Insulinothérapie : insuline ou analogues ? Injection ou perfusion ? Boucle ouverte ou boucle fermée ?

Abstract

Insulin has been purified, humanized and then synthesized by microorganisms. It is mandatory to be able to use insulin, whose kinetics and reproducibility allow glycemia near to normal without increasing hypoglycemia. Use of insulin analogs allows a slight improvement in glycemic control and decrease hypoglycemia frequency. Flexibility of treatment is also improved. “Continuous subcutaneous insulin infusion” (CSII) using rapid analogs mimics physiologic insulin secretion. Major indications are: high HbA1c despite well-managed basal-bolus regimen, severe hypoglycemia, brittle diabetes or “dawn phenomenon”. Children, adolescents as well as pregnancy are also good indications. “Continuous intraperitoneal insulin infusion” major interest is the predominant absorption via the portal system. Kinetic is comparable to rapid analogs delivered subcutaneously. The dramatic reduction of severe hypoglycemic events has been related to good reproducibility of insulin absorption and restoration of glucagon response. Hypoglycemia prone type 1 diabetic patients, uncontrolled with well-managed CSII as well as subcutaneous insulin resistance are the major indications. The association of optimized insulin therapy to “real time continuous glucose monitoring” allows better doses adaptation. Alarms can be set to avoid glycemic excursions and thus severe hypoglycemia. Using these devices, HbA1c is significantly improved without any increase in hypoglycemic events. These devices are one of the steps towards the “closed-loop insulin delivery” concept. Restoration of missing beta-cell function by an automated, glucose-modulated, insulin-delivery system would allow near normal glycemia without the risk of hypoglycemia. First studies show a good regulation of interprandial glycemia; prandial doses seem more difficult to assess. Nevertheless the “holy grail” might be closer than we think.