The introduction of human insulin and daily self monitoring of blood glucose instead of urine monitoring for those diabetics not affected by blood phobia has changed the therapy for the treatment of IDDM. With the introduction of more purified insulins in the late 1970's localised skin reactions and allergic reactions decreased.

During the first few weeks after diagnosis insulin requirements often decrease in children as endogenous insulin secretory capacity is restored during the honeymoon phase of IDDM. During puberty it is not uncommon to have to increase insulin doses by 20-30%. The relative insulin resistance which accompanies puberty is closely correlated with increased concentrations of sex hormones and growth factors. These changes occur about two years earlier in girls than in boys.

Dramatic decreases in insulin intake are often required in periods of marked physical activity, and for example during summer camps doses often have to be reduced by 25-50% despite a marked increase in food uptake. These reductions are attributable to increased levels in physical activity and at such times close glucose monitoring is usually required.

Symptoms of hypoglycemia frequently change with time, sometimes in subtle ways. Hypoglycemia unawareness and severe hypoglycemia in Europe in the 1980's may have resulted from over zealous treatment by well meaning physicians. Increasing the dose of pre-supper insulin can increase the risk of pre-dawn hypoglycemia and dawn hyperglycemia, sometimes resulting in noctural seizures.

Pen injectors are widely used in Europe however in the USA they have not become popular. This may be because currently available pen injectors do not readily allow dose-to-dose modification of rapidly and long acting insulins.

Insulins can go bad prior to expiry date especially in the summer months. This is possibly due to the reduced zinc content of many formulations leading to instability at higher temperatures. The main reason for bedtime and 01.00-03.00 glucose monitoring is safety to prevent severe hypoglycemia.

In the event of irrational behaviour treatment with glucose should be implemented immediately and blood glucose tests can be performed immediately afterwards when the situation has settled. Hypoglycemia unawareness is common with younger children and in children with a longer duration of diabetes. It is important that family, teachers, friends are aware what to do in the event of hypoglycemia as recurrent hypoglycemia may be associated with defects in neurobehavioural function in later life.

Treatment for IDDM children has improved over the last decade however hypoglycemia and inconvenience remain major problems and it appears that no real cure is just around the corner.

Immunogenecity and Allergenic Effects of Insulin

Immunological complications of insulin therapy have been evident since animal insulins became available in 1922. Today patients exposed to intermittent treatment by insulin appear to be at higher risk to more severe and persistent allergic reactions. Factors which appear to influence immune response to insulin can be divided into three catagories:

a) Insulin factors - purity; species (bovine>pork>human); physical properties (pH); retarding agents (zinc, protamin, surfen).

b) Individual factors - age; immunological background; presence of insulin autoantibodies.

c) Mode of insulin administration - subcutaneous>intravenous; insulin pumps; interrupted insulin therapy.

It has been found that transfer from highly purified porcine insulin to human insulin decreases the insulin binding to IgG in already sensitised patients in some cases. Human insulin has very low immunogenecity and allergenecity. Human insulin is therefore suitable for patients with insulin allergy, immunological insulin resistance or lipoatrophy.

The National Health Service Patients Charter and IDDM in the UK

Under the terms of the Patients Charter in the UK the NHS has a responsibility to advise patients of any side effects of treatment regimes. In the area of insulin dependent diabetes treatment in the UK the dissemination of knowledge of the side effects associated with the use of human and animal insulin appears to be sadly lacking and has led to a significant number of tragic circumstances.

To provide this information to patients, their relatives, friends and collegues, would enable the side effects of insulin treatment to be discussed and acute episodes of hypoglycaemia may be avoided as corrective action can be taken and glucose or glucogen administered. If not recognised and corrected hypoglycemia may lead to behavioural problems and neurological disorder or worse.

Diabetic patients never wish to be diabetic - it simply happens for a number of reasons and diabetics have to make the best of life. A stabilised diabetic can, like other normal people, make a major contribution to enhancing the wealth, prosperity, happiness and welfare of our country, the European Community and the rest of the world. The National Health Service has a duty under the terms of the Patiens Charter to ensure that diabetics receive acceptable treatment and are notified of the possible side effects of the treatment. The diabetic patient and his or her medical team and carers need to work together as a team to ensure that this happens.

From the patient's point of view hypoglycemia and hypoglycemia unawareness are the most feared complication of insulin treatment. Its management requires sensitive discussion and preventative strategies. Fatal outcome as a result of hypoglycemia has led to a number of unexplained sudden deaths amongst insulin dependent diabetics in the UK along with tragic car accidents and mobility accidents.

These are worrying factors if insulin dependent diabetic management is to rely on the use of human and animal insulin in the UK for IDDM patient treatment without the incorporation of an urgently required education programme within the NHS to advise IDDM patients and their families of the side effects of prescribed treatment regimes so that diabetics can live more comfortable and confident lives.