Patent Application: US-15011508-A

Abstract:
the present invention relates to methods and formulations for gad - vaccination to evoke a systemic effect rather that a gad - specific effect . the present invention may therefore be used in the treatment of disease in humans not bearing on a gad - specific effect . the invention includes a method to treat an autoimmune disease or disorder by administering at least one sequestered autoantigen in a prime and boost regimen for sensitization purposes followed by a boost for treatment purposes . this may be done upon diagnosis . examples of sequestered autoantigens include : gad65 , gad67 , pro - insulin , basic myelin protein , mog and chondrotoin ii . the present invention relates to medications and methods for treatment of autoimmune disease within six months from diagnosis .

Description:
in accordance with the foregoing summary , the following present a detailed description of a preferred embodiment of the present invention which is currently considered to be the best mode thereof . the present invention may be further appreciated from the following study of patients . the study was approved by the research ethics committee at linkoping university , sweden , and by the regulatory authorities in sweden . at eight pediatric clinics in sweden , 10 - 18 year old t1d patients who had presented with disease within the previous 18 months were screened for presence of gad65 autoantibodies ( gada ) and fasting c - peptide levels above 0 . 1 pmol / ml . a total of 70 patients were eligible and randomized to a double blind treatment of either 20 μg of recombinant human gad65 formulated in alum ( diamyd ®, diamyd medical , stockholm , sweden ; 35 patients ) or placebo ( the same formulation without rhgad65 ; 35 patients ). all patients were treated with multiple insulin therapy and both the patients and their parents or guardians provided informed consent . the trial objective was to evaluate the safety as well as the efficacy of treatment compared to placebo in preserving residual insulin secretion . the primary efficacy endpoint was change in fasting c - peptide level from baseline to month 15 . the secondary efficacy endpoints were changes from baseline in stimulated c - peptide levels and hba1c . each patient received a subcutaneous primary injection of either gad65 or placebo on day 1 followed by a boost one month later . patients remained in the clinic to be observed for three hours after injection . on day 1 and at months 3 , 9 and 15 , a mixed meal tolerance test ( mmtt ) was performed in accordance with the european study on estimation of beta cell function 25 which includes ingestion of 6 ml sustacal ®/ kg body weight ( sustacal ®, mead johnson , evansville , ind ., usa ). blood samples for c - peptide analysis were collected before , 30 , 60 , 90 and 120 minutes after beginning of the mmtt . safety evaluations , including neurological assessments , clinical examination , hematology , biochemistry , and impact of treatment on diabetes status were repeatedly assessed throughout the study . after completion of the main study period ( 15 months ), the treatment code was opened , and data analyzed including c - peptide levels ( fasting , max , area under the curve [ auc ]), hba1c , blood glucose , insulin requirement ( units per kg body weight and 24 hours ) and gada titre . with only the statistician , the sas programmer and the sponsor being informed of unblinded data , the study continues in a partly blinded fashion for an extension period of 15 months and additional mmtts will be performed at 21 and 30 months . laboratory analyses were performed at linkoping university , sweden . c - peptide levels were measured in serum samples with a time - resolved fluoroimmunoassay ( autodelfia ™ c - peptide kit , wallac , turku , finland ). results were validated with inclusion of a c - peptide control module containing a high , a medium and a low - level control in each assay ( commercially available from immulite , dpc , uk ). a 1224 multicalc ® program ( commercially available from wallac ) was used for automatic measurement and result calculation and measurements were expressed in pmol / ml . serum gada titres were determined in duplicate using a radio binding assay employing 35s - labelled recombinant human gad65 produced by in vitro transcription / translation ( pex9 vector kindly supplied by prof . ake lernmark , university of washington , seattle , wash ., usa ). sepharose protein a was used to separate free from antibody bound labeled gad65 . gada levels are presented with a maximum of 500 u / ml as it was decided to determine maximal titres at the end of the study . hla - dq a1 * and b1 * alleles were determined by pcr amplification of exon 2 sequences and hybridization with allele - specific probes detected by time resolved fluorescence as described . 26 as detailed in a population - based swedish case - control study 27 , the patients were then divided into very high risk , high risk , moderate risk , neutral and low risk subjects . results from a previous study in lada - patients 24 suggested that 35 patients in each treatment group would provide a power of 80 - 90 % for assessing differences in c - peptide levels , with a significance level of 5 %; assuming a mean difference of 0 . 12 pmol / ml and a standard deviation of 0 . 