[Progress and developments in insulin therapy]

BANTING and BEST revolutionized diabetes therapy with the discovery of insulin 57 years ago. Since then, progress in this area has been slow despite tremendous reseach efforts. The subcutaneous injection of a depot insulin does not provide optimal control of blood sugar. True progress has been brought about by intravenous insulin administration for the management of diabetic coma. The authors do not recommend ultra low dose therapy. The prognosis of diabetic coma is much better than 20 years ago, in particular because of much improved and continuous supervision of the circulation (CVP, ECG, K+ etc.). Pancreas and islet transplantation fail in man due to immunological rejection. The "artificial pancreas" with a glucose sensor is useful for research purposes, and for controlling blood sugar for a few days at most. The implantable glucose sensor is not yet in sight. The authors have treated diabetics successfully with a programmable flexible open loop infusion program. The basal insulin infusion rate can be varied from 0.25 to 2 U/h, and rectangular one hour extra insulin infusions between 2 and 10 U/h are superimposed by pushing a button on the steering unit. The pump automatically switches back to the basal rate after one hour. No hypoglycemic reactions have been observed in patients on ths program on the ward or at home. At present, technical problems with the catheter remain to be solved before this simple therapeutic approach can be applied routinely.