Timeline

commons.wikimedia.org/wiki/Main_Page
A papyrus record mentions Hesy-ra’s recognition of frequent urination as a symptom of Diabetes.

1552 BC

Diabetes Symptoms Described in Ancient Civilizations

The ancient civilizations of Egypt, Greece and India were the first to provide a description of diabetes. In Egypt, the physician, Hesy-ra, first documented an illness resulting in frequent urination. Around the same time Indian physicians identified a disease where the urine from the patient attracted ants. The Greek Physician Aretaeus (80-138 CE) named the condition Diabetes Mellitus because urine from the patient tasted sweet.

www3.rcsb.org/ligand/BGC
The structure of glucose from PDB ligand BGC

1797

Diabetes Diagnosed by Presence of "saccharine materials" in Urine

English physician Matthew Dobson conducted experiments, by evaporating urine, and showed that the urine of diabetes mellitus patients had elevated glucose levels. The structure and chemical composition of glucose is shown.

Portions of the image were adapted from Servier Medical Art
Specialized cells in pancreas (islets of Langerhans) produce hormones glucagon and insulin that are critical for maintaining blood glucose levels. In type 1 diabetes, the pancreas does not produce insulin. In type 2 diabetes, the body does not use insulin properly.

1889

Role of Pancreas in Diabetes Discovered

Oskar Minkowski and Joseph von Mering from University of Strasbourg, France, demonstrated the role of pancreas in diabetes by showing that removal of the pancreas renders dogs diabetic. English Physiologist Edward Albert Sharpey-Schafer (1850-1935), coined the term "insulin". He is regarded as the founder of endocrinology.

Loading

1921

Insulin Found to Lower Blood Glucose Levels

Frederick Banting and Charles Best discovered that a protein extract from healthy dog pancreas lowered blood glucose levels and effectively treated the diabetes induced in a pancreatectomized dog.

Loading

1922

First Diabetes Patient Treated with Insulin

Leonard Thompson, a fourteen year old, type 1 diabetes patient, received insulin injections at Toronto General hospital. He lived another 13 years before dying of pneumonia at age 27. This success demonstrated that diabetes mellitus can be treated by replacing insulin that is missing in the blood.

Loading

1923

Nobel Prize in Physiology or Medicine Awarded for Discovery of Insulin

The 1923 Nobel Prize in Physiology or Medicine was awarded to Frederick Grant Banting and John James Rickard Macleod for discovery of Insulin. Banting later shared his prize money with Charles Best, his partner in conducting experiments that led to the discovery of insulin.

Loading

1936

Mechanism to Prolong the Action of Insulin Discovered

Hans Christian Hagedorn and colleagues discovered that the duration of insulin action is prolonged by adding protamine (an arginine-rich peptide derived from river trout) to insulin.

More

In the 1950s Hans Christian Hagedorn founded the company Novo Nordisk, and marketed the insulin-protamine combination as “Neutral Protamine Hagedorn” (NPH) insulin. The NPH insulin formulation included protamine, zinc and insulin.

Loading

1941

Tablets for Testing Urine Glucose Introduced

Tablets for testing urine glucose became widely available. In the mid-1950s urine test strips also became available. Clinitest urine testing tablets used Benedict’s solution to test for the presence of glucose in urine.

More

In this reaction when reducing sugars are mixed with Benedicts reagent and heated, a reduction reaction causes the Benedicts reagent to change color. The color varies from blue to brick red, depending on the amount and type of sugar.

Loading

1948

Hyperglycemia Linked to Vascular Disease

Ernest Millard and Howard Root observed that diabetic patients with poor glucose control appeared to have more severe retinopathy than other patients.

More

Diabetic Retinopathy is characterized by an early phase, where blood vessels in the eye may be blocked and leak fluids into the retina, and an advanced phase, involving growth of new blood vessels in the retina. In the last decade, a number of growth factors have been found to be associated with the disease, with Vascular Endothelial Growth Factor (VEGF) receiving the most attention. Increased levels of this growth factor have been identified in the retina of diabetic patients.

