1. Immunopathogenesis of Type 1 Diabetes: Approaches to Prevention and Cure Peter A. Gottlieb, MD George S. Eisenbarth, MD, PhD Jay Skyler, MD + Barbara Davis Center University of Colorado Health Sciences Center + Diabetes Research Institute University of Miami Medical School

2. Magnitude of Diabetes Worldwide USA Approximately 6% are diagnosed (90%Type2) All with Type 1 and 1/3 of Type 2 will require insulin (Expected to Rise significantly) Cost $100-$140 billion annually Diabetes in Rest of the World 2 - 25% in different Countries (average 10%) Incidence rising every year everywhere, especially for Type 2 Diabetes Disease is still under-diagnosed and delayed in diagnosis Prevention of pre- type 1 and type 2 diabetes

3. Incidence Type 1 Diabetes per 100,000 per year Children <=14 Karvonnen et al., Diabetes Care, 23:1516, 2000

4. Type 1 DM incidence is rising 3-5% /year Type 1 DM incidence is rising 3-5% /year Incidence /100,000/ yr children age 0-14 1.4 million patients in the U.S. Rewers

5. Finland Incidence Type 1 DM/100K 1965-1996 Diabetes Care: 22:1066-1070

6. Main Points Type 1 diabetes is an autoimmune disease It is a predictable disease with different phases Approaches to prevention and cure are possible. Combination therapy targeting multiple pathways may hold the greatest hope for prevention and cure.

7. Progression to Diabetes vs Number of Autoantibodies (GAD, ICA512, Insulin) Percent not Diabetic Years of Follow-up 3 Ab n = 4117 8 1 2 Abs n = 442715 421 1 Abs n = 932314106 4 Verge et al, Diabetes 45:926-933, 1996 BDC

9. DQB1*0402 Asp57  Leu56   -chain  -chain BDC

10. HLA-Defined T1 DM Risk Groups DAISY, Denver Population, n=21,713

11. JapaneseCaucasian DRB1-DQB1 Type 1 diabetes HF 1) Type 1 diabetes HF haplotype susceptibility susceptibility DRB1*0405-DQB1*0401 susceptiblepresent unknown rare DRB1*0901-DQB1*0303 susceptiblepresent unknownrare DRB1*0301-DQB1*0201 unknownraresusceptiblepresent DRB1*0401-DQB1*0302 unknownraresusceptiblepresent DRB1*1501-DQB1*0602 protectivepresentprotectivepresent Different haplotypes are associated with T1D in Japanese and Caucasian populations 1) 1)HF: Haplotype frequency, http://square.umin.ac.jp/JSHI/frame.html

12. IDDM2 Genotypes in U.S. Caucasians I/IIIIII/III 0 20 40 60 80 100 I/I IDDMControls VNTR Class % Pugliese et al., J. Autoimm 7: 687- 694, 1994

13. Predisposing Class I VNTR Protective Class III VNTR Thymus INS Transcription VNTR alleles affect INS transcription in thymus Predisposing Class I VNTR Protective Class III VNTR Pancreas INS Transcription Class I VNTR cDNA DNA cDNA DNA Class III VNTR Pugliese et al. Nature Genetics 15:293-297, 1997

14. ChromosomeλsO.R.LODPgenome IDDM1 mhc 6p213.35“App 30”116.310(-4) IDDM2 ins 11p151.162.21.87.37 PTPN22 1p131.051.7NS IDDM12,7 (“CTLA-4”) 2q31-331.19 CTLA 1.01 “3” CTLA 1.1 3.34.016 3p13-p141.151.52.649 IDDM15 6q211.5622.4 9q33-q341.132.2.191 IDDM10 10p14-q111.12“3”3.21.021 11p151.161.87.371 12q14-q121.101.66.528 16p12-q11.11.171.88.363 16q22-q21.192.64.075 19p13.3-p13.21.151.92.338 No Evidence: IDDM 4,6,9,11,16,17,18 (O.R. MHC, DR3/4-DQ8) Adapted from Concannon et al, Diabetes: 54:2995-3001, 2005 BDC

