Incredible strides have been made since the discovery of insulin almost 100 years ago. Insulin formulations have improved dramatically, blood-sugar levels can be measured continuously and first-generation artificial pancreas systems have reached the market. Yet only a small percentage of people with type 1 diabetes (T1D) achieve their blood sugar goals. In a review published online in Cell Metabolism, members of the JDRF Research Team—including Aaron Kowalski, Ph.D., Esther Latres, Ph.D., and Dan Finan, Ph.D.—survey the road ahead for two of the most promising diabetes treatments: artificial pancreas systems, which can automate insulin delivery, and beta cell replacement therapies.

First-generation artificial pancreas systems combine a continuous glucose monitor (CGM) with an insulin pump and an algorithm that calculates and delivers an optimal amount of insulin based on current, and sometimes future predictions of, blood sugar trends. First-generation systems currently automate only insulin delivery, and they require users to deliver an extra dose of insulin at mealtimes. But Dr. Finan, lead of the Artificial Pancreas Program at JDRF, notes the following pathway to getting more advanced and convenient artificial pancreas systems to users:

• Dual-hormone approaches to complement insulin, like glucagon or amylin, which are made by a healthy pancreas and play a key role in blood sugar regulation
• Enhancements to make interfacing with technology—both on the body and interactional—considerably less burdensome than they are currently
• Tighter glucose control, with algorithms that account for factors such as exercise and stress

“Artificial pancreas systems are improving people’s lives today, and these systems will get significantly better over the foreseeable future, providing further benefits related to both glucose control and reduced burden,” says Dr. Finan. “While we are truly excited to realize the full potential these systems have to offer people who choose them, we also understand that they are not for everyone and that beta cell replacement therapies may drive even more value to the type 1 diabetes community.”

The replacement of insulin-producing cells by transplantation shows significant promise. It is limited, however, in application due to supply constraints and the need for chronic immunosuppression. Over the past decade, significant progress has been made to address these barriers to widespread implementation of a cell therapy.

A beta cell replacement therapy will require: (1) an unlimited cell source of highly functioning insulin-producing cells; (2) a strategy to protect the implanted cells from the immune-mediated destruction, which would eliminate the need for lifelong immunosuppression; and (3) an optimal implantation site that provides a nurturing niche in which it can release insulin to fluctuating blood sugar levels. At JDRF, we are funding these three gaps in beta cell therapy, with the aim to develop a beta cell replacement treatment that works for a lifetime.

“JDRF is at a unique crossroad to accelerate both artificial pancreas and cell-based therapies for the greatest benefit of people living with T1D,” says Dr. Latres, head of the Beta Cell Replacement Program at JDRF. “While cell therapies may have a longer path to deliver a functional cure, we look up to emulate the visionary roadmap that the artificial pancreas field has successfully planned and achieved to improve the outcomes and management of type 1 diabetes.”

So, the authors ask, who wins: artificial pancreas systems or beta cell replacement therapies? They don’t divulge, but ultimately the winner is people living with diabetes.

“One hundred years after the discovery of insulin, we stand upon another potential major advance—perhaps the true cure that was envisioned in 1921,” says the final sentence.

We hope so.

If you want to hear more about what JDRF is doing to bring type 1 into type none, go to jdrf.org.