Low-Dose Antithymocyte Globulin: A Pragmatic Approach to Treating Stage 2 Type 1 Diabetes

• Published in: Diabetes care Vol. 47; no. 2; pp. 285 - 289
• Main Authors: Foster, Timothy P., Jacobsen, Laura M., Bruggeman, Brittany, Salmon, Chelsea, Hosford, Jennifer, Chen, Angela, Cintron, Miriam, Mathews, Clayton E., Wasserfall, Clive, Brusko, Maigan A., Brusko, Todd M., Atkinson, Mark A., Schatz, Desmond A., Haller, Michael J.
• Format: Journal Article
• Language: English
• Published: United States American Diabetes Association 01.02.2024
• Subjects: Antilymphocyte serum; Antilymphocyte Serum - therapeutic use; Blood Glucose; Blood Glucose Self-Monitoring; C-Peptide; Child; Diabetes; Diabetes mellitus (insulin dependent); Diabetes Mellitus, Type 1 - chemically induced; Diabetes Mellitus, Type 1 - drug therapy; Globulins; Glucose monitoring; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Insulin; Peptides; Prospective Studies; Research design; Side effects; Thymocytes
• ISSN: 0149-5992; 1935-5548; 1935-5548
• DOI: 10.2337/dc23-1750

Low-dose antithymocyte globulin (ATG) (2.5 mg/kg) preserves C-peptide and reduces HbA1c in new-onset stage 3 type 1 diabetes, yet efficacy in delaying progression from stage 2 to stage 3 has not been evaluated. Children (n = 6) aged 5-14 years with stage 2 type 1 diabetes received off-label, low-dose ATG. HbA1c, C-peptide, continuous glucose monitoring, insulin requirements, and side effects were followed for 18-48 months. Three subjects (50%) remained diabetes free after 1.5, 3, and 4 years of follow-up, while three developed stage 3 within 1-2 months after therapy. Eighteen months posttreatment, even disease progressors demonstrated near-normal HbA1c (5.1% [32 mmol/mol], 5.6% [38 mmol/mol], and 5.3% [34 mmol/mol]), time in range (93%, 88%, and 98%), low insulin requirements (0.17, 0.18, and 0.34 units/kg/day), and robust C-peptide 90 min after mixed meal (1.3 ng/dL, 2.3 ng/dL, and 1.4 ng/dL). These observations support additional prospective studies evaluating ATG in stage 2 type 1 diabetes.