15 in fasting c - peptide levels . data management and the statistical analysis were performed by trial form support ab , lund , sweden . an analysis of covariance ( ancova ) model was used where the change from baseline to month 15 was used as response variable , treatment as explanatory variable and baseline value as a covariate . factors such as age , gender , duration of diabetes at intervention , gada titre , and hla type were identified in advance as possible factors for additional exploratory analyses . in all tests , the null hypothesis was that there is no difference between active treatment and placebo . for all tests two - sided hypotheses were used and the p - values presented together with 95 % confidence intervals . as there is only one primary analysis , the p - values are not adjusted for multiplicity . of 118 patients screened , 42 girls and 28 boys were eligible . the screening took place over two weeks in january and february 2005 . the first patient injection was in february 2005 , and the last patient completed the 15 - month visit in july 2006 . all but one patient received two doses of either gad65 or placebo ( figure a ). one patient ( girl , placebo ) was withdrawn from the study due to mononucleosis with icterus and received only one injection . sixty - nine patients , 35 diamyd ® treated and 34 placebo , were included in the per protocol analysis . no “ intention - to - treat ” analysis was performed as only one patient ( placebo ) dropped out . baseline data ( baseline = day of first injection , prior to injection ) shows that the two treatment groups were similar in most aspects ( table 1 ). the distribution of hla genotypes did not differ between the diamyd ® and the placebo group ( table 1 ). there were no treatment related serious adverse events in the study . an equal number of mild skin reactions ( erythema , edema and tenderness ) was observed at the injection site in the diamyd ® and the placebo groups . none required treatment or led to refusal of the second injection . neurological assessment , based on the potential concern of inducing stiff person syndrome , indicated no difference between the study groups . both treatment groups showed a progressive decrease from baseline regarding both fasting and stimulated c - peptide secretion , indicating a gradual loss of beta cell function . there was no significant effect on fasting c - peptide ( table 2 ). however , over the 15 months , stimulated c - peptide secretion , as measured by auc , decreased only half as much in the diamyd ® treated group as in the placebo group ( p = 0 . 01 ) ( figure b and table 2 ). also , maximum stimulated c - peptide deteriorated significantly less in the diamyd ® treated group ( p = 0 . 04 ) ( table 2 ). both treatment groups increased their insulin requirement , blood glucose and hba1c level during the study . as for c - peptide , all these parameters changed less in diamyd ® compared to placebo patients ( table 2 ). diamyd ® treated patients tended to have a gada titre above 500 after 15 months more often compared to placebo ( table 3 ). hla genotype neither affected the baseline nor the change in c - peptide auc during the 15 month period ( table 5 ). out of the patients who had a maximum stimulated c - peptide above 0 . 2 pmol / ml at baseline , only 19 % of the diamyd ® treated patients fell below that limit by month 15 compared to 42 % of the placebo patients ( table 4 ). covariate analyses of the changes in fasting and stimulated c - peptide from baseline to month 15 across the 69 patients were performed using baseline c - peptide and treatment as covariates together with either duration of diabetes , age , gender , or baseline gada levels . these analyses showed that only baseline c - peptide levels and treatment with diamyd ® had a statistically significant effect on residual insulin secretion during follow up ( data not shown ). the subgroups specified in the protocol regarding duration of diabetes , age , gender , baseline gada levels and hla classification were investigated for effects on the efficacy of gad65 . for this purpose the efficacy was defined as the lessening of the deterioration in auc from baseline until month 15 in the diamyd ® group compared to placebo . no formal statistical analysis was conducted due to small sample sizes and potential issues of multiple comparisons ( table 5 ). in all tests , the null hypothesis was that there is no difference between active treatment and placebo the preservation of residual insulin secretion was more pronounced among patients treated shortly after t1d onset ( figure c , table 5 ). no significant beneficial effect was found in fasting c - peptide , which was chosen as a primary endpoint based on the previous study in lada patients . 24 however , fasting c - peptide levels in recent onset t1d patients may remain near normal when fasting glucose is kept low because of active treatment 30 while stimulated c - peptide levels decline over time as a consequence of continuous beta cell destruction . this means that early in the course of the disease , stimulated c - peptide is a preferred endpoint for assessing preservation of beta cell function , which is correlated with improved glycemic control and less micro - vascular complications . 