Loading

1955

First Oral Medication for Type 2 Diabetes Introduced

Sulfonylureas are oral medications that stimulate the pancreas to release more insulin. The first generation sulfonylureas include Orinase (tolbutamide), Tolinase (tolazamide), and Diabinese (chlorpropamide). Newer forms of these drugs superceded the first generation sulfonylureas.

Loading

1958

Nobel Prize in Chemistry Awarded for Determining the Primary Structure of Insulin

Frederick Sanger was awarded the Nobel Prize in Chemistry for determining the amino acid sequence of insulin. Insulin is composed of two polypeptide chains, A (composed of 21 amino acids) and B (composed of 30 amino acids). Each chain has a specific sequence of amino acids.

Loading

1971

First 3D Structure of Insulin Reported

Dorothy Hodgkin and coworkers determined the first 3D structure of Insulin.

More

Dorothy Hodgkin advanced the technique of X-ray crystallography to determine the three dimensional structures of several important biological molecules such as, penicillin, vitamin B12 and also several small proteins including insulin. The insulin structure determination work began in 1934, was completed in 1969, and published in 1971. The PDB entry 4ins describes this particular insulin structure. Dorothy Hodgkin was awarded the Nobel Prize in Chemistry in 1964 for developing the technique of protein crystallography.

Loading

1977

Hemoglobin A1c Test Developed

Hemoglobin A1c blood test measures a person's long-term blood sugar control. It reflects the average blood glucose levels in a person, over the past 3 months.

More

When blood sugar levels are high, the glucose molecules attach to proteins present in the blood and in tissues lining blood vessels. For example, glucose binds to hemoglobin in red blood cells to form the modified (glycated) hemoglobin. Buildup of glycated hemoglobin, indicated by a high percentage of Hb A1c, suggests poor blood glucose control. The PDB entry 3b75 shows the structure of glycated hemoglobin.

Loading

1978

Synthetic Human Insulin Produced

Genentech, Inc., in San Francisco, cloned the human insulin gene. The company then proceeded to make the first synthetic human insulin in the laboratory, in Escherichia coli bacteria, using recombinant DNA technology. The synthetic insulin was chemically identical to that produced by the human pancreatic beta cells.

Loading

1982

First Recombinant Human Insulin Approved by US FDA for Clinical Use

In 1983 Eli Lilly and Company began manufacturing and marketing Humulin®, (recombinant human insulin licensed from Genentech) and Humulin N (NPH, an intermediate acting insulin).

Loading

1984

Second Generation Sulfonylurea, Glucotrol (Glipizide), Approved by US FDA for Treating Type 2 Diabetes

Glucotrol was the first second-generation sulfonylurea drug. This oral diabetes medicine acts on the Sulfonylurea receptor 1 and helps control blood sugar levels by stimulating insulin secretion from pancreatic beta-cells. The PDB currently does not have any structure of either Glucotrol or its receptor.

Loading

1987

Incretin Hormone GLP-1 Discovered

Glucagon-like peptide-1 (GLP-1) and Glucose-dependent Insulinotropic Polypeptide (GIP) are the two primary incretin hormones. These hormones are secreted from the intestine in response to food intake, and stimulate secretion of insulin from the pancreatic beta-cells. GLP-1 exerts its effects by binding to the GLP-1 receptor (GLP-1R), leading to an increase in the level of intracellular cAMP in pancreatic beta cells, which ultimately promotes insulin secretion.

Loading

1989

Glucose Transporters Identified

The gene for glucose transporter, GLUT4, was cloned and mapped. Glucose transporters deliver glucose molecules across cell membranes. There are over 10 different glucose transporters, the most important ones being GLUT1, GLUT2, GLUT3, and GLUT4. The GLUT4 transporters are insulin sensitive, while GLUT1 and GLUT3 transporters maintain a basal rate of glucose uptake. The GLUT2 transporters have low affinity for glucose and play important roles in glucose dependent insulin release. The PDB currently has the structures of GLUT1 and GLUT3 transporters (PDB entries 4pyp and 4zwc, respectively).

Loading

1995

Metformin Approved by US FDA for Treating Type 2 Diabetes

Metformin is a biguanide that prevents glucose production by the liver. After diet and exercise, it is currently the recommended first line of therapy for type 2 diabetes.

