In theory at least, there are individuals who do not respond to any of the measures recommended in Chapter 13 for the control of carbohy drate cravingand overeating.
Thesepeople can be helped slightly by a product caUed acarbose (Precose).
Acarbose is avaUable as 25 mg, 50 mg, and 100 mg tablets to inhibit action of enzymes that digest starches and table sugar,* thereby slowing or reducing the effects of these no-no foods upon blood sugars.
It is interesting that the ADA recommends eating starches and sugars and then the simultaneous use of acarbose to prevent their digestion.
The maximum recommended daUy dose of acarbose is 300 mg.
It is usuaUy taken at the time of carbohydrate consumption.
Its major ad verse effect, in about 75 percent of users, isflatulence (predictably), so it is wise to taper up the dose graduaUy.
It should not be used for pa tients with any intestinal disorders (e.g., gastroparesis).
I have never had the need to prescribe it.
PHLEBOTOMY: A LAST RESORT FOR SOME, BUT IT MAY WORK
Commercialairline pUots with diabetes are currently facedwith regu lations in the United States that threaten loss of Ucense (and UveU- hood) if they inject insulin.
Certainlythese people should try aU of the oral agents recommended above, as weU as a low-carbohydrate diet and strenuous exercise.
They should also consider vanadyl sulfate, magnesium, and the other supplements listed under "Other Consider ations" on page 245.
There is yet another potentiaUy powerful way of lowering insuUn resistance for people with this problem.
It's been demonstrated that men whose body iron stores placed them in the top 20 percent of the nonanemic population had much greater insuUn resistance than those in the bottom 20 percent.
Furthermore, their insulin resistance
*The enzymes are alpha-glucosidase and pancreatic amylase.
248 Treatment
dropped dramaticaUy when they donated enough blood every two months to keep them in the bottom 20 percent.I've actuaUy seen this work on my own patients.
A good measure of total body iron is the serum ferritin test.
Since some blood banks wiU not accept blood do nations from diabetics, it may be necessary to visit a hematologist for a phlebotomy (removalof blood from a vein) everytwo months.
It is likely that most insurance planswUl paythe hematologist's fee.
Women are much lesslikely than men to havehigh normal ferritin levels.
AND ONE MORE OPTION
The recent avaUabUity of the firstDPP-4 inhibitor (seepage 205) pro vides one more option for those who refuse to take injections. This new product, sitagUptin (Januvia) comes in piU form , 25, 50, and 100mg. The maximum adult dose for peoplewithout kidney impair ment is 100 mg once daUy. It wiU significantly reduce the effect of glucagon upon blood sugar during and after meals (Chinese restau rant effect). It can be used as part of a three-way combination with metformin and a thiazolidinedione.
16 Insulin: The Basics of SelMnjection
A s you may have learned from the preceding chapter, certain oral agents, such as ISAs and insuUn mimetics, are valuable for controlling blood sugars but can only go so far.
If you're taking the maximum effective doses of oral agents and your blood sugars remain elevated , in spite of diet, exercise (where feasible), and weight loss , injected insulin wiU be essential to bringing your bloodsugars down to yourtarget range.* Although many patients initiaUy balk at the idea of injecting in sulin, you should look at this as an opportunity, not a curse, because insulin injections will increase the likelihood that you can bring about a partial recovery ofyour pancreatic beta cell function.
This is especiaUy trueif you are a slimtype 2 or arecently diagnosed type 1.
If you're afraid of insuUn because youimagine that onceyou start, you'U never beable to stop, you've faUen victim to acommon myth.In reaUty, injected insulin is the best means we have at this writing for preventing beta ceU burnout.
The Biostator GCIIS, an "artificial pancreas," was a device devel-
*Investigators in Buffalo, New York, have demonstrated that injected insuUn ap pears to lower the production of inflammatory substances and increase levels of anti-inflammatoryagentsin obeseindividuals.
Since inflammationincreases the UkeUhood of atherosclerosis, chronic useof insuUn injections can lower risk of cardiac disease, peripheral vascular disease, and stroke, independent of its effects uponblood sugar.
