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Solution #2:
The treatment plan for Meyer included a number of important elements.
First, we had to deal with the disabling diarrhea that worried him
more than any of his other problems.
This was easy.
I gave him a low dose clonidine skin patch, the standard treatment
for diabetic diarrhea. He was instructed to change the patch weekly.
It immediately reduced the frequency and severity of episodes (explosions)
so we soon increased the dose to an intermediate strength patch.
This worked almost perfectly, and after eight months of improved
sugars, the diarrhea was gone. Initially, his blood pressure was normal,
and although clonidine is marketed as a powerful antihypertensive
agent, he did not experience any symptomatic worsening of his prior
blood pressure drops when standing. In my experience, this is usually
the case when clonidine skin patches are used.
Simultaneously, while addressing the diarrhea, we had to work on
improving Meyer's blood sugars. This would not be an easy job because
of the gastroparesis. The first step was to negotiate a meal plan
wherein foods would be soft and easily chewed but every low in carbohydrate.
These foods included whole milk unflavored yogurt
sweetened with stevia and flavored with liquid baking extracts (chocolate,
vanilla, banana, etc.), eggs, fish, chopped meat and chopped, cooked,
low-carbohydrate vegetables. Carbohydrate total six grams for breakfast
and 12 grams for lunch and inner.
The low carbohydrate diet was essential to eliminating Meyer's episodes
of sever hypoglycemia as it allows for lower doses of injected insulin—more
in keeping with the levels non-diabetic produce.
Next an insulin regimen had to be devised. The plan
was to initially under-estimate insulin needs, but to correct blood
sugar levels promptly so that ketoacidosis could no longer occur.
Then insulin doses could be increased slowly based upon blood sugar
records.
Our insulin regimen for type I diabetes emulates the manner and amounts
of insulin production in non-diabetics. People without diabetes make
small amounts of insulin all day long, even when fasting, to prevent
the liver from converting bodily protein (like muscles) to glucose.
This is called basal insulin production.
They also make small boluses of insulin while meals are being digested
to facilitate delivery of glucose derived from food into tissues where
it is used for energy or to build fat.
We inject long acting insulin (usually ultralente) on waking and
at bedtime to emulate basal insulin production. We inject rapid acting
insulin (regular or lispro) from about 15 minutes (for lispro) to
about 40 minutes (for regular) before meals to emulate the boluses
made by non-diabetics. Ideally the rapid insulin should begin to lower
blood sugar at the same time as the meal starts to raise blood sugar.
With the low carbohydrate diet and small doses of rapid acting insulin,
the net result is usually little or no change in blood sugar before,
during or after a meal. This regimen works elegantly if you don't
have gastroparesis. It obviously had to be modified for Meyer.
I put Meyer on our standard insulin regimen but with his meal-time
boluses of regular insulin given at the end of the meal rather than
the usual 40 minutes before eating. Gastroparesis can cause a feeling
of fullness early in a meal. This, combined with the fact that Meyer
is an especially slow eater, meant that Meyer was often unable to
finish a given meal.
With this insulin regimen, he could, on these occasions, reduce his
post-meal regular insulin dose accordingly. In order to prevent hypoglycemia
from occurring on those random occasions when meals are especially
slow in emptying, I kept his mealtime insulin doses below those usually
required by non-gastroparetics to cover similar meals.
This means that when a meal eventually finishes emptying, his BGs
can increase considerably. To correct such increases, I asked him
to check BGs before each meal and at bedtime. Elevations about 115
mg/dl would be brought down to 100 mg/dl with an injection of lispro.
Based on his weight, one-quarter unit of lispro lowers his BGs by
15 mg/dl. Indeed this calculation turned out to be valid. Note: I
never prescribe Lispro to cover meals for people with gastroparesis.
It just works too fast for the slow digestion.
I also had Meyer cover levels below 100 mg/dl with calibrated amounts
of oral glucose tolerance test solution.
Since neither Meyer nor his care giver could be relied upon to perform
the usual calculations, I gave them a table of doses of glucose (teaspoons
or tablespoons) and lispro for every possible BG between 0 and 300
mg/dl (in five mg/dl increments).
