Tuesday, June 25, 2013

Diabetes- Insulin Resistance and U 500 Insulin

Question from anonymous:

I am on 275 units of insulin a day and still my BS do not fall below 260. I am worried about taking so much insulin and not seeing any results. I would like to try this U500 insulin but I am also leary about taking something new. There is not much info on this insulin that I can read that is put into laymens terms. Is there a web sight that I can go to that will put it into words that I can understand? on severe insulin resistance and U 500 insulin

My thoughts:
   My personal experience with U 500 insulin was limited to 3 patients. They did achieve some slight improvement in their A1c but did not reach the target goal of 7 . all gained weight gained weight and the U 500 insulin is very expensive. My experience is not to much different than the results obtained in a study published a few years ago.

Clinical experience with U-500 insulin
risk and benefits
Angela Boldo, MD and Richard J. Comi , MD
Endocrine Practice 2012; 18(1):56-61

    66% decreased A1c by .5 or more
     8% achieved An A1c goal of of 7
     Weight gain- 61 to 74 pounds  ( 28 to 34 kg )

 They referenced another study for a definition of severe insulin resistance . 
     1.9 U/2.2 pounds ( 1.97 units/ kg )
 They also mentioned that U 500 insulin onset and duration of action is similar to NPH insulin.
      onset of effect about 45 minutes  
      peak effect 7 to 8.5 hours
      injection frequency 2 to 3 per day with it acting as a basal insulin and also using a rapid acting before meals.

I generally tried to help my patients avoid U 500 insulin for all of the above reasons. Most people with severe insulin resistance are over weight and many have polycystic ovary disease.
Suggested conversation with your doctor
    #1  Weight loss - increase your food management skills by working with a dietitian.
            Ask your dietitian about the Dash diet ( see reference to previous post below)
    # 2  increase exercise with your doctors approval
    # 3 medications to discuss with your physician. ( multiple medications are needed )
         -   Glucophage ( metformin ) is the first choice of medication for treating type 2 diabetes
         -     Byetta or the newer once a week injection of Bydureon
         -     Lantus insulin at bedtime to control your fasting glucose
         -     A rapid acting insulin such as Humalog or Novolog  regulated by insulin / carb.
               ratios may have to be added.

None of the above suggestion are easy and requires a lot of work with diabetes educators and dietitians. Your physician may want to refer you to an endocrinologist to help you work out the details of dealing with insulin resistance. My last consideration is a gastric bypass because of the risk  involved with any surgery.The newer procedures have corrected many of the problems we used to see with this procedure and I have to admit that some of the results have been very good.

Have fun , Be smart and just do what every is necessary to manage your diabetes and preserve your good health.
David Calder,MD

References to previous post on the above topic. Just click on the topic to review the discussion.


Monday, June 24, 2013

Thyroid Hormone replacement

I apologize for getting behind in my almost daily blog. My excuse is work is cutting into my blogging time. I enjoy writing on this website and I especially enjoy your comments. Yesterday, there were 6 comments.  I will do my best to respond to your questions or comments within 24 hours.   We all benefit from your input.

I  recommend reading the comment made by one of former endocrinology partners , Bryon
Musa, MD ,  on 3/19/13 . I have always thought of Bryon as one of the smartest persons I have every know and I had the pleasure of  sharing our endocrine practice for many years. Byron focused on the more complex endocrine problems allowing to focus my attention to diabetes .

Have fun ,Be smart and think about your thyroid hormone replacement
David Calder,

Your comments and questions are always welcome.

Saturday, June 8, 2013

Fainting , Diabetes , High blood pressure Sleep Apnea and the Vagus nerve

 Vagus nerve 
The vagus nerve is the longest most wide spread nerve in our body. This nerve supplies fibers to every organ except the adrenal gland.  Most of these fibers (80 % ) carry information towards the brain and some of these fibers are very sensitive to low blood glucose  and low oxygen levels resulting in a variety of symptoms .

 Common symptoms often associated with the vagus nerve.
   Heart rate - stimulation of the vagus nerve causes slowing of the heart rate and
                        severe stimulation can cause conduction blocks in the heart.
                               The patient discussed in a previous post had transient blocks in the electrical connection between the
                                upper and lower parts of his heart. 
    Sweating  -  especially facial sweating
   Gastrointestinal - Nausea

The patient discussed in a previous post had all of the above symptoms and testing revealed low oxygen levels of 78 %.  Click on the link below to review the case.

The patient above also had hypertension and pre-diabetes and his cardiology work up revealed episodes of slow heart rates including transient heart blocks occuring at night. Blood oxygen levels revealed 98 episodes of anoxia ( oxygen levels dropping to 78 %)  on the night tested. Normal oxygen levels are 95 to 99 % and values below 90% are considered abnormal.

He was diagnosed and treated for Obstructive Sleep Apnea and his oxygen levels and his symptoms have almost completely resolved with CPAP treatment.  He still has occasional mild symptoms of transient nausea and sweating that can be traced back to  an increased number of  night time episodes of apnea  3 to 4 /hour . ( normal is less than 5 ) the night before. The cause for the periodic increase in apnea ( usually for 2 nights ) has not yet been determined.  In addition , his BP is usually increased for 3 to 4 days during and after these periodic episodes.  His BP is nomally controlled  to 130 +- / 75 + - with a diuretic every other day. His Pre- diabetes has not progressed. .

Have Fun , Be Smart and do not overlook sleep apnea 
David Calder,MD