Development of insulin and its pharmacology and perioperative use: a narrative review

Diabetes mellitus is characterised by an elevated blood glucose concentration. Over the last two decades, a plethora of new agents have emerged to help treat the condition, of which several classes of agent have been shown to reduce the risk of cardiovascular morbidity and mortality. In addition, there have been several developments in the pharmacology of insulin, improving the pharmacokinetics and pharmacodynamics of insulin analogues to better mimic physiological insulin concentrations in the liver, skeletal muscle, and other tissues. Furthermore, the technologies used to deliver insulin and measure glucose have improved; for example, in the UK, hybrid closed loop systems are now the standard of care for people with type 1 diabetes mellitus. This review focuses on insulin and insulin delivery. We consider the history of insulin development and the pharmacology of newer insulin analogues. We also describe the novel technologies available and the considerations that need to be made by anaesthetists, surgeons, and other members of the perioperative team when looking after someone with diabetes mellitus on these insulins, or using these devices, to ensure safe care and the avoidance of complications.