Division of Endocrinology and Metabolism, University of Alberta, 9.114 CSB, Edmonton, AB, Canada.
Innovations in Type 1 Diabetes, Diabetes Action Canada, Toronto, Canada.
Curr Diab Rep. 2020 Aug 31;20(10):52. doi: 10.1007/s11892-020-01339-3.
Current approaches to insulin replacement in type 1 diabetes are unable to achieve optimal levels of glycemic control without substantial risk of hypoglycemia and substantial burden of self-management. Advances in biology and technology present beta cell replacement and automated insulin delivery as two alternative approaches. Here we discuss current and future prospects for the relative risks and benefits for biological and psychosocial outcomes from the perspective of researchers, clinicians, and persons living with diabetes.
Beta cell replacement using pancreas or islet transplant can achieve insulin independence but requires immunosuppression. Although insulin independence may not be sustained, time in range of 80-90%, minimal glycemic variability and abolition of hypoglycemia is routine after islet transplantation. Clinical trials of potentially unlimited supply of stem cell-derived beta cells are showing promise. Automated insulin delivery (AID) systems can achieve 70-75% time in range, with reduced glycemic variability. Impatient with the pace of commercially available AID, users have developed their own algorithms which appear to be at least equivalent to systems developed within conventional regulatory frameworks. The importance of psychosocial factors and the preferences and values of persons living with diabetes are emerging as key elements on which therapies should be evaluated beyond their impact of biological outcomes. Biology or technology to deliver glucose dependent insulin secretion is associated with substantial improvements in glycemia and prevention of hypoglycemia while relieving much of the substantial burden of diabetes. Automated insulin delivery, currently, represents a more accessible bridge to a biologic cure that we expect future cellular therapies to deliver.
在 1 型糖尿病中，目前的胰岛素替代方法无法在低血糖风险和自我管理负担较大的情况下实现血糖控制的最佳水平。生物学和技术的进步为β细胞替代和自动胰岛素输送提供了两种替代方法。在这里，我们从研究人员、临床医生和糖尿病患者的角度讨论了生物和心理社会结果的相对风险和益处的当前和未来前景。
使用胰腺或胰岛移植进行β细胞替代可以实现胰岛素独立性，但需要免疫抑制。尽管胰岛素独立性可能无法持续，但胰岛移植后，80-90%的时间在范围内，血糖变异性最小，低血糖消除是常规的。具有潜在无限供应的干细胞衍生β细胞的临床试验显示出希望。自动胰岛素输送（AID）系统可以实现 70-75%的时间在范围内，血糖变异性降低。由于对商业上可用的 AID 的速度感到不满，使用者已经开发出自己的算法，这些算法似乎至少与在传统监管框架内开发的系统相当。心理社会因素的重要性以及糖尿病患者的偏好和价值观正在成为评估治疗方法的关键因素，而不仅仅是其对生物学结果的影响。提供葡萄糖依赖性胰岛素分泌的生物学或技术与血糖的显著改善和低血糖的预防相关，同时减轻了糖尿病的大部分巨大负担。自动胰岛素输送目前代表了一种更易获得的桥梁，我们期望未来的细胞疗法能够实现生物治疗。
