gastroparesis, your doctor may ask you to take it 10,30, or 45 minutes before eating,insteadof the usual60-120 minutes.
If you'll be getting preprandial shots of regular insulin, your physician may want you to inject immediately before eating, instead of the usual 45 minutes.
If regular stiU works too rapidly for your slow digestion, you may be askedto take it afteryour meal.Alternatively, you might substitute 1 or more units of NPH insuUn for 1 or more units of regular in your sy ringe, to slow the action.
If, for example, you are asked to inject a preprandial mixture containing 4 units of regular and 1 unit of NPH, you would draw the 4 units of regular into the syringe in the usual manner (see pages 255-256).
Now insert the needle into the vial of NPH and shakethe vial and syringetogethervigorously a fewtimes, as illustrated in Figure 16-6.
Immediately but carefully draw 1 unit of NPH into the syringe.
Now remove the needle from the vial and draw in about 5 units of air.
The exactamount of airis not important.
The air bubble will act a bit like the metal ball in a can of spray paint to help mix the insulins.
Invert the syringe a few times to permit the air bubble to move back and forth, thereby mixing the two insuUns. (This is the only situation in which it is acceptable to mix two different in suUns in the same syringe.) Now you can inject the contents of the syringe, including the air.
The air wiUdissolve in your tissue fluids and cannot do any harm.
If this process confuses you, don't worry.Your physicianor diabetes educator should demonstrate it for you and check your technique.
If you use this procedure to slow down your preprandial dose of regular insulin, it'U keep working for an unknown period of time weU beyond the usual 5 hours.
If you routinely correct elevated blood sugars with additional shots of Uspro as described on page 301, you now have a real problem.
When do you correct an elevated blood sugar?
The answer is actuaUy simple.
Under these conditions, if you add the NPH to regular before every meal,you are Umited to correcting a high blood sugar only once daily, when you arise in the morning.
This wiU be about 12hours afteryour suppertime shot of the regular- NPH mixture.
Twelve hours is more than enough time for the mixture to have finished acting.
If you only use the NPH mixture before dinner, then you may safely continue to correct elevated blood sugars before breakfast and lunch (after waiting the usual 5 hours or more).
Delayed Stomach-Emptying Gastroparesis 379
Do not use lispro to cover meals if you have delayed stomach- emptying. The reasoning here should be self-evident. Feel free, how ever, to use it to bring down an elevated blood sugar using the methods previously mentioned.
IT MAY BE POSSIBLE TO HEAL THE VAGUS NERVE EVEN IF BLOOD SUGARS ARE NOT KEPT VIRTUALLY NORMAL
Remember the insuUn-mimetic antioxidants alpha lipoic acid (ALA) and eveningprimrose oil (EPO)?
WeU, studies in the United Statesand Germany haveshown them to heal the nervesinvolved in painful dia betic neuropathy of the feet.
These studies achieved their results in a matter of months, without any attempt to control blood sugars.
More recent brief studies have actuaUy brought about partial healing of the vagus nerve.
The studies that I read, however, utilized very high doses of one of these agents (25,000 mg of alpha lipoic acid), administered intravenously.A few naturopathic physicians in the United States and many in Europe administer such treatment.
I'm not set up to do this, but I do ask my patients to take large oral doses of alpha Upoic acid and EPO, as Usted in Chapter 15.
Asindicatedin that chapter,I suggest biotin supplementation whenever alpha lipoic acid is used.
The prob lem here is that at the doses listed on page 241 (1,800 mg ALA daily), the users must take 9-12 daily piUs over and above whatever other medications or supplements they may be taking.
Nevertheless, I con tinue to prescribe these supplements for those who can afford them in the hope that vagal healingcan be accelerated, but I don't reaUy expect a miracle.
As mentioned earUer in this book, many diabetics have another en docrine disorder, hypothyroidism.
Since diminished production of thyroid hormones can cause neuropathy even in nondiabetics, it would be appropriate for diabetics with neuropathy of the vagusnerve (gastroparesis) to be tested for thyroid insufficiency.
If this turns out to be present,the treatment is usuaUy 1piU daily.
An easy cure for gas troparesis,if it was not caused by high blood sugars.
380 Treatment
THOUGH "CURABLE," GASTROPARESIS IS SERIOUS BUSINESS
Don't hesitate to use combinations of the medications and other treat ments for gastroparesis that we have covered in this chapter.
