Type 1 Diabetes NOW

24 So Worried About Blood Glucose That I Cannot Eat To My Satisfaction

In Japan, if you have diabetes, every time you visit a medical institution, your blood glucose and HbA1c levels are measured. Many of you on insulin probably measure blood glucose at home also. (Patients do not necessarily have to measure blood glucose at home even if they are on insulin, and there are many patients who do not.)
Many of you may feel that you can never get away from blood glucose measurement no matter where you are.

1.Once you start feeling you are at the mercy of blood glucose
Among those of you who are on insulin and self-measure blood glucose, isn't there anyone who is fed up with blood glucose because your glucose keeps fluctuating and you cannot predict it at all despite regular measurement of blood glucose?
I had such patient just today. He sometimes has high blood glucose after meal whereas he develops hypoglycemia on the night of the same day. However, there is no consistent pattern. For example, he sometimes has hyperglycemia after breakfast and hypoglycemia before dinner, and at other times hyperglycemia after lunch and hypoglycemia during the night. If you adjust insulin dosage according to these variations, you could have even worse glucose control and develop more severe hyperglycemia or hypoglycemia.

Also consider injection sites
As I wrote before, one main reason for the fluctuations could be injection sites. Here is what happens.
If you keep using the same injection site, it causes swelling of the fat tissue under the skin of the site resulting in poor absorption of insulin. Then, even if you inject the same dosage, it may not bring down blood glucose levels as much. If you change the injection site, insulin is better absorbed enabling glucose level to go down more easily. In this way, blood glucose levels go up and down a lot.

2. Even only with super long-acting insulin?
I have an elderly patient with type 2 diabetes who injects super long-acting insulin once a day. (Compared to those with type 1 diabetes who inject insulin more frequently, his blood glucose should be less likely to fluctuate. In fact, in the case of another elderly patient with type 2 diabetes, his daily glucose levels move up and down only moderately.) However, this specific patient is having a hard time because his glucose moves up and down unexpectedly.
Why does he develop hyperglycemia or hypoglycemia - low enough to wake up during the night? He is a well-organized person. He is very sensitive to his blood glucose levels and reports to me his glucose went up or down every time he visits our clinic.

When I asked him in further detail, he told me that he often stays home due to old age and that he eats a good amount of fruits after meal. Since super long-acting insulin cannot lower blood glucose quickly, glucose levels end up surging in his case.
I also came to learn that he reflects on it and reduces dinner portion size. As a result, he ends up having hypoglycemia in the night.

It is probably out of sheer desire to show his doctor good glucose control that he makes his meal size inconsistent. I explained to him that his first priority would be to keep his meal size, especially the amount of carbohydrate consistent.

3.Honeymoon period
When people develop type 1 diabetes, they are usually hospitalized to get used to treatments for the disease and leave after ten to fourteen days on average. Some patients with light ketosis and a good understanding of insulin therapy including algorithm may receive treatment as outpatients without getting hospitalized. Those who are hospitalized start reducing insulin dosage as they are leaving the hospital. One or two months after they leave the hospital, they could develop hypoglycemia at times unless they significantly reduce insulin dosage. Such period is called "honeymoon period".

Why does honeymoon period occur? Among those who developed type 1 diabetes, some patients still have some insulin secretion. It is said that when such patients are supplemented with insulin well, their insulin-producing cells in pancreas are restored and produce more insulin than the time of the onset of diabetes. Thus, patients gradually reduce insulin dosage, and develop hypoglycemia if they do not.

There used to be some patients with type 1 diabetes who would experience honeymoon period where they develop hypoglycemia unless they stop insulin injections. These days, however, there are fewer patients with type 1 diabetes who have honeymoon period. There is hardly anyone who becomes insulin-free.

Another interpretation of honeymoon period
I once had a female high school student with type 1 diabetes sent to our hospital. She was considered to be in honeymoon period. When I asked her in detail, however, it became clear that she had anorexia. Since she was not eating much, her insulin dosage was getting smaller. When we were doctors in the making, diseases such as anorexia and bulimia were not observed, and we did not learn about them either.
It may be that honeymoon period with type 1 diabetes occurred because type 1 patients determined not to raise blood glucose levels adjusted meal portion size when they were about getting used to insulin injections.
©2007 Yasuko Uchigata



1. 血糖値に振り回されているという気持ちがでてくると
 食後に血糖が高かったと思うと、その日の夜は低血糖になったと言う。それも同じパターンではなく、朝食後の高血糖と夕食前の低血糖であったり、昼食後の高血糖と夜中の低血糖であったり。  こんなとき、それにあわせてインスリン調節をしていると、さらに悪化して、もっと高血糖と低血糖がはげしくなることがあります。

 同じ場所だけに注射していると、その場所がすこし膨らんで脂肪が増加してきて、注射しても皮下からの吸収が悪くなってしまうのです。そうすると同じ量を注射していても血糖が下がらないことがおきます。 すこし場所が変わったところに注射したときは吸収がよいので、良く血糖が下がりやすくなることも起こってきます。血糖がとても上下してきます。
2. 持効型溶解インスリン注射だけでも?


3. ハネムーン期
 1型糖尿病が発症すると、たいていは入院(平均10日から2週間くらい)していろいろ1型糖尿病の治療に慣れていたただき、退院しますね。ケト−シス状態が軽く、アルゴリズムを含めたインスリン治療が良く理解できる方なら、入院しないで外来診療だけで治療開始することもあります。  退院するころからインスリン注射量が減ってきて、退院後1カ月、2カ月すると、ときにはインスリン注射量を極端に減らさないと低血糖をおこすことがあります。これをハネ−ムーン期と呼びます。


 以前はインスリン注射をなしにしなければ低血糖をおこしてしまうようなハネムーン期が出現する1型糖尿病の患者さんもいらっしゃいました。 最近はどうしたわけか、ハネムーン期をもつ1型糖尿病患者さんがすくなくなりました。インスリンフリーになる患者さんはほとんどいません。

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