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November 22, 2002

Daily Care, Diagnosis and Symptoms

Question from Oakland, California, USA:

My 17 year old daughter who is 5 feet 5 inches tall and approximately 12 pounds overweight, was just told her glucose is 209 mg/dl [11.6 mmol/L] and will be taking the antibody tests to positively identify if she has type 1 diabetes in two days. The doctors have diagnosed her with type 1 because, they say, type 2 usually doesn't occur until about the mid 20s, and she will be starting insulin injections soon. Since they are not sure whether she has type 1, why can't she start on a type 2 regimen of pills and see if the pills bring her glucose to manageable levels? While the immediate benefit of definitive lowering of glucose from the injections is a consideration, why can't the pills be used as the initial response? She will have a whole lifetime of injections. Can't we try the pills as an alternative, at least after her glucose initially responds to the injections ?

Answer:

You have to ask these questions to your daughter’s diabetes team. They have some specific reasons, I would assume, for wanting to start insulin. The first goal is to control blood glucose levels while trying to decide if she has type�1 or type�2 diabetes.

Using pills to treat type 1 diabetes doesn’t work unless there is significant insulin resistance which is usually caused by obesity. So, I would assume this is why they do not suggest pills. Health care professionals do not usually recommend using medication unless there is some chance it will work. Type 1 diabetes patients have an autoimmune destruction of the beta cell production of insulin and so other diabetes “pills” don’t work under such circumstances.

SB
Additional comments from Dr. David Schwartz:
While I do not necessarily agree with your doctor that Type 2 diabetes
doesn’t usually begin until the 20s, I do agree with starting insulin. And
here is why.

Insulin will get the glucose levels down sooner than oral agents, which
can take weeks, depending on the agent. If she does indeed have Type
2 diabetes, then using insulin to get the glucose levels down, will make
an easier go if she is able to switched to an oral agent. Think of the
relief you will get if she gets to
stop
insulin! I have found that is an
emotional boost for the person who was diagnosed with diabetes
(regardless of type).

But in addition, if she really has Type 1, better to get a jump on matters.
Furthermore, some

oral hypoglycemic agents

work by promoting the
pancreas to work, thereby, potentially “using up” any insulin reserve
power, and perhaps leading to a shorter

honeymoon

phase.

So unless there are obvious features of Type 2 (elevated

C-peptide,

or
even

acanthosis nigricans

on exam), I would start with insulin in a
case like your child.

IDS