15. 6 and younger n= 38 7-10 n= 33 11-14 n= 42 15-24 n= 37 25 and older n= 37 Difference significant (log-rank and gen'ld wilcoxon p= 0.001, 0.001 ) Proportion of Twins Without Diagnosis of DM Years Since DM Diagnosis in Index Twin Redondo, Diabetologia

16. Type 1a Diabetes: An Autoimmune Disorder Autoantibodies to islet proteins: insulin, GAD 65, IA-2 (ICA512)Autoantibodies to islet proteins: insulin, GAD 65, IA-2 (ICA512) T cell responses to islet proteinsT cell responses to islet proteins HLA associationHLA association Immunosuppressive drugs can ameliorate the disorder – ex. CyclosporineImmunosuppressive drugs can ameliorate the disorder – ex. Cyclosporine Recurrence of autoimmunity in pancreas transplants between monozygotic twinsRecurrence of autoimmunity in pancreas transplants between monozygotic twins

17. Autoreactivity: CD4 and CD8 T cell responses

18. Prediabetic T cell responses to CD4 epitopes from IA-2  Keleman, Gottlieb et al. 2004. Journal of Immunology.15;172(6):3955-62.

19. Difficulty of Detecting T cell Responses to Insulin in T1DM Tree, et al. Diabetes 2004, 27:1692-1699 o – siblings - T1D

20. Blocking DQ Reduces T cell Responses to GAD65 in T1DM Tree, et al. Diabetes 2004, 27:1692-1699 o – siblings - T1D

21. Blocking of DQ leads to increased T cell Responses to Insulin in T1DM Tree, et al. Diabetes 2004, 27:1692-1699 o – siblings - T1D

22. Cytotoxic T-cells from HLA-A*0201 patients with T1D recognize preproIAPP 5-13 Diabetes 2003 52:2649 ELISPOT analysis of peripheral blood mononuclear responses to preproIAPP5-13 in patients with the correct HLA to recognize the peptide.

23. T cell reactivity to CD8 Epitopes from T1D subjects Ouyang, et al, submitted

24. Natural History of Type 1 Diabetes CELLULAR (T CELL) AUTOIMMUNITY LOSS OF FIRST PHASE INSULIN RESPONSE (IVGTT) (IVGTT) GLUCOSE INTOLERANCE (OGTT) HUMORAL AUTOANTIBODIES (ICA, IAA, Anti-GAD 65, IA 2 Ab, etc.) PUTATIVEENVIRONMENTALTRIGGER CLINICALONSET TIME BETA CELL MASS DIABETES “PRE”- DIABETES GENETIC PREDISPOSITION INSULITIS BETA CELL INJURY

25. Stochastic Model Antigen Specific Tx Immunosuppresive Tx Non Specific Tx

26. PREVENTION

27. Primary Prevention Xautoantibodies or diabetes as the endpoint Xavoidance of environmental agents ? Xinduction of autoantigen tolerance ? Rewers-BDC

28. Viral Infection as a trigger for T1 DM ?

29. Enterovirus Infection Finnish DIPP Study Hyoty et al Diabetes 49:1314, 2000

30. Enteroviruses - recent studies

31. Similar findings: Hummel et al. BABY-DIAB, Diabetes Care 1996 No association between immunizations and islet autoimmunity Graves et al., DAISY, Diabetes Care 1999 No difference in % vaccinated before 9 months of age No difference in the median age at the first dose of DTP, Hib, Polio, HepB No difference in the % receiving HepB at birth No difference in the median number of doses of Polio, DTP Rewers

32. Early childhood diet and T1 DM ?

33. Infant diet and beta-cell autoimmunity Hazard Ratio Norris et al. DAISY 2000 Adjusted for HLA-DR,DQ and relationship to type 1 diabetic person Prospective cohort study 27 cases and 1,022 controls

34. TRIGR 3-yr Follow-up Results Seroconversion to 1+ Autoantibody p=0.043 n=173

35. Nutritional Intervention to Prevent Type 1 Diabetes (NIP – Diabetes) Plan: Use of an omega 3 fatty acid (Docosahexanoic acid or DHA) to prevent the initial autoimmune process. DHA supplementation will begin in: the last trimester of pregnancy the first 6 months after birth It will be continued in medium or high risk infants for 3 years.