After several months of clonidine skin patches and improved blood
sugars Meyer's diarrhea stopped. At this point, I prescribed one tablespoon
of cisapride suspension about an hour before meals in the hopes of
easing his gastroparesis. Since this medication can cause diarrhea
in people without gastroparesis, I elected to wait until his diarrhea
was gone. The effectiveness of this product in people with severe
gastroparesis is uncertain. In any event, Meyer no longer complains
of belching and discontinued his habit of chewing antacid tablets
every hour or so.
Meyer was then started on 4.5 units of Ultralente insulin on waking,
five units of regular insulin after breakfast, 3.25 units of regular
after lunch, six units of regular after dinner, and 8.75 units of
ultralente at bedtime. The high bedtime dose is to cover that part
of his dinner that leaves his stomach while he is sleeping. This is
necessary even though his bedtime is five hours after he finishes
dinner. His care giver measures out small doses of lispro insulin,
according to his table, to bring elevated BGs down to a target of
100 mg/dl.
Summary:
Meyer's bouts of severe hypoglycemia are a thing of the past—not
one episode since the new regimen. His most recent HbA1c was 6.6%,
corresponding to a four-month average blood sugar of 164 mg/dl.
He no longer feels depressed and his gait and strength have improved.
His short-term memory, measured by repeating six digits in reverse
order, went from only one digit at his second visit to all six digits
currently.
Twenty-four hour urine glucose levels declined from 52 gm to one
gm. His kidney function, measured by creatinine clearance, improved
by 20 percent from 52 to 71 ml/min. This reflected a 20 percent drop
in serum creatinine. Finally, his serum fibrinogen level, a major
risk factor for heart disease, stroke, retinopathy and kidney disease,
dropped from 396 to a normal level of 272.
Meyer is no longer chronically tired and now
goes out for shopping, club meetings, social affairs and so on. His
children no longer dread the specter of ongoing emergencies.
I've heard a number of physicians comment that efforts to tightly
control blood sugars would be wasted on the elderly. What do you think?
Addendum to the Case of Meyer K.
At his last visit in February 1999, Meyer, now 85 years of age, was
alert and enjoying his new dog. His former ghostly pallor was replaced
by a natural pink tone. His diabetic diarrhea is totally gone, and
he no longer needs to be treated with clonindine. His frequent belching
has resolved. His heart rate variation on deep breathing (R-R Interval
Study), a quantitative test for autonomic neuropathy has improved
nearly sixfold from 2 percent to 11 percent. Normal for his age is
about 25 percent. If such improvement continues, his gastroparesis
should be totally cured in another two to three years. His 24-hour
urine glucose excretion dropped from 52 grams (about 17 packets of
sugar) to 0.1 grams, which is normal.
Meyer's HbA1c has dropped from 10.4% to 5.6%. This is the approximate
equivalent to a reduction in four-month blood sugar average from 316
mg/dl to 124 mg/dl. In spite of this, he has not had even one of the
frequent hypoglycemic episodes that had plagued his life for many
years.
About the Author:
Dr. Bernstein has had type I diabetes for 52 years and is in better
health than most non-diabetics his age. He invented self-monitoring
of blood sugar in 1969 and multi-dose intensive insulin therapy in
1970. Because he was unable to convince the diabetes medical establishment
that BGs could and should be normalized, he gave up his business career
and entered medical school in 1979 at the age of 45. In 1998, he was
granted a US Patent for a new approach to the treatment of obesity.
Dr. Bernstein limits his medical practice in Mamaroneck, New York,
to the treatment of diabetes and obesity. Most of his patients come
from around the country and overseas for intensive training in methods
for normalizing blood sugars. They are also given a physical exam
and laboratory tests designed to expose early diabetic complications.
Customized meal plans are negotiated with each patient and medications
prescribed accordingly. After training, patients fax their BGs to
Dr. Bernstein and he fine tunes their diet, mediations and exercise
over the telephone. Dr. Bernstein can be reached at (914) 698-7500.
Dr. Bernstein's latest book Dr. Bernstein's Diabetes Solution
was published by Little, Brown & Company in 1997.
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