Talking Type 1 Diabetes

podcast series

MODERATOR: Welcome to Talking Type 1 Diabetes, a podcast series for healthcare providers who manage or treat type 1 diabetes or those who just want to learn more about this life-changing progressive disease. Each episode features conversations between leading experts in the fields of endocrinology, primary care, and diabetes care.

MODERATOR: This episode is dedicated to understanding the vital role of autoantibody screening in early diagnosis of type 1 diabetes, its implications for T1D staging, and how to best communicate with patients. You'll hear from Dr Kashif Latif, the medical director at AM Diabetes and Endocrinology Center in Bartlett, Tennessee, where he also practices endocrinology. He is a recipient of the James R. Givens Outstanding Residence Award in endocrinology from the University of Tennessee College of Medicine. And, Dr Conan Tu, the regional chief of adult primary care for Eastern Long Island and an internal medicine physician at Optum Tri-State in Bethpage, New York. Dr Latif and Dr Tu are being compensated by Sanofi for this podcast episode.

MODERATOR: TZIELD is a CD3-directed antibody indicated to delay the onset of Stage 3 type 1 diabetes (T1D) in adults and pediatric patients aged 8 years and older with Stage 2 T1D. Please see important safety information on screen and reviewed at the end of this episode.

MODERATOR: Let's get started. Our experts will walk us through their approach to talking about T1D and the importance of screening.

DR CONAN TU: As a primary care doctor, we want to make sure that the patients are as healthy as possible, and that typically includes screening before they have symptoms of disease. So if I am doing a patient's history and I find out that they have a family history of type 1 diabetes, or if I find out that the patient has a personal history of autoimmune disease or a family history of autoimmune disease, that gives me an opportunity to decide if the patient would be a good candidate and if they're receptive to being screened for type 1 diabetes.

DR KASHIF LATIF: Fantastic, thank you for that, Conan. And in my practice, I see the other side of the spectrum, if you are dealing with all of these primary care people who have a family history or may not, but when I'm seeing people, majority of my people are already dealing with the condition of diabetes, most of them type 1 diabetes, and they also have other autoimmune conditions.

DR TU: I like to discuss with my patients about how autoimmune diseases are kind of all related and that the underlying problem is that the immune system is haywire, and when the immune system is haywire, whatever the immune system is attacking is the disease that we end up diagnosing. So if the autoimmune problem is that the immune system is attacking the thyroid, now you have Hashimoto's or autoimmune thyroid disease. If it attacks the skin, then you have vitiligo or alopecia areata. If it attacks the bowels, you can have all ulcerative colitis, you can have celiac disease, you can have Crohn's, but ultimately the condition is the same in that the immune system is going haywire and it's attacking things it should not be. If it attacks the pancreas, then you can get type 1 diabetes. And when I explain it to them that way, they kind of get it. They're like, oh, maybe I should be screened.

DR LATIF: Fantastic. I love that Conan because four or five years ago, we probably would not have gone down this path and we would not have looked for all of these interrelated immune conditions. It's a different time that we're in, and I am excited because I think that the future is going to be so much better for a lot of these people that we take care of. So I think we have to start changing the mindset of ourselves and the people that we take care of in addition to all of our peers, because type 1 diabetes is not really a glycemic condition. It is an immune condition. The consequence of that immune condition is the hyperglycemia, diabetes, disglycemia. So in my mind, the paradigm is this change in how we view type 1 diabetes itself.

DR TU: I also wanted to bring up that sometimes, especially in the primary care space, we have patients that come to us wanting to be screened, and they will be the ones that initiate the discussion because maybe they heard about it from their friends. Maybe they're in a social media chat group. Maybe they saw an influencer on TV because now we previously had Usher and Robin from Peloton as spokespeople, and now as recently as this week, now we have Chrissy Teigan as a spokesman that's advocating for awareness and screening. So a lot of times the patients come to us and as clinicians in the primary care space, if we're not up to date with what screening for type 1 is, we might mistakenly just get a glucose level or a hemoglobin A1C and think that that is screening for type 1, when in fact you really need to check for the antibodies.

