Les nouvelles insulines : intérêts et inconvénients

Abstract

Modern insulin treatment, known as “basal-bolus” is based on the physiology of insulin secretion with a permanent basal secretion over the 24 h and a peak of secretion at the time of the meals. The objective of this treatment is obtaining a strict normoglycemia (80 to 120 mg/dl fasting, less than 140 mg/dl postprandial, bringing glycosylated hemoglobin to around 6.5–7%) while minimizing the hypoglycemic risk and ensuring the best possible quality of life. The ideal basal insulin must meet the interprandial insulin needs, to provide stable interprandial blood glucose levels. Hitherto the basal insulin treatment was mainly provided by 2–3 daily NPH- or 1–2 daily ultralente insulin injections. The average duration of action of NPH insulin, 8-16 h, explains the need for multiplying the injections to cover the nyctemer. Its peak of action, 3–4 h after the injection, increases the risk of hypoglycemia at the end of the morning and at night. Insulin ultralente is no more available in France to the profit of analogues of long duration of action aiming at ensuring better glycemic stability (better reproducibility) and improved quality of life. These analogues of insulin are soluble, i. e. they do not require agitation, thus limiting educational time and the risk of error. The time of onset of action of conventional insulin explains the need for carrying out the injection 1/2–3/4 h before the meal to optimize the control of the postprandial blood glucose. This has a non-negligible impact on the quality of life. The long (5–8 h) duration of action of conventional insulin promotes hypoglycemias. Fast analogues of insulin were developed to improve these kinetics characteristics: they have shorter time of onset and shorter duration of action. When associated with a basal insulin treatment, fast-acting insulin, injected right before the meals, authorizes flexible hours of meals. Skipping meals is also possible. A new educational method, called “functional insulin treatment”, makes it possible, amongst other things, to give the keys to the patients using basal-bolus insulin regimen to adjust the amount of fast-acting insulin to variable quantities of glucids at the price of intensive self-monitoring of blood glucose levels.