1550 BCE-Papyrus describes polyuria and its treatment
4 th century BCE-Ayur Veda of Susruta (India) described sugarcream urine which attracted ants.
7 th century CE-Chinese physician Chen Chuan recorded sweet urine in diabetes
1869-Langerhans describes islets
1909-the name insuline is suggested by Jean de Meyer (Brussels)
1921-Banting and Best-report discovering Insulin used in 1922
BANTING-1891-1941 & BEST-1899-1978 Orthopod who became a physiologist and died in air crash in Newfoundland while on wartime mission Together they isolated insulin and Banting won the Nobel Prize in 1923 knighted in 1934
Prevalence of Diabetes in the US Diagnosed Type 1 Diabetes 1.5 Million(1:400-600 children) Diagnosed Type 2 Diabetes 14 million Undiagnosed Diabetes 6 Million 1.5 million new cases of diabetes were diagnosed in people aged 20 years or older in 2005
Good Glycemic Control (Lower HbA 1c ) Reduces Incidence of Complications DCCT Research Group. N Engl J Med . 1993;329:977-986. Ohkubo Y et al. Diabetes Res Clin Pract . 1995;28:103-117. UKPDS 33: Lancet . 1998;352:837-853. HbA 1c Retinopathy Nephropathy Neuropathy Macrovascular disease DCCT 9 7% 63% 54% 60% 41%* Kumamoto 9 7% 69% 70% – – UKPDS 8 7% 17-21% 24-33% – 16%* * not statistically significant
Every 1% HbA 1c Increase Above Goal Elevates the Risk of Diabetic Complications Increase in Any Diabetes-Related Endpoint Increase in Risk of Myocardial Infarction (MI) Increase in Risk of Stroke Increase in Risk of Microvascular Complications Incidence of Diabetes- Related Complications (%) +21% +37% +12% +14% Adapted from Stratton et al. BMJ . 2000;321:405-412.
Physiology of Insulin and blood glucose Breakfast Lunch Dinner Basal Insulin Insulin secretion Basal blood glucose Blood glucose
Insulin Preparations Onset of Duration of Action Peak Action Humalog/Novalog 5 to 15 min 1 to 2 hr 4 to 6 hr Human Regular 30 to 60 min 2 to 4 hr 6 to 10 hr Human NPH 1 to 2 hr 4 to 6 hr 10 to 16 hr Human Lente 1 to 2 hr 4 to 6 hr 10 to 16 hr Human Ultralente 2 to 4 hr Unpredictable <24 hr Lantus 30minutes none 24hr
“ Less than optimal glycemic control during the early years of diabetes has a lasting detrimental effect on the development and progression of complications, even after better glycemic control is established later in the course of the disease.”
Adapted from White, N et al, J Pediatr. 2001 Dec; 139(6): 804-12.
Patients on pump have better control of their blood glucose level
Better control allows extension of the “honey moon” period
Treatment Algorithm Algorithm #2 Algorithm #1 Treatment algorithm Group 1 (number of patients = 24) Treatment algorithm Group 2 (number of patients = 11) All patients with new onset diabetes were discharged within 3-5 days. All patients with new onset diabetes were discharged within 24 hours. Patients and parents were taught within 3 to 5 days in-hospital how to manage diabetes by pediatric endocrinology team. Patients and parents were taught within first 24 hours in-hospital how to manage diabetes by pediatric endocrinology team. Patients were started on Humalog and NPH in the hospital after correction of diabetic ketoacidosis. Patients were started on Humalog and Lantus after correction of diabetic ketoacidosis and regiment was continued for the first 1-2 weeks. CSII was started within first 14 days after diagnosis. A pediatric endocrinologist was available 24 hours a day 7 days a week to support insulin dose adjustment and education over the phone for the patients and parents. A pediatric endocrinologist was available 24 hours a day 7 days a week to support insulin dose adjustment and education over the phone for the patients and parents.
CSII vs. MDI With Glargine in Children Boland et al., Diabetes 2003, 52:S1, A45, 192-OR CSII (aspart) n=12 MDI (aspart/glargine) n=14 Injection therapy Randomized, Parallel-group, 16 week study Subjects at baseline Age: 8-19 yr (mean 12.7 ± 2.7) Type 1 DM > 1 yr duration Standard insulin therapy (2-3 injections/day)
Pump Group Achieved Better Control Overall Changes in HbA1c Levels 6.5 7 7.5 8 8.5 Baseline 4 wks 8 wks 12 wks 16 wks Pump MDI Boland, E. Diabetes 52,(Suppl 1), 2003 Abstract 192. p = .03 p=.30 (NS) p=.15 (NS) p=.001