Wednesday, October 2, 2013

Test Results

Karl developed an aversion to blood work, but on the second try and quite a bit of help from the folks at Philomath Family Medicine, we got it done.

The trick was to get a prescription for Lidocaine ointment and apply this topical anesthetic an hour before the appointment, telling Karl that this would help a lot, and doing the blood draw in a different room from usual. This process was more to his liking, which is just as well, because it took the nurse quite some time to find the vein!

Blood Sugar Well-Controlled

Two years after being diagnosed with Type 1 diabetes, his average blood sugar level, as measured by the Hemoglobin A1c test, is at 5.3% -- within the normal range! Yay, Karl! This presumably means that he is no more likely to have diabetes-related health complications than a non-diabetic. Whew!

How do we do this? Karl's rigid dietary preferences help, because we know how many grams of carbs are present in everything he eats. And the sensible use of intensive insulin therapy, with long-lasting basal insulin and fast-acting mealtime insulin, is essential.

Adjusting insulin dosage. One thing we do that many people don't do is to adjust Karl's dosage based on experience. We don't wait for a doctor's okay -- or even ask, for that matter.  Some people wait until the next time they see their doctor to adjust anything, even if their next appointment isn't for a year and their numbers are way out of line! That's a bad idea.

For his basal insulin -- we use Lantus -- you can find the "titration" recommendation online. Basically, we look at the morning blood-sugar levels and adjust the dose until they're in the right range. This can be repeated if they wander out of the range again (looking at a few weeks as an average). Karl started out with about 7 units of Lantus a day and is getting 18 now. We split this into a morning injection and an evening injection.

Similarly, for mealtime (bolus) insulin, if the blood sugar numbers are consistently high or low after meals, we're clearly giving the wrong amounts of insulin. Over the past two years, the right amount has drifted from 20 grams of carb per unit of insulin to 10.

Being willing to adjust the dosage according to the data is probably a big reason why Karl's A1c numbers are so good.

Pancreas Hanging in There

Another important test, C-Peptide, measures how much insulin Karl's pancreas is still making. The "acceptable" range is 0.9-6.9 ng/ml, and Karl came in at 0.7. It was actually in the "acceptable" range last time we tested it, two years ago, which shows how blood tests don't tell the whole story, since being hospitalized with extreme levels of blood sugar isn't what I'd call acceptable!

People will tell you that Type 1 diabetics don't have any pancreatic function at all, and their C-Peptide tests will come in at zer0. That's nonsense. Pancreatic function in Type 1 diabetics is impaired, and typically declines, often to zero -- but writing the pancreas off is pessimistic and stupid.

To help preserve the pancreas, we do a few simple things:
  • Maintain excellent blood-sugar control. This puts less of a load on the pancreas, which isn't literally killing itself by producing all the insulin it possibly can, 24/7, because the injected insulin is removing much of that load.
  • Supplement with niacinamide and vitamin E. A few studies show benefit from this.
  • Maintain a low-ish carb diet. The more carbs you eat, the poorer you blood-sugar control and the more your blood sugar spikes. Carbs reach the bloodstream faster than injected insulin, but the fewer carbs you eat, the smaller the spike And an error of, say, 20% in estimating the carbs in a meal makes only half as much difference if you're eating only half as many carbs. Karl eats only about half as many carbs as are recommended for a typical diet.

Wednesday, June 5, 2013

Two Years of Type 1 Diabetes

Next month will be the second anniversary of Karl's illness, hospitalization, and diagnosis of Type 1 diabetes, and it's so far, so good. 
His insulin usage has gradually increased, and is now at 17 units of Lantus per day for a basal dose, plus one unit of Novolog for every ten grams of carbohydrates in his meals. I rough figures, this is about twice his original dose, meaning that his pancreas has been gradually producing less and less insulin.
We were told to expect a "honeymoon period" of relatively low insulin requirements and stable insulin requirements that ended suddenly, but this didn't happen. 

Possibly this is because we deliberately decided to see what we could do to to stretch things out. Among these things were:
  • Use of a relatively low-carb diet (averaging around 60 grams of carbs per meal, which requires less insulin and thus allows better control of blood sugar.
  • Use of the Novopen Junior insulin pen, which officially allows insulin to be delivered with a half-unit resolution, but which probably allows precision to one-quarter unit or better. (For example, if we want to give 5.25 units, we dial in 5.5 units, then back off to halfway between the 5.5 mark and the 5.0 mark.)
  • Karl likes the same meals over and over, so we get really good at comparing the before-and-after blood sugar levels to find the right level of insulin.
  • Giving Lantus morning and night, rather than at bedtime only, because its response curve doesn't stay flat for a full 24 hours for everybody.
  • Use supplements: Insulow and evening primrose oil at every meal and daily supplements of mutlivitamin, vitamin B3, and vitamin E.
  • Refusing to freak out.
Karl's very fussy about maintaining his insulin kit just so, and that means we're almost never caught short when we go out to eat.
On the downside, Karl has refused to let the nurse take blood samples the last couple of times, so we haven't done detailed bloodwork recently. And his blood glucose regulation is getting less good as his insulin requirements increase, since the pancreas is far better at this kind of thing than any kind of insulin therapy, however spiffy and modern, so the less his pancreas contributes, the wider the blood-sugar swings, though we're still doing pretty well.
What's next? Perhaps reducing Karl's carbohydrate intake some more. The fewer carbs he eats, the less need for insulin, the lower the load on his pancreas, and the narrower his blood-sugar swings will be. We've done pretty well at keeping a typical meal at 60 grams of carbs, but Dr. Bernstein's regimen recommends no more than eight grams of carbs per meal, and that would be a huge change! 
So far, Karl has had no hypoglycemic episodes and no infections, and we'd like to keep it that way.