36. Dietary Intake – Western Diets The Ratio of n-6 to n-3 Fatty Acids in our diet: 1800’s = 1 or 2 (n-6) to 1 (n-3) Present = 20 or 30 (n-6) to 1 (n-3) High n-3: anti-inflammatory anti-thrombotic hypolipidemic vasodilatory (High n-6 has the opposite effect) (Am J. Clin Nutr. 70, 560-569, 1999)

37. III) Mechanisms of Action of Omega 3 Fatty Acids   Decrease AA in cell membranes  alters PGE 1 and 2 production (inflammatory prostaglandins)   Decrease pro-inflammatory cytokines TNF , IL-1 and IL6 (  efficacy of IL4 and IL10)   Decrease ICAM-1 on monocyte surfaces in humans fed 3g fish oil/dx 21 days (  chronic inflammation)   DHA and /or vit D may have important immune modulating effects in babies at risk for developing T1DM

38. ENDIT: Kaplan-Meier failure curve - European Nicotinamide Diabetes Intervention Trial (ENDIT) Group Lancet 2004; 363: 925–31

39. Ongoing or Completed Prevention Trials TRIGR - Casein Hydrolysate - ongoing (Cow’s Milk Elimination) NIP - Nutritional Intervention to Prevent T1DM – Starting June, 2006 DIPP - Nasal Insulin - ongoing INIT - IntraNasal Insulin Trial ENDIT - Nicotinamide - Ineffective DPT-1 - Oral Insulin – May be effective in subgroup - Parenteral - Ineffective Anti-CD3 and Exanitide- proposed Late stage Early stage

40. Antigen Specific Therapy Magic bullet Approach Targets autoreactive cells Generates protective cells Spares rest of immune system Minimal Toxicity Timing may be critical to efficacy

41. Insulin Beta Cell Specific Predominant T-cell reactivity islets NOD Insulin expressed lymphoid tissue by dendritic and macrophage-like cells Thymic messenger RNA for insulin related to “protective” insulin allele Proinsulin expression in thymus prevents NOD diabetes

42. Effect of Insulin Injections on Diabetes & Insulitis Female NOD Mice Atkinson, Diabetes 1991

43. Serum anti-insulin autoantibody levels in Insulin Knockout NOD mice Figure 1. Figure 1: a) Insulin 1-/-, insulin 2-/-, transgene+ NOD mice fail to develop IAA. b) Insulin 1+/-, insulin 2-/-, transgene+ or transgene-) produce IAA. Nature 2005, 435(7039): 220-223.

44. Lack of Native Insulin Expression Reduces DM in Ins knockout ProIns (A16) NOD mice Figure 4: a) NOD mice lacking both native insulin genes. b) and c) Speed congenic female NOD mice surrounding the insulin genes (insulin 1 region (b); insulin 2 region (c)). d) Founder Tg strain F with mutated preproinsulin gene on NOD background (insulin 1+/+, insulin 2+/+, transgene+). e) Adoptive transfer of diabetes is delayed. Nature 2005, 435(7039): 220-223.

45. Prevention of Diabetes with B:9-23 Peptide “Immunization” 0102030405060 0 20 40 60 80 100 Age in Weeks Percent Not Diabetic Tetanus control B:9-23 peptide D.Daniel,D.Wegmann. PNAS,1996

46. Efficacy of NBI-6024 in animal models with ‘new onset’ Type I diabetes. Figure 3. NBI-6024 Treatment of NOD mice Near Onset of Disease Alleva, et al, Diabetes 2002

47. NBI-6024-specific Th2 cells adoptively transferred protection in NOD mice APL-specific Th2 cell line transfer Figure 4. From Alleva, et al. Diabetes. 2002 51(7):2126-34.

