Autoimmune diabetes and targets for immunomodulation

In Type 1 diabetes (T1D), pancreatic β cells are progressively lost, resulting in insulin insufficiency. Although exogenous insulin is essential for disease management, it is not a cure, and inadequate glycemic control continues to result in long-term complications. Thus, there is a need for therapies that address the underlying autoimmune response, a key component of T1D pathogenesis. This review examines a wide range of actionable immunomodulatory targets at the tissue, cellular, and molecular levels that form the basis of current and emerging therapies for T1D. Particular emphasis is placed on T cell populations, which play a central role; with other immune cell types contributing to varying degrees also discussed. Immune-modifying therapies aim to prevent or reverse the pathogenic functions of these cells, including their interactions with β cells. Many of these approaches are directed at specific immune cell populations, but not only the pathogenic ones. Recent advances have enabled more precise targeting, based on tissue relevance or antigen specificity. The immune system may also be indirectly modulated by targeting the microbiome, offering potential new strategies for early prevention of T1D. Many of these targets were identified from animal models and remain to be validated in humans, leaving numerous therapeutic avenues open for exploration.