More

Metformin decreases blood glucose levels by lowering hepatic glucose production, lowering intestinal glucose absorption, and also by increasing insulin sensitivity. The PDB currently does not have any structure of metformin. The structure and chemical composition of metformin is shown.

Loading

1995

Third Generation Sulfonylurea, Amaryl (Glimepiride), Approved by US FDA for Treating Type 2 Diabetes

Amaryl (glimepiride) is an oral blood glucose lowering sulfonylurea, that potentiates increased insulin secretion and sensitivity of peripheral tissues to insulin. The structure and chemical composition of glimepiride is shown.

Loading

1996

Alpha Glucosidase Inhibitors, Precose (Acarbose) and Glyset (Miglitol) Approved by US FDA for Treating Type 2 Diabetes

Precose (acarbose) and Glyset (miglitol) are alpha-glucosidase inhibitors that slow digestion of some carbohydrates. Maltase-glucoamylase is one of the pharmacological targets for these drugs.

Loading

1996

First Rapid-Acting Insulin Humalog (Lispro) Approved by US FDA for Clinical Use

Humalog (insulin lispro) is an analogue of natural insulin. Reversal of the order of two amino acid residues (a lysine and a proline) near the C-terminus of the B-chain weakens the interaction between insulin monomers, making its hexamer 200 times less stable than the native form's hexamer. Ready dissociation of the lispro hexamer results in its rapid-action.

Loading

1997

First Drug in the Thiazolidinedione Class of Anti-Diabetic Drugs Approved by US FDA

Rezulin (troglitazone), the first approved drug in the class of thiazolidinedione was removed from the market due to liver toxicity. Two other drugs in this class, Avandia (rosiglitazone) and Actos (pioglitazone), were introduced later.

More

This class of drug enhances tissue sensitivity to insulin by acting as a selective and potent agonist of peroxisome proliferator activated receptors (PPAR) at the sites of insulin action. The PPAR gamma/DNA complex is the pharmacological target for the glitazone class of drugs (e.g., rosiglitazone, pioglitazone).

Loading

1998

First Drug in the Meglitinide Class, Prandin (Repaglinide), Approved by US FDA, for Treating Type 2 Diabetes

Prandin (repaglinide) is a short-acting insulin secretagogue, which acts by stimulating insulin release, in the presence of glucose. The PDB currently does not have any structure of either repaglinide or its receptor. The structure and chemical composition of repaglinide is shown.

Loading

1998

Glucagon Approved by US FDA for Treatment of Severe Hypoglycemia

Glucagon is a single chain polypeptide hormone produced by the pancreatic alpha cells. Release of glucagon in response to low blood sugar levels induces release of glucose from glycogen stores maintained in the liver.

Loading

2000

First Long Acting Insulin Lantus (Glargine) Approved by US FDA for Clinical Use

Lantus (glargine), an analogue of human insulin, was made by replacing the asparagine residue at position 21 in the A-chain with glycine and adding two arginines to the C-terminus of B-chain (positions B31 and 32).

More

These changes induce insulin glargine to form microprecipitates under physiological conditions. Small amounts of the drug is slowly released from the microprecipitates over a 24-hour period, making this a long-acting insulin.

Loading

2000

Second Rapid-Acting Insulin NovoLog (Aspart) Approved by US FDA for Clinical Use

NovoLog (insulin aspart) was designed to act fast and for a shorter duration of time. Substituting the proline residue at position 28 in chain B of insulin with aspartic acid reduces the tendency of this insulin to form hexamers, which in turn results in faster dissociation to monomers, insulin receptor binding and onset of action.

Loading

2003

Human genome project completed

An inward voyage of discovery to sequence and map the entire human DNA genome was completed in 2003. The genome is the blueprint for building every human cell and holds the key to the better understanding of human health and diseases.

Loading

2005

Symlin (Pramlintide) Approved by US FDA for Treating Diabetes

Symlin (pramlintide), a 37-amino acid polypeptide, was designed as a functional analogue of amylin. Amylin is co-secreted with insulin and is deficient in diabetic patients. Pramlintide helps to control blood glucose by modulating the rate of gastric emptying. The PDB currently does not have any structure of pramlintide. The amino acid differences between Symlin and Amylin are highlighted by the yellow residues.

