Doctor's Review: Medicine on the Move

August 28, 2014
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Diabetes then & now

From the Ancients to Insulin... and Beyond

Medical practitioners have known about diabetes for thousands of years and, over the ages, physicians did their best to treat the disease. The 20th century has seen one breakthrough after another.

Diabetes BCE

Back in 1500 BCE, the Egyptians recorded a disease of “excessive urination” in the Papyrus Ebers. At around the same time in India, Hindu doctors noticed that bugs were attracted to some patients’ urine. In the name of science, they tasted it — and found it sweet. Ahead of their time, they blamed it on too much food and wine. In the 2nd century, Greek physician Aretaeus of Cappadocia coined the term “diabetes,” meaning “to siphon” — a reference to these individuals' prodigious urine flow.

The Middle Ages: sex, drugs and riding

People with diabetes in the Western world were relatively lucky during these years: doctors prescribed wine, opiates and even aphrodisiacs. In China, the outlook was bleaker, since physicians there advised avoiding sex and booze.

Avicenna, an 11th-century Persian physician and avid urine-taster himself, prescribed emetics and horseback riding to “employ moderate friction.” Galen of Rome pronounced diabetes a renal disease, and prescribed purgatives to ease kidney strain.

1600s-1700s: Great Britain’s urine brigade

Londoner Thomas Willis first distinguished between the various forms of diabetes, a feat accomplished by — how else? — tasting urine. He believed the blood was to blame, not the kidneys. In 1750, Scotsman William Cullen added the term “mellitus” — Latin for “honey-sweet” — to diabetes. Englishman Matthew Dobson empirically proved that the urine of people with diabetes really did contain sugar. But even after Thomas Cawley pointed out the damaged pancreas of a person with diabetes during an autopsy in 1788, most physicians still implicated the kidneys.

19th century: diets and diabetic dogs

Diet became the rage around 1800 after John Rollo confirmed the existence of excess blood sugar in people with diabetes, concluding that low-carb, high-protein diets worked best. Seventy years later, French physician Appolinaire Bouchardat discovered during a food shortage that starvation worked well for his patients. By the 1880s, periodic fasting and starvation were the norm.

German medical student Paul Langerhans first identified islet cells in the pancreas in 1869. In 1889, Josef von Mering and Oskar Minkowski removed the pancreas of a dog and voilà! — instant diabetes. Scottish endocrinologist Edward Sharpey-Shafer made the leap in 1910, suggesting that the pancreas secreted an “antidiabetic” chemical, which he dubbed insulin.

1922: the year it all changed

In 1922, Canadians Frederick Banting and Charles Best injected their purified pancreatic extract into a young boy suffering from juvenile diabetes. His virtually immediate recovery declared that diabetes treatment had been revolutionized. The following year, the first commercial preparations of bovine insulin appeared.

1940s and ’50s: Sanger and sulfonylureas

By the late 1940s, insulin syringes became available, and in the 1950s, people with diabetes could easily monitor the sugar in their urine, thanks to tablets and test strips. In 1958, people with type-2 diabetes caught a big break when oral sulfonylureas — which stimulate the pancreas to release more insulin — hit the market.1

Englishman Frederick Sanger was awarded the Nobel Prize in 1958 after identifying the structure of insulin, laying the groundwork for synthetic insulin.

1960s and ’70s: proinsulin and pumps

Blood-glucose testing strips became available in 1962. In 1965 Donald Steiner identified proinsulin, the natural precursor of insulin. This led to purer insulin preparations, reducing allergies, side effects and resistance.

The 1970s welcomed new diagnostic and delivery methods, such as the first blood-glucose meters and portable insulin pumps.

1980s and ’90s: the human touch

By the early ’80s, researchers in California, using recombinant DNA technology,2 had figured out how to trick E. coli bacteria into producing human insulin.
In 1983, the first biosynthetic human insulin was introduced to rave reviews.

People with diabetes hailed the arrival of one-step insulin pens in 1986, and the 1990s saw a host of new drugs approved to treat type 2 diabetes, including acarbose, metformin, and repaglinide.

The future is now

New drugs and breakthroughs in dosing and delivery systems have quite literally revolutionized the treatment of both type 1 and type 2 diabetes over the last few years. The 2008 Canadian Diabetes Association Clinical Practice Guidelines emphasize the need to use a wide range of medications, health care providers, and patient motivation strategies to keep blood glucose under control.

The range of medications to control blood glucose levels in type 2 diabetes has expanded, and insulin regimens can now be adjusted very precisely to the individual patient with type 1 or type 2 diabetes. Patients can become much more involved in controlling meal-time spikes by adjusting the dosage of short-acting prandial insulin to the particular meal. Insulin aspart, lispro and glulisine can be administered up to 15 minutes before or 15 minutes after starting a meal.13

Diabetes remains a complex and complicated disease. However today, health professionals are equipped to tailor treatments and combinations designed to help keep their patients with diabetes on target.

References:

  1. Patlak M (2002). New weapons to combat an ancient disease: treating diabetes.
    FASEB J. 16 (14): 1853. PMID 12468446.
  2. Johnson I (1982). Human insulin from recombinant DNA technology. Science 219 (4585): 632-637.
  3. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008; 32(supp 1):S30.
  4. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S46-49.
  5. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S47.
  6. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. 2003; 289:2259.
  7. Porcellati F, Rosetti P, Busciantella NR, et al. Comparison of pharmacokinetics and dynamics of the long-acting insulin analogs glargine and detemir at steady state in type 1 diabetes: a double-blind, randomized, crossover study. Diabetes Care. 2007; 30:2451.
  8. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S49.
  9. Bode B, Weinstein R, Bell D, et al. Comparison of insulin aspart with buffered regular insulin and insulin lispro in continuous subcutaneous insulin infusion: a randomized study in type 1 diabetes. Diabetes Care. 2002; 25:439.
  10. DeWitt DE. 2003; 289.2254.
  11. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S46-47.
  12. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S56.
  13. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. 2008: S47.

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