1. Do we understand the development of type 1 diabetes? Approaches to future therapy Anette-G. Ziegler Institut für Diabetesforschung and Krankenhaus München-Schwabing

2. Natural history of type 1 diabetes Islet autoimmunity single multiple Genetic susceptibility Clinical diabetes

3. Markers of ‘pre-diabetes’ in the blood

4. Target autoantigens of autoantibodies in T1DM Insulin Glutamic Acid Decarboxylase (GAD) IA-2/IA-2 

5. Prospective birth studies in type 1 diabetes BABYDIAB, Munich Germany DAISY Diabetes Autoimmunity Study, Denver, Colorado Australian BABYDIAB study DIPP Diabetes Prediction and Prevention Study, Finland

6. Genetic heirarchy of T1DM prevalence Family history of T1DMRisk None0.3% First degree relative3-5% Identical twin50%

7. BABYDIAB since 1989: Prospective study from birth in offspring of mothers and/or fathers with T1DM Follow-up visits (blood samples and questionnaires) Birth 9 mo 2 yr5 yr8 yr11 yr 1610 offspring were eligible and entered in the study 14 yr Supported by Juvenile Diabetes Research Foundation JDRF

8. Age 2 years Insulin autoantibodies Multiple autoantibodies Clinical diabetes Disease is ‘generally’ progressive

9. Time from first Ab (years) Diabetes (%) 86420 100 80 60 40 20 0 86420 100 80 60 40 20 0 multiple antibodies Single IAA Hummel et al., Ann Intern Med, June 2004 Progression to multiple Abs is necessary for disease

10. 0246810 0 2 4 6 8 Islet autoantibodies in BABYDIAB offspring – multiple AAbs are early Age (years) Islet Abs (7.8%) Multiple islet Abs (3.7%) Single islet Abs Hummel et al., Ann Intern Med, June 2004

11. First antibody is insulin/proinsulin 108642 0 8 6 4 2 0 IAA IA2A GADA 108642 0 8 6 4 2 0 Age (years) Cumulative frequency (%)

12. Not all IAA positive children develop multiple antibodies Who does is defined very early by maturity of antibody response (affinity)

13. 10 4 10 5 10 6 10 7 10 8 10 10 11 IAA Affinity (L/mol) 10 9 10 12 multiple Abs IAA only IAA affinity is high in children who develop multiple islet Abs P<0.0001 Achenbach, J Clin Invest, 2004

14. Lack of progression to diabetes of NOD mice lacking both insulin native genes. Ins1-, ins2-: n= Ins1+, ins2-: n= 25 10 14 21 23 1111 2424 Life table update 5/19/05 Nakayama et al, Nature, 2005

15. What influences the development of islet autoimmunity? Genetics Environment

16. 02468 0 5 10 15 20 25 30 Multiple autoantibodies (%) both parents or parent + sibling mother only father only Age (years) P = 0.05 Development of islet autoantibodies - Proband relationship affects risk P < 0.0001

17. 02468 Age (years) 0 5 10 15 20 Multiple Ab frequency (%) DR3/4-DQ8 DR4/4-DQ8 Moderate DR4-DQ8 Moderate DR3 Protective Neutral Development of islet autoantibodies - HLA DR-DQ affects risk Walter et al, Diabetologia 2003 (updated 2004)

18. HLA and family history are independent - risk of 50% achieved with combination Age (years) Cumulative Multiple Ab frequency (%) 86420 40 35 30 25 20 15 10 5 0 Child of T1DM parent DR3/4, 4/4 child of T1DM parent And multiple family history 50 45

19. Environment is likely to be major reason for rising incidence 0 10 20 30 40 50 60 70 80 19501975200020252050 YRS INCIDENCE (per 100,000/yr) OBSERVED PREDICTED

20. Environmental factors that may affect the development of islet autoantibodies Neonatal and maternal: - Maternal autoimmunity - Diet - Vaccinations - Infections

21. Risk for developing islet Abs in relation to birth autoantibody status in offspring of T1D mothers 10 8 6 4 2 0 8642 % with multiple Abs Age (years) POS GADA or IA2A at birth n = 476 NEG GADA and IA2A at birth n = 244 P = 0.007 Koczwara et al, Diabetes 2004 Father T1D