48. Effect of NBI-6024 on T cell responses to native B9-23 and APL over time in NBI-6024-0003 Trial Alleva, et al. 2006. Scand J Immunol. 63(1):59-69

49. BHT-3021 QW BHT-3021 Q2W BHT-3021 Q4W Mouse BHT-3021 provides significant delay of diabetes onset in hyperglycemic mice at all dosing frequencies

50. Treatment of hyperglycemic mice with mouse BHT- 3021 restores normoglycemia

51. Altered Peptide Ligand APC T cell MHC TCR IFNγ APC T cell MHC TCR IL-4 Greenbaum, C;Benaroya Research Institute; Seattle, WA

52. DPT-1 Parenteral Study – Time to Diabetes By Treatment 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 16917014413196101696939401314 1 Number at Risk Survival Distribution Function P- Value= 0.796 (Log Rank Test) InterventionObservation 0 1234567 Years Followed STRATA: Intervention Observation Control Treated New Engl J Med 2002; 346:1679

53. Rationale for Oral Insulin T H1 Cell s IFN- , IL-2 Destructive Cytokines T H2 Cells IL-4, IL-5, IL-10 TGF-  T H3 Cells Protective Cytokines

54. Oral Antigen Protocol Initial results appeared to suggest no effect of oral insulinInitial results appeared to suggest no effect of oral insulin Secondary analysis suggests that for original cohort (IAA>80) there is delay in onset compared to placebo treated patients.Secondary analysis suggests that for original cohort (IAA>80) there is delay in onset compared to placebo treated patients. In fact, the higher the titer of IAA, the greater the protective effect that was observed.In fact, the higher the titer of IAA, the greater the protective effect that was observed. A new trial to confirm these observations is being planned by TrialNet (Start Date – Nov, 2006)A new trial to confirm these observations is being planned by TrialNet (Start Date – Nov, 2006)

55. Recent and Ongoing Antigen-specific Immunotherapy Trials in T1DM Joslin Parenteral Insulin: “Delay” Schwabing Parenteral Insulin: “Delay” DPT-1 Parenteral:No Effect DIPP (intranasal):? Melbourne (intranasal):? DPT-1 Oral Insulin: Possible for subgroup Italy/France Oral Insulin:No Effect Maclaren Oral Insulin: ? NBI 6024-0003 (Neurocrine) – Phase II Spring, 2007 B chain – Orban, Joslin - Phase I? hGAD s.c. in alum (Diamyd) 20ug dose only Peptor Heat Shock Protein? Proinsulin DNA vaccine (Bayhill)Fall, 2006 Prediabetes New Onset

56. Secondary Prevention XGoal - induction of diabetes remission and preservation of C-peptide Xnon-antigen-specific interventions Xantigen specific interventions

57. EDIC: Long Term Benefit of Intensive Treatment - -The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med 2000;342:381-9.

58. EDIC: Long Term Benefit of Intensive Treatment - -The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med 2000;342:381-9.

59.  -Cell Function and Complications in the Diabetes Control and Complications Trial - Steffes MW, et al. Diabetes Care 26:832–836, 2003

60.  -Cell Function and Hypoglycemia in the Diabetes Control and Complications Trial - Steffes MW, et al. Diabetes Care 26:832–836, 2003

61.        NK B Th1 MO Tc1 Target Effector Cells CD4CD25 Th2 NKT Th3 Tr1 Regulatory Cells Cellular Mechanics of Autoimmune Type 1 Diabetes MMFDZBAnti-CD3ATG InsulinGADIGRPHSP60 Cellular Therapy Regenerative Therapies Rituximab

62. Past Trials in New Onset Type 1 DM Cyclosporine A - no lasting effect Imuran- no lasting effect Corticosteroids- no lasting effect Plasmapheresis- no lasting effect BCG (Denver) - no effect Nicotinamide (DENIS)- no effect ( At risk ) Gluten-free diet (Italy)- no effect Q fever vaccine s.c. - no effect Nicotinamide and Vitamin E- no effect

