A 16 year old girl from a village in Bihar was my first patient in clinic that day, who came in with her parents with a hope to listen from me that her diabetes can be cured. I am not the first one she has visited in hope of cure, her previous encounters were with several ayurvedic and homeopathic doctors over last two years, who are selling hope to many who seek it. However it is only a matter of time before she like many others realised that the hope they provided was an empty shell of words, wrapped around increasing despair in the form of increasing glucose numbers and deteriorating health.
The only treatment available as of now is insulin, at least 4 times a day along with glucose monitoring 4 times a day. Unfortunately there is not cure for type 1 diabetes today, in future there may be, but that doesn’t mean there is no hope!
Hope is not black or white, it is all the gradients in between.
Diabetes affects millions of lives in India, most have type 2 diabetes, some type 1. Treatment of type 2 diabetes includes choice of 8 different medicines including insulin which is required in some of them; treatment of type 1 diabetes has only one choice i.e. insulin, whose discovery 100 years back was a story of hope to all those people affected with type 1 diabetes who did not have any hope to survive.
We have come a long way in last 100 years since the discovery of insulin-from that black, bleak stories of dying young children to people with type 1 diabetes living a long, meaningful, fulfilling lives. The journey continues with ongoing technological advancements enhancing convenience and care towards ever brighter futures.
The demands of managing diabetes include-the mentally taxing job of making the right choices about- what to eat, when to eat, how much to exercise, when and how many times a day prick fingers to know your blood glucose level, to use that information intelligently to decide how much insulin, what type of insulin and to time it right. Even best of mathematicians would find the calculations daunting, and doing these adjustments when the high or low glucose levels influencing your decision making.
Technological advances which might help with some of these tasks are: insulin pumps delivery system, continuous glucose monitoring system (CGMS) and combining the two where a computer can calculate your dose based on CGMS values.
What is Diabetes?
- Diabetes is when glucose levels in blood are high enough to cause organ damage over several years.
Why is it needed to control diabetes?
- There is a consensus based on robust data that organs exposed to high blood glucose for years might be damaged irreversibly.
- There is enough knowledge that by controlling glucose organ damage can be prevented.
How to control glucose levels in diabetes?
- The way to control blood glucose levels is by making right food choices, increasing physical activity and medications (at least 8) which act through different mechanisms to bring down glucose level.
- The reason why there are so many different medicines is because diabetes is a complex disease which results from effect on various organs and the connections between them, especially the commonest type of diabetes I.e. type 2 diabetes.
- The less common kind of diabetes is called type 1 diabetes in which the defect is in the insulin secreting cells of pancreases-the beta cells. This can be dealt with currently only by replacing insulin. The only method to replace insulin is through injections, multiple times a day.
Why is it challenging to manage type 1 diabetes?
- MULTIPLE PRICKS: People living with type 1 diabetes need insulin multiple times a day and also need to check glucose levels multiple times a day-the more, the better.
- VARIABLE GLUCOSE and COMPLEXITY: The insulin dose has to be varied based on blood glucose values because blood glucose values vary throughout the day depending on what one eats, how much one exercises, the time of the day, insulin dose. The variation of glucose is difficult to manage because the patterns are very complex and baffling to best of mathematicians.
- LOW GLUCOSE-THE LIMITING FACTOR: Not just high, but low blood glucose is also a problem, a real danger in managing diabetes with insulin because if glucose levels drop too low, the glucose supply to brain shuts down and that can be sometimes fatal.
- CALCULATIONS: It is therefore mentally overwhelming to check glucose several times a day and use that information to decide how much insulin dose to inject.
- NOCTURNAL HYPOS: The insulin is injected into subcutaneous tissue, from where it is absorbed into the blood at varying rate. The long acting insulin is slowly and steadily absorbed over about a day. However body’s insulin requirement is not same throughout the day. Usually insulin requirement drops at night, so there is risk of sugars going low at night if we try to control daytime glucose with basal. Or we may end up having high glucose during some times to avoid hypos at the low period. Thus the differing requirement at different times of day is a challenge.
- GLUCOMETERS PROVIDE LIMITED DATA: Using glucometers to check glucose provides only limited data of this variability and the pain and hassles of checking glucose is also challenging. Deciding insulin dose with missing glucose data is challenging.
- FOOD ABSORTION VARIES: The fast acting insulin gets absorbed usually over 4-5 hours. However different food items have different rate of information and may result in high and low glucose after meal even with same dose of fast acting insulin before meals (bolus). Differing absorption of food presents a challenge to correct bolus dosing.
- PENS HAVE ONLY 0.5 to 1 unit dialling possible: Insulin doses can be changed by 1unit or maybe half unit. Sometimes smaller titrations are required.
New diabetes technologies
- Insulin pumps are devices which continuously inject insulin into subcutaneous tissue, the rate of infusion can be finely tuned.
- Continuous glucose monitoring systems (CGMS) are devices which can measure glucose every 5 minutes in the interstitial fluid (which correlates with glucose levels in blood).
- One can read the glucose level using a scanner intermittently- intermittently scanning CGM (isCGM or flash CGM) or the value is transmitted in real time to a reader or a phone (real time CGM)
- The CGM can also connect with a pump and regulate rate of infusion. If the glucose level is low or going low, the basal infusion rate is suspended for sometime. These devices are called sensor augmented pumps (SAP).
- In the newer versions of insulin pump, the basal rate of insulin is adjusted based on CGM. Bolus insulin is however decided by the patient based on timing and amount of meals. These are called hybrid closed loop pumps.
Saksham 