31 the results demonstrate that two injections of 20 μg gad65 significantly improves preservation of residual insulin secretion in patients with recent onset t1d during a follow - up time of similar length as in other intervention studies ( 14 , 16 , 17 ). in the responding patients , mainly newly - diagnosed , the effect size and duration is similar with gad65 as with anticd3 ( 16 , 17 ), but without adverse events after gad65 treatment residual insulin secretion affects important clinical outcome parameters . furthermore , a smaller proportion of patients in the gad65 than in the placebo group lost their capacity to secrete more than 0 . 2 pmol / ml of c - peptide in response to a meal . in the diabetes control and complications trial ( dcct ), patients with less than 0 . 2 pmol / ml in stimulated c - peptide had a higher risk for retinopathy and severe hypoglycemia than patients above that threshold . 5 , 28 this may be explained by improved overall metabolic control , less blood glucose fluctuations and possibly , by greater c - peptide exposure , which itself may have biologic effects . 29 to our knowledge there are few clinical trials with an immunomodulation approach that have achieved a reduced loss of residual insulin secretion as in the present study . both treatment groups increased their insulin requirement , blood glucose and hba1c level during the study . however , all three parameters showed a reduced , but statistically non - significant , increase in the diamyd ® compared to the placebo group . a tendency to increase in gada levels was seen in the drug treated group which was expected as gad65 was injected in an immunomodulatory vaccine formulation . the effect on other auto - antibodies as well as on cell - mediated immunity will be subject to further analysis . small and insignificant differences in the demographics of the drug treated patients and the placebo patients are unlikely to be relevant . while the drug treated patients were slightly older , the placebo patients had a somewhat shorter disease duration and higher residual insulin secretion on average at intervention . the distribution of hla genotypes were comparable and did not explain differences between the diamyd ® and placebo groups . it was important to carefully evaluate the possible role of hla as it has been shown that gada in t1d patients were associated with hla - dqa1 * 0501 - b1 * 02 in t1d patients . 27 further studies in larger number of patients will be needed to evaluate the possible importance of hla genotypes in response to diamyd ®. as a previous study had suggested effect of gad85 vaccination in lada patients with slowly progressive autoimmune diabetes , we chose to include not only newly - diagnosed t1d patients , but those with a duration up to 18 months . however , the protective effect of diamyd ® on stimulated c - peptide tended to be especially pronounced in patients treated shortly after diagnosis . our design makes subgroup analyses difficult , but , if confirmed , patients with short disease duration and good residual insulin secretion might improve their function enough to go into complete remission , were the ongoing autoimmune attack abated by the treatment . the mechanism of how diamyd ® treatment altered disease progression in t1d patients is not yet clear . the same type of insulin treatment in all patients , and the small difference in hba1c should exclude that the preserved beta cell function is the consequence of more intense insulin treatment or better metabolic control in the gad65 group . numerous animal studies in nod mice have shown that gad65 can induce potent regulatory response in mice with established autoimmunity and after the onset of t1d . 22 , 23 it is of interest in this regard that the prior dose - finding study revealed that diamyd ® induced an increase in the ( cd4 + cd25 +)/( cd4 + cd25 −) cell ratio at 24 weeks suggesting a possible effect on regulatory ( cd4 + cd25 +) t cells . 24 in conclusion , the treatment with alum - formulated gad65 had a protective effect on residual beta cell function 15 months after intervention . the demonstrated efficacy of gad65 , in line with or better than other developing treatments reported so far , gives hope that autoantigen - specific immunomodulation , alone or used in combination therapy , may eventually prevent t1d . it is promising that the protective effect on beta cell function in this study occurred with the use of a drug which is very easy to administer and well tolerated with mild and few adverse events , not differing from placebo . fig1 - 17 are graphs of results of a study elucidating the present invention . in addition , the foregoing study , using the same methods and study design described herein , has been continued to determine whether administration of gad - alum in young t1d patients of recent onset was safe and could reduce or halt the loss of residual insulin secretion . the following reports the results after a 21 - month study period . with only the statistician , the sas programmer and the sponsor being informed of unblinded data , the study continues in a partly blinded fashion for an extension period of 15 months with mmtts performed at 21 and 30 months . here we report data from the 21 - month follow - up . hba1c was analyzed by an immunological method , calibrated against the swedish national standard mono - s and continuously controlled against the external quality assurance in laboratory medicine in sweden ( eqalis ) reference method . continuing the study as described above , results from a previous study in lada - patients 24 suggested