Calling it "a major breakthrough" in the treatment of diabetes, Dr. Tom Flood, Director of the Diabetes Centre in Atlanta, was in Bermuda last week to share information on the new long-lasting insulin called Lantus (insulin glargine).

Dr. Flood, who has more than 30 years of experience working with people with diabetes, first as Director of Boston's prestigious Joslin Clinic for 14 years, and since 1984 in Atlanta where he runs his own practice, gave a public talk on Lantus Insulin and then met with local doctors and healthcare professionals in a lunchtime talk the next day to discuss the insulin which has been available in Bermuda for about a year.

He explained that Lantus has been on the market for about three years and was developed in Germany. It is a very long acting insulin which is given once a day and is peakless, which means that people using Lantus will not have low blood sugars that are commonly associated with other long acting insulins.

"Now that they can make insulin in the lab, you can literally make designer insulin," explained Dr. Flood.

"The first two that were produced were knock-offs of the old fashion, regular insulin. It's quick acting insulin but much quicker acting, so it is very suitable for covering meals. The old long acting insulin we've had for years and years is called NPH and has been around since the mid-1950s.

"It's a good insulin but has a sharp peak and doesn't really last for 24 hours. Now, in their ability to make designer insulins, they are saying `how can we make a better basal insulin that will last for 24 hours and not be peaking'?

"When they did the first studies (comparing the insulins) they found they were the same and gave the same control, but because Lantus didn't have this peak, there was much less risk of hypo glycemia (low blood sugar). The risk isn't zero with Lantus, but because it is peakless there is considerable less blood sugars overnight."

The most common form of diabetes is Type 2, which is also known as adult-onset diabetes, and is a condition in which the body cannot use its own insulin very well to change food into energy. Type 2 develops gradually over many years, usually without symptoms.

"Most patients with Type 2 diabetes will get to a point where, because of the natural history of the disease, their own pancreas's ability to produce insulin is gradually getting less," explained Dr. Flood.

"The group average is about ten to 15 percent a year, which means in any given week if I see 100 patients doing beautifully at this point in time, in one year ten to 15 percent of them will have slipped out of control and their pancreas's ability to make insulin diminished slightly over that time. It's called secondary failure.

"So because of the secondary failure phenomenon, most patients with Type 2 diabetes reach the point where all of the pills are no longer effective. They are taking two or three different types of pills which formerly worked but now they are simply not working and it is time to add insulin.

"Lantus then becomes the ideal insulin to use at night, to control the blood sugars overnight and then in many cases the pills will hold the line during the day if we can start them off with a good looking blood sugar in the morning."

Marketed by Aventis in the United States and by Hoechst in Europe, Dr. Flood says Lantus has been "very, very well received".

"The other group of patients who have found a lot of use from Lantus are Type 1 patients who also take Lantus at night to start the day with a controlled blood sugar, and then they take three injections of fast acting insulin to cover each one of their meals," said Dr. Flood.

"It's called the `poor man's insulin pump', top of the line treatment for Type 1 diabetics. Type 1 are juvenile diabetics who make no insulin at all, are completely insulin depleted, but are only about five percent of the diabetic population."

Dr. Flood is a regular visitor to Bermuda and is familiar with the Island's history of diabetes over the last two decades.

"My first trip to Bermuda was in 1977 and it was at that time I suggested a self contained laboratory to study diabetes," Dr. Flood revealed.

"I was the one who suggested there should be a Diabetes Association. When they launched it two years later in 1979, I was invited back to give a kick-off lecture. Then in 1999 I came back to give the 20th anniversary lecture which was quite an honour. I have been here many times in between."

Dr. Flood is seeing diabetes increase throughout the world, Bermuda no exception.

"It's a worldwide epidemic," he said.

"The really frightening thing is, whereas in the old days we saw very little Type 2 diabetes in young people, worldwide we are seeing it a lot more. It's a function of our fast food, super-size-it society and lack of exercise.

"When I was a youngster, I couldn't stay in the house, my mother would kick me out and tell me to go and play. Nowadays they are on the computer and playing video games so we're unfortunately breading a population of overweight adolescents and young adults and seeing frightening incidents of diabetes in these young people."

Added Dr. Flood: "When I came here 20 years ago I spoke to both patients and doctors and gave a strong pitch for controlling diabetes, which was strictly an anecdotal observation because we had no proof that it really worked.

"Many of the doctors were sceptical, they said `well, we respect the fact that you have this large practice and have made these observations that control and prevent complications, but where is the scientific proof'. Until 1981 we did not have a marker to objectively measure long term blood sugar control. Now we have it, the test is called haemoglobin A1C.

"Starting in the early 1980s, up until the early 1990s there were three huge studies that unequivocally proved the observation that a good regulation of their blood sugar levels make a dramatic difference in terms of preventing eye, kidney, never and blood vessel complications before the major complications of diabetes.

"That was from 20 years to ten years and in the last ten years we've gone from one type of pill to five and have developed these new designer type insulins for better control."

A cure for diabetes is still to be found but better drugs and techniques are being developed.

"The exciting thing to me is it is now no longer anecdotal, the whole world knows control will make a difference and we have tremendous new tools to accomplish control that we didn't have a decade ago," said Dr. Flood.

"The progress has been incredible. The two major breakthroughs that are still needed relate to how we administer insulin. Perfect control still eludes us.

"The incidents of diabetes is one out of every 20 people over the age of 40, one out of every ten people over age 60, so in the US we have 21 million people with diabetes and here in Bermuda I believe it's something like 11 per cent of the population. It's a huge public health problem.

"Lantus is a major breakthrough, a very useful insulin and I expect to see other designer type insulins appear over the next decade."