Interesting Diabetes info from my primary care physician

[Athena]

Since we have a fair number of Diabetics 'round here, I thought I'd share some interesting news my PCP told me during my appointment this morning.

- There's going to be an artificial pancreas out within 2-5 years that will incorporate a subcutaneous continuous blood glucose monitoring device and an insulin pump. You just wear one of these babies and it literally does all the work for you. He says they already have them for use for inpatient diabetics, but there's still issues with the blood glucose monitor gunking up. They're on the verge of fixing that and once they do, it'll be something that anyone can wear.

- The development of the above will drastically change how doctors treat diabetes. Things are going to get MUCH better, and they ain't bad as it is.

- A lot of the complications that used to be associated with Diabetes are going away now that the Insulin we have is human insulin as opposed to pig or cow insulin. He said that even though the pig/cow stuff was good, our bodies didn't accept it the way we accept the human stuff, and kidney problems in particular are going away now that we have human Insulin.

Just wanted to pass all that on, since it's good news!

Other that, he told me I'm fine and to stop worrying so much about being diabetic

[Kricket]

Is it inside or outside of the body?

One of my sons friends is diabetic and should probably have a pump but because he is so active (biking, skateboard, swimming) he refuses to get one.

He's almost 20 and has such a build up of scar tissue on his stomach the doctors have told him his insulin sometimes doesn't get to him right.

His recent highs have been over 600 in the hospital and he dropped down to 43 a few days ago. He wants me to go to a class with him so I can learn more about it since he spends alot of time at our house.

He also has issues with kedosomething? Any simple websites out there anyone can suggest? I've looked it up and know that it's nothing good.

[Athena]

I'm not sure if the artificial pancreas is inside or outside. I'm thinking it's like a pump, where it's outside, with a catheter that injects the insulin, but that's just a guess.

From what I gather, a lot of younger people really oppose the pump. I guess I can't really blame them - if I were 20, the last thing I'd want to be explaining to a potential boyfriend is why I have this thing attached to me. But once you get over that, everyone seems to looooove the pumps. Apparently they make things a lot easier.

Kedosomething is probably Ketoacidosis, which is bad stuff, but beyond that I don't know much about it.

As far as web sites... there's a lot of info about diabetes out there. I can't say I really have a favorite site. I've been relying more on books, since it's really hard to wade through all the information (and misinformation, unfortunately) that's out there.

[Aguecheek]

I hate to sound skeptical, but do you have a cite for the artificial pancreas thing? I've stopped telling my wife about all these wonderful new treatments "on the horizon," because she's been hearing about different ones since she was 10, and has since become somewhat of a cynic.

She's just been fitted with a pump, and I know that this particular model also comes with a glucose monitoring system if the insurance would pay for it, which it wouldn't. Her blood sugar is still all over the place (although pregnancy could have something to do with it). I think she's becoming quite disenchanted with it as a result.

Diabetes sucks.

[Aguecheek]

Hm. www.artificialpancreas.org, set up by the Juvenile Diabetes Foundation. They've got an article at http://www.jdrf.org/index.cfm?page_id=104576 (.pdf!).

I'ma gonna have a look at it at lunchtime. This could be...interesting!

[kenobi 65]

Thanks for sharing that info, Athena!

Being diabetic still stinks, but it surely seems like it stinks far less than it did a generation ago, and the future sure does look promising.

[dactylic hexameter]

As I understand it, the problem with a combined pump/glucose monitoring, is that it has to be accurate literally 100% of the time. Not 99%, certainly not 95% percent. If the glucose monitor checks your blood sugar 10 times a day, and automatically releases the appropriate insulin, it simply cannot mismeasure/be wrong once very two days, or even once a week. So it mistakenly reads your bsl at 250 when it is actually 150, injects insulin and all of a sudden your severely hypoglycemic. Causing you to pass out or get dizzy while driving your car. The problem is that too much insulin is deadly. Period. The prick'n'inject (or prick'n'pump) allows you, the user, to monitor the glucometer results. You can look at it and say, wait a sec, I haven't eaten in 6 hours, no way I'm at 250, lets check again, before I inject the insulin, or dial up the pump. So until that glucose monitor is 99.9% accurate, don't get too excited.

[Rodd Hill]

This will come in handy when I am farming the ocean floor, or zipping around in my JetPak (tm).

[Ann Onimous]

Our daughter has an Animas ping insulin pump. We were told at a recent conference that within the next year they will be incorporating a CGMS with the pump. The CGMS will still be a separate unit, as it is now: but the readings will be beamed to the remote that the ping uses. The remote is also the BG meter, so when we do a carb bolus, it adds in the last BG reading if it's taken within 15 minutes.

