Exciting, even revolutionary, developments in diabetes care lie on the horizon. Eva Tsalikian, MD, is charting a course that will help children and adolescents benefit from new treatments.
Tsalikian is professor and vice chair for clinical affairs in the UI Department of Pediatrics and director of the department’s endocrinology and diabetes division. In her clinical practice, she takes a special interest in children with diabetes.
As a scientific investigator, Tsalikian, along with her UI Children’s Hospital colleagues, helps advance a research agenda aimed at no less than curing the disease. But first, medical scientists must address the efficacy of the latest techniques for managing type 1 diabetes in both children and adults.
One such tool is continuous glucose monitoring. According to a recent paper by the Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, of which Tsalikian is a member, the latest monitoring devices are more practical for everyday use but their effectiveness in managing type 1 diabetes has not been established. Tsalikian led the UI’s participation in the study, published by the New England Journal of Medicine in October.
Improved Control
Enrolling 322 patients in all, the study found that the use of continuous glucose monitoring devices could be associated with improved glycemic control—but only for those aged 25 and older. For those aged 8 to 14 and 15 to 24, the difference between the continuous monitoring and control groups was not significant, although statistical analysis did show some benefit for the youngest patients.
A related finding—that use of the monitoring devices varied substantially among the age groups, with patients 25 and older having the highest and most consistent level of use—may explain why the benefits of continuous glucose monitoring showed up for older but not younger patients, the study group suggested.
“We know that intense management of diabetes is what’s recommended if we want to prevent problems later on,” Tsalikian said. The continuous glucose monitors “added a tool to help patients monitor their blood sugar in real time, and the study showed that if you use the monitor it improves glycemic control.”
Managing type 1 diabetes is a challenge for everyone who has the disease, Tsalikian noted. Patients have to check their blood sugar anywhere from four to 10 times a day, carry food with them to eat when their blood sugar drops, and give themselves insulin injections before meals and at bedtime.
Parental Involvement
“These folks have a lot to do,” she said. Young children have the advantage of parental involvement to help them manage their diabetes, but adolescents often experience a reduction
of glycemic control as they become more independent, the study group observed.
Ironically, Tsalikian explained, preventing high blood sugar can lead to the inverse problem. “When you achieve good control with intense management, the improvement comes at the expense of having hypoglycemia,” she said.
“This is a problem we’ve had with children, and we’ve tried to find ways to address it.” Blood sugar below about 70 mg/dl risks serious consequences for anyone, Tsalikian continued, but is a particular concern for children and adolescents. “Children, to grow well and be healthy, have to be very active. But this can cause low blood sugar and deprive the brain of the fuel it needs.”
Continuous glucose monitors, if used consistently, could help those with type 1 diabetes reduce the number of “excursions” their blood sugar takes both above and below the optimum level; they even have alarms to alert the wearer to such events. But the devices only provide information about blood glucose—it’s still up to patients to take the appropriate action. Tsalikian and other physician-scientists hope one day to reduce or even eliminate the burden of self-care for diabetes.
Artificial Pancreas
Development of an artificial pancreas would be a logical extension of the continuous glucose monitor, Tsalikian said, but hurdles remain before such a device becomes feasible. “Creating an algorithm by which the computer would know how to respond to different events is a significant obstacle,” she said. Still, an artificial pancreas would be a boon to patients. “If you don’t need to check your blood sugar so often and take insulin, either by injection or directing the pump to give it, it’s much easier to manage your diabetes.”
An even more revolutionary approach is to prevent type 1 diabetes from developing at all. Screening relatives of diabetes patients for the antibodies that attack the pancreas’ insulin-producing islet cells is the first step, followed by testing drugs such as monoclonal antibodies to counteract the autoimmune process in recently diagnosed patients. “If they can keep patients from destroying their own cells, then we’ve almost gotten to a cure,” Tsalikian said. |