that 35 patients in each treatment group would provide a power of 80 - 90 % for assessing differences in c - peptide levels , with a significance level of 5 %; assuming a mean difference of 0 · 12 pmol / ml and a standard deviation of 0 · 15 in fasting c - peptide levels . data management and the statistical analysis were performed by trial form support ab , lund , sweden . an analysis of covariance ( ancova ) model was used where the change from baseline to month 21 was used as response variable , treatment as explanatory variable and baseline value as a covariate . factors such as age , gender , duration of diabetes at intervention , gada titre , and hla type were identified in advance as possible factors for additional exploratory analyses . in all tests , the null hypothesis was that there is no difference between active treatment and placebo . for all tests two - sided hypotheses were used and the p - values presented together with 95 % confidence intervals . as there is only one primary analysis , the p - values are not adjusted for multiplicity . of 118 patients screened , 42 girls and 28 boys were eligible . the screening took place over two weeks in january and february 2005 . the first patient injection was in february 2005 , and the last patient completed the 21 - month visit in february 2007 . all but one patient received two doses of either gad - alum or placebo ( figure a - 21 ). one patient ( girl , placebo ) was withdrawn from the study due to confirmed infectious mononucleosis with icterus and received only one injection . sixty - nine patients , 35 treated and 34 placebo , were included in the per protocol analysis . no “ intention - to - treat ” analysis was performed as only one patient ( placebo ) dropped out . baseline data ( baseline = day of first injection , prior to injection ) shows that the two treatment groups were similar ( table 1 ). the distribution of hla genotypes did not differ between the gad - alum treated and the placebo group ( table 6 ). there were no treatment related serious adverse events in the study . an equal number , x in each group , of mild skin reactions ( erythema , edema and tenderness ) at the injection site in the gad - alum and the placebo groups was observed . none required treatment or led to refusal of the second injection . neurological assessment , based on the potential concern of inducing stiff person syndrome , indicated no difference between the study groups to date . both treatment groups showed a progressive decrease from baseline regarding both fasting and stimulated c - peptide secretion , indicating a gradual loss of beta cell function . there was no significant effect of treatment on fasting c - peptide ( fig1 a and table 7 ). however , over the 21 months , stimulated c - peptide secretion , as measured by auc , decreased significantly less in the gad - alum treated group than in the placebo group ( p = 0 · 01 for all time points throughout the study ) ( fig1 b and table 7 ). maximum stimulated c - peptide , being a part of auc , also deteriorated significantly less in the gad - alum treated group ( p = 0 · 03 ) ( table 7 ). both treatment groups increased their insulin requirement and hba1c level during the study ( table 7 ). hba1c did not differ between the groups as it was used by physicians as a therapy target ( table 7 ). there was no significant difference regarding number of patients with gada titre above 500 at 21 months ( table 8 ). the statistically significant effect of treatment on change in stimulated c - peptide remained after adjusting for differences in duration of diabetes , age , gender , and baseline gada levels ( data not shown ). the subgroups specified in the protocol regarding duration of diabetes , age , gender , hla and baseline gada levels were also investigated for interaction effects ( data not shown ). of these , only duration of diabetes had a significant influence on the efficacy of treatment ( p = 0 · 04 ). the preservation of residual insulin secretion was more pronounced among patients treated with gad - alum soon after t1d onset . in patients treated within 6 months of diagnosis stimulated c - peptide secretion , as measured by auc throughout the study period , decreased significantly less in the gad - alum treated group than in the placebo group ( p = 0 · 02 ), while no such difference could be observed in patients with a duration of diabetes of 6 months or more ( fig1 ). despite the lack of effect on fasting c - peptide , which was chosen as the primary endpoint based on the previous study in lada patients , there was a highly similar to observations from other immune intervention studies 16 , 17 no significant beneficial effect of gad - alum treatment in c - peptide responses 24 . fasting c - peptide levels in recent onset t1d patients may remain near normal when fasting glucose is kept near normal 29 while stimulated c - peptide levels usually decline over time as a consequence of continuous beta cell destruction . as a result early in the course of the disease , stimulated c - peptide has tended to be the endpoint for assessing preservation of beta cell function , since it is correlated with both improved glycemic control and less micro - vascular complications . 16 , 17 , 31 the foregoing results demonstrate that two injections of 20 μg gad - alum significantly improves preservation of residual stimulated insulin secretion in patients with recent onset t1d during a follow - up time of similar length as in other intervention studies . 