I'm optimistic that something better will happen in her lifetime. I hope to still be alive to see it happen.

[GythaOgg]

Originally Posted by Athena

- A lot of the complications that used to be associated with Diabetes are going away now that the Insulin we have is human insulin as opposed to pig or cow insulin. He said that even though the pig/cow stuff was good, our bodies didn't accept it the way we accept the human stuff, and kidney problems in particular are going away now that we have human Insulin.

I wouldn't count quite so much on that one. Human insulin (humulin) has been around since the late 1970s/early 1980s, and I can assure you that the rate of complications has not dropped appreciably in that time or now. The cause of most DM complications is very well understood, and has more to do with poor glycemic control and the micro and macrovascular complications and damage of high blood sugar levels than with the body 'accepting' pig or cow insulin.

Still, outlooks are better now, particularly for type II diabetics who are caught early. Early control of BG levels means fewer complications later on.

[Pseudocode]

Originally Posted by dactylic hexameter

As I understand it, the problem with a combined pump/glucose monitoring, is that it has to be accurate literally 100% of the time. Not 99%, certainly not 95% percent. If the glucose monitor checks your blood sugar 10 times a day, and automatically releases the appropriate insulin, it simply cannot mismeasure/be wrong once very two days, or even once a week. So it mistakenly reads your bsl at 250 when it is actually 150, injects insulin and all of a sudden your severely hypoglycemic. Causing you to pass out or get dizzy while driving your car. The problem is that too much insulin is deadly. Period. The prick'n'inject (or prick'n'pump) allows you, the user, to monitor the glucometer results. You can look at it and say, wait a sec, I haven't eaten in 6 hours, no way I'm at 250, lets check again, before I inject the insulin, or dial up the pump. So until that glucose monitor is 99.9% accurate, don't get too excited.

The accuracy is not the problem. Modern blood glucose monitors are accurate enough for this kind of feedback system. The system would check much more than 10 times a day (I would think once a minute or more), and it would have enough trend information in the short term to be able to know if there was an error with one specific reading.

The hard part is figuring out how to deal with different situations that cause the same short term trend, but cause different long term trends. For example, an increase in adrenaline might cause your blood glucose to rise as if you ate a candy bar. However, after a while those two trends may start to differentiate.

Of course, you could always take the long-term view and allow for more fluctuation, but that's not going to work much better than an insulin pump would. The whole point of the feedback system is to be able to handle blood glucose changes that may not be perceptible to the patient.

[Athena]

Originally Posted by GythaOgg

I wouldn't count quite so much on that one. Human insulin (humulin) has been around since the late 1970s/early 1980s, and I can assure you that the rate of complications has not dropped appreciably in that time or now. The cause of most DM complications is very well understood, and has more to do with poor glycemic control and the micro and macrovascular complications and damage of high blood sugar levels than with the body 'accepting' pig or cow insulin.

Still, outlooks are better now, particularly for type II diabetics who are caught early. Early control of BG levels means fewer complications later on.

I'm not counting on anything.

That said, I think we're talking about two different things. Doc didn't say that good blood glucose control wasn't important. What he said was that there were other issues that were caused by the cow/pig insulin which were going away, specifically kidney problems.

I didn't ask him to cite his sources, so I don't know whence they came. But he's a pretty smart guy and good doc, so I tend to believe that his statements come from a valid source.

[gigi]

Originally Posted by Aguecheek

She's just been fitted with a pump, and I know that this particular model also comes with a glucose monitoring system if the insurance would pay for it, which it wouldn't. Her blood sugar is still all over the place (although pregnancy could have something to do with it). I think she's becoming quite disenchanted with it as a result.

My friend's releases the same amount of insulin all the time and then she still has to enter info from the fingerstick and it tells her how much to bolus. It doesn't do any adjusting on its own based on readings it takes.

[AHunter3]

My sister has one of the pumps and has had for approx. 20 years. It's not quite THAT snazzy: she has to manually hit some buttons to get it to taste her blood, then she accepts the info as input values and ok's the administration of insulin, which the pump then injects over time into her bloodstream.

I think a couple years ago they were first offering the kind that automatically do blood sugar sampling without user involvement and add additional insulin as and when appropriate also without user intervension, but I guess that was still experimental; at any rate she didn't get one of those (yet).

This sounds like a refinement of the latter. Hers is an external system, a device approx the size of an iPod or large cellphone that she wears on her belt, with a skinny tube that goes to a subcutaneous needle inserted into her abdomen.

