New insulins and insulin therapy: needs and reality

Abstract

The isolation of insulin was an event of utmost clinical importance for all patients suffering from diabetes mellitus type 1 and the late stages of type 2. The subsequent development of different strategies of insulin replacement helped to establish forms of insulin therapy with predictable metabolic outcome. This success was greatly helped by the availability of blood glucose monitoring and control by the patient himself as well as by the introduction of HbAlc measurements. Further progress has been set in motion by the advent of molecular engineering and recombinant DNA technology, which permitted the synthesis in vitro not only of insulin but also of new polypeptides with insulin action. Such insulin analogues can be tailored to either provide for more rapid or slow absorption from a subcutaneous site. These new pharmacokinetic properties help to better adapt strategies of insulin replacement to the daily routine of patients and to thereby improve their quality of life and motivation to comply with the rules of insulin treatment. This in particular applies to rapidly acting insulin analogues. Such artificial polypeptide hormones will, however, not substitute patient compliance with the rules and needs of insulin therapy or remove residual insulin antigenicity. Occasionally, insulin analogues may even exert increased myogenic action, which makes close toxicologic scrutiny of each new insulin analogue mandatory. From the above it is obvious that currently available short acting 'modern' designer insulins will not revolutionise insulin therapy but are to be regarded as an additional therapeutic tool for specific subgroups of diabetic patients with otherwise severe postprandial hyperglycaemia and for those living a hectic daily routine.