Periodic Reporting for period 4 - TRANSLATIONAL (A new translational strategy for tailored treatment of type 2 diabetes)
Periodo di rendicontazione: 2025-04-01 al 2025-09-30
Type 2 diabetes (T2D) is an escalating health problem of enormous proportions. Current treatment strategies are unable to stop disease progression and prevent the devastating complications. Clinical guidelines emphasise the need for personalized treatment. However, this is currently implemented on trial-and-error fashion. We have recently found that T2D patients can be divided into different clusters, each with different characteristics. This represents a major step forward by pointing out the high variability of the pathophysiology and leads us to propose that anti-diabetic treatment should ideally target the underlying pathophysiology of each patient. The overarching goal of TRANSLATIONAL was to test this proposition, both by the use of existing drugs and by investigating previously unexplored avenues to enable more precise interventions guided by the disease mechanisms.
The objectives were to
1) test the effect of existing anti-diabetic drugs in patients with different disease characteristics;
2) determine the functional and gene expression changes that cause impaired insulin secretion; and
3) investigate the effects and mechanisms of action of new potential anti-diabetic compounds.
This is important for society as we need new means to counteract the increasing burden of T2D.
The objectives were to
1) test the effect of existing anti-diabetic drugs in patients with different disease characteristics;
2) determine the functional and gene expression changes that cause impaired insulin secretion; and
3) investigate the effects and mechanisms of action of new potential anti-diabetic compounds.
This is important for society as we need new means to counteract the increasing burden of T2D.
In Aim 1 we enrolled participants with type-2 diabetes and features of Severe Insulin-Deficient Diabetes (SIDD) or Severe Insulin-Resistant Diabetes (SIRD), representing subgroups with different pathophysiology and increased risk for complications. Participants were randomly assigned to the GLP-1-receptor agonist semaglutide or the SGLT2-inhibitor dapagliflozin during six months. Semaglutide induced a larger reduction of HbA1c than dapagliflozin with a pronounced effect in SIDD. We also found that continuous measures of BMI, blood pressure, insulin secretion and insulin resistance can be used to identify those who will likely have the largest improvement of glycemic control and cardiovascular risk factors by adding semaglutide or dapagliflozin.
Moreover, we have analyzed further hormonal data, particularly glucagon and somatostatin, from these patients. Glucagon and somatostatin are central metabolic hormones, but their role in determining treatment response has been unknown. Interestingly, we found that fasting glucagon and somatostatin determines the response to GLP1ra and SGLT2i. Patients with low fasting glucagon and somatostatin had pronounced response to GLP1ra and patients with high fasting glucagon and somatostatin had the best response to SGLT2i. This opens a previously unrecognized opportunity to identify those who will benefit most from GLP1ra and SGLT2i.
In Aim 2 we set up a methodology to study beta-cell function and gene expression on the single-cell level. The direct coupling between physiology and gene expression enables us to determine the heterogeneous changes of beta-cell function during the development of type 2 diabetes in an unprecedented manner. By directly correlating function and gene expression at the single-cell level we have identified pools of low- and high-functioning beta-cells with distinct gene expression and a surprisingly inverse pattern in type 2 diabetes. The high-functioning cells in normal condition are characterized by high expression of genes involved in mitochondrial metabolism. In type 2 diabetes, these cells become, however, the least functioning cells, suggesting that the high mitochondrial metabolism makes them more vulnerable to diabetic conditions. We have also verified this new pathophysiological hypothesis experimentally by increasing mitochondrial metabolism by BCH and found that BCH-treated cells have increased insulin secretion in normal conditions but get particularly impaired when cultured in diabetes-like conditions with high glucose and palmitate. And when we in an opposite manner reduce mitochondrial metabolism by mannoheptulose, the cells perform poorer in normal conditions but are spared when cultured in diabetes-like conditions. This is yet a largely unexplored area, and the results are expected to benefit a range of researchers by addressing critical knowledge gaps and facilitate more specific drug development.
We have in Aim 3 conducted a randomized trial of individuals with impaired fasting glucose and found that sulforaphane-containing broccoli sprout extract (BSE) significantly reduced fasting blood glucose compared with placebo. Furthermore, a data-driven cluster analysis identified three pathophysiological subgroups of impaired fasting glucose. Individuals of the largest subgroup, characterized by mild obesity, low insulin resistance and reduced insulin secretion, had a pronounced treatment response. Gut microbiota analyses showed that responders had a higher abundance of a Bacteroides-encoded transcriptional regulator required for the conversion of the inactive precursor to bioactive sulforaphane. The abundance of this gene operon correlated with sulforaphane serum concentration. These findings suggest a new model for how the host pathophysiology and gut microbiota interact to influence metabolic treatment response that may have broad implications. The findings suggest that sulforaphane-containing BSE could provide a new modality for early anti-hyperglycemic intervention and represent a first step towards precision treatment of prediabetes based on the individual pathophysiology.