Loading

2005

First GLP-1 Mimic Byetta (Exenatide) Approved by US FDA for Clinical Use

Byetta (exenatide) was developed as a synthetic, injectable version of exendin-4, a hormone found in the saliva of the Gila monster. Exenatide is an analogue of GLP-1 that works by increasing insulin production in response to high blood glucose levels. PDB entry 1jrj depicts the structure of this biologic drug.

Loading

2005

Long-Acting Insulin Levemir (Detemir) Approved by US FDA for Clinical Use

Insulin Levemir (detemir) was developed as a long-acting human insulin analogue to maintain basal levels of insulin in diabetic individuals. Chain B in detemir is one residue shorter than normal insulin and the last amino acid in this chain (lysine 29) has a 14-carbon fatty acid (myristic acid), attached to it. The myristoyl side chain increases the self-association and albumin binding properties of this insulin molecule, thereby prolonging the drug's duration of action.

Loading

2006

First Non-Substrate-Like Inhibitor of DPP-4, Januvia (Sitagliptin) Approved by US FDA for Clinical Use

Januvia (sitagliptin) was developed as an orally active, non-substrate-like DPP-4 inhibitor. By blocking DPP-4 enzymatic activity, sitagliptin increases the half-life of incretin hormones, GLP-1 and GIP, which results in insulin secretion. The PDB entry 1x70 displays the structural basis of DPP-4 inhibition by sitagliptin.

Loading

2006

X-ray Structure Provides a Glimpse of Insulin Receptor

Although insulin was discovered in 1921, the 3D structure of its receptor had evaded scientists until recently. Insulin receptor is a large flexible molecule that traverses the membrane. Insulin binds to its receptor outside of the cell, leading to shape changes that are propagated inside the cell, activating the insulin signaling pathway. In 2006 McKern et al., reported a structure of the insulin receptor ectodomain (PDB entry 2hr7).

More

In 2013, Menting et al., determined several crystal structures of insulin in complex with the insulin binding domain of the insulin receptor (PDB entry 3w14). This work represents a milestone in insulin research and lays the groundwork for designing insulin analogues with better pharmacokinetics and enhanced receptor binding.

Loading

2009

First Substrate-Like Inhibitor of DPP-4, Onglyza (Saxagliptin) Approved by US FDA for Treatment of Diabetes

Onglyza (saxagliptin) was designed as a substrate-like inhibitor of DPP-4. It promotes blood glucose control through inhibition of the enzyme DPP-4. Unlike Januvia, Onglyza inhibits DPP-4 through a reversible, covalent complex formation with DPP-4. The PDB entry 3bjm presents the structure of this drug in complex with its pharmacological target, DPP-4.

Loading

2010

Second Generation GLP-1 Analog, Victoza (Liraglutide) Approved by US FDA for Clinical Use

Victoza (liraglutide) is an injectable Glucagon-Like Peptide-1 (GLP-1) agonist used for the treatment of type 2 diabetes. Like exenatide, this drug is an incretin mimetic that stimulates the release of insulin in response to food intake.

More

GLP-1, in its natural form, is short-lived peptide, as it gets degraded by DPP-4. Exenatide also has a short half-life, hence the dosing is twice daily. Liraglutide, however has a longer half-life thus making it suitable for once-daily dosing. The longer half-life of liraglutide is achieved through the attachment of a fatty acid to Lysine 26. This modification allows the drug to bind to albumin which results in slower degradation and reduced elimination from the body. The PDB entry 4apd shows the structure of liraglutide.

Loading

2013

First Drug in the SGLT-2 Class, Invokana (Canagliflozin), Approved by US FDA for Treating Diabetes

Invokana (canagliflozin), was the first in a new class of drugs known as the SGLT-2 inhibitors. Sodium glucose co-transporter 2 (SGLT-2) reabsorbs glucose from the kidneys. By blocking the function of SGLT-2, canagliflozin is able to reduced glucose re-uptake, which results in reduced blood glucose levels. Several other drugs in this class were approved in 2014 (Farxiga, Jardiance). The PDB currently does not have any structure of either SGLT-2 or its inhibitors. The structure and chemical composition of canagliflozin is shown.

