A NEW ROAD FOR TYPE 1 DIABETES

IS BEING PAVED TODAY

The International Summit on Insulin Independence April 24, 2012

Table of Contents

Slide No. Speaker

3 Louis Cocco Jr

4-16 Claresa Levetan MD, FACE

17-24 Susan Pierce, CDE, MPT

25-39 Desmond Schatz, MD

40-52 Paolo Pozzilli, MD

53-65 Donald Bergman, MD, FACE,MACE

66-71 Lois Jovanovic, MD, FACP, FACN,FACE, MACE

72-85 Aaron Vinik, MD, PhD, FCP, MACP,FACE

What I Know About Diabetes by Louis Cocco, Jr Age 11

Despite all of the advances, diabetes is the leading cause of amputations, blindness and kidney disease requiring dialysis.1

Diabetes killed 284,000 Americans last year.2

Every 17 seconds another American is diagnosed with diabetes.1

10-15% have type 1 diabetes, which has risen by 70% among children under the age of 5 years old.3,4

In 2012, $245 Billion was spent on care of patients with diabetes1

More than the $150 billion in damage caused by Hurricane Katrina. 2

As much the conflicts in Iraq, Afghanistan and the global war on terrorism combined. 2

I know that this group of doctors will get me off of insulin before I am a grownup.

1) http://usatoday30.usatoday.com/news/health/2008-01-23-diabetes-cost_N.html Accessed 4.13.13

2) http://www.diabetes.org/diabetes-basics/diabetes-statistics/ Accessed 4.13.13

3) Christopher C et al., Incidence trends for childhood type 1 diabetes in Europe during 1989—2003 and predicted new cases 2005—20: a

multicenter prospective registration study The Lancet, (373)9689, Pages 2027 - 2033, 13;2009

4) Lipman T, et al., Diabetes. March 2013. Population-based Survey of the Prevalence of Type 1 and Type 2 diabetes in School Children in

Philadelphia . [Epub ahead of print]

3

• Distinctions between Islets of Mice and Men

• Why immune tolerance agents work in mice, but not man

• Why man requires an immune agent and a regeneration agent to reverse the underlying mechanisms of disease in type 1 diabetes

• My colleagues will then discuss the therapies we have now and into the future to reverse type 1 diabetes

Claresa Levetan MD, FACE

4

Islets of Man and Mouse

Red Cells--Beta cells making insulin and amylin

Green Cells---Alpha cells making glucagon

Blue Cells—Delta cells making somatostatin

Black Holes in human islet are blood vessels

>70% of Beta Cells in the human islet direct connect with other cell types

Beta cells are attacked by the immune system in type 1 diabetes resulting in

complete islet dysfunction and destruction of the entire islet

5

What Is an Islet?

Islets are small organs within the pancreas that contain 5 different cell types making 6 different hormones, all necessary for glucose homeostasis

Alpha cells make glucagon

Beta cells make insulin and amylin

Delta cells make somatostatin,

Gamma cells make pancreatic polypeptide

Epsilon cells make ghrelin

In man, 6 islet hormones communicate with one another and all have been shown necessary for normal glucose metabolism

Among both type 1 and 2 diabetes, autopsy studies show not only reduced beta cells, but also reduced islet numbers

Type 1 diabetes will be reversed when 5-celled new islets are generated in an immune protected environment

We have the ability to generate new islets that are protected from immune attack, NOW 6

Distinctions between Islets

of Mice and Men

Mice eat continuously and beta cells are constantly turning over during their 1 year lifespan1

Islets in man are designed to regulate glucose based upon emotional stress and long periods of feast or famine

Islets of mice have predominately beta cells, which are centrally clustered and man has a smaller percentage of beta cells dispersed throughout the islet, which are in direct contact with the other 4 cell types

The autonomic nervous system in man through innervates islet blood flow suggesting human islet a have a unique reaction to emotional stress compared to mice2

100s of immune studies have reversed diabetes in mice, but not in man, because man’s islets have a complex infrastructure that cannot be regenerated simply by blocking the immune attack on the pancreas

In man, in order to generate new islets containing all 5 cell types, requires immune therapy and regeneration therapy, both of which are now available

1) Levetan C and Pierce S .Endocr Pract. 2012 Nov 27:1-36. [Epub ahead of print]

2) Rodriguez-Diaz R et al., Cell Metab. 2011;14:45-54.

7

Type 1 Diabetes is more than an

Autoimmune Disease in Man

Humans require both immune protection and generation of

new islets to reverse the underlying disease process of type

1 diabetes

Diabetes in mice can be reversed with only an immune agent

because beta cell turnover is faster in mice than man

Islet Regeneration in man is possible, even among patients

with type 1 diabetes for 20 years or longer

Type 1 diabetes is not just an autoimmune disease as it is in

NOD mice, but is a disease of 1) autoimmunity, 2) beta cell

deficiency and 3) lack of beta cell regeneration

We have human gene peptides and growth factors that

transform pancreatic ductal cells into new islets that we can

use NOW in type 1 patients 8

One machine pumping both insulin and

glucagon

Glucose measurements taken and based

upon glucose levels, the correct dosage of both

insulin and glucagon were automatically given

to the patient

This is same concept as the “new” artificial

pancreas of 2013 now in clinical trials

Even the bionic pancreas did not normalize

glucose levels, because it only replaced two

missing and malfunctioning hormones

All five cell types generating 6 different

hormones within a functioning islet are required

for normal glucose homeostasis

Scientific studies show that all 6 hormones

have a role in glucose metabolism

Treatment vs. Cure

*http://www.thefreeresource.com/insulin-pump-facts-informtion-and-resources *http://idsa.org/catalyst/LMBVT/case_studies_2010_minimed.pdf *Kadish AH. A servomechanism for glucose monitoring and control