63. Are CD4 + CD25 High T cells Abnormal in Human T1DM?

64. %CD4 + CD25 + 0 2.5 5.0 7.5 NCT1D 0 1 2 3 %CD4 + CD25 high NCT1D ab n=19n=17n=19n=17 Frequency of CD4+CD25+ T cells in long-standing T1D and controls (From Vendrame, Putnam et al, Journal of Autoimmunity, 2005)

65. Suppression by CD4+CD25High T cells in T1D and controls in T1D and controls (From Vendrame, Putnam et al, Journal of Autoimmunity, 2005)

66. Cultured CD4CD25+ T cells Retain Their Suppressive Properties (From Vendrame, Putnam et al, Journal of Autoimmunity, 2005)

67. Metabolic Effects of AZA and Prednisone at 1 year in New Onset T1DM - Silverstein, et al. NEJM 1988, 319:599-604

68. Lack of Effect of BCG Vaccination in New Onset T1D subjects < 12 >=12 Age Fasting C-Peptide Stimulated C-Peptide Adapted from Allen, et al, Diabetes Care 1999, 22:1703-07

69. Ongoing and Proposed Non-antigen Specific Immunotherapy Trials in New Onset Type 1 DM MMF and DZB - Peter Gottlieb, TrialNet Multidose anti-CD3 hOKT3 - Kevan Herold, NY; Lucienne Chatenoud, France HSP 65 p277 s.c. - (Peptor) – Jerry Palmer, Seattle Multi-dose DZB - Henry Rodriguez, Indiana Exanitide and DZB – David Harlan, NIH Oral hIFN-alpha - Staley Brod, Texas Anti-CD20 – Mark Peskovitz, Indiana, TrialNet ATG (Sandostat) – Steve Gitelman, UCSF, ITN, TrialNet Rapamycin and IL-2, Alex Rabinovitch, Canada Fish oil - A-G Ziegler, Germany Diazoxide - E Bjork+A Karlsson, Sweden Lisofylline i.v. - S Kirk, Virginia Vitamin E+nicotinamide - P Pozzilli, Italy

70. MMF/DZB TN-02 Participating Centers The Barbara Davis Center Indiana University Stanford University University of Florida University of Minnesota Virginia Mason (Washington) Joslin Diabetes Center Columbia University UCSF Children’s Hospital of Los Angeles Kansas City, Kansas Toronto, Canada Milan, Italy and Munich, Germany New Centers Existing Centers

71. MMF/DZB TN-02 study (Mycophenolate Mofetil and Daclizumab) MMF protects BB rats from developing DM; MMF/DZB protect PolyIC:Treg depleted DR BB rats from DM MMF is effective in islet allograft transplantation in mice, but not in NOD mice as a single agent MMF effective in a number of human autoimmune conditions including psoraisis, uveitis, autoimmune hepatitis and lupus nephritis. MMF has been an effective addition to multi-drug transplantation protocols in place of Azathioprine or as replacement for Calcineurin inhibitors where nephrotoxicity or islet toxicity is a concern (Polastri, et al, Acta Diabet, 2002).

72. Effect of MMF and Vitamin D Analogues on Islet Allograft Survival Gregori, et al, JI, 2001

73. Mycophenolate Mofetil (MMF) Inhibits inosine monophosphate dehydrogenase (IMPDH) Inhibits de novo pathway of guanosine nucleotide synthesis –T and B cells need de novo pathway (other cell types use salvage pathway)

74. APC T cell MHC TCR IL-2 Blocking of activated T and B cell proliferation and antibody formation Does not block IL-1, IL-2 production MMF: Mode of action Greenbaum, C Benaroya Research Institute Seattle, WA

75. MMF Toxicities LeukopeniaLeukopenia GastrointestinalGastrointestinal Increased rate of viral infectionsIncreased rate of viral infections Lymphoproliferative disorder? No increase in multidrug regimens. No increase in single drug use (Psoriasis).Lymphoproliferative disorder? No increase in multidrug regimens. No increase in single drug use (Psoriasis). Cancer? (Psoriasis data – No).Cancer? (Psoriasis data – No).

