My 11 year old was diagnosed with Type 1 diabetes about 6 months ago. He is going through puberty. He sees an excellent pediatric endocrinologist. The doctor mentioned that my son seems to be insulin insensitive.
He is currently using 50 NPH and 50 Regular, both in the morning and with dinner, and is adjusting both lunch and a bedtime snack with about 30 units of Regular. This is almost 300 units and we're nowhere close to a glucose of 200. We are still adjusting the doses daily to try to achieve control.
I understand the autoimmune response that he's having, but there is little available about how this is treated. My son's doctor wants to start him on some oral medications. In order to ask the doctor intelligent questions when he does this next month, I'd like to know which possible drugs he could choose to prescribe so that I may read up on them. I suspect Glucophage and Rezulin are the drugs, but the drug information on the web is real sketchy for Type 1 IDDM and insulin insensitivity especially in this area. If you can point me in the right direction I'd really appreciate it.
To start with, the figures you give show that your son is indeed insulin resistant, and needing a daily dose that is close to ten times the average requirement of a typical boy with Type 1A or autoimmune diabetes. I think, however that you should still ask his endocrinologist whether an antibody test was done, and whether a fasting serum insulin level has been obtained. I say this because there have been very rare instances where a young person has contrived to dilute the insulin as a part of a complicated plea for help. I think this is extremely unlikely in your son's case; but it would still reassuring to know that the antibody test was negative and the serum insulin level above normal.
The field of insulin resistance is a very complicated one and little is understood about the various forms in specific molecular terms. This in turn means that getting a really precise diagnosis is seldom possible, and that treatment really involves ringing the changes on conventional therapy to see what works best. There is a somewhat complex and now not quite up to date account of these forms of diabetes by Jeffrey Flier in Chapter 140 of the 2nd edition of Principles and Practice of Endocrinology and Metabolism 1995, published by Lipincott. Your nearest medical library should be able to give you a copy of this and I'm sure your son's endocrinologist would like one too!
Very broadly speaking, there are several groups of conditions to think about. There are the situations where the insulin resistance is secondary to conditions like obesity and Type 2 diabetes as well as certain genetic conditions (not likely here). There is an autoimmune form (Type B) where there are antibodies to the insulin receptor.
In theory, I suppose this could co-exist with Type 1A Diabetes; but I have never heard of it. Then there are a variety of syndromes (Type A) in which insulin resistance, obesity, abnormal distribution of subcutaneous fat, acanthosis nigricans (patches of irregular pigmentation usually on the face, and upper body) and hypertension are combined in various ways. Sometimes the diabetes component is quite mild and in some instances chromosomal abnormalities have been described. Laboratory findings include high serum insulin levels, hyperlipidemia especially hypertriglyceridemia and hyperferritinemia.
In terms of glucose control, you will still need large amounts of insulin; but there is a possibility that as different molecular forms of insulin become available (e.g. HOE 901), they may be more effective; it is conceivable though unlikely that inhaled insulin might help. Glucophage (Metformin) may help and in theory Rezulin should too though it did not help in the last case here. It is also very expensive and liable to cause liver complications, which is why it has been withdrawn from the market in Britain. But diet and exercise and even perhaps oral medications like acarbose may help always remembering that there may be limits to what he can tolerate emotionally. Finally, if there is hyperlipidemia, this may need to be treated too to avert problems like pancreatitis and cardiovascular complications. The newer Fibrozil group of drugs like Gemfibrozil are the first recourse.
I hope this gives you some ideas to discuss with your sons endocrinologist!
Additional Comments from Linda Mackowiak, diabetes nurse specialist:I have one more question for you: Who is giving the insulin injections? If your son is independently giving his shots, then please also make sure that your son is actually getting this dose. For example, you may need to give him his insulin for a while to verify. I have had some situations where kids have not been giving the doses we thought. If this were the situation, watch for hypoglycemia with these doses of insulin.
Original posting 18 Oct 1998
Additional comments added 2 November 1998
Posted to Insulin
Last Updated: Tuesday April 06, 2010 15:09:00
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