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Scott King
June 18, 2000. A question by e-mail:
Dear Mr King,
I am a physician with a Type I diabetic daughter and have been following your islet sheet project, am encouraged by your results, but have a question about your animal model. Does a pancreatectomized dog model for diabetes really replicate the immunological status of the Type I diabetic?
I am pleased to see that dogs can be injection free after implntation of your sheet, but is that really an indication of their viability in a hostile immunological setting? Is there any way to sensitize the dogs to create an autoimmune process similar to the human?
Sincerely,
Mike Richie
Scott's reply: Hi Mike--That is a good question.
The sheet must protect from two types of immunological response: autoimmune and allo immune. The panc'ed dog model only establishes the latter. But we are nearly certain that a bioartificial pancreas that could protect the second can protect the first. Why? Because the autoimmune reaction is cellular, antibody killing is not important. The allo graft reaction is more vigorous. So we are not worried.
There are some autoimmune dogs, and we may study some of them. There is no known wat to induce an autoimmune diabetes response.
Scott
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Carolyn Robertson
June 3, 2000. A question by e-mail:
My son is 22 years old & has lived with this horrific disease for 10+ years. Derek weighs approx 145 & is 6'. He also has autism, so I must manage his diabetes. Since the onset of his disease, he has been maintained on 2 shots/day of Humulin N (35u AM; 11u at 4PM) & prn Humalog. I know this sounds like alot of insulin for his weight, but everytime I try to decrease it, I end of with hyperglycemia. We also live with lows, not that often, but when they occur its bad. I check his sugar 2 - 4 times/day; his last glycohemoglobin was 6.3. It's hard to get a regular Doctor's visit, because Derek has trouble with anxiety. He is on Paxil & Xanax for that. I need some help & advice.
I want to get Derek on a better insulin regimine, but don't know how; & the Doctors I've spoke with want to leave him in the 200 range because of his autism; that's unacceptable to me. So I struggle. Please respond. I'm also an RN, I feel after all these years I know diabetes very well, but am not comfortable doing a drastic insulin change without outside medical advice.
Sincerely,
Estelle
Carol's reply: Dear Estelle, Thanks for your letter. I am not sure that I will be able to provide you with the answers you need but perhaps I can give you some suggestions that will provide you and your diabetes team with some solutions.
I have two observations.
First, Derek has a great A1c value. A glycohemoglobin of 6.3% usually representsan average blood sugar of 130mg/dl.But this value is only an average. It does not identify the range of blood sugars in a 24hour day. It is possible to have a"good" glycohemoglobin and blood sugar levels that vary from 40 to 350mg/dl.
Second, his insulin plan provides 24hour coverage but it is not a plan that duplicates the insulin that is released by an individual without diabetes. Patients with Type 1 diabetes usually require 3 or more injections per day or aninsulin pump to mimic the insulin activity of a nondiabetic. It is possible that this insulin plan is good enough to lower the premeal values but not good enough to control the postmeal values. It is also possible that his insulin plan may be causing the blood sugar overnight to fall to levels that might be too low.
Of course, there are exceptions to every observation. You need to determine which if any of the statements may be true for Derek by conducting a small experiment. Consider increasing the number of times that you monitor his blood sugar. If you and he are willing, you could take a two to three day period and take an intense look at his patterns.
For three days, test the blood sugar level before each meal, 1 hour after each meal, at bedtime and again at 2am. Keep a log of the insulin dose and time; the food and beverages consumed; and the amount and duration of activity during this three day period.
Another alternative would be to look at specific time periods. Instead of doingeverything within a three day period, spread out the testing over 12 days. For the first three days, test the blood sugar before and after breakfast and before lunch. Record the insulin, food, and activity that occurred during that time period. On day 4, stop the breakfast testing. Now test the blood sugar before and after lunch and before supper. Record the insulin, food, and activity that occurred during that time period. On day 7, stop the lunch testing. Now test the blood sugar before and after supper and before bedtime. Record the insulin, food, and activity that occured during that time period. On day 10, stop the supper testing. Now test the blood sugar at bedtime, at 2am and on arising the next morning. Record the insulin, food, and activity that occured during that time period.
Now, the problem solving begins. You, Derek and his diabetes health care team would then need to review the blood sugars, decide if the values were desirable. If not, then you would need to consider changing the insulin &/or the food &/or the activity that was responsible for the undesired blood sugar level.Often times, this level of problem solving is done with the assistance of a diabetes educator.
I wish you and Derek success!
Carolyn
June 6, 2000. A question by e-mail:
I have read some of the information that you have written regarding higher than normal blood sugar levels in the morning,but they all address the diabetic that uses insulin. I have had diabetes Type 2 for 8 years and I am now 66 years old. I have been able to control my diabetes by diet,exercise and using vitamins and minerals.
Lately my glucose levels in the morning have risen to 140-150,which is high by my historical standards. However during the day when I take readings the levels will drop to 102-120.
This has been a recent change in my condition,my usual readings in the morning have been 105-125.What could cause this change in readings and what could you suggest to alleviate the problem?
Carol's reply: Dear letter writer', Type 2 diabetes is a disease that has two abnormalities. There is an insulin resistance - a situation where the individual cells are unable to utilize the insulin that is circulating within their body. There is also a defect in the cells that produce the insulin - the beta cell.
Type 2 diabetes is often able to increase the amount of insulin they produce to overcompensate for both the insulin resistance and the beta cell defect. This adaptive response enables them to maintain their blood sugar in more normal range. I suspect that you were in this category. The addition of diet, exercise and vitamins increased your success in getting the blood glucose numbers that you reported.
Unfortunately, the disease of type 2 diabetes is both chronic and progressive. The longer a person has type 2 diabetes, the less able the beta cell is able to compensate. As a result the beta cell begins to produce less insulin. Consequently, the blood sugar levels begin to rise. It is possible that this is the explanation for your rising blood sugar levels.
Fortunately, there are several medications that may reverse or at least slow the trend. There are medications that restore insulin sensitivity, medications that help stimulate the beta cell as well as medications that slow the absorption of food which can give the beta cell more time to respond and medications that provide supplemental insulin.
What can you do?
Consider getting more information. Increase the number of times you monitor your blood sugar levels after meals. You could expect that the blood sugar level one hour after a meal should not rise by more than 40 to 60 mg/dl. If it is rises more than this amount, then you have some opportunities to affect a change. You could vary the amount, type or distribution of your meal. You could change the time or the type of exercise. You could talk to your Health care team about starting medications that decrease insulin resistance. You could talk to your health care team about starting medications that increase the amount of insulin in your circulation.
I wish you success.
Carolyn
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