76. MMF/DZB study Rationale for DZB (Mycophenolate Mofetil and Daclizumab) Anti-IL2R Ab protects BB rat, but not NOD islet grafts IL2-Receptor + Cells increased at diagnosis of DM IL-2R+, CD4hi population harbor autoreactive T cells (mouse and man) DZB is effective as part of Edmonton protocol and in other transplantation regimens DZB has been shown to be effective in autoimmune diseases such as uveitis and MS Relative known toxicities of drugs are low

77. DZB inhibits disease activity in multiple sclerosis patients failing to respond to interferon Bielekova et al, PNAS, 2004

78. Daclizumab (Zenapax) Humanized IgG monoclonal antibody that binds to the alpha subunit (CD25, p55alpha, Tac) of IL-2 receptor on the surface of activated lymphocytes Greenbaum, C Benaroya Research Institute Seattle, WA

79. Activated T cell α γ IL-2 ß Activated T cell α γ IL-2 ß DZB DZB: Mode of action Inhibit IL-2 mediated activation of lymphocytes Greenbaum, C;Benaroya Research Institute; Seattle, WA

80. Daclizumab in Pediatric Transplantation: CD25 and 7G7 Expression on T Cells % T cells Baseline Day 0 Ettenger RB. Transplant Proc. 1998;30:1956-1958.

81. MMF/DZB TN-02 Study 3 arm study: MMF alone, MMF and 2 doses of DZB and placebo3 arm study: MMF alone, MMF and 2 doses of DZB and placebo 36 subjects per arm, 120 total, through TrialNet centers (6 initially)36 subjects per arm, 120 total, through TrialNet centers (6 initially) Type 1 diabetes (autoantibodies) within 12 weeks of diagnosisType 1 diabetes (autoantibodies) within 12 weeks of diagnosis Ages 8-45, without significant other diseaseAges 8-45, without significant other disease Outcomes: HbA1c, C-peptide, hypoglycemia, T cell assaysOutcomes: HbA1c, C-peptide, hypoglycemia, T cell assays Start Date: Aug. 1, 2004. 92 patients enrolled, expect to finish enrollment this fall. No major problems to date. First subjects nearing 2 year window.Start Date: Aug. 1, 2004. 92 patients enrolled, expect to finish enrollment this fall. No major problems to date. First subjects nearing 2 year window.

82. Potential Benefits of the Study Patient will be the most important part of a research team that is attempting to learn more about type 1 diabetes. Diabetes may be easier to manage. Less chance for long-term complications of diabetes.

83. Anti-CD3 Monoclonal Antibody in New-Onset Type 1 Diabetes Mellitus Kevan C. Herold, MD; William Hagopian, MD, PhD; Julie A. Auger, BA; Ena Poumian-Ruiz, BS; Lesley Taylor, BA, David Donaldson, MD; Stephen E. Gitelman, MD, David M. Harlan, MD; Danlin Xu, PhD; Robert A. Zivin, PhD; & Jeffrey A. Bluestone, PhD Herold K. et al., N Engl J Med 2002; 346:1692-8.

84. hOKT3  1(Ala-Ala) Ala-Ala Binds to CD3 hOKT3  1(Ala-Ala) is a monoclonal antibody that binds to the CD3 (T cell receptor) on human T cells. The drug is a “humanized” antibody with a mutation in the Fc chain to prevent binding to the Fc receptor. Binding to the Fc receptor and crosslinking of the CD3 molecule is thought to activate T cells, cause release of cytokines, and account for the toxicity of OKT3.

