Small molecule inhibitors of glycoconjugate metabolism are being exploited for therapeutic benefit in a number of human disorders. As examples of this class of compound, imino sugars, as monosaccharide mimics, have a number of advantages for compound design and synthesis to define biological activity. As polyhydroxylated molecules, each chiral centre offers manipulation to generate isomers with restricted or enhanced mimicry, and the endocyclic nitrogen atom is readily modified to gain selectivity, increase potency or improve pharmacodynamics. This review focuses on the discovery of imino sugars that have considerable potential for treating a diverse range of diseases, from lysosomal storage disorders diabetes and cystic fibrosis to viral pathogenesis, and addresses the mechanism of action that is dictated by structural modification.