Explore the evolving landscape of type 1 diabetes with Dr. Amara Ogbonnaya-Whittlesey, Director of Medical Affairs at Breakthrough T1D. Discover advances in early detection, staging, and disease-modifying therapies, and learn about the role of C-peptide in understanding insulin production and its relevance to T1D progression and treatment. Gain insight into emerging research and therapies that may help preserve the body’s ability to produce insulin.
Video: Why C-Peptide Matters in Type 1 Diabetes Care
Medical Affairs - Breakthrough T1D
Davida Kruger
Welcome to Diabetes Care Conversations, the podcast from the Association of Diabetes Care and Education Specialists. I'm your host, Davida Kruger. Joining me today is Amara Ogbonnaya-Whittlesey, Director of Medical Affairs at Breakthrough T1D. We'll discuss some of the evolving science and clinical considerations in type 1 diabetes, including what emerging developments may mean for health care professionals and the people they serve. Amara, welcome to Diabetes Care Conversations.
Before we dive in, can you introduce yourself, share a bit about your background, and tell us about Breakthrough T1D?
Amara Ogbonnaya-Whittlesey
Thank you so much. My name is Amara Ogbonnaya-Whittlesey. I am an adult and pediatric rheumatologist. I joined Breakthrough T1D in January of this year as the US Director of Medical Affairs. Thank you so much for having me.
Davida
And I’m really excited about the topic today because I think it'll be new and exciting for our audience. So, could we start by you describing, what is C-peptide?
Amara
So C-Peptide is a piece of a protein that's made at the same time as insulin in the body. So they're both made from a larger protein called pro insulin at the same time and in equal amounts.
Davida
That's great description. Can you now tell our audience why C-Peptide is clinically relevant?
Amara
Yes, absolutely. So when we're talking about C-Peptide, we're really talking about how much insulin the body is still able to produce on its own. Insulin gets broken down, metabolized relatively quickly, so within a few minutes. So when you measure it, it doesn't provide you an accurate picture of how much insulin your body is making. But C-Peptide lasts longer in the body, it's not broken down as quickly and can provide a very clear picture of how much insulin your body is able to make.
And, you know, for various reasons this is becoming important to know in people who have T1D.
Davida
Absolutely. Can you talk about the stages of T1D? This may be a new concept for some of our listeners. Can you briefly talk about that? Explain what that means to us.
Amara
Yes, absolutely. We used to diagnose type one once someone had clinical symptoms or needed insulin injection therapy, but we know the autoimmune process that causes type one starts much earlier. And we've changed our terminology to reflect that. We can actually detect type one diabetes long before someone has symptoms or needs insulin by checking autoantibodies. So stage one is when a person has multiple antibodies but their blood sugars are still in normal range.
In stage two, the autoantibodies are still there, but blood sugars start to become out of range. Insulin injections aren't needed regularly, but blood sugars are not always within range. Now in stage three, this is when people can have clinical symptoms of type one like increased thirst, increased hunger, and fatigue. And this is when a person does need insulin injections to stay alive.
Davida
You know, I find that so interesting because I've been engaged in diabetes care for the last forty-five years. And of course, the only thing we really talked about is what we are now calling stage three. And that's when the patient came in in DKA or a lot of different issues for those individuals. And we said, guess what? You have type one diabetes. So to be able to stage it and all the things that go along with it, that's really, really exciting. So can you talk to us now about how C-Peptides relate to the stages that you've just described?
Amara
C-Peptide, it actually can stay within range initially. So you can imagine the cells that are making insulin in the body called the beta cells, even though some of them are getting destroyed, the remaining cells kind of work overtime to keep up with making enough insulin initially. But as the disease progresses and people get closer to stage three, the C-Peptide level starts to drop and the body is not able to make enough insulin to keep everything healthy, and insulin injections become necessary.
Davida
Right, okay. So that gives us a picture of maybe we should be looking closer at each of those stages, which I think is pretty exciting also. So let's switch just a tad and talk about breakthrough T1D’s focus on early detection and disease modifying therapies or what we call DMT.
Amara
Breakthrough T1D, formerly JDRF, has been supporting efforts to get people with T1D diagnosed earlier, so before they need insulin. So there are lots of screening programs in place to be able to identify people before they have symptoms. We also, as an organization, have been supporting the development of treatments that aim to slow the progression of type 1 diabetes and keep the body making some of its own insulin longer. This could mean giving people more time without insulin, or if someone is already on insulin, it could allow them to make some of their own insulin longer. The reason we're interested in doing that is we know having some of your own insulin production can help protect from some complications like kidney disease, eye complications, and heart disease.
Davida
Even just knowing that to me is exciting that we know the relationship to making your own insulin. You know, you guys have been doing wonderful research to help look at this whole concept. So to me that's wonderful. But why don't you tell me a little bit more about the disease modifying therapies? Are there any approved therapies for type one diabetes?
