April 2, 2006
Diagnosis and Symptoms
Question from Santiago, Chile:
I’m 26 years old and I was diagnosed with type 1 seven month ago. Before the diagnosis, I had been feeling tired and sick for some months, not knowing why. One day, a friend of mine who is a doctor told me he thought I had diabetes because of my symptoms, all day fatigue, thirst–drinking more than seven or eight liters of water per day, constant urinating, eating a lot, craving sweets. Some days later, another friend thought I was acting really strange, having real bad memories and a little confusion. She brought me an Accu-Chek machine. Later, I tried it and the result was HI. I thought the machine was not working. The next morning, my glucose level was about 380 mg/dl [21.1 mmol/L]. I was hospitalized and got insulin.
The first week, I used 30 units of Lantus and 32 (14/6/8) units of NovoRapid. After two weeks, I began to use only 24 units of Lantus and six (2/2/2) units of NovoRapid until today. My first A1c was in October, two months after diagnosis, and the result was 9.2. In December, my A1c was 5.2 and recently it was 5.1. When I did it, people asked me, “Are you sure you really have type 1 diabetes?” Some time ago, I asked my doctor about it. We have never checked antibodies nor C-Peptide, so, I think there’s been no positive evidence I have type 1 and not type 2. But, he told me it was not useful to do those tests, because he was sure of the type 1 diagnosis. But, he didn’t say why.
Nowadays, my blood sugars are usually in normal ranges, having some exceptional post-prandials about 200 to 220 mg/dl [11.1 to 12.2 mmol/L], very rarely 250 mg/dl [13.9 mmol/L], and just once 280 to 290 mg/dl [15.6 to 16.1 mmol/L]. They seem to be produced by overeating (not sugar, but complex carbohydrates) and psychological stress. I have NEVER had a fasting blood sugar over 200 mg/dl [11.1 mmol/L] since diagnosis, as I am usually in normal range.
Starting a week ago, and without asking my doctor, I began an experiment. I’ve not used insulin at all and my blood sugars are still normal. Twice, I was moderately high, but am usually about 120 to 140 mg/dl [6.7 to 7.8 mmol/L] fasting and 220 mg/dl [12.2 mmol/L] post prandial. What do you think? Could I really have type 2?
Also, I have a real thirst problem. It began four months ago. When I asked my doctor, we did some tests, but everything was okay. Beginning two weeks ago, it has increased, I’m thirsty all day long, drinking more than four liters of water a day, and urinating twice or three times in a hour, sometimes. Right now, after drinking 1 liter of water in the last hour, my mouth is completely dry. However, my blood sugar is normal, 108 mg/dl [6.0 mmol/L], four hours after lunch. I’m really concerned about that thirst and frequent urination, but my doctor thought (four months ago) it was psychological. I’m a clinical psychologist, and, believe me, I’m sure it’s not. Please, could you explain me what might be happening to me? Could it be an effect of using unnecessary insulin?
Answer:
I am glad you have had an improvement in your blood sugars. You are demonstrating a typical pattern for someone with type 1 diabetes who is now in a honeymoon phase. The model for type 1 diabetes is such that there are months to years of asymptomatic attack on the beta cells of the pancreas by the immune system. At some point, the amount of damage crosses the line and results in rising blood sugars. Fortunately, there are usually still functioning beta cells making insulin at the time of the diagnosis. However, they don’t work well in an environment of high glucose. We refer to this as glucotoxicity. The insulin helps bring the glucose down and allows the surviving beta cells to work more efficiently. They will actually make insulin and can allow you to become insulin-free for a limited time. The honeymoon phase can last up to a year. It would be unusual to last longer. The duration of the honeymoon phase is prolonged with good glucose control. Therefore, if you need only a little insulin to have good control, rather than using no insulin with high blood sugars, it is probably better to use small amounts of insulin so you can have good control over a longer duration.
Your doctor is probably correct in that doing these antibody tests for the confirmation of type 1 diabetes, when all clinical factors point to type 1 diabetes, is probably not necessary. It is probably unlikely that you have type 2 diabetes. It becomes a bit more difficult to conclude this in patients who are obese, have a strong family history, and do not present with very high blood sugars. Those patients might benefit more from antibody testing to make sure of the diagnosis.
As for your symptoms of thirst, make sure it is not associated with elevated blood sugars. Remember that the blood sugar several hours earlier is associated with the increased urination. There are other reasons for thirst and urination. They include frequent drinking of fluids. Are you causing the problem by drinking too much without being thirsty? There are also some medications and other medical conditions that can cause frequent urination that you will have to discuss with your doctor. I do not think this is caused by an excessive use of insulin. That explanation does not fit here.
JTL
