From the Microsoft Network:
I am 30 and was diagnosed with Type 2 diabetes about seven weeks ago. After some initial dietary modifications and exercise which did not satisfactorily reduce my blood sugar, my doctor put me on Glucophage [metformin] and Glucotrol [a sulfonylurea]. These seem to work in nothing other than a random fashion. Blood sugar levels taken about two hours after meals with medication range from 160 to 350.
Furthermore, many of my symptoms match that of Type 1 diabetes: sudden onset, rapid weight loss, a trace of ketones in my blood, and isolated vomiting with no other symptoms of flu or food poisoning.
My doctor diagnosed me as Type 2, but did not give satisfactory answers to my concerns that I may actually be Type 1. I would greatly appreciate a response to the following questions.
- Does my random reaction to oral medication indicate that my pancreas is not producing insulin?
- How can I have these symptoms and not be Type 1?
- Are Type 1 and 2 100% mutually exclusive? (Is destruction of beta-cells exclusive to Type 1?)
- Is Type 1.5 a real classification with unique and specific indications?
- Does the effect of oral drugs stabilize over time?
Only relatively recently and since the availability of antibody testing has it been easy to distinguish Type 1 Diabetes from Type 2 Diabetes; but with the availability of new oral medications it has become more important to try to make a specific diagnosis. Anyway here are some answers to your questions.
- Oral medication alone given to a Type 1 diabetic would be expected to have an erratic response. Some years ago though oral medication combined with insulin did seem to have a role in the early management of Type 1. If you are really concerned about the possibility of being Type 1 and therapy is not going well telling the difference between the two types can be accomplished by getting an antibody test. This is now available commercially, or from a nearby center participating with the DPT-1 trial (for which you are not eligible) and in this rather tortuous way with the nearest lab that can do the test. An intravenous glucose tolerance test with 1 and 3 minute insulin levels would be easier to organise perhaps; but not so specific in interpretation.
- Your symptoms do sound as though they could be Type 1.
- Type 1 and Type 2 are not mutually exclusive. The complete loss of insulin production nearly always occurs within a few months of the clinical onset in Type 1 and may not occur for many years in Type 2.
- Type 1.5 Diabetes is slowly giving way to more specific genetic forms of diabetes. The most common forms are several variants of glucokinase deficiency, an enzyme that plays an important role in the energy supply to the islet cells. Diagnosis is rather complex and the diabetes usually very benign. in other words an improbable diagnosis in your case.
- Many drugs have tiresome side effects in the first few weeks of use, which subside with time. If you are in fact proved to have Type 2 and are not having satisfactory results with your present medication you should perhaps talk to your doctor about two new oral drugs. The first is metformin [Glucophage® brand] which reduces the liver output of glucose (which you are on), the second is troglitazone [Rezulin® brand] which increases the sensitivity of the insulin receptors.
Finally, I think you need to press your doctor again for a more specific diagnosis not only for your peace of mind; but because there is a small possibility that if you are indeed Type 1 an intercurrent infection might precipitate an episode of acidosis. You may also want to consider transferring to a specialised diabetes care unit with associated educational programs and telephone accessibility.
[Editor's comment: The questions raised here show the inadequacy of the present classification system, which dates to the late 1970's, before antibodies were understood to be part of the process of development of Type 1 diabetes. There's a new classification being developed, which will be a bit more rational (but different, of course!). Until we get and understand the new classification scheme, we'll all have to hang in there, and realize that the average doctor (and sometimes we endocrinologists also) have problems classifying some patients. WWQ]
Original posting 23 Mar 97
Last Updated: Tuesday April 06, 2010 15:08:52
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