed at an earlier phase of beta-cell damage.