14 , 16 , 17 in the newly - diagnosed patients , the effect size and duration is similar with gad - alum treatment as with anticd3 16 , 17 , but differs in so far as gad - alum treatment has been without adverse events . residual insulin secretion affects important clinical outcome parameters . 5 although not limited to the theory of the invention , this may be explained by improved overall metabolic control , less blood glucose fluctuations and possibly , by greater c - peptide exposure , which itself may have biologic effects . 29 both treatment groups increased both their insulin requirement and hba1c level during the study and , as hoped , the aggressive treatment to hba1c target did not result in any significant difference in hba1c between the groups . nor was there any significant difference in gada levels between the two groups . the effect of our immunomodulatory vaccine formulation using gad65 on other autoantibodies as well as on cell - mediated immunity will be subject to further analysis . minimal and insignificant differences in the demographics of the drug treated patients and the placebo patients are unlikely to be relevant . while the drug treated patients were slightly older , the placebo patients had a somewhat shorter disease duration and , on average , higher residual insulin secretion at baseline . it was important to carefully evaluate the possible role of hla as it has been shown that gada in t1d patients are associated with hla - dqa1 * 0501 - b1 * 02 . 27 however , the distribution of hla genotypes were comparable and could not explain the highly differences in c - peptide responses between the gad - alum and placebo groups . if anything , the gad - alum patients had fewer neutral and low risk alleles ( n = 22 ) compared to the placebo patients ( n = 36 ). 7 further studies in larger number of patients will be needed to evaluate the possible importance of hla genotypes in response to gad - alum . as a previous study had suggested effect of gad - alum vaccination in lada patients with slowly progressive autoimmune diabetes , we chose to include not only very recently diagnosed t1d patients , but those with duration up to 18 months . however , the protective effect of the gad - alum treatment on stimulated c - peptide tended to be especially pronounced in patients treated & lt ; 6 months after diagnosis . the mechanism of how gad - alum treatment altered disease progression in tld patients is not clear . the intense insulin treatment and the ability to achieve the target hba1c in all patients , as well as the minimal differences in hba1c and insulin dose between groups , should exclude the significant differences in preserved beta cell function being attributed to more intense insulin treatment or better metabolic control in the gad - alum group . animal studies in nod mice have shown that gad65 can induce potent regulatory response in mice with established autoimmunity and after the onset of t1d . 22 , 23 it is of interest in this regard that the previous dose - finding study revealed that gad - alum induced an increase in the ( cd4 + cd25 +)/( cd4 + cd25 −) cell ratio at 24 weeks suggesting a possible effect on regulatory ( cd4 + cd25 +) t cells . 24 in conclusion , treatment with alum - formulated gad65 had a protective effect on residual beta cell function 21 months after intervention with infrequent and minor adverse side - effects . the demonstrated efficacy of gad - alum , in line with or better than other developing treatments reported thus far , gives hope that autoantigen - specific immunomodulation , alone or used in combination therapy , may eventually prevent t1d . it is promising that the protective effect on beta cell function in this study occurred with the use of a drug which is very easy to administer and well tolerated . at eight pediatric clinics in sweden , 10 - 18 year old t1d patients who had presented with disease within the previous 18 months were screened for presence of gad65 autoantibodies ( gada ) and fasting c - peptide levels above 0 . 1 pmol / ml . a total of 70 patients were eligible and randomized to a double - blind treatment of either 20 μg of recombinant human gad65 formulated in alum ( diamyd ®, diamyd medical , stockholm , sweden ; 35 patients ) or placebo ( the same formulation without rhgad65 ; 35 patients ). all patients were treated with multiple insulin therapy and both the patients and their parents or guardians provided informed consent . the trial objective was to evaluate the safety as well as the efficacy of treatment compared to placebo in preserving residual insulin secretion . the primary efficacy endpoint was change in fasting c - peptide level from baseline to month 15 . the secondary efficacy endpoints were changes from baseline in stimulated c - peptide levels and hba1c . each patient received a subcutaneous primary injection of either gad65 or placebo on day 1 followed by a boost one month later . patients remained in the clinic to be observed for three hours after injection . on day 1 and at months 3 , 9 and 15 , a mixed meal tolerance test ( mmtt ) was performed in accordance with the european study on estimation of beta cell function 25 which includes ingestion of 6 ml sustacal ®/ kg body weight ( sustacal ®, mead johnson , evansville , ind ., usa ). blood