Type 1 Treatment And Management

There is no choice with type 1 treatment, as they are going to require insulin, administered either by subcutaneous injection or by pump.

It is an unfortunate fact that insulin cannot be taken as a pill because the acid in the stomach destroys it. However modern type 1's can count themselves lucky, before the discovery of insulin in 1921, there was no treatment.

Insulin used to be got from cows and pigs but now we have human insulin. No, it is not got from humans, it is produced by yeasts or bacteria, but mimics human insulin - one point in the favour of genetic engineering! Put simply, the human gene which codes for insulin was cloned and then put inside yeast or bacteria. A few genetic tweaks and vats of bacteria or yeasts obligingly make tons of human insulin. Smart hey?

What one is trying to do with insulin treatment is to match, as closely as possible, the workings of a normal pancreas. This clever organ makes a little insulin available to the cells throughout the day and steps up it's production when you eat.

This is not so easy for us to accomplish artificially and various insulin therapies have been devised to try and find the best options for different people. It takes trial and error to discover the one that works best for you.

Your doctor will probably start you on a low dose and depending on your daily blood glucose readings (BG's) gradually increase it, sometimes by as much as 2 units every couple of days, until you achieve good BG's. Eventually you will probably adjust your own insulin usage, from day to day, in response to your particular needs.

First you need to understand that there are various types of insulin.
They are grouped on three criteria:-
1. How long they take to start working.
2. The amount of time they operate at full strength.
3. The length of time they continue to work for.

Rapid acting insulin.
Sometimes called rapid onset or short duration insulin.
This works very fast, from 5-10 minutes after injection.
It operates at full strength for 1 - 2 hours.
Continues working for 3-5 hours.
e.g.
Humalog, (generic - Lispro)
(this insulin is 50% more potent than other insulins)
Novorapid, (generic - Aspart)
Apidra.

Short-Acting Insulin
Sometimes called clear insulin, because it is transparent.
This starts to work within 30 minutes after being injected.
It works at maximum strength for 1-3 hours.
Continues for around 6 hours.
e.g.
Actrapid, the brand name for regular insulin
Humulin-R
Novolin (generic Toronto)

Intermediate-Acting Insulin
Sometimes called cloudy insulin because of it's appearance.
This starts to work within 2-4 hours.
Works at maximum strength between 4-14 hours.
Continues for around 24 hours.
e.g.
Humulin L - (generic is Lente)
Novolin N and Humulin N - (generic is NPH)
(Neutral Protamine Hagedorn).
The latter, NPH, is not popular with a lot of users because it they claim it's absorption is erratic and it's peaks unstable.

Long-Acting Insulin
Starts to work within 6 hours.
Works at maximum strength after 8-12 hours.
Continues to operate for up to 36 hours.
e.g.
Humulin U - (generic Ultralente) (from the Latin ultra, meaning very; lente, meaning slow).
Lantus - (generic Glargine)
Levemir - (generic Detemir)
Lantus has become immensely popular. It has no pronounced peak so is very stable. It is however more sensitive to heat than other insulins, so it must be kept in the refrigerator. Even when picking it up it would be a good idea to take along a cooler bag if you live in warmer climes.

Lantus does have the problem of lasting for 36 hours in some people. If that applies to you then perhaps Detemir is the answer as it has a much more even absorption and only lasts for 18 hours.

Pre-mixed insulin
These are a mixture of either rapid-acting insulin and intermediate acting insulin or fast-acting insulin and intermediate acting insulin. There are a number of these including: 10/90, 20/80, 30/70 (the most popular one), 40/60, 50/50 and Mix 25.

Some doctors feel that insulins should never be mixed, that you lose the time effect of both. I guess it is up to the patient to try and see what works for him.

Due to the way the rapid action insulins work they give one more flexibility in the timing of your meal and the quantity and type of food eaten. Given just before a meal they control the peak in blood sugar that occurs at mealtimes. Thus they are often called 'bolus insulins'.

However, they are more expensive than regular insulin and are often not sufficient to cover the whole 24 hours so another intermediate or long acting insulin is needed to provide an all day, all night insulin effect. They are termed the 'basal insulins' This means, needless to say, yet another injection or sometimes two, not something that is too popular with diabetics who are already sick to death of sticking needles into themselves!

