Hungry for More?
A multiple-dose disposable insulin pen. Corbis photo.
A Short Biography of Type 1
This page is in process. Until it is completed, we offer this essay by Dr, Andrew Drexler of our Scientific Review Committee, which notes some of the key events in our growing knowledge about diabetes and its treatment.
Diabetes: Past, Present, Future
July 27, 2009
Diabetes is one of mankind’s oldest known diseases, having been first described in Ancient Egypt in the Ebers papyrus. However, treatment of diabetes only changed in the 20th century. Prior to 1922, the best treatment for Type 1 diabetes was the Allen diet – an extremely low-carbohydrate and low-calorie diet. The quality of life associated with this unsustainable therapy was poor and adherence only prolonged life for weeks in most cases. Dr. Allen commented that patients were rarely compliant with this diet, often smuggling in a piece of bread. Pictures of the patients from this time reveal severe wasting, now seen only in photos of concentration camp victims and during severe famines.
Insulin, discovered in 1922, changed this. However, the initial insulin preparations were very crude and often made patients very sick. Problems existed as well with allergic reactions to either insulin or contaminants in the insulin preparations. Infections and abscesses were also common with these initial preparations. While short-lived, there were initial questions about the appropriateness of insulin injections as both unnatural and dangerous. The 100% mortality of any other therapy quickly resolved these questions. Initial treatment consisted of multiple injections of what we now call Regular insulin during the day and overnight.
After the initial enthusiasm abated, patients began demanding a way to prolong insulin’s action so that a single injection once a day would suffice. Long-acting insulins were developed, such as protamine zinc. We now know that this advance was actually a step back, and that patients on these once-daily insulin preparations had higher rates of blindness, kidney failure and nerve damage than individuals who had been treated with multiple injections. With either therapy it was unusual for patients diagnosed in childhood to live past age 45. Furthermore, their final years were often unpleasant, with loss of vision and kidney failure as well as heart disease.
The current era in diabetes treatment began in the late 1970s and early 1980s with the introduction of hemoglobin A1c testing, patient self glucose testing, multiple daily injections and insulin pumps. These advances have permitted highly motivated patients to live longer than in the past, and in some cases without complications from the diabetes. These results, however, can only be achieved with a level of constant vigilance that is impossible for many to emulate. Even when achieved, there are significant risks associated with low blood sugar reactions that can pose a potentially lethal complication in some cases.
Current research of future diabetes treatments is focused on mechanical devices and biological approaches. The mechanical approach, or “artificial pancreas,” has many limitations because current technology cannot accurately monitor blood sugar levels and calculate how much insulin to administer. The biological approach – some method of transplanting islet cells or islet stem cells – has limitations as well. Transplants generally require immunosuppression drugs, which is a major drawback. Equally important is the absence of adequate islet cell sources for transplant. The use of nonhuman islet cells potentially solves this latter problem but makes the immunosuppresion complications much worse because more intense and therefore more toxic immune suppression drugs are required to prevent rejection of nonhuman islets. The use of stem cells may solve some of these problems, but is still far off in the future and may carry new risks that we currently don’t know.