samples for c - peptide analysis were collected before , 30 , 60 , 90 and 120 minutes after start of the mmtt . safety evaluations including neurological assessments , clinical examination , hematology , biochemistry and impact of treatment on diabetes status were repeatedly assessed throughout the study . after completion of the main study period ( 15 months ), the treatment code was opened , and data analyzed including c - peptide levels ( fasting , max , area under the curve [ auc ]), hba1c , blood glucose , insulin requirement ( units per kg body weight and 24 hours ) and gada titre . with only the statistician , the sas programmer and the sponsor being informed of unblinded data , the study continued in a partly blinded fashion for an extended period of 15 months . laboratory analyses were performed at linkoping university , sweden . c - peptide levels were measured in serum samples with a time - resolved fluoroimmunoassay ( autodelfia ™ c - peptide kit , wallac , turku , finland ). results were validated with inclusion of a c - peptide control module containing a high , a medium and a low - level control in each assay ( commercially available from immulite , dpc , uk ). a 1224 multicalc ® program ( commercially available from wallac ) was used for automatic measurement and result calculation and measurements were expressed in pmol / ml . serum gada titres were determined in duplicate using a radiobinding assay employing 35 s - labelled recombinant human gad65 produced by in vitro transcription / translation ( pex9 vector kindly supplied by prof . ake lernmark , university of washington , seattle , wash ., usa ). sepharose protein a was used to separate free from antibody - bound labeled gad65 . gada levels are presented with a maximum of 500 u / ml as it was decided to determine maximal titres at the end of the study . hla - dq a1 * and b1 * alleles were determined by pcr amplification of exon 2 sequences and hybridization with allele - specific probes detected by time - resolved fluorescence as described . 26 as detailed in a population - based swedish case - control study 27 , the patients were then divided into very high risk , high risk , moderate risk , neutral and low risk subjects . results from a previous study in lada patients 24 suggested that 35 patients in each treatment group would provide a power of 80 - 90 % for assessing differences in c - peptide levels , with a significance level of 5 %, assuming a mean difference of 0 . 12 pmol / ml and a standard deviation of 0 . 15 in fasting c - peptide levels . data management and the statistical analysis were performed by trial form support ab , lund , sweden . an analysis of covariance ( ancova ) model was used in which the change from baseline to month 15 was used as response variable , treatment as explanatory variable and baseline value as a covariate . factors such as age , gender , duration of diabetes at intervention , gada titre , and hla type were identified in advance as possible factors for additional exploratory analyses . in all tests the null hypothesis was that there is no difference between active treatment and placebo . for all tests two - sided hypotheses were used and the p - values presented together with 95 % confidence intervals . as there is only one primary analysis , the p - values are not adjusted for multiplicity . of 118 patients screened , 42 girls and 28 boys were eligible . the screening took place during two weeks in january and february 2005 . the first patient injection was in february 2005 and the last patient completed the 15 - month visit in july 2006 . all but one patient received two doses of either gad65 or placebo ( figure d ). one patient ( girl , placebo ) was withdrawn from the study due to mononucleosis with icterus and received only one injection . sixty - nine patients , 35 diamyd ® treated and 34 placebo , were included in the per protocol analysis . no “ intention - to - treat ” analysis was performed as only one patient ( placebo ) dropped out . baseline data ( baseline = day of first injection , prior to injection ) shows that the two treatment groups were similar in most aspects ( table 1 ). the distribution of hla genotypes did not differ between the diamyd ® and the placebo group ( table 1 ). there were no treatment - related serious adverse events in the study . an equal number of mild skin reactions ( erythema , edema and tenderness ) were observed at the injection site in both the diamyd ® and the placebo groups . none required treatment or led to refusal of the second injection . neurological assessment , based on the potential concern of inducing stiff person syndrome , indicated no difference between the study groups . of the patients who had a maximum stimulated c - peptide above 0 . 