Loading

2014

First GLP-1 Analogue Fused With Human Albumin, Tanzeum (Albiglutide), Approved by US FDA for Clinical Use

Tanzeum (albiglutide) was developed to improve glycemic control in adults with type 2 diabetes. Albiglutide is an injectable GLP-1 analogue that was fused with human albumin and engineered to be resistant to degradation by DPP4. Albiglutide has a much longer half-life compared to other GLP-1 analogs - exenatide and liraglutide. The PDB currently does not have any structure of albiglutide.

Loading

2014

First GLP-1 Analogue Fused to Human Antibody Fragment, Trulicity (Dulaglutide), Approved by US FDA for Treating Diabetes

Trulicity (dulaglutide) is indicated for the treatment of type 2 diabetes. It was designed as a GLP-1 analogue and covalently linked to a human immunoglobulin heavy chain fragment (IgG4-Fc) by a small peptide linker. This makes the drug resistant to degradation by DPP4 and hence it has a longer half-life. The PDB currently does not have any structure of dulaglutide.

Loading

2015

Second Generation Long-Acting Insulin, Tresiba (Insulin Degludec) Approved by US FDA for Clinical Use

Tresiba (insulin degludec) is a long-acting insulin that improves blood sugar control in adults with type 1 or type 2 diabetes. This long-acting insulin was created by attaching a hydrocarbon chain to the C-terminus of the B-chain of insulin (top figure), which leads to the formation of multi-hexamers (bottom figure). The monomers of insulin are slowly released into the blood from the multihexamers, creating a long-acting insulin.

Loading

2015

Lucentis (Ranibizumab) Approved By US FDA for Treating Diabetic Retinopathy

Lucentis (ranibizumab) is used to treat diabetic retinopathy. It inhibits the biological activity of human vascular endothelial growth factor A (VEGF-A), which has been implicated in diabetic retinopathy.

 
Diabetes Diagnosed by Presence of "saccharine materials" in Urine
1797

Diabetes Diagnosed by Presence of "saccharine materials" in Urine

Role of Pancreas in Diabetes Discovered

Insulin Found to Lower Blood Glucose Levels

First Diabetes Patient Treated with Insulin

Nobel Prize in Physiology or Medicine Awarded for Discovery of Insulin

Mechanism to Prolong the Action of Insulin Discovered

Tablets for Testing Urine Glucose Introduced

Hyperglycemia Linked to Vascular Disease

First Oral Medication for Type 2 Diabetes Introduced

Nobel Prize in Chemistry Awarded for Determining the Primary Structure of Insulin

First 3D Structure of Insulin Reported

Hemoglobin A1c Test Developed

Synthetic Human Insulin Produced

First Recombinant Human Insulin Approved by US FDA for Clinical Use

Second Generation Sulfonylurea, Glucotrol (Glipizide), Approved by US FDA for Treating Type 2 Diabetes

Incretin Hormone GLP-1 Discovered

Glucose Transporters Identified

Metformin Approved by US FDA for Treating Type 2 Diabetes

Third Generation Sulfonylurea, Amaryl (Glimepiride), Approved by US FDA for Treating Type 2 Diabetes

Alpha Glucosidase Inhibitors, Precose (Acarbose) and Glyset (Miglitol) Approved by US FDA for Treating Type 2 Diabetes

First Rapid-Acting Insulin Humalog (Lispro) Approved by US FDA for Clinical Use

First Drug in the Thiazolidinedione Class of Anti-Diabetic Drugs Approved by US FDA

First Drug in the Meglitinide Class, Prandin (Repaglinide), Approved by US FDA, for Treating Type 2 Diabetes

Glucagon Approved by US FDA for Treatment of Severe Hypoglycemia

First Long Acting Insulin Lantus (Glargine) Approved by US FDA for Clinical Use

Second Rapid-Acting Insulin NovoLog (Aspart) Approved by US FDA for Clinical Use

Human genome project completed

Symlin (Pramlintide) Approved by US FDA for Treating Diabetes

First GLP-1 Mimic Byetta (Exenatide) Approved by US FDA for Clinical Use

Long-Acting Insulin Levemir (Detemir) Approved by US FDA for Clinical Use

First Non-Substrate-Like Inhibitor of DPP-4, Januvia (Sitagliptin) Approved by US FDA for Clinical Use

