Endocrine Abstracts

The limitations of s.c. insulin lead to post prandial hyperglycaemia and a high risk of hypoglycaemia particularly in the post-absorptive state. Nocturnal hypoglycaemia continues to be a common and major problem for patients with insulin treated diabetes and is a major barrier in preventing patients reaching tight glycaemic targets.

The development of basal insulin analogues, insulin glargine and insulin detemir which deliver insulin over a longer period more consistently and with less of a peak effect compared to human insulin are considered a useful advance. Meta-analyses have reported only modest benefit although importantly rates of nocturnal hypoglycaemia are rarely included as an end-point. Nocturnal hypoglycaemia is reduced usefully in many individuals and is a robust indication for the use of these insulins. In some individuals long-acting analogues can be admininstred once daily although many need two injections each day to provide full 24 h coverage.

The development of ultra long acting insulin potentially offers a further advance with universal once a day adminstration and more stable background levels. Although a number of insulins of this type are being developed, only one has been brought to market. Insulin degludec (Tresiba) has been approved for use in Europe and Japan following an extensive clinical development programme. Clinical trials report enouraging and clinically relevant reduced rates of nocturnal hypoglycaemic episodes in patients with either type 1 diabetes or type 2 diabetes. In addition, the precise timing of adminstration is not critical and when given at varying time intervals still leads to stable background concentrations. A single injection of basal insulin in patients with type 1 diabetes brings new challenges in dealing with exercise and other lifestyle issues but ongoing work should provide guidance to clinicians and patients in adjusting insulin and calculating appropriate bolus doses.