Highlight
• Zimislecel is an innovative stem cell-derived, fully differentiated islet cell therapy for type 1 diabetes that aims to restore physiologic insulin production.
• A phase 1-2 clinical trial demonstrated successful engraftment, islet function evidenced by C-peptide production, insulin independence in 83% of participants, and freedom from severe hypoglycemic events.
• Glucocorticoid-free immunosuppression was used to reduce adverse effects, with neutropenia as the most common serious adverse event.
• Despite a small sample size and short follow-up, these outcomes recommend further research into zimislecel’s therapeutic potential.
Study Background and Disease Burden
Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease characterized by destruction of insulin-producing pancreatic beta cells, necessitating lifelong exogenous insulin therapy. Despite improvements in insulin delivery and glucose monitoring, many patients experience challenges such as hypoglycemia, variable glycemic control, and long-term complications. There remains a critical unmet need for therapies that can restore endogenous, physiologic insulin secretion and improve clinical outcomes.
Islet transplantation from deceased donors can achieve insulin independence and glycemic stability but is limited by donor shortage, alloimmune rejection, and need for lifelong immunosuppression. Stem cell-derived islet therapies represent a promising approach by providing a potentially limitless supply of functional beta cells. Zimislecel is an allogeneic stem cell-derived islet-cell product designed to replace lost beta cells and restore glucose-responsive insulin secretion in T1DM patients. However, clinical data on the safety and efficacy of zimislecel are limited, necessitating rigorous evaluation.
Study Design
This phase 1-2, open-label, single-arm clinical trial enrolled individuals with type 1 diabetes and undetectable baseline C-peptide production. The study was conducted in three parts:
- Part A: Participants received a half dose of zimislecel (0.4 × 109 cells) infused into the portal vein. A second half dose could be administered within 2 years if required.
- Parts B and C: Participants received a full dose (0.8 × 109 cells) as a single infusion into the portal vein.
All participants were treated with a glucocorticoid-free immunosuppressive regimen to minimize steroid-associated adverse effects. The primary endpoint for part A was safety. The primary endpoint for part C was sustained freedom from severe hypoglycemic events from day 90 through 365 post-infusion, alongside maintenance of a glycated hemoglobin (HbA1c) <7% or a decrease of ≥1% from baseline between days 180 and 365. Secondary endpoints in part C included safety and insulin independence during this period. The primary and secondary endpoint analyses for part C included participants who received the full dose in parts B and C. Engraftment and islet function were assessed by detection of serum C-peptide during a 4-hour mixed-meal tolerance test. All analyses were interim and not prespecified.
Key Findings
Fourteen participants completed at least 12 months of follow-up: 2 in part A and 12 in parts B and C. Baseline serum C-peptide was undetectable in all participants, confirming absence of endogenous insulin secretion. Key outcomes included:
- Engraftment and Islet Function: Post-infusion, all participants exhibited detectable C-peptide, indicating successful engraftment and functional islet cell activity.
- Glycemic Control and Hypoglycemia: All 12 participants receiving a full dose were free from severe hypoglycemic events during days 90 to 365. They maintained an HbA1c <7% and spent over 70% of time within the target glucose range (70 to 180 mg/dL), marking significant improvement in glycemic stability.
- Insulin Independence: 10 of the 12 full-dose recipients (83%) achieved insulin independence at one year and were not using any exogenous insulin.
- Safety: Neutropenia was the most common serious adverse event, occurring in 3 participants. Two deaths were reported — one from cryptococcal meningitis, likely related to immunosuppression, and one from severe dementia with agitation related to progression of preexisting neurocognitive disease. No other unexpected safety signals emerged.
These preliminary results suggest that zimislecel can restore endogenous insulin secretion and reduce dependence on exogenous insulin while improving glycemic control without severe hypoglycemia in carefully selected patients.
Expert Commentary
These findings represent a significant step forward in stem cell-based regenerative therapy for type 1 diabetes, highlighting the potential of allogeneic islet-cell sources to overcome donor shortages inherent in traditional islet transplantation. The use of glucocorticoid-free immunosuppression could mitigate many complications associated with conventional regimens.
However, the study’s small sample size and interim analysis warrant cautious interpretation. Longer-term follow-up is needed to assess durability of engraftment, sustained insulin independence, chronic safety risks (including infection, immunologic rejection, and malignancy), and broader patient applicability.
Additional investigations should explore optimization of dosing, immunomodulation protocols, and functional outcomes. Integration with emerging technologies such as encapsulation or immune tolerance induction may further enhance therapeutic benefits.
Conclusion
This phase 1-2 trial provides promising evidence that zimislecel, an allogeneic stem cell-derived, fully differentiated islet-cell therapy, can effectively restore physiologic islet function, improve glycemic control, prevent severe hypoglycemia, and achieve insulin independence in patients with type 1 diabetes. These encouraging results justify expanded clinical trials to further evaluate long-term efficacy, safety, and mechanistic pathways. If confirmed, zimislecel and similar approaches could transform the therapeutic landscape of type 1 diabetes, offering potential cure strategies beyond conventional insulin replacement.
References
1. Reichman TW, Markmann JF, Odorico J, et al; VX-880-101 FORWARD Study Group. Stem Cell-Derived, Fully Differentiated Islets for Type 1 Diabetes. N Engl J Med. 2025 Sep 4;393(9):858-868. doi: 10.1056/NEJMoa2506549.
2. Shapiro AMJ, Pokrywczynska M, Ricordi C. Clinical pancreatic islet transplantation. Nat Rev Endocrinol. 2017 May;13(5):268-277. doi: 10.1038/nrendo.2016.159.
3. Pagliuca FW, Melton DA. Stem cell-derived β cells: a diabetes treatment breakthrough? Cell Stem Cell. 2013 Oct 3;13(4):396-8. doi: 10.1016/j.stem.2013.09.001.
