Evolution of Diabetes Treatment
When I first opened my office for endocrinology in the 1980s, patients used to test their urine and chart the results. I had a few types of insulin, one oral agent, and general guidelines about diet. The insulin was matched to an appropriate diet and then the patient had to rigidly stick to it. Diet, which is still the cornerstone of diabetes treatment, is now much more scientific. Because of the advent of long-acting peakless insulin coupled with very short acting insulin which can be used as a bolus, patient who are insulin dependent learn how to count the carbohydrates in a meal and then calculate the appropriate amount of insulin. Insulin injection is much easier now with the new pens that were available. When an inhaled insulin was developed in the late 1990s, the patients actually preferred injections because they were faster, easier, and did not have the risk of causing pulmonary disease. Many patients now have insulin pumps. Some patients are able to monitor their plasma glucose continuously with a continuous glucose monitor.
In the over 30 years I have been in practice, I have also seen the development of new medications which are helpful for Diabetes type 2. While diet and exercise still remain the cornerstone of good diabetes treatment, the number of different classes of medication have increased from one to five. Patients are often on a combination of medications to help them achieve control. In addition to having a medication that stimulated a tired pancreas to release insulin, doctors can now choose drugs to lower blood sugar by a number of other mechanisms. The other mechanisms by which blood sugar can be lowered include decreasing glucose release from the liver, improving insulin sensitivity, slowing down the rate at which ingested glucose is absorbed and decreasing appetite. At the present time, a new drug is being developed which increases release of sugar by the kidneys. Genetic testing may determine who is likely to develop diabetes (different testing for type I and II) and ways to prevent it from developing into frank diabetes. Medications to modify the immune system are being developed in an attempt to provide a possible cure for type I but are still a long way off. Some large institutions have completed pancreas transplants which have enabled some people with type I Diabetes to come off insulin. While people with Diabetes are impatient feeling little progress since the development of insulin in 1929, scientists are developing new treatment and improving on the old treatment. While there is no cure, they need to maintain the best control they can.