2 pmol / ml at baseline , only 19 % of the diamyd ®- treated patients fell below that limit by month 15 compared to 42 % of the placebo - treated patients ( table 4 ). covariate analyses of the changes in fasting and stimulated c - peptide from baseline to month 15 for 69 patients were performed using baseline c - peptide and treatment as covariates together with either duration of diabetes , age , gender , or baseline gada levels . these analyses revealed that only baseline c - peptide levels and treatment with diamyd ® had a statistically significant effect on residual insulin secretion during follow up ( data not included ). the subgroups specified in the protocol regarding duration of diabetes , age , gender , baseline gada levels and hla classification were investigated for effects on the efficacy of gad65 . for this purpose the efficacy was defined as reduction of the deterioration in auc from baseline until month 15 in the diamyd ® group compared to placebo . no formal statistical analysis was conducted due to small sample sizes and potential issues of multiple comparisons . ( table 5 ) in all tests the null hypothesis was that there is no difference between active treatment and placebo the preservation of residual insulin secretion was more pronounced among patients treated shortly after t1d onset ( figure e , table 5 ). current opinion holds that stimulated c - peptide is a preferred endpoint for assessing preservation of beta cell function in type 1 diabetes patients and this is correlated with improved glycemic control and fewer micro - vascular complications . 31 the results demonstrate that two injections of 20 μg gad65 significantly improves preservation of residual insulin secretion in patients with recent onset t1d during a follow - up time of similar length as in other intervention studies ( 14 , 16 , 17 ). furthermore , a smaller proportion of patients in the gad65 than in the placebo group lost their capacity to secrete more than 0 . 2 pmol / ml of c - peptide in response to a meal . in the diabetes control and complications trial ( dcct ), patients with less than 0 . 2 pmol / ml in stimulated c - peptide had a higher risk for retinopathy and severe hypoglycemia than patients above that threshold . 5 , 28 this may be explained by improved overall metabolic control , less blood glucose fluctuations and possibly by greater c - peptide exposure , which itself may have biological effects . 29 to our knowledge there are few clinical trials with an immunomodulatory approach that have achieved such a reduced loss of residual insulin secretion as in the present study . as a previous study had suggested an effect of gad65 vaccination in lada patients with slowly progressive autoimmune diabetes , we chose to include not only newly - diagnosed t1d patients but also those with a duration of up to 18 months prior to first treatment . however , the protective effect of diamyd ® on stimulated c - peptide tended to be especially pronounced in patients treated shortly after diagnosis . our design makes subgroup analyses difficult , but if confirmed , patients with short disease duration and good residual insulin secretion might improve their function enough to go into complete remission , whereby the ongoing autoimmune attack will be abated by the treatment . the mechanism of how diamyd ® treatment altered disease progression in t1d patients is not yet clear . the same type of insulin treatment in all patients , and the small difference in hba1c should exclude that the preserved beta cell function is the consequence of more intense insulin treatment or better metabolic control in the gad65 group . numerous animal studies in nod mice have shown that gad65 can induce potent immune regulatory response in mice with established autoimmunity and after the onset of t1d . 22 , 23 it is of interest in this regard that the prior dose - finding study revealed that diamyd ® induced an increase in the ( cd4 + cd25 +)/( cd4 + cd25 −) cell ratio at 24 weeks , suggesting a possible effect on regulatory ( cd4 + cd25 +) t cells . 24 in conclusion , the treatment with alum - formulated gad65 had a protective effect on residual beta cell function 15 months following intervention . the demonstrated efficacy of gad65 , in concordance with or better than other developing treatments reported so far , gives hope that autoantigen - specific immunomodulation , alone or used in combination therapy , may eventually prevent t1d . it is promising that the protective effect on beta cell function in this study occurred with the use of a drug which is very easy to administer and well tolerated with mild and few adverse events . the preservation of residual insulin secretion was more pronounced among patients treated with gad - alum soon after t1d onset . in patients treated within 6 months of diagnosis stimulated c - peptide secretion , as measured by auc throughout the study period , decreased significantly less in the gad - alum treated group than in the placebo group ( p = 0 · 02 ), while no such difference could be observed in patients with a duration of diabetes of 6 months or more ( fig1 ). in the group of patients that had been diagnosed with the disease within six months a deterioration of stimulated c - peptide is seen as a function of time and subgroup analysis indicates that the drug is suitable to be used three times within an approximate three month period . increased deterioration of stimulated c - peptide at around 6 - 15 months after treatment initiation indicates that the study drug is suitable to be used four times within a 12 month period for long - term preservation of beta cell function . in the newly - diagnosed patients the effect size and duration is similar with gad - alum treatment as with anti - t cell therapies 16 , 17 , but differs in so far as gad - alum treatment has been without adverse events . 1 . atkinson m a , eisenbarth g s . type 1 diabetes : new perspectives on disease pathogenesis and treatment . lancet 2001 ; 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