Trans. Am. Soc. Artificial Internal Organs 9. 363. 1963 *Kadish AH. Automation control of blood sugar. Biomed Sci. Instr. 1, 172, 1963 Available for viewing at the Keck Graduate Institute, Science Heritage Center, Clairemont,

CA

The First Successful Bionic

Pancreas was developed in

1963 by Dr. Arnold Kadish*

9

Regeneration of the Pancreas

Clamping of the pancreas resulting in new islet formation has been described for a century

Based on a paper in 1920, in which patients with pancreatic stones had new islets, Frederick Banting clamped the pancreatic ducts of dogs for 10 weeks and collected the pancreatic secretions that became known as insulin

Before insulin was readily available, surgeons tied off part of the pancreas among type 1 children, which transiently helped their diabetes, but likely the ongoing autoimmune destruction of new islets contributed to why these surgical successes were only temporary

10

Severely ill diabetic

children underwent

ligation of the

pancreatic duct to

improve their diabetes

between 1910 and

1930*

Benefits were positive,

but short-lived likely due

to autoimmune

destruction of new

insulin-producing cells*

*Cusi 1911; Bierry and Kollman, 1929; DeTakats, 1930

11

In 1983, Dr. Vinik Rediscovered that Wrapping the Pancreas

with Cellophane turned Pancreatic Ducts into Islets

New islets were shown by Dr. Vinik by wrapping the pancreatic ducts of hamsters

A peptide was specifically isolated in 1992 by Dr. Vinik’s team that has been shown to transform pancreatic ducts into 5-celled new islets

In human trials with Dr. Vinik’s, there was a 27% rise in C-peptide within 2 months in type 1 patients with a 20 year history of diabetes and no baseline C-peptide, but without immune protection, these results were not sustained. A rise in GAD antibodies were seen reflecting the immune system was seeing new beta cells3

As much as a 75% reduction in insulin requirements was seen after 4 weeks of gastrin and epidermal growth factor in type 1 patients2

1) Dungan KM et al., Diabetes Metab Res Rev 2009; 25: 558–565

2) Jamal AM et al., Cell Death and Differentiation (2005) 12, 702–712.

3) Transition Therapeutics, March 5, 2007 http://www.transitiontherapeutics.com/media/archive.php Accessed January 1, 2013

Duct Islet2

12

Islet Relationship to Ducts

DUCTS

ISLET

13

Not until the Early 1980s Was Diabetes

Considered to be an Autoimmune Disease

In the 1980s, nearly 100% of patients became insulin-free when the immune agent Cyclosporine A was begun immediately after diagnosis, thus protecting the remaining few beta cells

By 2 years, almost all patients in remission, required insulin, demonstrating that an immune tolerance agent alone, does NOT mean that there will be generation of beta cells in man

It is only now after 100s of studies using a variety of immune tolerance agents and immune approaches that we can look back and see that in man, diabetes is a disease NOT only of autoimmunity

We now have both immune tolerance agents and beta regeneration agents (some are already FDA-approved therapies) that can address the underlying mechanisms of disease in type 1 diabetes: 1) autoimmunity 2) beta cell deficiency and 3) lack of beta cell regeneration

14

Type 1 Diabetes

“Insulin is not a cure for diabetes; it is a treatment.”

Frederick G. Banting, 1923, Nobel Prize Speech

Merging immune tolerance agents with beta regeneration agents; a platform for future insulin independence

Type 1 Diabetes is a disease of

Autoimmunity

Beta Cell Deficiency

Lack of Beta Cell Regeneration

15

Immune

Tolerance Agent Protect newly

generated and existing

beta cells

Potential for Insulin Independence 2015

2013

More potent

beta

generation

agents

Insulin

Independence among existing

and new onset

Regeneration

Agent

Remission

followed by

maintenance

Immune

Tolerance Agent Protect newly

generated and existing

beta cells

Insulin

Independence among existing

and new onset

16

• What are normal A1Cs and glucoses?

• Is it patients or the pancreas that are non-compliant?

• Current therapy and technology is not enough

Susan Pierce CDE, MPT

17

What IS the Normal Glucose Range for

Someone without Diabetes?

Continuous Glucose Monitoring

Shows that out of 288 readings/day

95% of glucose levels < 120 mg/dL 1

80% of glucose levels 60 - 100 mg/dL 1

1. Christiansen JS. What is normal glucose? – Continuous glucose monitoring data from healthy subjects. Presented at: 42nd Annual Meeting of the EASD; September 14-17, 2006; Copenhagen, Denmark.

18

In those without diabetes, 95% of daily (24 hour) life

is spent with a glucoses less than 120 mg/dl

80% of daily (24 hour) life is spent with glucose levels

of 60-100 mg/dl

http://www.diabetes-symposium.org/index.php?menu=view&id=322

19

*Updated mean sA1C adjusted for age, sex, and

ethnic group.

Stratton I, et al. UKPDS 35. BMJ. 2000;321:405-412.

0

2

0

4

0

6

0

8

0

0 5 6 7 8 9 1 0 1 1

Myocardial

infarction

Microvascular

complications

Updated Mean HbA1c (%)*

% I

ncid

en

ce p

er

1,0

00 P

ati

en

t-years

A1Cs Above 5.5% Increase Complication

Risk in Non-Diabetic Individuals as well as those with

Type 1 and Type 2 Diabetes

20

Can a normal A1C be achieved

without too many lows?

