Are our insulins more or less predictable than our patients?

Abstract

AbstractPatients with insulin‐treated diabetes often report day‐to‐day variability in blood glucose levels. Suboptimal patient self‐management may often be considered the most likely cause, but studies have not consistently demonstrated a relationship between adherence and control. Patient behaviours such as insulin resuspension and dose setting technique will contribute to erratic glycaemic control, but because many patients who appear to adhere faithfully to their insulin regimens still report erratic, unpredictable blood glucose, it seems likely that limitations in the prescribed therapy itself might be at least partly causal. Indeed, studies investigating repeat doses of exogenous insulins have shown that the pharmacokinetic and pharmacodynamic profiles that follow each individual insulin injection can vary considerably from the overall mean profiles, both within and between patients. For traditional basal insulin preparations (such as NPH), this variability, combined with a peak in absorption, may contribute to nocturnal hypoglycaemia, which will limit the attainment of glycaemic targets. Recent biotechnological advances have, however, allowed insulin analogues with modified pharmacokinetic properties to be designed with the intent of improving post‐prandial or basal glycaemic control. For example, two analogue preparations (insulin glargine and insulin detemir) have recently been marketed and offer a protracted profile of action that is well suited to basal insulin substitution. Insulin detemir, for example, has been shown to offer greater within‐person predictability in duration of action and maximal effect than other basal insulins. Such improvements offer the potential to provide better and more predictable glucose control through modification of the insulin regimen as well as through the encouragement of improved patient self‐management techniques. Copyright © 2004 John Wiley & Sons, Ltd.