February 15, 2007
Diagnosis and Symptoms, Pills for Diabetes
Question from Ventura County, California, USA:
My son was diagnosed with type 1 diabetes in mid-December. My husband (his father) has lived with type 1 for almost 25 years and is EXCELLENT health. Because of our knowledge of the symptoms of hyperglycemia, we tested our son at home when he started showing signs (frequent urination, lethargy, excessive thirst). His blood glucose was 388 mg/dl [21.6 mmol/L]. We called my husband’s endocrinologist, who recommended we visit him in the morning. By that point, my son’s blood glucose was 88 mg/dl [4.9 mmol/L]. The endocrinologist ordered laboratory work. My son’s A1c was 7.5 and his GAD tested positive. Thus, my son was diagnosed.
Despite the fact that our endocrinologist gave us recommendations to spot-treat my son’s highs, we placed him on a carbohydrate counting diet and restricted all processed sugar. With diet and exercise, we have been able to control his blood glucose level between 70 mg/dl [3.9 mmol/L] and 180 mg/dl [10.0 mmol/L] with infrequent (two to three times a week) blood sugars above 200 mg/dl [11.1 mmol/L]. He has not taken ANY insulin and we test approximately four to six times a day. His fasting blood sugars are under 90 mg/dl [5.0 mmol/L] and it’s been almost two months.
At the last visit, our endocrinologist was puzzled and impressed with our control without insulin. He liked what he saw, but decided to try an “experiment.” He prescribed Januvia for my son, so we have been giving him 25 mg per day since January 28 (about two weeks). I read in “Diabetes Forecast” (Spring 2007) that “some animal studies suggest [DDP-4 Inhibitors] may help insulin-producing beta cells in the pancreas survive and grow.” I cannot tell if the medication is helping or not. But, my son’s numbers have remained below 170 mg/dl [9.4 mmol/L], except for two occasions when he was 240 mg/dl [13.3 mmol/L] (for eating too many chips on SuperBowl Sunday) and 225 mg/dl [12.5 mmol/L] (maybe because he has a cold).
Are any studies actually being done on the effects of Januvia in the beginning stages of type 1 or on children? What do you see as the potential risks of my son using this medication? Has anyone who has been diagnosed with type 1 ever sustained without ever using insulin? If not, then what is the longest that an individual with type 1 has sustained blood glucose control without insulin therapy? Should I hold onto hope that his insulin-producing cells may survive?
Before the discovery of insulin, individuals with type 1 diabetes were treated with low carbohydrate starvation diets and sometimes lived up to two years. I’m not surprised that you are able to have reasonable control of your son’s blood sugars with carbohydrate restriction as you diagnosed his diabetes very early. If he is still going above 200 mg/dl [11.1 mmol/L], he clearly isn’t making enough insulin. There is some data to suggest that starting insulin early, before absolutely necessary, might prolong the honeymoon phase and, perhaps, prolong continued minimal insulin production which may decrease risks of complications later on (though this is not proven). As far as I know, there are no studies using DDP-4 inhibitors in children with type 1 diabetes and none planned. Even if these medicines help regenerate islet cells, the new islet cells might be destroyed by the same autommmune process that caused them to fail in the first place.
I would strongly recommend that you start some insulin, even if only a small dose of a basal insulin like Lantus, once a day. Many years ago at a camp for children with diabetes, I saw a child in remission who had been treated with diet only for a year. She had a fasting glucose of 160 mg/dl [8.9 mmol/L] the first morning of camp and a cholesterol almost 1000! She was fine all day playing sports, developed a “stomach ache” later that day and within two hours was in frank, severe ketoacidosis. Ten days after starting insulin, her cholesterol was normal. If your child develops the flu or other infection, he could go into ketoacidosis VERY quickly if he is not on insulin.
If your doctor feels comfortable prescribing Januvia, I would strongly suggest giving some insulin in addition.
[Editor’s comment: You said that you were taking your son to your husband’s endocrinologist. I am assuming this is an adult endocrinologist. Given that you indicated your son is young, you should have him seem by a pediatric endocrinologist.