Newer Insulins in Search of a Niche
- Sachin Majumdar, MD; and
- Eugene Barrett, MD, PhD
- From University of Virginia, Charlottesville, VA 22908.
In 2007, diabetes was estimated to affect 7.8% of Americans (23.6 million) (1), and among persons older than age 60 years, the prevalence exceeded 23% (1). Diabetes is a major contributor to blindness, renal failure, limb amputation, stroke, and heart disease. Beyond these dire health-related complications, the annual direct and indirect cost of diabetes in America increased to about $174 billion by 2007 (2).
Several large trials have shown that improving glycemic control decreases diabetes-associated complications. The DCCT (Diabetes Complications and Control Trial) showed that in patients with type 1 diabetes, intensive versus usual insulin therapy decreased hemoglobin A1c (HbA1c) levels by 1.7% over 6.5 years and decreased the incidence or progression of retinopathy, microalbuminuria, and neuropathy by 76%, 39%, and 60%, respectively (3). Follow-up of 93% of these patients after 17 years showed a 42% reduction in risk for cardiovascular disease and a 57% reduction in risk for nonfatal myocardial infarction, stroke, or death from cardiovascular disease with intensive therapy (4). The clinical tradeoff for intensive therapy was a 3-fold increase in serious hypoglycemic events (5). In the UKPDS (United Kingdom Prospective Diabetes Study), intensive glycemic control over 10 years in patients with newly diagnosed type 2 diabetes resulted in a clinically significant decrease in progression to microvascular end points (6) with only a 1.5-fold relative risk for serious hypoglycemia (7).
These trials show that intensive insulin therapy improves meaningful clinical end points at the expense of an increased risk for hypoglycemia. Consequently, insulin therapies have evolved, from animal insulins to recombinant human insulins to insulin analogues to various insulin combinations, in the effort to minimize hypoglycemia while improving glucose control. Newer, more costly insulin formulations expand pharmacodynamic flexibility for diabetes treatment toward achieving this goal, so we must decide …
This 100-word excerpt has been provided in the absence of an abstract.
Most Read