22. Breast feeding only 55 % Milk based food supplements 40 % Non-gluten solid foods 3.5 % ! 3.5 % ! Gluten foods 1.5 % ! Ziegler et al, JAMA 2003 Food supplementation before 3 months of age in 1610 BABYDIAB offspring

23. Age (years) Gluten-containing food Non gluten solid food Milk based supplements only: Breast feeding only 8642 0 Islet autoantibody frequency (%) 25 20 15 10 5 p < 0.005 Food supplementation before age 3 months and islet Abs risk in BABYDIAB offspring Ziegler et al, JAMA 2003 Norris et al, JAMA, 2003

24. Limitations of BABYDIAB and national studies

25. The Environmental Determinants of Diabetes in the Young Novel international study to identify environmental triggers in type 1 diabetes supported by NIH, NIDDK, JDRF

26. TEDDY centers Colorado (Denver) Georgia/Florida Washington Germany (Munich) Finland (Tampa, Oulu, Turku) Sweden (Malmö) Data Coordinating Center (Tampa, Florida)

27. TEDDY Genetic screening: 220,800 babies worldwide to identify children at increased genetic risk for T1DM To include > 7000 babies into intense follow-up programme duration: –4 years recruitment –15 years individual follow-up

28. Purpose of natural history studies Predict and prevent disease

29. Natural history of type 1 diabetes Islet autoimmunity Genetic susceptibility Clinical diabetes Diabetic complications

30. INSULIN NEEDS FOLLOWING CD3 ANTIBODY THERAPY IN NEW-ONSET TYPE 1 DIABETES New England Journal of Medicine 2005 Bart Keymeulen1, Evy Vandemeulebroucke1, Anette G. Ziegler2, Chantal Mathieu3, Leonard Kaufman4, Geoff Hale5, Frans Gorus1, Michel Goldman6, Markus Walter2, Sophie Candon7, Liliane Schandene6, Laurent Crenier6, Christophe De Block8, Jean-Marie Seigneurin9, Pieter De Pauw1, Denis Pierard1, Ilse Weets1, Peppy Rebello5, Pru Bird5, Eleanor Berrie5, Mark Frewin5, Herman Waldmann5, Jean-François Bach7, Daniel Pipeleers1, Lucienne Chatenoud7

31. Anti-CD3 Europa Inclusion criteria: Newly diagnosed diabetes Age 12-39 years Islet antibody positive C-Peptid basal > 0.2 pmol/l Insulin therapy < 4 weeks Treatment 6 days of infusion with 8 mg ChAgly CD3 each day follow-up 48 months Phase II Trial multicentric, placebo controlled (80 patients were randomized)

32. 0.10 0.20 0.30 0.40 0.50 0.60 0.70 Baseline6m12m18m ChAglyCD3 Placebo IU/kg/day P=0.015P=0.006P=0.03 Anti-CD3 new onset trial Insulin needs Keymuellen et al, NEJM 2005

33. 00.20.40.60.81.01.21.4 ChAglyCD3 Placebo IU/kg/day Insulin needs at 18 months: >P50 patients

34. 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 6m12m18mT0 > P50 nM/min Evolution of C-peptide release after glucose stimulation : effect of initial secretory response

35. Therapy with oral insulin in patients with islet autoantibodies Projected risk of 30- 50% in 5 years

36. DPT-1 Oral Study - Time to Diabetes - By Treatment Subset: IAA Confirmed > 80 nU/ml 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Survival Distribution Function 0 1234567 Years Followed 130 133 122 121 104 96 86 69 66 46 40 32 23 12 Number at Risk P- Value= 0.015 (Log Rank Test) Oral Insulin Oral Placebo STRATA: Oral Insulin Oral Placebo Control Treated Diabetes Care 2005; 28:1068-76

37. prevent.diabetes@lrz.uni-muenchen.de Thank you Markus Walter, Michael Hummel, Sandra Hummel, Kerstin Koczwara, Peter Achenbach, Thomas Kaupper, Martin Füchtenbusch, Ezio Bonifacio, Annette Knopff, Ulrike Mollenhauer, Andrea Baumgarten, Angelica Locher, Steffi König, Sabine Marienfeld, Christiane Winkler, Diana Zimmermann, Daniela Hanak, Doris Huber