A critical appraisal of the role of insulin analogues in the management of diabetes mellitus.

Insulin is one of the oldest and best studied treatments for diabetes mellitus. Despite many improvements in the management of diabetes, the nonphysiological time-action profiles of conventional insulins remain a significant obstacle. However, the advent of recombinant DNA technology made it possible to overcome these limitations in the time-action profiles of conventional insulins. Used as prandial (e.g. insulin lispro or insulin aspart) and basal (e.g. insulin glargine) insulin, the analogues simulate physiological insulin profiles more closely than the older conventional insulins. If rapid-acting insulin analogues are used in the hospital, healthcare providers will need a new mind-set. Any error in coordination between timing of rapid-acting insulin administration and meal ingestion may result in hypoglycaemia. However, guidelines regarding in-hospital use of insulin analogues are few. The safety profile of insulin analogues is still not completely established in long-term clinical studies. Several studies have shown conflicting results with respect to the tumourigenic potential of this new class of agents. The clinical implications of these findings are not clear. Although novel insulin analogues are promising 'designer drugs' in our armamentarium to overcome some of the limitations of conventional insulin therapy, cost may be a limiting factor for some patients.

Drug therapy of diabetes in the elderly.

The prevalence of type 2 diabetes mellitus is increasing in the elderly. Although type 1 diabetic patients are living longer, over 95% of elderly people affected with diabetes have type 2 diabetes. This segment of the population, comprising men and women older than 65 years of age, is more likely to develop coexisting illnesses predisposing to the development of diabetes and complicating its management. In addition to changes in lifestyle, inherent age-related changes in carbohydrate metabolism contribute to the development of type 2 diabetes in old age. The long-term outcome of tight blood sugar control in the elderly is not known. Nevertheless the principles of management of type 2 diabetes in the elderly are essentially the same as in young- or middle-aged diabetic patients. Lifestyle modifications remain the cornerstone of medical therapy. When diet and exercise fail to achieve proper glycemic control, oral pharmacologic therapy and/or insulin therapy is indicated. The recently available oral glucose lowering agents in the market along with the newer types of insulin can be used in elderly diabetic patients. The effect of aging on metabolism and drug elimination kinetics must, however, be taken into consideration. In particular, it should be borne in mind that the risk of hypoglycemia is more deleterious in the elderly and should be avoided. In this review, the various pharmacologic agents available for the management of diabetes will be reviewed and some pertinent clinical guidelines will be suggested.