The more methods you find that wiU work for you,the betterthe likelyoutcome.
There is one exceptionto this rule , do notuse both domperidone and metoclopramide.
Use only one or the other, as they both work by the same mechanism and their potential for adverse effects wiU increase with the combined dosage.
The effects upon blood sugar of even asymptomatic (symptom- free) delayed stomach-emptying from any cause can be dramatic.
Don't think that because you have no symptoms you're free from its effects upon blood sugar.
If you're uncertain, ask your physician to perform an R-R interval study.
If you're foUowing the guidelines of this book and your blood sugars arestillunpredictable,suggestthat he or she read this chapter.
23 Routine Follow-up Visits to Your Physician
Taking responsibiUty for the care of yourown diabetes may free you from habits thathave beenwith you for manyyears.
It also requires the estabUshment of new habits, such as exercise and blood sugar self-monitoring, that are easier to abandon than to foUow.
Once yourblood sugars have become controUed, it may only takea few months for you conveniendy to forget about the pain you usedto have in your toes, or the parent or friend who lost a legor vision due to compUcations of diabetes, and so on.
As time goes on, you wiU find thatwithdiabetes, as withlife in general, youwiU graduaUy tendto do what is easiest or most enjoyable at the moment.This backsliding is quite common.
When I haven't seen a patient for six months, I'll usuaUy take a meal history and find that some of the basic dietary guidelines have been forgotten.
Concurrendy blood sugar profiles, glycosylated hemoglobin levels, Upid profiles, andeven fibrinogen lev els may have deteriorated.
Such deterioration can be short-circuited when I see patients every two months.
We aU need alittle nudge to get back on track, and it seems that a time frame of about two months does the trick for most of us.
I was not the first diabetologist to ob serve this, and your physician may likewise want you to visit him at simUar intervals.
Dosage requirements for insulin or ISAs may change over time, whether due to weight changes, to deterioration or improvement of betaceU output, or just to seasonal temperature changes.
So there's an ongoing need for readjustment of these medications.
Again, two- month intervals are appropriate.
What are some of the things that your physician may want to con sider at these foUow-up visits?
382 Treatment
First of aU, your doctor shouldtry to answer anynew questionsthat youmay have.
These maycover ahostof subjects, from somethingyou read in the newspaper to new physical complaints or dissatisfaction with your diet.
Write down your questions in advance, so that you won't forget them.
Your physician wiU, ofcourse, want to review your blood sugar data sheets covering a period of at least two weeks.
It makes no sense for your doctor to review prior data, as that is old history.
If he or she wants to adjustyour medications or meal plan, the changes shouldbe based upon current information.
Remember, however, that the data must be complete and honest.
This means, for example, that if you spenta few hoursshopping oroverate, it shouldbe noted on yourdata sheet.
It doesn't make sense,and can be dangerous, for your doctor to change your medications based upon high blood sugars caused by a few unrecorded dietary indiscretions.
Yourphysician wiU also wantto draw someblood.At each visit your HgbAlc (glycated hemoglobin) should be checked.
You need not be fasting for this test.
Up-to-date physicians are now performing this test in the office using a smaU drop of finger-stick blood.
Results can be had in about 6 minutes.
At least once annuaUy, a complete lipid profile including LDL subparticles should be performed, and fibrino genlevels should be checked; C-reactive protein also should be mea sured.
Kidney function studies including crystatin-c should also be performed.
You'U recaU that these require a 24-hour urine coUection, which must be completed on the day of the visit (see Chapter 2).
Re member that the "normal values" for lipid profiles are based upon fasting determinations.
Soif yourphysician hasplanned suchtests, try to book anearly-morning appointment, anddon't eatbreakfast.
If you skip breakfast, be sure also to skip your preprandial insulin or ISA if you usuaUy usethese medications to cover breakfast.
Do not omit glu cose tablets or Humalog (Uspro) needed to correct low or elevated blood sugars.
Also remember to take your basal dose of ISA or long- acting insuUn, as their purpose is merely to hold blood sugar level whUe fasting.
Your physician may also want to perform other blood tests from time to time, such as a blood count and a chemical profile.
If you are taking a statin drug for elevated levels of smaU dense LDL, Uver function tests should be performed.
A partial physical examination, including weight, should be per formed every two months.