[Athena]

Check this out. VERY cool - tattoo that changes color based on your blood sugar level.

[GythaOgg]

Originally Posted by Athena

I'm not counting on anything.

That said, I think we're talking about two different things. Doc didn't say that good blood glucose control wasn't important. What he said was that there were other issues that were caused by the cow/pig insulin which were going away, specifically kidney problems.

I didn't ask him to cite his sources, so I don't know whence they came. But he's a pretty smart guy and good doc, so I tend to believe that his statements come from a valid source.

Seriously? I do diabetic education on a daily basis, will be testing for my CDE when they do the next round of testing in the spring, and this is something I have never, ever, ever heard, and I am doing a heck of a lot of extra studying right now. The kidney complications of diabetes are still very much with us, the rate is not dropping, and they are, so far as I know, due entirely to complications of high blood sugar and elevated blood pressure, which tends to come along with diabetes.

Just on a professional basis, I'd be interested in knowing the source of the info. A quick web search at my usual sources tonight is only turning up articles about how some diabetics feel beef and pork insulin worked better for them and they had fewer complications and better control using them and are outraged they are no longer made. I'm always interested in learning something new.

[Lynn Bodoni]

Originally Posted by Aguecheek

I hate to sound skeptical, but do you have a cite for the artificial pancreas thing? I've stopped telling my wife about all these wonderful new treatments "on the horizon," because she's been hearing about different ones since she was 10, and has since become somewhat of a cynic.

She's just been fitted with a pump, and I know that this particular model also comes with a glucose monitoring system if the insurance would pay for it, which it wouldn't. Her blood sugar is still all over the place (although pregnancy could have something to do with it). I think she's becoming quite disenchanted with it as a result.

Diabetes sucks.

I was very excited about the prospect of inhaled insulin. It was put on the market and then withdrawn again within a matter of months. My doctor was also excited about it, and wanted to try me on it. However, I didn't have an appointment in the narrow window of time when it was available to the general public with the proper prescription.

I would still like to try it, if they clear up the problems with it.

[Nava]

Originally Posted by GythaOgg

I wouldn't count quite so much on that one. Human insulin (humulin) has been around since the late 1970s/early 1980s, and I can assure you that the rate of complications has not dropped appreciably in that time or now. The cause of most DM complications is very well understood, and has more to do with poor glycemic control and the micro and macrovascular complications and damage of high blood sugar levels than with the body 'accepting' pig or cow insulin.

Add "hiding from your children and doctor that you have a supurating foot wound" to the list of "things that don't get fixed by humulin"

[Qadgop the Mercotan]

Most of the new stuff mentioned by the OP applies to Type I DM, not Type II DM (the most common kind).

Kidney disease continues to be a consequence of DM to a great degree, despite most insulin now being human-derived.

Weight loss, diet change, and exercise continue to be the most effective treatments for Type II DM. Use of drugs such as metformin, glyburide, glipizide, pioglitazone, insulin, and others represents a failure of those first 3 principles to control the disease.

Type I diabetics have an absolute need for insulin due to the failure of their own pancreas to produce any at all. Pancreas transplants and artificial pancreases are good options for them.

Type II diabetics have insulin resistance: Their body ignores more and more of the insulin the pancreas produces, causing the pancreas to produce tons of insulin, trying to get the body to respond to it. Eventually the pancreas burns out, and then makes very little insulin. But here a new pancreas would just encounter the same problem, as would an artificial one.

There's lots of fine distinctions and basic principles I'm omitting, but that's it in a nutshell. Besides, my plane is boarding soon......

[Ann Onimous]

Actually, a surprising amount of type 2 diabetics who are on insulin are turning to the pump as an option. No reason type 1s should get to have all the fun...

[Athena]

Originally Posted by Qadgop the Mercotan

Eventually the pancreas burns out, and then makes very little insulin. But here a new pancreas would just encounter the same problem, as would an artificial one.

Yeah, except the artificial one doesn't burn out and quit making insulin. Right?

And as Juliana sorta says, and from what I can tell by my reading, early and intense insulin treatment is more and more looking like one of the best treatments for Type 2s, as it preserves any existing pancreatic function. So really, my OP is meant for all insulin-using diabetics. I'm one of the lucky ones who went straight to insulin. Alas, diet, exercise, and weight loss doesn't do it for everyone...

[beckwall]

Interesting stuff. Still seems like end stage renal disease will continue to occur related to diabetes, since even small fluctuations in the blood glucose cause all kind of problems in the tiny blood vessels that innervate the kidneys and allow them to work. Diabetes is a tough disease, that's for sure. I hope something promising like this will become a reality soon.