The leading diabetes researchers of the DCCT believed that insulin alone could restore a glucose to < 6.05% without hypoglycemia 1

An A1C of < 6.05% was attained at least once during the 10 year study by 44% of the patients receiving intensive therapy 1

The intensively managed group maintained an average A1C throughout the study of 7.2% 1

1. The DCCT Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. 21

Is New Technology Helping?

Sensor-augmented pump studies recently

Demonstrated a decrease of A1C levels from 8.3% to

7.5% over 12 months (1)

With further reduction to 7.4% after an additional 6

months on the sensor (2)

These achievements were made without associated

weight gain or hypoglycemia

Despite advances in sensors and pumps, sensor-

augmented pumps did not improve the A1C levels

as much as did the DCCT decades ago

1) Bergenstal RM, Tamborlane WV, Ahmann A, et al. N Engl J Med. 2010;363:311-320.

2) Bergenstal RM, Tamborlane WV, Ahmann A, et al. Diabetes Care. 2011;34:2403-2405. 22

I need my human pancreas back!

Even pumping all 6 missing hormones --- insulin,

amylin, glucagon, ghrelin, somatostatin, pancreatic

polypeptide --- would not

There is no computer that can integrate stress and

other factors the way the human islet does.

23

Restoring Normal Glucose

Restoring 5-celled new islets that generate 6

hormones that all communicate with one

another and the brain to maintain glucose

levels < 120mg/dL 95 % of the time

In order to maintain new islets immune

protection must be in place

Drs. Vinik and Bergman will describe how we

now have therapies to transform pancreatic

ducts into 5-celled islets

Drs. Pozzilli and Schatz will describe how we

can optimally protect the new islets 24

4

The need to change the paradigm of

diabetes simply being an autoimmune

disease.

Desmond Schatz, MD

25

Ge

ne

tic

Ris

k

“P

re”-D

iab

ete

s

New-

Onset Established Complications

A

nti

bo

die

s

OPPORTUNITIES FOR PREVENTION

AND CURE

PREVENTION

INTERVENTION CURE

WITHOUT PREVENTION

THERE CAN NEVER BE A

CURE

26

27

• Concept rejected initially…”lacks evidence, not

novel, too presumptive, etc.”

• Based on lessons learned from past

experiences), efficacy in other disorders

(cancer, HIV, transplantation), and mechanisms

underlying type 1 pathogenesis

Diabetes Care, 2002

THE CONCEPT FOR COMBINATION

28

DO WE HAVE CLUES AS TO WHAT

IS THE “BEST” COMBINATION?

Difficult question to answer, based on:

Differences in preclincial studies?

Potential differences in mouse to man?

29

AAV murine IL-10

AAV rat preproinsulin gene (vLP-1)

Adenovirus expressing mIL-4

Aerosolinsulin

Allogenic thymic macrophages

Alpha Galactosylceramide

Alpha-interferon (rIFN-alpha)

Alpha/beta T cell receptor thymocytes

Aminoguanidine

Androgens

Anesthesia

Antioxidant MDL 29,311

Antisense GAD mRNA

Azathioprine

Anti-B7-1

Bacille Calmette Gue’rin (BCG)

Baclofen

Bee venom

Biolistic-mediated IL-4

Blocking peptide of MHC class II

Bone marrow transplantation

Castration

Anti-CD3

Anti-CD4

CD4+CD25+regulatory T cells

Anti-CD8

Anti-CD28 MAb

Cholera toxin B subunit-insulin protein

Class I derived self-I-A beta(g7) (54-76) peptide

Cold exposure

Anti-complement receptor

Complete Freund’s adjuvant

Anti-CTLA-4

Cyclic nucleotide phosphodiesterases (PDEs)

Cyclosporin

Cyclosporin A

DC deficient in NF-kappaB

DC from pancreatic lymph node

DC with IL-4

Deflazacort

Deoxysperogualin

Dexamethasone/progesterone/growth hormone/estradiol

Diazoxide

1,25 dihydroxy Vitamin D3, KH1060

1,25 dihydroxycholecalciferol

1,25 dihydroxyl Vitamin D3

Elevated temperature

Emotionality

Encephalomyocarditis virus (ECMV)

Essential fatty acid deficient diets

FK506

FTY720 (myriocin)

GAD 65 peptides in utero

Anti-GAD monoclonal antibody

Galactosylceramide

Glucose (neonatal)

Glutamic acid decarboxylase

(intraperitoneal, intrathymic, intravenous, oral)

Glutamic acid decarboxylase 65 Th2 cell clone

Glutamic acid decarboxylase peptides

(intraperitoneal, intrathymic, intravenous, oral)

Gonadectomy

Guanidinoethyldisulphide

Heat shock protein 65

Heat shock protein peptide (p277)

Hematopoietic stem cells encoding proinsulin

Housing alone

Human IGF-1

I-A beta g7(54-76) peptide

Anti-I-A monoclonal antibodies

Anti-ICAM-1

IgG2a antibodies

Immobilization

Inomide

Anti-integrin alpha 4

Insulin (intraperitoneal, oral, subcutaneous, nasal)

Insulin B chain (plasmid)

Insulin B chain/B chain amino acids 9-23 (intraperitoneal, oral, subcutaneous, nasal)

Insulin-like growth factor I (IGF-I)

Anti-intercellular adhesion molecule-1 (ICAM-1)

Interferon-alpha (oral)

