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Question:

From Swift Current, Saskatchewan, Canada:

I think there was some misunderstanding about some parts of my previous questions and another required more information for an appropriate answer. I will try to respond in order for clarity.

My first question related to needing LESS insulin during early morning hours. My response to your question asking if I am active is that no, I am NOT physically active at all. This is due to that fact that exercise often causes severe HYPERglycemia with me, followed by a drop only approximately 30% of the time. So, I can never plan for it. This occurs regardless of the type of exercise done. Due to this "unknown," I tend to avoid exercise as it makes my diabetic control WORSE. Thankfully, I am thin and have high HDL, low HDL, etc. I actually wanted to know why I need LESS insulin to bring down a high, not more. I understand it is common to need more, but why do I need LESS insulin that usual when high? Does this mean I still make some insulin or am I so insulin sensitive that I never need more than four units? I have almost never needed more than four units to bring down a severe high outside of illness or menstruation, even if my correction factor would dictate that I should be using more. After my blood sugar is over 18 mmol/L [324 mg/dl], my "usual" correction factor no longer applies as I need LESS insulin. This occurs at any point in the day, with me needing about one-third of my usual factor during early morning hours. Can you speculate as to WHY I would be having these periods of insulin sensitivity though? Does every type 1 diabetic have this? If not, why am I? If this is the case, I am obviously an insulin sensitive person having increased periods of extreme sensitivity...but why and what is the next step in evaluation?

I am aware of hormone antagonists (progesterone) causing insulin resistance, but I would like to know the general physiological mechanism and if there is an adaptation reason for this. Do they interfere with receptor sites? Why?

The main reason for the majority of my questions is that I feel like I am a hopeless case destined to die young. No doctor has been able to give me any answers or solutions, other than "apply for an islet transplant," which usually fails within one year and may cause organ damage, death from infection, and cancer. I have a very poor quality of life due to diabetes, despite having no diabetes complication. Due to this, it is hard to get most doctors to understand that this disease can essentially disable you without such complications. I would appreciate very much if someone could provide me with answers or refer me to a physician who can.

Answer:

I would be glad to readdress your questions with the additional responses. First, thank you for clearing up your question for me. It appears you have an extreme problem that is not uncommon in people with type 1 diabetes. This centers around how to handle blood sugar control around exercise. How can something so often subscribed to be physicians be such a destabilizing factor with blood sugar control? To answer this, you have to understand how exercise causes these swings. During the actual exercise, your body activates the sympathetic nervous system, the "fight or flight" system that gets your heart rate up, your sense of alertness up, and helps you to acutely meet the demand of increased energy requirements. There is a variable time after the conclusion of the exercise when this turns off and depends on the duration and intensity of the exercise. When epinephrine and other hormones are up as part of the sympathetic nervous system response to exercise, these hormones counteract the effect of insulin. When the response goes away, you have those muscles hungry to replace their glycogen (stored glucose) supplies. This can cause a downturn in glucose levels. So you see, there can be a lot of unstable glucose changes. When you get very low, this is the glucose uptake occurring and goes along with you being very insulin sensitive. You would almost have to plan on having less insulin around after the exercise and not overplay the mild rise that occurs during the exercise.

Second, with regard to needing less insulin for a high glucose, I would suggest that means you are more sensitive to insulin than others. Hopefully, this is because you have kept your weight down. This is also genetically determined. Not everyone with type 1 diabetes has this problem. However, there can be other complex issues going on. Over a long time, some people develop anti-insulin antibodies that circulate in your blood and serve as a reservoir of releasable insulin. The problem with this release is that it is uncontrolled and can occur any time. These antibodies can be measured in the clinical laboratory.

Progesterone probably causes its insulin resistance through indirect effects and not as a direct effect on the insulin receptor.

Finally, I would not give up hope. Find a physician who will work with you. It sounds like it should probably be an endocrinologist since you have exhausted the usual means for your care. Although pancreas and islet transplant have been advocated for severe hypoglycemia unawareness, they are not typical therapies. There may also be hope for you with using the new continuous glucose sensors that are available. They give you immediate feedback with your blood sugars and may offer you additional help in meeting some of the unexpected changes in your blood sugars.

JTL

DTQ-20080709175337
Original posting 18 Jul 2008
Posted to Daily Care and Insulin

  
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Last Updated: Tuesday April 06, 2010 15:10:16
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