Since the patient had Addison’s Disease, she was followed closely for other autoimmune diseases. At the age of 40 she was diagnosed with type I diabetes. It is considered type I since it is an autoimmune disease.

Oral medication was initially attempted but did not control the blood glucose levels. She is very sensitive to insulin which means she takes smaller amounts than many diabetics. It also means she can easily develop low blood glucose levels.

• Managing Diabetes
• The Insulin Pump
• Insulin Facts
• Continuous Monitoring and Injection Systems
• Insulin Levels Following Meals
• Diabetic Retinopathy
• Some Additional Information and Images

The patient would typically use 4 to 6 injections of insulin daily for the first 7 or 8 years.

She would also check her blood glucose levels 4 to 8 times a day.

For the past 15 years the patient has used an insulin pump. The pump is programmed to give a basal amount of insulin which varies with the time of day. The patient still checks her blood glucose levels multiple times a day and with the pump gives a bolus of insulin before meals or any time the blood glucose level is high.

Her present glucose meter sends her blood glucose readings to the pump. The pump then recommends the amount of insulin to inject.

The left photo shows the needle that supplies the insulin with the patch that the tube from the pump is inserted into. The second patch helps prevent the needle from being pulled out. The photo on the right shows the needle and tubing in place. The needle must be changed every two or three days.

With the insulin pump a fast acting insulin is used since it is constantly being provided. For many years she used Humalog® insulin. Some patients had problems with it clogging the tubing of the insulin pump. More recently Apidra® insulin (insulin glulisine), also a fast acting insulin, was developed to prevent this problem.

Pharmacokinetic profiles of insulin glulisine (Apidra) and regular human insulin showing the fast action.

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Insulin pumps that continuously monitor the blood glucose levels have just started to come on the market. They provide constant monitoring (every 1 to 5 minutes) with automatic feedback to the pump to inject the required insulin.

A sensor is inserted and transmits to the meter. The sensors last 72 hours. Two needles are in place, the sensor and the pump.

• Abbott Freestyle Navigator
• MiniMed Paradigm REAL-Time System
• MiniMed Guardian
• DexCom STS

One of the problems with controlling glucose levels is the increase following meals. A bolus of insulin can be given based on the amount and type of food eaten. However, there can still be a spike in glucose levels. If enough insulin is given to prevent the spike most likely following the spike the patient will have a low blood glucose level.

There is diagnostic instrumentation to continuously monitor glucose levels, the Medtronic Continuous Glucose Monitoring System. It can be worn for several days. The output is a graph for each 24 hour period.

Medtronic Continuous Glucose Monitoring

Due to the increase in blood glucose levels following a meal, the patient was prescribed Symlin (pramlintide). It is a synthetic hormone that resembles amylin produced in the pancreas and released after meals. Symlin was just approved in March of 2005. It acts in several ways:

• It slows the rate food is absorbed from the intestine
• Reduces the production of glucose by the liver
• It reduces appetite

Symlin is injected subcutaneously prior to a meal. The patient must build up the dosage over several days to prevent nausea and other side effects.

For type 1 diabetics they normally start with 15 mcg and increased in 15 mcg increments to 30 to 60 mcg as tolerated.

They need to decrease the insulin when using Symlin.

Symlin Medication Guide

Side effects of Symlin:

• Nausea
• Hypoglycemia
• Vomiting
• Headaches
• Abdominal pain
• Weight loss*
• Fatigue

Symlin drug information on MedicineNet.com
Symlin drug facts from Drugs.com

Following the use of Symlin she wore the continuous monitoring meter again, below are the readings graphed by meal. As can be seen in most cases the peaks following meals is less. However, notice that the levels on awakening were high, thus the basal insulin levels were increased during the night.

The continuous monitoring plotted by time of day for one week:

The patient has been very fortunate to have only minimal retinopathy, the result of working to control blood glucose, diet, proper medication, keeping weight down and exercise.

Glycosylated hemoglobin A1C values are an indication of the average blood glucose levels over the past 3 months.

Even with all the patient’s efforts her A1C’s run around 8.0.

This is not uncommon with type 1 diabetics. A problem that can spike the blood sugar is needle site becoming plugged or for some reason does not allow the insulin to flow. The patient does not know this until the next blood glucose reading at which time it may be 300 or 400.