Interferon-gamma

Anti-interferon-gamma

Interferon-gamma receptor/IgG1 fusion protein

Interleukin-1

Interleukin-4

Interleukin-4-Ig fusion protein

Interleukin-4-plasmid

Interleukin-10

Interleukin-10-plasmid DNA

Interleukin-10-viral

Interleukin 11-human

Interleukin-12

Intrathymic administration of mycobacterial heat shock protein 65

Intrathymic administration of mycobacterial heat shock peptide p277

Islet cells-intrathymic

L-Selectin (MEL-14)

Lactate dehydogenase virus (LDH)

Large multilamellar liposome

Lazaroid

Anti-leukocyte function associated antigen (LFA-1)

Anti-LFA-1

Linomide (quinoline-3-carboxamide)

Lipopolysaccharide-activated B cells

Lisofylline

Lymphocyte choriomeningitis virus (LCMV)

Anti-lymphocyte serum

Lymphoctyte vaccination

Lymphocytic choriomeningitis virus

Anti-L-selectin

Lymphotoxin

LZ8

MC1288 (20-epi-1,25-dihydroxyvitamin D3)

MDL 29311

Metabolically inactive insulin analog

Anti-MHC class I

Anti-MHC class II

MHC class II derived cyclic peptide

Mixed allogeneic chimerism

Mixed bone marrow chimeras

Monosodium glutamate

Murine hepatitis virus (MHV)

Mycobacterium avium

Mycobacterium leprae

Natural antibodies

Natural polyreactive autoantibodies

Neuropeptide calcitonin gene-related peptide

Nicotinamide

Nicotine

Ninjin-to (Ren-Shen-Tang), a Kampo (Japanese traditional) formulation

NKT cells

NY4.2 cells

OK432

Overcrowding

Pancreatectomy

Pentoxifylline

Pertussigen

Poly [I:C]

Pregestimil diet

Prenatal stress

Preproinsulin DNA

Probucol

Prolactin

Rampamycin

Recombinant vaccinia virus expressing GAD

Reg protein

Reg protein

Rolipram

Saline (repeated injection)

Schistosoma mansoni

Semi-purified diet (e.g., AIN-76)

Short term chronic stress

Silica

Sirolimus/tacrolimus

Sodium fusidate

Soluble interferon-gamma receptor

Somatostatin

Non-specific pathogen free conditions

Streptococcal enterotoxins

Streptozotocin

Sulfatide (3’sulfogalactosylceramide)

Superantigens

Superoxide dismutase-desferrioxamine

Anti-T cell receptor

TGF-beta 1 somatic gene therapy

Th1 clone specific for hsp60 peptide

Anti-thy-1

Thymectomy (neonatal)

Tolbutamide

Tolerogenic dendritic cells induced by vitamin D receptor ligands

Top of the rack

Treatment combined with a 10% w/v sucrose-supplemented drinking water

Tumor necrosis factor-alpha

TX527 (19-nor-14,20-bisepi-23-yne-1,25(OH)(2)D(3))

Vitamin E

Anti-VLA-4

Thymoglobulin

Anti-CD3

ALS + Exendin-4

LSF + Exendin-4

EGF + Gastrin

Regulatory T Cells

Islet Transplantation

Microspheres

FTY720

sICAM-Ig (Adenovirus Vector)

IDS 2004, Cambridge (Atkinson & Roep)

N=193;

Now ~400

THERAPIES PREVENTING DIABETES IN NOD MICE

30

WHAT CONSIDERATIONS NEED TO

GO INTO SELECTIONS FOR

COMBINATION RX?

Selecting combination therapies should occur,

with a combination of thoughts regarding

mechanism of action, synergy, safety, and

potential for efficacy

31

USE COMBINATIONS THAT IMPROVE EFFICACY

0 25 50 75 100 125 1500

20

40

60

80

100Control

GCSF

ATG

ATG + GCSF

Days Post Onset

No

rmal G

lycem

ia (

%)

32

USE COMBINATIONS THAT IMPROVE

ALLOW FOR LOWER DOSING OF DRUGS

33

USE COMBINATIONS THAT

IMPROVE SAFETY

p values @ 4 weeks

(n is still increasing)

ATG vs. A+G = .0128

ATG vs. CD3 = .3569

ATG vs. 3+G = .2141

A+G vs. CD3 = .0005

A+G vs. 3+G < .0001

CD3 vs. 3+G = .9135

34

RECENT NEW-ONSET DIABETES STUDIES

Published - * α-CD3 (x4) - * α-CD20 - Mycophenolic Mofetil + anti-CD25 - GAD x2 - * CTLA-4

- * DiaPep - * Autologous non-myeloablative transplantation - Cord Blood - IL-2 plus Sirolimus (Phase 1) - Canakunimab; Anakinra Completed enrollment - Mesenchymal Stem Cells - Cord Blood Phase 2 (+ Vit D + Omega 3 FA) - Meticulous Metabolic Control - GCSF - ATG-GCSF Enrolling - T reg - α-1 antitrypsin

35

WHAT HAVE WE LEARNED?

We can do well designed, adequately powered, and carefully conducted intervention and prevention studies

Sample sizes require a collaborative, cooperative, multi-center approach

If a response is seen, it is likely to be evident soon after therapy begun (3-6 months)

Long term benefit largely unknown 36

WHY LIMITED SUCCESS TO DATE? BACK TO THE FUTURE…..

RETHINKING MECHANISMS LEADING TO TYPE 1

DIABETES?

1986: Suicide or Homicide of β Cell Bottazzo …..

Is the autoimmune/inflammatory process in humans really

primary or secondary to hitherto unknown β cell defects/killing??

- limited success of immune interventions

- no treatment mediated decrease in islet cell Ab

- what have we really learned from animal models ?