The plan your doctor will work out for you will depend on a number of factors.
1. Your age.
2. Your weight.
3. How active you are.
4. Your eating patterns / lifestyle.
5. Where your blood sugars should be (targets) and how much effort you are prepared to put in to get them there.
6. Your ability to control any hypoglycaemia (low blood sugars). Do you recognise the symptoms and know how to prevent them?
7. Your attitude to managing your diabetes.

It would be no use asking someone with a hatred of injections to follow a regime that involved 5 a day, however good the control they might achieve. They probably would not do it, at the cost of their health. Better less injections even if the control is not quite so tight.

The attitude to this disease is as varied as the people that have it. Some just don't seem to care and give it just enough attention to stop themselves totally falling over. Others are very determined to do anything within their power to get perfect blood glucose levels while yet others are angry and approach it as if it is an enemy that needs to be dealt with - sometimes it takes a while to learn acceptance of the inevitable! See Emotional Issues of diabetes for this topic.

We are all individuals and that is why a good diabetic doctor or nurse will treat us as such and tailor their therapies to suit.

Symlin
A new drug, approved by the FDA only in March 2005, claims to be the first non-insulin drug to be developed for use by type 1's since the 1920's. It's name is Pramlintide and is sold in the States under the brand name Symlin. It is a synthetic version of a hormone named amylin, also produced by the beta cells, that diabetics, for obvious reasons, either lack or don't have enough of.

It is especially useful for those diabetics who need better blood sugar control despite their insulin regime.

It is injected at mealtimes and slows down the movement of food through the stomach so sugar does not enter your blood as quickly after eating. It is always used together with insulin to help lower blood sugar during the 3 hours after meals. It can lead to a reduction in the amount of pre-meal insulin that is needed.

Symlin is not for everybody. You should not use it if you are one of those people who cannot tell when you are hypoglycaemic (known as hypoglycaemia unawareness), also it you suffer from Gastroparesis, a situation where your stomach delays emptying.

Side effects of Symlin:-
1. Hypoglycaemia - although the intention is to lower your blood sugar it may drop too low. The degree of hypoglycaemia that occurred with the Symlin/insulin mix was so great that the drug was almost banned. This drop occurs in the first 3 hours after the injection and it would be advisable not to drive a car or operate machinery in this time period if possible.
2. Nausea and vomiting.
3. Decreased appetite.
4. Indigestion and stomach pain.
5. Dizziness.
6. Tiredness.
7. Redness, bruising or pain at injection site.

Symlin must never be mixed with your insulin but injected separately. If you are on any other medications they will also pass through your stomach slowly, which may affect their uptake into the body. This can be solved by changing the times you take such meds.

The injecting of insulin or Symlin is not the only change you need to make to control your diabetes. It requires lifestyle changes as well.

1. Keeping physically fit is important, so exercise regularly and try to maintain an even weight. This helps prevent complications such as heart disease and cholesterol. Beware, exercise can sometimes cause a drop in your BG - either eat beforehand or have glucose handy.

2. Then there is your diet, where you need to eat nutritionally but keep a watch on your carbohydrate intake as this converts in the system into glucose. Over a period of time high glucose levels can harm almost every organ of the body and result in the complications associated with diabetes.

3. BG testing. You will need to know the effect the foods you are eating have on your glucose levels and how your insulin regime is working to control this, also what impact illness, stress, exercise, changes in hormone levels etc will have on those BG's. To do this you will need to monitor your BG regularly - known as SMBG - Self-monitoring of blood glucose. This is done with a home BG meter. Your healthcare advisors will also want to see this data as it tells them how well their advised treatment is working and how to adjust it if necessary.

4. Learn to recognise the signs of high blood sugar (hyperglycaemia) and low blood sugars (hypoglycaemia) because these can be life threatening. Always carry some form of glucose, e.g. glucose tablets, in case of a sudden drop in blood glucose.

5. Have regular check-ups on your eyes, feet and kidneys to ensure that you are not developing any problems. See Diabetic Complications

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