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January 26, 2003

Daily Care

Question from Overland Park, Kansas, USA:

My 13 year son, who currently takes 111 units of insulin per day, is growing like a weed and is very insulin resistant. It seems like no matter how hard we try, his numbers are good for about a week and then he's out of whack again. With Lantus (insulin glargine), he runs high, and on Ultralente he ran low. It has been recommended that he consider the pump, but He does not want to have anything to do with it. As his parent, I want him to have a voice in his treatment. Our family is so controlled by this disease and right now that it is having a negative affect on everyone. My thought is that we make him go on the pump because we've exhausted our other options. Sometimes we become very close minded to the unknown before we give it a chance. Is it wrong to force this issue? Our son can't think straight, his grades have always been good and now they are suffering, his self esteem is not as strong as it has been. How much is being 13? How much is the whole package of being 13 with a disease that all of a sudden is a major pain? What are your thoughts?

Answer:

You seem to have very appropriate insight. Assuming your son is not obese, 111 Units/day is a load of insulin, alright! If he is obese, then 111 units may be a degree of, but not severe, insulin resistance. But another question is to know just how “skinny” he is. There is a rare diabetes condition, associated with remarkably low body fat (not just “thin”) that is associated with insulin resistance. This is called lipoatrophic diabetes which difficult to diagnose and treat.

I also assume that you have really “gone back to the basics” — and by that I mean taking a critical look at meal planning and insulin dosing and administration. Offhand, I am tempted to suggest that putting him into the controlled setting of the hospital, whereby nursing staff can (and should!) administer the insulin and meals, can better delineate his true insulin resistance. but t you indicated that after a week of better control with your changes, things deteriorate again; therefore several days in the hospital may not shed enough light. I would suggest that you dose all his insulin for the next two to three weeks, if you are not already doing so.

I think the most important question is, “Why is your son so seemingly insulin resistant?” Poor insulin and poor meal planning is certainly an answer, but there are other, perhaps more worrisome conditions. Your local children’s hospital has some talented people; have them try to answer this “why” question. Perhaps your son has developed antibodies to insulin or he could have a problem with his insulin “receptors.” (You may recall that insulin is “like the key that fits into the lock to open the door to allow glucose in.” The insulin receptor is the keyhole.) Perhaps other hormones that are antagonistic to insulin are being secreted excessively. One would hope that getting to the heart of the insulin resistance would lead to the better treatment options.

There are oral hypoglycemic agents, used in type 2 diabetes, that enhance the body’s sensitivity to insulin. They may play a role for your son.

An insulin pump may indeed be a good option, but if your son has antibodies to insulin or have an insulin receptor defect, a pump will likely not overcome that. Remember that a pump is simply another method to deliver subcutaneous insulin. There are rare situations where the body “attacks” and deteriorates insulin under the skin, but intravenous insulin works fine. I agree that your child should have and deserves input as to his diabetes regimen and if he is not keen on a pump, it may likely fail. But if he has worrisome insulin resistance, then he may have little say into whatever treatment is decided.

Again, assuming non-obesity, the insulin resistance you infer can be very problematic. You may wish to call or have your Diabetes Team call investigators at the National Institutes of Health (outside of Washington, DC in Bethesda, Maryland) who have been investigating various forms of insulin resistance for some time. I also know that physicians at Harvard have been working on this.

DS