- no markers in humans other than islet Ab

……….of immune dysregulation or β cell killing

- lack of correlation of insulitis with islet Ab (nPOD)

37

OUR FUTURE CHALLENGES

Current treatment quite good – but…insulin not a biological cure

Primum non nocere (safety)

Re-evaluate study design (smaller, shorter studies in new-onset patients)

Define clinical significance (efficacy)

- superiority or ease over current treatment if new-onset

- only do if translatable (therapy or prevention)

Better understand triggers (TEDDY)/mechanisms leading to disease

Use a `cocktail approach’

(Immunoregulatory/regenerative)

38

PUTATIVE

ENVIRONMENTAL

TRIGGER

TIME

FUTURE PREVENTION

OF TYPE 1 DIABETES

BE

TA

CE

LL

MA

SS

M

DIABETES

“PRE”-

DIABETES

GENETIC

PREDISPOSITION

INSULITIS

BETA CELL INJURY

Early Monotherapy

Late Combinations

SAFE

MORE TOXIC ?

39

Prof. Paolo Pozzilli Università Campus Bio-Medico, Roma, Italy

Barts' and The London Hospital, UK

Outcomes with immune tolerance agents in

Type 1 Diabetes

from Cyclosporine to Current Therapies

40

Roma,1989: First International Meeting

on this topic

President: D Andreani

Vice-President: G Gambassi

Scientific Coordinators: P Pozzilli, H Kolb

Scientific Advisors: JF Back, GD Bompiani, P

Brunetti, JJ Duprè, GS Eisenbarth, G Ghirlanda,

L Harrison, NK Maclaren, J Nerup, G Pozza, CR

Stiller

Scientific Secretariat: A Corcos, E Killick, N

Visalli

“Immunotherapy of Type 1 diabetes”

41

Nearly 100% insulin-free remission if used very early in the course of disease within 2-3 days of insulin therapy and before weight loss (Eisenbarth GS Immunotherapy of Diabetes and Selected Autoimmune Diseases CRC Press, 1989)

Remissions are not typically sustained more than 2 years

Maintaining trough levels of 75-250 ng/ml did not demonstrate significant insulin-free remissions (Miami Study and IMDIAB1)

CyA was abandoned because it was not curative and not because of short term adverse effects. There was fear of long term adverse effect at kidney level

There were no beta cell regenerative agents available at the time to use in conjunction with CyA to sustain potential regeneration of beta cell mass, nor was it understood that outcomes in man would be different than mice when using immune tolerance agents

42

CyA for Type 1 diabetes: history

(n= 692 treated patients)

Bougneres PF et al. Diabetes 1990 43

Skyler JS et al. Diabetic Medicine 1993 44

Disease State Drug Oral Injectable

Organ Transplant Sandimmune 14-18 mg/kg/day, taper to 5-10

mg/kg/day in 1-2 weeks

5-6

mg/kg/day

Neoral or a bioequivalent generic 7-9 mg/kg/day, taper to 5-10

mg/kg/day in 1-2 weeks

Rheumatoid Arthritis Neoral or a bioequivalent generic 2.5–4 mg/kg/day in two divided

doses

Psoriasis Neoral or a bioequivalent generic 2.5–4 mg/kg/day in two divided

doses

Crohn's Disease Sandimmune 4 mg/kg/day

Ulcerative Colitis Sandimmune 4 mg/kg/day

Nephrotic Syndrome Brand not specified 3.5 mg/kg/day in two divided doses

Multiple sclerosis

Brand not specified

7.2 mg/kg/day

Lupus Brand not specified 2.5 mg/kg/day

Alopecia Areata Brand not specified 3-5 mg/kg/day

Atopic Dermatitis Brand not specified 5 mg/kg/day

Dermatomyositis Brand not specified 3-10 mg/kg/day

Lichen Planus Brand not specified 6 mg/kg/day

Myasthenia Gravis Brand not specified 5 mg/kg/day

Polymyositis Brand not specified 2.5 mg/kg/day

Psoriatic Arthritis Brand not specified 3.5 mg/kg/day

Pulmonary Sarcoidosis Brand not specified 5-7 mg/kg/day

Uveitis Brand not specified 2.5-5 mg/kg/day

Today usage and dosages of CyA

45

Minimal renal adverse effects as shown by Assan and others if trough levels are <300 ng/ml

Among 285 patients on 19.9 months of CyA averaging 6.5 mg/kg/day for 19.9 months and followed for 13 years, no long term renal effects seen. Trough goal of < 300 ng/ml with reductions if creatinine more than 30% above baseline (Assan R, Blanchet F, Feutren G et al., Diabetes Metab Res Rev. 2002;18(6):464-72)

Minimal renal adverse effects if dosage maintained in a range of 5 mg/kg/day after initial dosage of 7.5 mg/kg/day with trough goal of 300 ng/ml with reduction of dosage if creatinine rises above 30% of baseline

A direct toxicity effect of CyA on beta cells function has not been demonstrated

46

Renal Effects of CyA in patients with T1D

Modify from Reimann M et al. Pharmacology & Therapeutics 2009

GAD65

HSP60

IL-1 receptor antagonist

GAD65

HSP60

Anti CD3 MoAb

CTLA-4

Anti CD20 antibody

Today’s main strategies with immune tolerance

agents to halt progression towards beta cell failure

47

Pozzilli P. Immunotherapy 2012

Results of main trials with immune tolerance agents in T1D

48

We know the good and the bad about CyA, so we should be

feel confident enough about its use. This is not the case with

all the other immune tolerance agents tested so far for lack

of long term studies.