DR LATIF: That's such a great point because I was at one of the pediatricians group a few weeks ago and we were talking about T1D screening therapies and all that stuff, and one of the comments was that more mothers are now asking for it and they're talking about it. So I think this awareness, the milieu right now with all of these celebrities, it is fantastic. And whereas instead of trying to explain it to 100% of our patient population, at least 20, 30% are proactively asking for it.

MODERATOR: Thank you. For some patients, hesitancy to screen can be a barrier to appropriate management of T1D. Let's hear how our experts address this in their practices.

DR LATIF: We have been part of TrialNet for about two decades now, and it used to be a difficult conversation at times with a lot of parents, especially of children who had diabetes or a lot of people who had diabetes themselves and are adults. And we would say, can we screen you for type 1 diabetes for TrialNet? And because we have a great bit of good research going on around this area that may yield positive results, and over 50% of times parents would say no because of the anxiety, just the thought of testing was anxiety provoking.

DR TU: Yeah, I absolutely agree with you, Dr Latif. You know, as endocrinologists, primary cares, diabetologists, we have a longstanding relationship with our patients. We don't just see them once and then we never see them again. We're not an urgent care, we're not an emergency room. And I think it's important to develop a relationship with your patients. A lot of times we have, especially in primary care, we have a checklist of different things to talk about. Do you want your colonoscopy? Do you want to get your mammogram? Do you want to get screened for type 1? And a lot of times the answer might not be yes for all of them at once, right? So you might have to mention it and come back to it again in the future. A lot of times, patients, again, they have a longstanding relationship with us, they trust us. They're like, yeah, let's do that, let's do that. Oh, what does that entail? They might not go into a lot of questions because they trust you and they're like, oh, it's just a blood test. That's fine. Let's do it. Let's add it onto the blood work. But that being said, you do have some patients that are more inquisitive. They want to know more. So it's imperative that even primary care doctors get a little bit of background knowledge in case the patients do ask. That's why it's important for us to know that screening for those four antibodies is important, and it's not just about checking the A1C and the fasting glucose, so we should be prepared to answer in more depth, but I don't routinely go into depth unless the patient requests it.

MODERATOR: These are great insights. Patients and clinicians are often unaware of the stages of type 1 diabetes. Our experts will walk us through how they communicate this information to their patients.

DR LATIF: So when we test them, and if somebody tests positive for two autoantibodies, they actually have the diagnosis of type 1 diabetes. Now that is the diagnosis. And the corollary to that is their metabolic status as we discussed earlier. And the metabolic status is what is their blood glucose level? What is their glycemic state? And if you do a glucose tolerance test and it is absolutely normal, then they're in Stage 1. And if you do their glucose tolerance test and they have impaired glucose tolerance or impaired fasting glucose, or you call prediabetes then they're in Stage 2, and if the testing meets the criteria for diabetes itself, then they're in Stage 3. We're going to see tremendous evolution in this. And the more I try to learn about it and learn about it, the more excited I get because this is something that is unprecedented. And so what we're talking about is screening, and in my mind, it's not really screening, it's diagnosing. We are diagnosing one way or the other, and we say, okay, your antibody status is negative. You just reassure them out the wazoo and then rescreen, depending on the risk of the person we screened. And if you have positive antibodies, then I think there's hope, and we give them a tremendous amount of hope. So huge, huge spectrum from diagnosing or screening to monitoring and so on and so forth.

DR TU: I too love to give patients hope because I think that is a gift that us as physicians have the ability to speak to our patients, that we have the trust, they come to us, they seek our knowledge and our opinion, and we could make it very doomy and gloomy. A lot of them, they had come to us, they're like, oh, I have type 1 diabetes. My antibodies are positive. That's it. I'm going to be on insulin. But I love giving them hope. I love giving them optimism, and I tell them, no, this is a blessing that you have found out that you are at risk for needing insulin. Could be one year, five years, 10 years, but now you are empowering yourself. It's like going for a colonoscopy and catching things at an early stage. It gives you options. It gives you time. You can prepare. We know we need to watch you a little bit closer now. We need to watch you make sure that as we progress later on through these stages to Stage 2 and Stage 3, that you don't end up crash landing and ending up in the hospital unnecessarily. So this is a blessing to find out at an earlier stage so that you can prepare and be aware of those symptoms. So giving optimism is so important.

