Treatment of Presymptomatic (Stage 1) Type 1 Diabetes Pediatric Patients With Treg Cell Preparations and Anti-CD20 Antibody

Participants: screening of approximately 2500 high-risk subjects will be conducted until no less than 150 participants with confirmed stage 1 (preclinical) type 1 diabetes mellitus are randomized; randomization 2:1:1:2; 50 participants treated with Tregs and anti-CD20 antibody; 25 participants treated with Tregs; 25 participants treated with anti-CD20 antibody; control: 50 participants receiving placebo and sham Tregs.

Inclusion of participants: up to 36 months. Trial intervention: Total duration of the trial intervention for each participant will be approximately 3 Months. After completion of the trial intervention, participants will be monitored at the sites for the onset of type 1 diabetes mellitus for a maximum of five years counting from the first dose of Tregs.

Follow-up time: post-treatment observation of all participants to 57 months (day "0" is the day of administration of the first dose of Treg/sham preparation).

Trial time: 96 months. Trial type: Prospective randomized (phase 2), placebo-controlled, parallel group, blinded trial.

Blinding: The following roles indicated below will not be made aware of the treatment group assignment during the trial:

• participant
• legal representatives
• site staff excluding pharmacists (applies to anti-CD20only)

Inclusion criteria

• Age 3-18
• 5 ≤ BMI ≤ 95 percentile (acc. to OLAF, or WWF in the case of children under six years old) with a lower weight threshold of 20 kg
• Venous plasma glucose levels < 100mg% at fasting (70 to 100 mg/dl) and normal glucose tolerance test (at 120 minutes glycaemia <140 mg/dl) (acc. to PTD)
• Insulin independence
• C-peptide levels ≥ 1.0 ng/ml (central laboratory limit of normal) in fasting and post-stimulation tests increase ≥ 100%
• Participant has not yet been diagnosed with stage 2 or 3 type 1 diabetes mellitus (no history of dysglycemia, no history of clinical symptoms of type 1 diabetes mellitus)
• HbA1c level (%) <5,7% (acc. to ADA)
• Positive autoantibody titres (ICA, IAA, GAD, IA-2/ICA512, ZnT8) - low titers of two or more antibodies (2 times the normal* or higher); if high titer of one of the antibodies (≥ 4 times the norm, not applicable to ICA) re-screening allowed (the participant can be included in the trial only after confirming two or more antibodies)
• Ability to give informed consent by the child's legal representatives (and the child himself or herself if he or she is over the age of 13 at the time of the trial [according to local law])
• Ability of the child's legal representatives to manage diabetes, defined as blood glucose levels control at least three times a day and the ability to dose insulin correctly.
• Venous access to guarantee blood donation

• Standard defined depending on the method used

Exclusion criteria

• Refusal to participate in the trial or lack of a signed informed consent form
• Suspicion or diagnosis for a type of diabetes other than type 1 diabetes mellitus
• Age under 3 or above 18
• IgA deficiency or history of other diagnosed immunodeficiency (max. 7 infections/year allowed, and the prognosis should indicate that the patient will remain in the study throughout its duration)
• C-peptide levels < 1.0 ng/ml fasting and in post-stimulation tests increase < 100%
• Glucose levels in venous blood ≥ 100mg% fasting
• Glucose levels in venous blood after 1 and 2 hours in OGTT ≥ 200mg%
• Glycated hemoglobin level (HbA1c) in venous blood ≥ 5,7%
• BMI < 5th percentile or > 95th percentile for age, or body weight < 20 kg
• History of hypersensitivity to anti-CD20 or other components of the preparation
• History of hypersensitivity to penicillin and/or streptomycin
• Past or active infection with HBV, HCV, HIV, HTLV I/II, mycobacterium tuberculosis, syphilis. Laboratory evidence of infection without the need for clinical signs and symptoms is sufficient for diagnosis.
• Active infection with the EBV or CMV virus (positive IgM)
• Any fungal, parasitic, viral, or bacterial infection
• History of past or active cancer
• Anemia, lymphopenia, neutropenia, or thrombocytopenia defined as a blood cell count below the lower limit of normal for age found within the last 6 weeks prior to trial inclusion
• Elevated thrombotic activity/history of thrombosis episode
• Any disease prior to inclusion in the trial currently requiring medication for more than 3 months in history
• Diagnosed autoimmune disease other than type 1 diabetes mellitus, including a history of Hashimoto's disease and coeliac disease
• Taking anti-diabetic medication (including insulin) in the last 4 weeks prior to trial inclusion
• History of retinopathy
• History of hypertension
• Current or history of albuminuria
• For women in childbearing potential/menstruating women: pregnancy (from medical interview) or unwillingness to exercise sexual restraint or use effective forms of contraception for the duration of the trial and up to 4 months after completion, if applicable.

The following contraceptive methods are acceptable: bilateral fallopian tube closure, sterilization in men, appropriate use of hormonal contraception that inhibits ovulation, hormone-releasing IUDs, and copper IUDs, male or female condoms with spermicide; and cap, uterine disc, or sponge with spermicide.

• Breastfeeding
• For males over 15 years of age: expressed intention to have offspring or donate sperm during the trial or within 4 months after the end of the trial, if applicable
• Excessive anxiety of the participant or his/her legal representatives regarding the procedures used in the trial
• Any medical problem that, in the opinion of the investigator, may adversely affect the participant's health if included in the trial
• Legal representatives and/or children over the age of 15 with an identified alcohol and/or psychoactive substance addiction
• History of disease of unknown etiology
• History of Creutzfeldt-Jacob disease
• History of progressive dementia or degenerative neurological disease, including of unknown origin
• History of taking hormones derived from the human pituitary gland (e.g., growth hormone)
• Treatment with immunosuppressants
• History of corneal, scleral, and dural transplant or undocumented neurosurgery
• History of occurrence of risk factors related to the participant's travel, where there is a possibility of exposure to regional infectious diseases
• Physical signs that indicate the risk of an infectious disease
• History of xenogeneic transplant