What To Do About Brittle Diabetes

Q: I am a brittle diabetic and live in fear every day as my blood sugar goes from high to very low within a few hours, and I never know it’s low until it is too late. I understand there’s a new oral drug for this, and I hope you can share some information with me. Also, I’d like to know what’s new in terms of a cure-I hear rumors, but never see the new techniques or good news in doctor’s offices. Please share any news of new treatment.

A. M. Craft
Ashland, KY

A: You have really asked three good questions, and I will address them separately.

1. You are very correct to be concerned about the very low blood sugars, especially if you can’t sense it until it is “too late.” It is very important that you review this with your doctor, and a change in insulin regimen be made. “Hypoglycemia unawareness” is not rare, and is generally treated by allowing the blood sugars to rise high enough that the low blood sugars are eliminated. One then seeks to attain a more stable or predictable level of control of higher blood sugars, and then slowly bring them down.

Causes of unexplained hypoglycemia include life-style problems (unexpected stresses, erratic food habits, etc.), gastroparesis (slow and unpredictable emptying of food from the stomach), erratic insulin absorption from injection sites (especially if there is a buildup or breakdown of fat below the skin), and other factors. All of these should be reviewed with your doctor.

For erratic life-style issues, a more structured program is helpful. For gastroparesis, medications such as Reglan, Motilin, or Cisapride may be effective, as may having some liquid portion at each meal. Remember that fat tends to be released from the stomach more slowly in all people.

For areas of abnormal fat buildup or breakdown under the skin (lipohypertrophy or lipoatrophy), avoiding those sites can improve constancy of insulin absorption. Sticking to one site for injections, such as the abdomen, may also be helpful.

2. There are a number of new approaches to be considered for hypoglycemia. Amylin is a substance that is produced with insulin and may minimize hypoglycemia. This is in the early stages of testing, and so it is too soon to be certain what the improvement will be. Amylin is also made by the beta cells of the pancreas, and so amylin production ability is destroyed when insulin production ability is destroyed. That is one theory of the development of “brittle” diabetes. Look for announcements from the Amylin Company and in the scientific literature over the next year.

Another aid to people with hypoglycemia may be the new analog insulins which act very rapidly, and can be administered in small doses shortly before a meal. Because their course of action should be shorter and therefore more predictable, the chance of hypoglycemia should be minimized.

3. Finally, your question regarding a “cure” is a very long and complex one. Many articles in DIABETES HEALTH have addressed different aspects of this. You have probably recently heard about the transplantation of encapsulated islet cells, and you may also have heard about a number of strategies for preventing and reversing early type I diabetes with immune therapies and other therapies. Our enthusiasm regarding a cure must be tempered by the realization that any of the possibilities remain years away and in the short run no more important factor than tight control can give us the chance to prevent diabetic complications.

Dr. Daniel Einhorn
San Diego, CA

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Q: I’m grateful for your newsletter, as it gives more useful information than the others I have read. It is more up beat, giving us a feeling of hope. What I would like to know is if anyone has developed a time-release type of oral medicine. Does this sound feasible?

Mitchell Black
Bronx, NY

A: I agree that DIABETES HEALTH gives some of the most useful and practical information regarding diabetes, and it provides it in a most readable, timely, and accurate fashion.

“For type 2 diabetes, the traditional oral agents are sulfonylureas, which are indeed rather long-acting and can be given once daily…”

When you ask about a timed release type of oral medication, I assume that you mean insulin. To date, there is no such type nor is one likely to be developed soon. Oral insulin has been used as an immunologic strategy to prevent type I diabetes, but it is not effective in controlling blood sugars. This is because insulin is broken down as a protein by the digestive process.

“Oral insulin has been used as an immunologic strategy to prevent type I diabetes, but it is not effective in controlling blood sugars…”

For type 2 diabetes the traditional oral agents are sulfonylureas, which are indeed rather long-acting and can be given once daily. There are new oral agents being developed for type 2 diabetes and these too have a long duration of action.

Dr. Daniel Einhorn
San Diego, CA

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