Moreover, we have analyzed further hormonal data, particularly glucagon and somatostatin, from these patients. Glucagon and somatostatin are central metabolic hormones, but their role in determining treatment response has been unknown. Interestingly, we found that fasting glucagon and somatostatin determines the response to GLP1ra and SGLT2i. Patients with low fasting glucagon and somatostatin had pronounced response to GLP1ra and patients with high fasting glucagon and somatostatin had the best response to SGLT2i. This opens a previously unrecognized opportunity to identify those who will benefit most from GLP1ra and SGLT2i.
In Aim 2 we set up a methodology to study beta-cell function and gene expression on the single-cell level. The direct coupling between physiology and gene expression enables us to determine the heterogeneous changes of beta-cell function during the development of type 2 diabetes in an unprecedented manner. By directly correlating function and gene expression at the single-cell level we have identified pools of low- and high-functioning beta-cells with distinct gene expression and a surprisingly inverse pattern in type 2 diabetes. The high-functioning cells in normal condition are characterized by high expression of genes involved in mitochondrial metabolism. In type 2 diabetes, these cells become, however, the least functioning cells, suggesting that the high mitochondrial metabolism makes them more vulnerable to diabetic conditions. We have also verified this new pathophysiological hypothesis experimentally by increasing mitochondrial metabolism by BCH and found that BCH-treated cells have increased insulin secretion in normal conditions but get particularly impaired when cultured in diabetes-like conditions with high glucose and palmitate. And when we in an opposite manner reduce mitochondrial metabolism by mannoheptulose, the cells perform poorer in normal conditions but are spared when cultured in diabetes-like conditions. This is yet a largely unexplored area, and the results are expected to benefit a range of researchers by addressing critical knowledge gaps and facilitate more specific drug development.
We have in Aim 3 conducted a randomized trial of individuals with impaired fasting glucose and found that sulforaphane-containing broccoli sprout extract (BSE) significantly reduced fasting blood glucose compared with placebo. Furthermore, a data-driven cluster analysis identified three pathophysiological subgroups of impaired fasting glucose. Individuals of the largest subgroup, characterized by mild obesity, low insulin resistance and reduced insulin secretion, had a pronounced treatment response. Gut microbiota analyses showed that responders had a higher abundance of a Bacteroides-encoded transcriptional regulator required for the conversion of the inactive precursor to bioactive sulforaphane. The abundance of this gene operon correlated with sulforaphane serum concentration. These findings suggest a new model for how the host pathophysiology and gut microbiota interact to influence metabolic treatment response that may have broad implications. The findings suggest that sulforaphane-containing BSE could provide a new modality for early anti-hyperglycemic intervention and represent a first step towards precision treatment of prediabetes based on the individual pathophysiology.
The study of Aim 1 was the first randomized trial of personalized medicine in T2D and showed the potential of systematically analyzing pathophysiological variables to identify those who will benefit most from GLP1-RA or SGLT2i. Our subsequent finding that fasting glucagon and somotostatin jointly determine treatment response was an unexpected finding that opens a way of using these hormones to predict treatment response. Assessment of these hormones in conjunction with patient history and comorbidities could afford a new and comprehensive model for personalized treatment of type-2 diabetes based on the underlying pathophysiology.
In aim 2, our new single-cell methodology enables for the first time the dissection of the cellular heterogeneity and delineation of the functional dysregulation during the progression of the disease in human cells in vitro as well as in animal models of diabetes. This represents a major advance over current state-of-the-art methodologies, which focus either on whole islets or single-cell expression profiling without functional information. The findings that beta-cells have an inverse expression pattern in type 2 diabetes than in normal conditions and identifiction of the genes involved is a major step forward in our understanding of the pathophysiology.
In Aim 3 we show a new model for how gut microbiota and pathophysiology interact, which can have broad implications for several diseases. We also highlight the potential of using sulforaphane to treat prediabetes with a function food. Prediabetes is a condition that is in many cases untreated, and new means to treat it could have broad clinical impact. Data from our trial as well as long-term studies on cancer prevention show that BSE has few adverse effects. This is important in prediabetes, where tolerance for side effects is presumably lower. The provision as a BSE rather than a traditional drug might also be attractive to individuals with impaired fasting glucose, who do not necessarily view themselves as being ill.
In aim 2, our new single-cell methodology enables for the first time the dissection of the cellular heterogeneity and delineation of the functional dysregulation during the progression of the disease in human cells in vitro as well as in animal models of diabetes. This represents a major advance over current state-of-the-art methodologies, which focus either on whole islets or single-cell expression profiling without functional information. The findings that beta-cells have an inverse expression pattern in type 2 diabetes than in normal conditions and identifiction of the genes involved is a major step forward in our understanding of the pathophysiology.
In Aim 3 we show a new model for how gut microbiota and pathophysiology interact, which can have broad implications for several diseases. We also highlight the potential of using sulforaphane to treat prediabetes with a function food. Prediabetes is a condition that is in many cases untreated, and new means to treat it could have broad clinical impact. Data from our trial as well as long-term studies on cancer prevention show that BSE has few adverse effects. This is important in prediabetes, where tolerance for side effects is presumably lower. The provision as a BSE rather than a traditional drug might also be attractive to individuals with impaired fasting glucose, who do not necessarily view themselves as being ill.