Amara
That's a great question. So medicines that aim to keep people producing their own insulin longer or to slow, halt, or reverse type 1 diabetes progression are called disease modifying therapies. And actually there is now one approved therapy called to Teplizumab for people who are in stage two, where blood sugars are abnormal but they don't yet need insulin injections to delay progression to stage three. And it was more recently approved in the US for people ages eight through seventeen years within the first fifty-six days of a stage three diagnosis to keep their bodies hopefully producing insulin and C-Peptide longer.
Davida
Many of us order fasting blood sugars and C-Peptides for our Medicare patients, which it's required for us to get them an insulin pump, which is what we do. So we order fasting blood sugar, we get a C-Peptide, the number has to be s something in a range. Right. and then we can order devices. But that's not what you're talking about when we talk about C-Peptide and using that for disease modifying treatments, getting people into clinical trials for some of these new medications and so forth. So will you talk to us a little bit about the C-Peptide and how you're talking about it and how it would be used for these things?
Amara
It's a very good point that you bring up. So for example, for Teplizumab, the recently approved therapy for treatment of type 1 diabetes, when this medicine is given in stage three, you have to have a certain amount of C-Peptide in the body. So you have to be able to show that the body is still making some insulin. So when you're measuring C-Peptide for, you know, the purpose of getting a pump, usually that's done fasting. You measure it fasting with a fasting blood glucose.
But when you're trying to figure out how much insulin the body is still making, you need to give it a reason to make insulin. So you need to stimulate it by giving, you know, something to eat or drink. So the body has more of a reason to make additional insulin. Then when you measure the C-Peptide, you're getting a more accurate measure of how much insulin the body can still make.
Davida
So let me just backtrack for my brain and for the audience, because I think that's really exciting what you just told me. So when I'm doing it for a pump, I have to prove that the patient's making no insulin or near no insulin to qualify. What you're saying, I think you're saying to me, is when they're in stage two, we want them to have some insulin on board so that the medications that are available will work. Is that correct?
Amara
So really this C-Peptide comes into play with the stage three type one diabetes. So in stage three, you want to measure the C-Peptide to show the person is still able to produce some insulin. In stage two, you actually don't need to measure C-Peptide. The person is eligible without measuring the C-Peptide.
Davida
Okay, thank you for that clarification. Again, I find it really exciting that we have any therapies to be used for people with diabetes or prediabetes or I don't even know if we have a term for it, but it's certainly having the staging of the one, two, or three. So are there other therapies like this being developed or studied for people with type one diabetes, clinical trials, other things that you're looking at?
Amara
Yes, it's a very exciting time. There are a lot of potential disease-modifying therapies that are currently in clinical trials. Some of these are oral medications, some of them are infusions. One example is a medication called Baricitinib, which is an oral medication. This is already approved for the treatment of some other autoimmune conditions like autoimmune hair loss or alopecia and rheumatoid arthritis.
There are also some other medications like Anti-thymocyte globulin, which is given as an infusion, which all seem promising in delaying progression of type one diabetes. I think one thing to point out is like we see with other autoimmune diseases, it's not gonna be a one size fits all. Different people will respond to different things, but the great news is that we're gonna have multiple options for people living with T1D in the future.
Davida
All very, very exciting. And I hope you'll come back at a future time to talk a little bit about how do we screen people to qualify for not only these disease modifying treatments, but potentially for clinical trials, because there's so much to be done out there. So that would be amazing. Amara, do you have any closing comments for us?
Amara
I do. I just wanted to point out that as we mentioned, you don't want to check the C-Peptide fasting because that can give a low result and people might miss out on the opportunity to receive an approved therapy or participate in a clinical trial for disease modifying therapies. There are a few other things that can also affect your C-Peptide. So having a recent episode of diabetic ketoacidosis can cause the result to be falsely low. So usually it's advised to wait at least two weeks from the time of resolution of DKA before checking a C-Peptide. So you have a better chance of getting accurate numbers. The beta cells are not as shocked from that high blood sugar as they were in the weeks before that. Additionally, if you have a low blood glucose the morning of the test, that can also temporarily make that C-Peptide level lower. So you may consider repeating on a day when someone has not had a low. Then there are some other things that might you know, change the C-Peptide level, which are important to keep in mind, like kidney function. If someone's kidney function is already low, it might make the C-Peptide look falsely higher than it is. So I just wanted to, you know, share those other considerations when you're thinking about measuring C-Peptide.
Davida
Those are great and I appreciate you sharing those with us.
Thank you for listening to this episode of Diabetes Care Conversations and engaging with ADCES. You can find resources from Breakthrough T1D for currently recruiting disease modifying clinical trials, Breakthrough T1D's video and overview on C-Peptide in the show notes for this episode.
Remember, being an ADCES member gets you access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at ADCES.org/slash join.
The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice, and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.