Journal
LANCET
Volume 378, Issue 9788, Pages 319-327Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/S0140-6736(11)60895-7
Keywords
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Categories
Funding
- US National Institutes of Health
- Eli Lilly
- Medtronic
- Diamyd
- Tolerx
- Bayhill Therapeutics
- Macrogenics
- Omni BioTherapeutics
- Merck
- Osiris Therapeutics
- Aegera
- Andromeda Biotech
- Biodel
- Boehringer Ingelheim
- Calibra
- CPEX
- Generex
- Hoffman-LaRoche
- MannKind
- Novo-Nordisk
- Reata
- Pfizer
- Genentech
- Halozyme
- Intuity
- Becton-Dickinson
- MannKind Corporation
- GlaxoSmithKline
- Salutria Pharmaceuticals
- Veroscience
- Roche
- Exsulin
- NIH through the National Institute of Diabetes and Digestive and Kidney Diseases
- National Institute of Allergy and Infections Diseases
- Eunice Kennedy Shriver National Institute of Child Health and Human Development [U01 DK061010, U01 DK061016, U01 DK061034, U01 DK061036, U01 DK061040, U01 DK061041, U01 DK061042, U01 DK061055, U01 DK061058, U01 DK084565, U01 DK085453, U01 DK085461, U01 DK085463, U01 DK085466, U01 DK085499, U01 DK085505, U01 DK085509, HHSN267200800019C]
- National Center for Research Resources [UL1 RR024131, UL1 RR024139, UL1 RR024153, UL1 RR024975, UL1 RR024982, UL1 RR025744, UL1 RR025761, UL1 RR025780, UL1 RR029890, UL1 RR031986, M01 RR00400]
- Juvenile Diabetes Research Foundation International (JDRF)
- American Diabetes Association (ADA)
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Background Glutamic acid decarboxylase (GAD) is a major target of the autoimmune response that occurs in type 1 diabetes mellitus. In animal models of autoimmunity, treatment with a target antigen can modulate aggressive autoimmunity. We aimed to assess whether immunisation with GAD formulated with aluminum hydroxide (GAD-alum) would preserve insulin production in recent-onset type 1 diabetes. Methods Patients aged 3-45 years who had been diagnosed with type 1 diabetes for less than 100 days were enrolled from 15 sites in the USA and Canada, and randomly assigned to receive one of three treatments: three injections of 20 mu g GAD-alum, two injections of 20 mu g GAD-alum and one of alum, or 3 injections of alum. Injections were given subcutaneously at baseline, 4 weeks later, and 8 weeks after the second injection. The randomisation sequence was computer generated at the TrialNet coordinating centre. Patients and study personnel were masked to treatment assignment. The primary outcome was the baseline-adjusted geometric mean area under the curve (AUC) of serum C-peptide during the first 2 h of a 4-h mixed meal tolerance test at 1 year. Secondary outcomes included changes in glycated haemoglobin A(1c) (HbA(1c)) and insulin dose, and safety. Analysis included all randomised patients with known measurements. This trial is registered with ClinicalTrials.gov, number NCT00529399. Findings 145 patients were enrolled and treated with GAD-alum (n=48), GAD-alum plus alum (n=49), or alum (n=48). At 1 year, the 2-h AUC of C-peptide, adjusted for age, sex, and baseline C-peptide value, was 0.412 nmol/L (95% CI 0.349-0.478) in the GAD-alum group, 0.382 nmol/L (0.322-0.446) in the GAD-alum plus alum group, and 0.413 nmol/L (0.351-0.477) in the alum group. The ratio of the population mean of the adjusted geometric mean 2-h AUC of C-peptide was 0.998 (95% CI 0.779-1.22; p=0.98) for GAD-alum versus alum, and 0.926 (0.720-1.13; p=0.50) for GAD-alum plus alum versus alum. HbA(1c), insulin use, and the occurrence and severity of adverse events did not differ between groups. Interpretation Antigen-based immunotherapy therapy with two or three doses of subcutaneous GAD-alum across 4-12 weeks does not alter the course of loss of insulin secretion during 1 year in patients with recently diagnosed type 1 diabetes. Although antigen-based therapy is a highly desirable treatment and is effective in animal models, translation to human autoimmune disease remains a challenge.
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