No long term renal toxicity has been shown with CyA used

at 7.5 mg/kg per day for 1 year

The concept of combination therapy using an immune

tolerance agent with a beta cell regenerative compound

should be considered, and among the different immune

tolerance agents, CyA still holds a prominent role.

49

Rationale for reconsidering CyA in patients

with recent onset T1D

Leslie RD. Diabetes 2010

The spectrum of autoimmune diabetes extends

across all ages and varies with age at diagnosis

50

Key issues to consider for trials

in type 1 diabetes

51

Future directions:

combination therapy

52

Ability to use proton pump inhibitors to

increase gastrin, which increases beta cell

regeneration.

Donald Bergman, MD, FACE, MACE

53

Gastrin

• Gastrin plays a role in pancreatic growth and development in fetal life1,2

• Pancreatic gastrin expression is suppressed after birth and then found as a growth factor in the gastric antrum and duodenum (G cells) after fetal development1

• Excessive gastrin has been associated with new islet and beta cell formation since the 1950s3,4

• Gastrin hypersecretion results in the formation of new islets containing new pools of beta cells5

• Gastrin’s mechanism of action is the transformation of pancreatic ducts to islets5

1. Tellez N. Endocrinology, 2011, 152(7):2580–2588 2. Larsson LI. et al.,1976 Nature 262:609–610. 3. Zollinger RM and Ellison EH. Ann. Surg., 142:709-728, 1955. 4. Bryant JG, Smith JV. Calif Med. 1965 Jan;102:49-52. 5. Suarez-Pinzon WL, et al., The Journal of Clinical Endocrinology & Metabolism 90(6):3401–3409

54

The Association between Gastrin and Insulin

• Patients with Zollinger-Ellison Syndrome-- increased gastrin

producing nests of cells found both in the pancreas and GI tract have new islets and increased beta cell replication2

• Patients infused with gastrin had heightened insulin

responses to glucose compared to those not receiving a gastrin infusion.1

1) Rehfeld JF, Stadil F. 1973. J Clin Invest 52:1415–1426 2) Zollinger RM and Ellison EH. Ann. Surg., 142:709-728, 1955.

55

Gastrin’s Mechanism of Action

Gastrin has been shown by specialized studies including BrdU studies to transform ductal (extraislet) tissue into new islets*

On the left, a single, larger black cell represents the presence of gastrin and the pink cell representing a progenitor cell within the ductal population. Blue cells indicate beta cells and red cells represent alpha cells, with delta cells present to a smaller extent in green. *Telez, et al., Endocrinology, July 2011, 152(7):2580–2588

56

Gastrin Transforms Human Ducts to Islets

• Gastrin alone, has been shown the ability to induce new human islets from human duct cells without other growth factors (Suarez-Pinzon, J Clin Endocrinol Metab, June 2005, 90(6):3401–3409)

• A combination of Gastrin with Epidermal Growth Factor given to type 1 patients for 4 weeks resulted in – up to a 75% decrease in insulin requirements when followed

for 3 months post treatment

– an A1C from 6.7% at baseline down to 4.7% at 3 months post-treatment (Transition Therapeutics, March 5, 2007 http://www.transitiontherapeutics.com/media/archive.php Accessed January 1, 2013)

57

Proton Pump Inhibitors increase Gastrin • Proton pump inhibitors (PPIs) are used extensively for the treatment of

peptic ulcer and related symptoms and indirectly elevate gastrin levels • Studies have shown a dose- and duration-dependent relationship between

PPIs and gastrin levels1,2,3 • Gastrin levels rise significantly with typical dosages for GI disease • PPIs are safe (with some concerns) • Complete hepatic metabolism with some potential for drug-drug

interactions • Long-term usage among postmenopausal women associated with an

increased risk for hip fracture, infectious diarrhea, particularly among hospitalized patients

1) Hu YM. World J Gastroenterol. 12:4750–4753 2) Ligumsky M. 2001. J Clin Gastroenterol 33:32–35 3) Cadiot G,. Gastroenterol Clin Biol 19:811–817

58

PPIs

• Substituted benzimidazole derivatives

• Block the terminal step in acid production

• Inhibit the function of hydrogen-potassium adenosine triphosphatase on the luminal surface of parietal cell membranes in the stomach.

Madanick. Cleveland Clinic JM 2011;78:39-49

59

Studies Confirm Lower A1C on PPI • Retrospective review of 347 type 2 diabetes

– Those taking PPI had lower A1Cs (7.0%) compared to patients not on PPIs (7.6%) (p=0.002) (1)

• Retrospective of 73 type 2 patients – A1C of patients on insulin with PPI was 7.11% compared to 7.70% of patients

not on PPI (p=0.001)

– Patients on multiple oral diabetic agents and PPI had A1C of 7.26% vs. 7.8% (p=.002) (2)

• Cross-sectional study of 97 patients type 2 patients – Those on insulin and PPI had a 0.8% to 1.48% lower A1C than those not on

PPIs (95%, CI: -0.12)

– Those on oral agents and PPI had a 0.6% to 0.83% lower A1C on oral agents (95%, CI: -0.12) (3)

• Retrospective review of 21 type 2s on esomprazole for 12 months – 0.7% lower A1C than those not on PPI (4) 1 )Mefford IN, Wade EU. Med Hypotheses. 2009;73:29-32. 3 3) Boj-Carceller D., et al World J Diabetes 2011 December 15; 2(12): 217-220.

2) MA Crouch. J Am Board Fam Med 2012;25:50 –54. 4) Hove KD, et al.,Diabetes Res Clin Pract. 2010;90(3):e72-4.

