Future prospects for people with diabetes

Advances in prevention, cure and treatment

As diabetes is a common condition and seems to be increasing in incidence worldwide, there is a great deal of research into prevention, cures and treatment of any complications.

Prevention

The ideal treatment would be to prevent diabetes occurring at all. Our understanding of the causes of diabetes has increased dramatically over the last few decades but there is still much to be learnt.
In particular we do not understand what it is that triggers the damage to the small beta (ß) cells that produce insulin in the pancreas. The genes that
predispose patients to this damage are being identified but precisely what they control and how the damage is initiated remain unclear.
Nevertheless, once these questions are answered it is perhaps feasible that repairing these genes in patients at risk of diabetes could prevent them developing the condition, although such developments are a long way from being a practical option.
Two studies from Finland and the USA have shown that modest exercise of around three hours’ brisk walking per week, combined with a weight loss of around five per cent, can dramatically reduce the risk of people with impaired glucose tolerance going on to develop type 2 diabetes.
These results emphasise the importance of healthy living, exercise and weight control as the best way of preventing type 2 diabetes.
Recent research in the UK has raised the exciting prospect of a vaccine to prevent type 1 diabetes. This preliminary work is unlikely to lead to widespread treatment for some time, however.

Cures and treatments

Many patients ask if it is possible to have a transplant to cure their diabetes. For patients with type 1 diabetes this is an attractive prospect. If it were possible to isolate the small beta cells that make insulin and then either inject them or replace them in the patient, insulin production should be restored.
There has been a great deal of research in this area over the last few decades, but a major problem remains with rejection of the transplanted cells. In addition, actually collecting the cells from the pancreas of donors is extremely laborious and time-consuming, and there would never be enough of these cells to supply all the people with diabetes worldwide.
Recently, however, scientists in Canada have developed a new technique for both extracting and transplanting islet cells. They have used a powerful combination of anti-rejection drugs, which avoid steroids, and as a result some patients have remained free from insulin injections for several years.
These promising results have led to a large research study being funded by Diabetes UK to see if they can be reproduced over here. In 2005 the first successful transplant using this technique was reported in the UK. This treatment has recently been approved by NICE.
New approaches taking cells from other animals or small segments of the skin of patients with diabetes, and transforming them into insulin-producing cells, are eliciting a great deal of interest.
There is also research into converting stem cells (cells in the body that retain the ability to be changed into any other specialised cell) into insulin-producing cells.
Finally, scientists have recently been able to reprogram liver cells in mice to make insulin by using genetic engineering. Many problems remain with these ideas, although it is possible that trials may start within the next five to ten years.
For people with type 2 diabetes, the problem is more complicated because they may be making insulin but are resistant to its action. New tablets such as the thiazolidinediones (glitazones) improve insulin sensitivity and it is very likely that newer medicines that improve this will be developed in the not too distant future. New compounds that are showing particular promise are islet amyloid polypeptide, which is a naturally occurring substance that lowers blood glucose, and the newer agents that act on GLP-1 (see page 49).
Insulin itself has been chemically altered to change the rate at which it is absorbed from under the skin. This has led to the development of quicker-acting and longer-acting types and some of these new ‘analogues’ are already available on prescription. This will provide greater flexibility for patients, particularly those with more irregular mealtimes. There is intense research into developing insulin that it will be possible to take by mouth.

Treatments to reduce the complications of diabetes

For the vast majority of patients it is important to discover new treatments to prevent or reduce the risk of developing some of the more serious complications.
These treatments will concentrate on some of the basic mechanisms that cause eye, kidney and nerve damage. As mentioned in ‘If it gets complicated’ (page 107), it seems that the exposure of these delicate structures to high glucose values for a prolonged period of time causes chemical changes, leading to retinopathy, nephropathy and neuropathy.
Chemicals have been developed to interfere in this process in subtle ways and it may be that long-term treatment with these medicines will prevent complications. Clinical trials are both ongoing and in the early stages of planning.
Careful control of blood pressure and cholesterol levels has also been shown to be effective and it is likely that newer treatments in these areas will be developed in the next few years.
It is important to remember, however, that much can be done to reduce the risks of problems from your diabetes by regular care by both yourself and your diabetes care team. Structured supervision and examination of your eyes, urine tests, blood pressure, feet and tests for cholesterol can indicate areas for treatment that can prevent complications. Already the range of treatments and understanding of the disease have greatly improved the outlook for patients with diabetes and I am sure that this progress will be continued in the future.

KEY POINTS

Prevention of diabetes remains distant for type 1 diabetes, but careful diet, regular exercise and weight control reduce the chances of developing type 2 diabetes
Cure of insulin deficiency by transplanting or modifying cells to make insulin is the subject of intensive research
New treatments to prevent or reverse complications are currently being developed and tested