85. Changes from Study Entry to 12 Months in the Total C-Peptide Response to Mixed-Meal Tolerance Testing Herold K. et al., N Engl J Med 2002; 346:1692-8. Total Area under the C-Peptide Response Curve (nmol/l/4 hr) Monoclonal-Antibody Group Total Area under the C-Peptide Response Curve (nmol/l/4 hr) Control Group

86. A single course of h  (Ala-Ala) at dx of diabetes improves insulin secretion for over 2 years ** (p<0.0001**p<0.02)

87. Regenerative Therapies: Exenatide(Byetta): Glucagon-like Peptide (GLP-1) analogues Regenerative Therapies: Exenatide(Byetta): Glucagon-like Peptide (GLP-1) analogues i.A GLP-1 analogue ii.Helps regulate insulin secretion and gastric emptying iii.Initial studies =  FPIR and improved OGTT iv.Animal studies =  beta cell mass v.Much experience in humans with T2D

88. Regenerative Therapies: Exenatide(Byetta): Glucagon-like Peptide (GLP-1) analogues i.A GLP-1 analogue ii.Helps regulate insulin secretion and gastric emptying iii.Initial studies =  FPIR and improved OGTT iv.Animal studies =  beta cell mass v.Much experience in humans with T2D

89. Cellular Therapies CD4+CD25+ T regulatory cells – non- specific or antigen-specific Naïve Dendritic Cells pulsed with autoantigens to induce T Regs Stem Cells that can restore regulatory balance – what type?

90. How do we correct autoreactivity? Lessons from Animal Models: Modalities of Immunotherapy of T1DM Therapy of diabetes may eventually require combination therapy!

92. TrialNet Sites

93. TrialNet International Sites AustraliaAustralia United KingdomUnited Kingdom FinlandFinland Italy & GermanyItaly & Germany

94. NIDDKNIAIDNICHDNCRR ADA JDRF Sponsors

95. TrialNet Interventions New-Onset Diabetes –Anti-CD3 (via ITN collaboration) –Mycophenolate Mofetil +/- Anti-CD25 –Anti-CD20 –IL-2 plus Sirolimus – Phase 1 Safety Study Relatives At Risk –Natural History –Oral Insulin –Beta Cell Preservation (exenatide) – pilot study Newborns –Nutritional : Omega-3-Fatty Acids

96. Other TrialNet Studies Comparison of Mixed Meal Tolerance Test and Glucagon Stimulation Test for Stimulation of C- Peptide Reproducibility and Validation of T-Cell Assays for Monitoring of Diabetes Intervention Trials Collaboration with Type 1 Diabetes Genetics Consortium (T1DGC)

97. What We Need Proven biomarkers for disease progression or improvement Better mechanistic assays Better rationale for moving potential interventions to RCTs The courage to study interventions with potential adverse side effects

98. Summary Antigen specific therapy trials in new onset and prediabetic subjects are being undertaken.Antigen specific therapy trials in new onset and prediabetic subjects are being undertaken. Immunomodulatory trials are ongoing in new onset patients and the results with anti-CD3 are encouraging.Immunomodulatory trials are ongoing in new onset patients and the results with anti-CD3 are encouraging. Multicenter trials and networks will help us find effective therapies during the next decade.Multicenter trials and networks will help us find effective therapies during the next decade. Combination therapy targeting multiple pathways may hold the greatest hope for prevention and cure.

99. 1-800-HALT-DM1 (1-800 – 425-8361) www.diabetestrialnet.org

100. Acknowledgements Gottlieb Lab Amy Putnam Becky Wagner Jennifer Rockell Marybeth Magilie BDC Katie Keleman John Hutton UCHSC Dan Waid David Wagner University of Siena Francesco Vendrame Francesco Dotta Neurocrine Biosciences Inc David Alleva Rich Maki Roland Jimenez Paul Conlon University of British Columbia Qin Ouyang Dina Panagiotopoulos Bruce Verchere Rusung Tan Virginia Mason Research Institute Nathan Standifer Jerry Nepom Funding from NIDDK and NIAID

101. Thank you. 1-800-HALT-DM1 (1-800–425-8361) www.diabetestrialnet.org For copy of slides - www.barbaradaviscenter.org

102. Thank you!