Randomized Trials Using PPIs Among Type 2 Diabetes

Pantoprazole/Protonix* • 12 week trial with 31 patients randomized • 38% rise in gastrin • 1.2% drop in A1C from 7.9% to 6.8% in PPI group • Placebo group A1C from rose from 7.5 to 7.9% • Improvement in beta cell function by 30% (HOMA) • The decrease in A1C correlated with an increase in gastrin and insulin • No adverse side effects in Protonix seen over that in the control group. Nausea,

vomiting , headache and myalgia were the same in control and Protonix group Esomerprazole/Nexium** • 12 week trial with 41 patients • Patient further randomized to yogurt or placebo taken with Esomerprazole • There was a 2 kg greater weight gain in those on Esomerprazole and yogurt • Area under the curve for insulin was significantly decreased in the control group

compared to no change in the intervention group (p=0.002)

*Singh PK et al, J Clin Endocrinol Metab 97: E2105–E2108, 2012 **Hove KD et al, Diabetologia 56;22-30, 2013

61

Current Trial with Lansoprazole in Type 1

Patients to Assess Beta Cell Function* • Current Trial with Lansoprazole (Prevacid) in type 1 patients

– ages 11-45 – for 12 months being used with Sitigliptin (Januvia) to assess beta cell function

(no immune tolerance agent being used) – Subjects age 11-17 years will take 30 mg capsule once daily of lansoprazole

with 50 mg of Sitigliptin once daily – Subjects age 18-45 years will take 60 mg of lansoprazole once daily with 100 mg

of sitigliptin once daily

• Primary Outcome Measures: 2 hour C-peptide AUC in response to mixed meal tolerance at 12 months

• Secondary Outcomes Measures:

– 2 hour C-peptide AUC in response to MMTT [ Time Frame: months 6, 18, and 24 ]

– A1C levels – Insulin use in units per kilogram body weight per day – Safety (adverse events frequency, severity)

*http://www.clinicaltrials.gov/ct2/show/NCT01155284?term=lansoprazole+type+1+diabetes&rank=3 62

PPI side effects: clopidogrel

• PPIs inhibit a P450 enzyme which is required for activation of clopidogrel

• Contradictory data in literature

• One retrospective study found no adverse effect and found decreased GI bleeding in combined use

• FDA warning

Ray et al. Ann Int Med 2010; 152:337-345 63

PPI side effects: fracture, pneumonia, enteric infection

• Fracture risk: conflicting reports. Risk greater in those with other risk factors for fracture. FDA: possible association

• Pneumonia risk: 4.5 times higher in PPI users but only 18% had documented pneumonia

• Enteric infection risk: C. Diff. 127000 patients odds ratio 2.05.

• Enteric infection: bacterial overgrowth and SBP (small studies)

Madanick. Cleveland Clinic JM 2011;78:39-49 65

PPI side effects: nephritis, iron, B12 deficiences

nephritis

• 64 cases documented in the world literature in PPI users

• Not enough evidence to support a causal relationship

Iron, B12 deficiency

• Iron: acid needed to dissociate iron salts from food

• B12: acid needed to separate B12 from food proteins

• No convincing evidence in the literature

Madanick. Cleveland Clinic JM 2011;78:39-49

65

Ability for women with decades of type 1

diabetes to become insulin independent within

weeks of pregnancy.

Lois Jovanovic MD, FACP, FACN, FACE,

MACE

66

Normal Pregnancy

Associated with a 2-4 fold rise in insulin

Among those without diabetes, normal glucose levels are considerably lower during pregnancy than in the non-pregnant state

Goals Glucose During Pregnancy The American College of Obstetricians and Gynecologists

recommends the following goals when self-monitoring blood glucose levels during pregnancy: Fasting glucose concentrations ≤95 mg/dL

Premeal glucose concentrations no higher than 100 mg/dL

One-hour postmeal glucose concentrations no higher than 140 mg/dL

Two-hour postmeal glucose concentrations no higher than 120 mg/dL

The American Diabetes Association recommends the following glucose goals: Premeal, bedtime, and overnight glucose concentrations 60 to 99 mg/dL

Peak postmeal glucose concentrations 100 to 129 mg/dL (5.6 to 7.2 mmol/L) one to two hours after the beginning of the meal

67

Each Pregnancy is Unique

Among pregnant type 1 women, there is often a decline in the need for insulin

Often see hypoglycemia among type 1 patients in pregnancy with a peak incidence in the first trimester due to new insulin production by the mother

Some women have been insulin-free throughout their pregnancy, only to return to insulin requirements after delivery

New insulin production has been seen among type 1 patients with a history of diabetes for more than 20 years

68

Am J Obsetet Gynecol 1976, 15;125(2):264-5.

1976

Known Insulin Remissions Among Pregnant Type 1

Patients Date Back Decades

69

Patients with No Detectable Insulin

Before and Significant Rises During Pregnancy*

C-peptide/Endogenous insulin concentration before pregnancy

and at 10 weeks of gestation

0

0.05

0.1

0.15

0.2

0.25

0.3

1 2 3 4 5 6 7 8 9 10

Patients with Type 1 Diabetes

C-p

ep

tid

e (

nm

ol/

l)