[Qadgop the Mercotan]

SubQ glucose monitoring is not all it's cracked up to be yet, either. At present, it involves up to 8 to 12 fingersticks a day to correlate what the subQ monitor is showing compared to what a standard glucometer shows.

And pumps are a management tool and often a convenience, not a huge leap forward. They've been around since the 1980's, and non-compliant diabetics have just as many problems with them as with standard therapies. I've several patients and a daughter with a pump, so I'm pretty aware of how they're used and misused.

As for pumps in insulin-resistant folks, well, the pump provides more insulin, the body resists it, the pump supplies more insulin, the body resists it more, and pretty soon the individual is requiring massive doses of insulin. Same as with shots.

I've been working with pumps and insulin-monitoring for over 25 years now. They're better tools than we used to have, but IMHO they are not a paradigm shift in how we manage the disease. Frankly I think the introduction of metformin was a bigger breakthrough, which has helped far, far more type II DMs.

So in theory, the idea of a continually adjusting insulin pump slaved to a continuously running glucose monitor is wonderful, but the reality is that it doesn't translate into an artificial pancreas. Despite certain drug company hype to the contrary.

Early intervention with insulin for type IIs may indeed be better for select type II patients. But more data is needed, frankly, before we can say that is a given. Insulin itself is thought to be somewhat atherogenic (causing plaque to build up in arteries), so the medical community is still trying to sound out risk vs. benefit of all these approaches.

I don't mean to rain on your parade, and I'm happy that better and better tools are being created. But I've been in the trenches of diabetic care, both professionally for over a quarter of a century and personally for nearly 15 years too. And the basics are still the same: If on (short acting) insulin, check your sugars frequently & take your insulin as required; count your carbs, get your exercise.

BTW, I've been hearing that the subQ monitoring would be the thing for all diabetics within 2 to 5 years, for over 5 years now.

[Athena]

Just curious, Qad - what do you suggest for massively insulin resistant types who don't respond well to the various drugs that work on resistance, and who are as a result having to take massive doses of insulin? How bad is it to be taking a whole lotta insulin?

Also, what do you think of the insulin/weight issue? I've read quite a bit from people claiming their inability to lose weight is because of all the insulin they take, but most medical journals say that insulin, by itself, does not cause weight gain - it's misuse of insulin to allow one to eat unhealthy food that causes weight gain. I'm having trouble sorting out what the straight dope is on that one.

[Qadgop the Mercotan]

Well, insulin does let folks who are morbidly obese get by with HgbA1C levels of 7 or lower, which is essentially excellent control of blood sugar. And tight control reduces risk, regardless of BMI.

And insulin along with weight reduction does increase the risk of more hypoglycemic episodes occurring as insulin needs change. Of course, the treatment for the episode is to take glucose. But it's hard to stop from eating excessively when one's glucose level is 40, & then afterwards, get back onto the diet.

But it can be done with frequent blood sugar checks, close carb counting, and appropriate exercise, and decent supervision by doctor or DM RN.

As for your first question about those taking lots of insulin: The bad effects of high doses of insulin (atherosclerosis) are mostly theoretical and in the future. The bad effects of not taking enough insulin are well-demonstrated and in the present & near future. So if one needs more insulin to achieve target blood sugar levels, more insulin should be taken.

[Athena]

So you don't buy into the whole "I take insulin, that's what makes me fat and it's impossible to lose weight when you take insulin" schtick that I see all over the diabetes forums? I think the idea is that insulin somehow makes it easier for your body to make fat, and also taking a lot of insulin makes you hungrier. I don't think they're talking about going low and having to eat carbs to get their sugars back up, it's something about the insulin itself that they say makes them fat.

My gut feeling (and what I read) is that they are simply used to eating more than they should because of the diabetes, and once their blood sugars are back in line they don't adjust their diet to compensate for that. But I'm not a doc, and I'm wondering if there's any truth to it.

[Qadgop the Mercotan]

Statistically, most type II DMs who go on insulin will gain weight. That's a fact. I expect part of it is from having more of their glucose get taken up by the cells rather than exiting the body via the kidneys. I also expect part of it is due to occasional hunger from low blood sugars. And another part is due to having an insulin regimen established which gives good glucose control, but has too many calories in it. So yes, I expect your gut feeling plays a role in the equation too.

It truly does seem to be harder to lose weight while on insulin. But then again, weight loss is never real easy, especially for folks who tend to get type II DM.

[Athena]

Interesting. Thanks for the answers. There's just so many factors in this whole thing, it's hard to get it all straight.