X-ray Structure Provides a Glimpse of Insulin Receptor

First Substrate-Like Inhibitor of DPP-4, Onglyza (Saxagliptin) Approved by US FDA for Treatment of Diabetes

Second Generation GLP-1 Analog, Victoza (Liraglutide) Approved by US FDA for Clinical Use

First Drug in the SGLT-2 Class, Invokana (Canagliflozin), Approved by US FDA for Treating Diabetes

First GLP-1 Analogue Fused With Human Albumin, Tanzeum (Albiglutide), Approved by US FDA for Clinical Use

First GLP-1 Analogue Fused to Human Antibody Fragment, Trulicity (Dulaglutide), Approved by US FDA for Treating Diabetes

Second Generation Long-Acting Insulin, Tresiba (Insulin Degludec) Approved by US FDA for Clinical Use

Lucentis (Ranibizumab) Approved By US FDA for Treating Diabetic Retinopathy

1250
1260
1270
1280
1290
1300
1310
1320
1330
1340
1350
1360
1370
1380
1390
1400
1410
1420
1430
1440
1450
1460
1470
1480
1490
1500
1510
1520
1530
1540
1550
1560
1570
1580
1590
1600
1610
1620
1630
1640
1650
1660
1670
1680
1690
1700
1710
1720
1730
1740
1750
1760
1770
1780
1790
1800
1810
1820
1830
1840
1850
1860
1870
1880
1890
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
2060
2070
2080
2090
2100
2110
2120
2130
2140
2150
2160
2170
2180
2190
2200
2210
2220
2230
2240
2250
2260
2270
2280
2290
2300
2310
2320
2330
2340
2350
2360
2370
2380
2390
2400
2410
2420
2430
2440
2450
2460
2470
2480
2490
2500
2510
2520
2530
2540
2550
1742
1743
1744
1745
1746
1747
1748
1749
1751
1752
1753
1754
1755
1756
1757
1758
1759
1761
1762
1763
1764
1765
1766
1767
1768
1769
1771
1772
1773
1774
1775
1776
1777
1778
1779
1781
1782
1783
1784
1785
1786
1787
1788
1789
1791
1792
1793
1794
1795
1796
1797
1798
1799
1801
1802
1803
1804
1805
1806
1807
1808
1809
1811
1812
1813
1814
1815
1816
1817
1818
1819
1821
1822
1823
1824
1825
1826
1827
1828
1829
1831
1832
1833
1834
1835
1836
1837
1838
1839
1841
1842
1843
1844
1845
1846
1847
1848
1849
1851
1852
1853
1854
1855
1856
1857
1858
1859
1861
1862
1863
1864
1865
1866
1867
1868
1869
1871
1872
1873
1874
1875
1876
1877
1878
1879
1881
1882
1883
1884
1885
1886
1887
1888
1889
1891
1892
1893
1894
1895
1896
1897
1898
1899
1901
1902
1903
1904
1905
1906
1907
1908
1909
1911
1912
1913
1914
1915
1916
1917
1918
1919
1921
1922
1923
1924
1925
1926
1927
1928
1929
1931
1932
1933
1934
1935
1936
1937
1938
1939
1941
1942
1943
1944
1945
1946
1947
1948
1949
1951
1952
1953
1954
1955
1956
1957
1958
1959
1961
1962
1963
1964
1965
1966
1967
1968
1969
1971
1972
1973
1974
1975
1976
1977
1978
1979
1981
1982
1983
1984
1985
1986
1987
1988
1989
1991
1992
1993
1994
1995
1996
1997
1998
1999
2001
2002
2003
2004
2005
2006
2007
2008
2009
2011
2012
2013
2014
2015
2016
2017
2018
2019
2021
2022
2023
2024
2025
2026
2027
2028
2029
2031
2032
2033
2034
2035
2036
2037
2038
2039
2041
2042
2043
2044
2045
2046
2047
2048
2049
2051
2052
2053
2054
2055
2056
2057
2058
2059
2061
2062
2063
2064
2065
2066
2067
2068
2069

2017, Sutapa Ghosh