Pre-Pregnancy

10 weeks of gestation

Patients had a mean duration of diabetes 21.2 years

By 10 weeks of gestation, endogenous insulin levels were

not only detectable, but into the normal range

Some women have been insulin-free not only during this

time, but throughout pregnancy

*Jovanovic L, et all.,Diabetologia. 2000 Oct;43(10):1329-30. 70

New Insulin Production Occurs

Quickly

Islet Neogenesis Proceeds Beta Cell Regeneration in pregnancy*

Pregnancy is one of the few times postnatally when new islets form

Once new islets form, there are new pools of beta cells for

replication

Most islets are formed by the time of birth

Only in rare instances do islets regenerate. These times include

acute pancreatic injury, pancreatitis, pancreatic stones and

pregnancy

By 10 weeks of pregnancy, new endogenous levels of insulin are

seen

This is the time similar to the original study by Banting and Best

when they collected secretions from clamped pancreatic ducts at

10 weeks

71

*Johansson M., et al., Endocrinology 2006. 147(5):2315–2324

Combination Therapies Enhance

Prospects of “Curing” Diabetes

Aaron Vinik MD, PhD, FCP, MACP, FACE

Murray Waitzer Chair of Diabetes

Research

Eastern Virginia Medical School Strelitz

Diabetes Center and

Neuroendocrine Unit

Norfolk Virginia.

72

Background (Sarandipity) Saran wrapping reverses streptozotocin-

induced (STZ) diabetes in hamsters

• Ilotropin, a crude pancreatic extract from CW, induces new islet formation from ductal epithelium.

• Ilotropin reverses streptozotocin-induced diabetes in hamsters.

• mRNA differential display led to

• THE DISCOVERY OF INGAP

Rafaeloff, Quin, Barlow, Rosenberg and Vinik

Febs Letters378, 219-223, 1996

Rafaeloff, Pittenger, Barlow, Qin, Yan, Rosenberg, Duguid, Vinik

J Clin Invest 99: 2100-2109, 1997 73

Production of a Biologically Active INGAP

Peptide by Biochemical Techniques and

Effects on Islet Neogenesis and STZ Diabetes

5’UTR Signal peptide Mature peptide 3’UTR

1 78 35 540 646

3’UTR

766

C C C

35 46 68

C C C

146 163 171

C= cysteine

AA= amino acid

N= potential N glycosylation

IGLHDPSHGTLPNGS AA 104 AA 118

N N

N

74

Restoration of Normal Blood Glucose in INGAP-

treated C57BL/6J STZ Diabetic Mice

INGAP/SALINE

Rosenberg, Vinik et al. Ann Surg. 2004 Nov;240(5):875-84.

75

76

INGAP and Human Health and Disease

Is INGAP present in the human pancreas?

Does INGAP affect human pancreatic tissue in

vivo and in vitro? Will it reverse diabetes?

77

Transdifferentiation of Human Islets-The

Effects of INGAP Peptide

Human islets after isolation

CK19 –tive and following

induction of reverse trans-

differentiation to a duct-like

epithelial structure CK19 +

Effects of INGAP peptide

on transdifferentiation

of ductal cells (CK19 +)

to islet (CK19-)

INGAP Peptide induced

transition from ductal cells

to insulin producing cells

and fully formed

islet with expression of

insulin (brown) 78

Accelerating Factors

“THE INGAP INDUCERS” AP-1-activators

STAT-activators

PAN-activators

NEOGENESIS INGAP

NEW

ISLETS

Taylor Fishwick, Vinik et al J Endocrinol. 2006 Mar;188(3):611-21

Hamblet et al Pancrease 36, 17671772, 2008

Pittenger, Taylor Fishwick, Vinik Diabetologia 52:735-7382009.

Taylor Fishwick, Hughes, Vinik Pancreas 39(1):64-70, 2009.

Chang et al Molecular and Cellular Endocrinol, 335:104-109, 2011

79

INGAP is Overexpressed in

Human Islet Neogenesis

Insulin Red

INGAP Green

Semakula C, Pambucian S, Gruessner R, Kendall D, Pittenger G, Vinik A, Seaquist E JCEM 2003

Recapitulation of Fetal Development of Islets in NIPHS Syndrome

•a) insulin blue/ Ki

67 red

•B)Proinsulin

•C) amylin

•D) PDX

•E) NKX 6.1

•F) Insulin / Ki 67

Won Pittenger, Vinik et al Clinical Endocrinology 2006:65, 566-578

HBA1c Response to INGAP in T1 DM per Protocol

Trial

0 28 56 84 112 140

-0.5

0

+0.5

-1.0

Days

Me

an

Ch

an

ge

fro

m B

as

elin

e (

AU

C)

Placebo300 mg

600 mg

INGAP Treatment

Duncan, Buse and Ratner Diabetes Metab Research and Reviews, 25, 558-565.,2009

82

Quiescent

Duct Cells Initiation

Differentiation

Proliferation

Apoptosis

Pro-apoptotic New islets

Anti-apoptotic

Islet Neogenesis

Glitazone

GLP analogs

Anti inflammatory, Lysophylline,

Immunomodulatory,Ustekinumab

INGAP

EGF/gastrin

83

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

Saline

LSF

INGAP

INGAP/L

SF

Pre

Tx

Delay

ed P

reTX

Rate

of

Rem

issio

n (

<200m

g/d

l)

All Mice

Low Starters (<350mg/dl)

High Starters(>350mg/dl)

Hyperglycemia remission rates in INGAP +

Lisofylline (LSF) treated NOD Mice

Tersey et al J of Diabetes 2: 251-257, 2012 84

Conclusion

• It is not beyond the realms of reason to anticipate that regenerating agents such as INGAP, alone, or in combination with other factors, anti-apoptotic and anti-inflammatory agents, e.g. lisophylline, anti-apoptic agents e.g. GLP-1 or an analog, DPP IV inhibitors or Glitazones, small surrogate molecules that activate the receptor, or gene manipulation will provide a cure for certain forms of diabetes in humans

Thank you for your attention! 85

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86