Injected insulin also facUitates thedilation (opening) of coro nary and other arteriesthat maybe constricted in many diabetics and even in nondiabetics.
It also has been found to improve the absorption of oxygen by blood flowing through the lungs.
250 Treatment
oped in the 1970s when the average insulin-usingdiabetic took a sin gle, daily, industrial dose of insulin.
The device may still be available.
In any case, its initials stood for "glucose-controlled insulin infusion system." That's exactly what it aimed to do , infuse insulin as a pan creas would, based on blood glucose levels.
It attached to the patient through two intravenous connections, one that measured blood sug ars constantly and another that deliveredglucose or insulin to correct blood sugars to 90 mg/dl virtually instantaneously.
Although it was not practical for home use (it had a staff of two , one to operate the machine and one to service it , and rented for tens of thousands of dollars a month), it did useful research, the most important element of which was that it showed that beta cell burnout could be reversed or halted, even by relatively short exposure to normalized blood sugars.
How?
Many years ago, Gerald Reaven, MD, author of Syndrome X, con ducted a study with thirty-two diabetics, half of them female, half of them male.One at a time, he put them into the hospital and had them attached to the Biostator for two weeks.
His staffchecked HgbA,c on arrival, at discharge, and every three months thereafter.
They found that HgbA,c plummeted during the two-week treatment period, but the most important thing they found was that when the subjects went back to their ordinary lives and their poor diets, their HgbAJC mea sures took an average of two years to return to their high, pretreat- ment values.
Considerable beta cellrecoveryclearlyoccurred after just two weeks of normal blood sugars.
In fact, it took two years to undo those two weeks of healing.
I'm not inviting you to normalizeyour blood sugars for two weeks and then go back to your old diet.
My intent is to demonstrate the value of using insulin, and the value of normalized blood sugars.
We might envision that a mild diabetic still has three types of beta cells, active, dying, and dead.
Myown beta cells are likely all of the last variety, dead.
I've mentioned it previously, but if I'd had the kind of treatment upon my diagnosis more than sixty years ago that I advocate today, I might still have a significant number of working beta cells.
If you have some beta cell function left, you can probably increase it by normalizing your blood sugars.
If the prospect of injecting yourself horrifies you, don't let it.
Many people assume injections must be painful, but they needn't be.
If you've alreadybeen using insulin for years and find the shots painful, the likelihood is you were taught to inject improperly.
Insulin: The Basics ofSelf-Injection 251
HOW TO GIVE A PAINLESS INJECTION Ifyouhave type 2 diabetes, sooner or lateryou may require insulin in jections, either temporarily (as during infections) or permanently.
This is nothing to be afraid of, even though many people with long standing type 2 diabetes spend literally years worrying aboutit.
I usu ally teach all my patients how to inject themselves at our first or second meeting, before there's any urgency.
Once theygive themselves a sample injection of sterile saline (salt water), they find out howeasy and painless it can be, and they are spared years of anxiety.
If you're anxious about injections, after you read this section please ask your physician or diabetes educatorto allow you to try a self-administered injection (without the insulin).
Insulin is usually injected subcutaneously.
This means into a layer of fat under theskin.
The regions ofthe body thatare likely to contain appropriate deposits of fat are illustrated in Figure 16-1.
Examine your body to see if you have enough fat at the illustrated sites to com fortably grab a big hunk between your thumb and first finger.
Most diabetics are erroneously taught to inject into their thighs in spite of the obvious: most thighs have inadequate fat for satisfactory injections.
The net result is that the injection ends up going into mus cle instead of fat and the timing of the insulin is sped up inappropri ately.
Fig. 16-1. Potential sitesfor subcuta neous injections.
252 Treatment
To show you how painless a shot can be,your teacher should self- administer a shot to illustrate that no pain is felt. Your teacher should next give you a shot of saline or "throw" the needle into your skin to prove the point.Now it's time foryou to give yourself an injection, us inga syringe that's already empty or has been partly fiUed for youwith about 5 "units" of saline.