Diabetes

ABC of Diabetes
by Peter J. Watkins

The unstable Type 1 diabetic patient

Blood glucose concentrations inevitably oscillate considerably over 24 hours in many Type 1 diabetic patients. If these swings are used as a definition of instability then such patients might be classified as unstable. Indeed the ardent desire of some doctors to “stabilise” these patients sometimes leads the patient to undertake innumerable blood tests, to keep obsessional records, and to make themselves thoroughly miserable. The failure to succeed leads to recriminations, admissions to hospital, and absence from work. This form of physicianinduced, unstable diabetes is made worse by the inappropriate use of home blood glucose monitoring. It needs considerable patience to unravel the effects of such advice, but a more relaxed approach, together with fewer tests, can have a remarkably beneficial effect.

Very unstable diabetes (sometimes described as “brittle”) disrupts the lives of a small group of insulin treated diabetic patients, with repeated admissions to hospital due either to hypoglycaemia or ketoacidosis. Homelife, school, and work are totally disrupted. With very few exceptions, this is probably not a special type of diabetes; it most commonly occurs in teenage girls, it is almost always temporary, and problems appear to vanish as life itself stabilises with employment or marriage.

Management of disruptive diabetes demands time and patience; the doctor must identify any technical errors, recommend the best possible diabetic treatment, search for intercurrent illness, and seek social or psychological problems which might cause the patient to manipulate his or her diabetes. Some elderly patients also experience serious problems from violent swings of blood glucose. Loss of support at home following separation or bereavement can be added to the specific problems already described.

Solving technical problems

After all the technical issues have been checked, the dose and type of insulin should be adjusted to the best possible regimen (ideal insulin regimens have been described elsewhere). Some obsessional patients respond well to a reduction of the number of daily injections. A few unstable diabetic patients may benefit from continuous subcutaneous insulin infusion, which may also alleviate unpleasant hypoglycaemic episodes.

If recurrent hypoglycaemic episodes are the chief problem then careful education is needed to eliminate them (see chapter 8); careful attention needs to be given not only to the dose of insulin but also to the timing and amount of food, the effects of exercise, and the judicious use of home measurement of blood glucose. Sometimes excessive amounts of insulin, especially soluble insulin, may cause severe hypoglycaemia. Improvement results either from reducing the dose or changing the insulin regimen.

In a few women menstruation regularly causes severe upset of diabetes; control usually deteriorates in the premenstrual phase, causing ketoacidosis at times, followed by an increase in insulin requirement and sometimes troublesome hypoglycaemia. A carefully planned campaign of insulin adjustment usually overcomes this problem.

Above all, patients need encouragement and restoration of self-confidence together with the reassurance that they are neither physically nor mentally abnormal. The telephone number of the doctor or nurse offers added security. If at all possible unstable patients should not be admitted to hospital. If all these measures fail, however, and life is still disrupted by diabetes, then an admission is after all required.

Admission to hospital

In hospital the nursing staff take over the administration of insulin completely—both the procedure of drawing up the insulin and giving the injections. If some measure of stability is then achieved the patient’s equipment is returned for self injection: if chaos resumes it seems likely that the patient is either incompetent or cheating.

If diabetes continues to cause disruption even when the nursing staff are giving insulin injections, some form of manipulation should be suspected. Some patients use great ingenuity; insulin may just be concealed in a locker, but it has also been found inside transistor radios, in the false bottoms of jewellery boxes, and taped outside hospital lavatory windows.

Note: The rest of the chapter is omitted.