DR LATIF: So to your point, we as practitioners and providers, and I use the term loosely as healers, we take care of the person in totality. We look at their metabolic status, we look at their physical status, but more so we are there to take care of their emotional status. And all of this is combined together, and how we address a situation is really, really important. And so like what we are talking about and how do we address screening, how we do that as physicians, as providers, as caretakers, it has to come with a lot of empathy. It has to come with a lot of emotion and support.

MODERATOR: Thank you to Dr Latif and Dr Tu for your invaluable insights. We greatly appreciate your expertise on the importance of screening and autoantibody testing for diagnosing type 1 diabetes, as well as practical advice on discussing screening and testing results.

MODERATOR: Thank you for listening to Talking Type 1 Diabetes, a podcast series for healthcare providers who manage or treat type 1 diabetes. Be on the lookout for other episodes of the Talking T1D podcast available on TZIELDHCP.com and YouTube. For more information regarding TZIELD, visit our website at TZIELDHCP.com.

MODERATOR: Please be aware of the TZIELD indication and important safety information.

MODERATOR: Indication and Usage: TZIELD is a CD3-directed antibody indicated to delay the onset of Stage 3 type 1 diabetes in adults and pediatric patients aged 8 years and older with Stage 2 type 1 diabetes.

MODERATOR: Warnings and precautions.

MODERATOR: Cytokine Release Syndrome (or CRS): CRS occurred in TZIELD-treated patients during the treatment period and through 28 days after the last drug administration. Prior to TZIELD treatment, premedicate with antipyretics, antihistamines, and/or antiemetics, and treat similarly if symptoms occur during treatment. If severe CRS develops, consider pausing dosing for 1 to 2 days and administering the remaining doses to complete the full 14-day course on consecutive days; or discontinue treatment. Monitor liver enzymes during treatment. Discontinue TZIELD treatment in patients who develop elevated alanine aminotransferase or aspartate aminotransferase more than 5 times the upper limit of normal (or ULN) or bilirubin more than 3 times ULN.

MODERATOR: Serious Infections: Use of TZIELD is not recommended in patients with active serious infection or chronic infection other than localized skin infections. Monitor patients for signs and symptoms of infection during and after TZIELD administration. If serious infection develops, treat appropriately, and discontinue TZIELD.

MODERATOR: Lymphopenia: Lymphopenia occurred in most TZIELD-treated patients. For most patients, lymphocyte levels began to recover after the fifth day of treatment and returned to pretreatment values within 2 weeks after treatment completion and without dose interruption. Monitor white blood cell counts during the treatment period. If prolonged severe lymphopenia develops (less than 500 cells per microliter lasting 1 week or longer), discontinue TZIELD.

MODERATOR: Hypersensitivity Reactions: Acute hypersensitivity reactions including serum sickness, angioedema, urticaria, rash, vomiting, and bronchospasm occurred in TZIELD-treated patients. If severe hypersensitivity reactions occur, discontinue TZIELD and treat promptly.

MODERATOR: Vaccinations: The safety of immunization with live-attenuated (live) vaccines with TZIELD-treated patients has not been studied. TZIELD may interfere with immune response to vaccination and decrease vaccine efficacy. Administer all age-appropriate vaccinations prior to starting TZIELD. Administer live vaccines at least 8 weeks prior to treatment. Live vaccines are not recommended during treatment or up to 52 weeks after treatment. Administer inactivated (killed) vaccines or mRNA vaccines at least 2 weeks prior to treatment. Inactivated vaccines are not recommended during treatment or 6 weeks after completion of treatment.

MODERATOR: Adverse Reactions: Most common adverse reactions (more than 10%) were lymphopenia, rash, leukopenia, and headache.

MODERATOR: Use in Specific Populations: Pregnancy: may cause fetal harm. Lactation: A lactating woman may consider pumping and discarding breast milk during and for 20 days after TZIELD administration.