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why don’t they treat type 1 diabetes with oral meds

Posted Dec 13 2010 11:21am

I’ve been wondering about this question for a long time. Clearly, I knew that people with type 1 diabetes produce no insulin so any of the oral meds that help you to produce more insulin would be useless. But it has always seemed that some of the medications that help one to use insulin more effectively would be helpful to some people with type 1 diabetes who have trouble controlling their blood sugars with insulin alone.

I asked our friend Wil this question this past weekend and he very kindly responded to my somewhat scattered thoughts and is allowing me to post his answers here. Wil is a Diabetes Educator, Author ( here and here ) and one of my favorite bloggers. He also answers diabetes related questions over on ShareCare. In addition, he has made his book Taming the Tiger available for free as an e-book.

Dear Wil,

There’s a question I’ve had for a while that I’ve been afraid to ask since it might be incredibly stupid or worse, offensive.

I have type 2 diabetes which is under good control. I’ve lost weight and the insulin my body still produces is adequate with the help of metformin. I fit the profile for “metabolic syndrome” or you can call me insulin resistant or glucose intolerant. They all seem to boil down to the same thing. I don’t respond well to carbohydrates and I don’t use insulin efficiently.

We know that there are a lot of people with the same issues. We know as a society that we eat too much and exercise too little. We know that obesity is an increasing problem across the board. Therefore, it only makes sense to me that a percentage of people with type 1 diabetes, in addition to not producing insulin at all, may not use insulin as efficiently as a so-called normal person.

So why is it that I hardly ever hear of someone with type 1 diabetes taking oral medications to improve their body’s ability to use insulin as well as injecting or pumping insulin? The few examples that I can think of off the top of my head of people taking both oral meds and insulin (other than lantus or levemir) are people who were initially diagnosed with type 2 and then later determined to be insulin dependent.

From the outside it seems to make sense that someone having difficulty controlling blood sugar levels on insulin alone might benefit from oral meds. Is there a perfectly logical reason of which I am not aware that this does not work? Is there just a bias that if you have type 1 you just keep adding insulin?

I appreciate you reading this and when you have some time, I’d love to hear your response. I have been curious about this for a long time and since I don’t think that I am likely to be much more insightful than the rest of the medical community, I’m guessing there is a reason why oral meds are apparently rarely prescribed to someone with type 1. I would just like to understand why.

Thank you,
Zazzy

Hi, Zazzy!

The only stupid question is the one not asked.

A true Type-1 produces zero insulin, so most of the oral meds simply won’t work. The entire hormonal loop is dead.

The one kind of med that can be used in T-1s is the TZD class (Avandia and Actos). If you have an insulin resistant T-1, which is rare, but does happen, a TZD can lower the amount of insulin needed.

We don’t use this often however, because even heavy T-1s usually need only a fraction of the insulin that even a thin T-2 would need. This is because T-2 is a disease of insulin resistance. It’s this lack of ability to use insulin effectively that is the foundation of T-2. Even “insulin dependant” T-2s need more insulin than we T-1s do. This is because if a T-2′s pancreas wears out, requiring insulin injections, the underlying resistance problem is still there.

Did that make it clear?

W

Dear Wil,

Thank you so much for your response. That does make things much more clear and led me to some interesting searches for more information. I had one thing that I hoped you might be able to clarify.

I know that type 1 and type 2, although they have similar effects, are totally separate diseases. At least as far as medical science knows at this point. So, type 1 and type 2 are not statistically related. Other possible conditions or traits should be represented reasonably equally between the two main types of diabetes and the general population. I mean, for example, that the percentage of people with type 1 diabetes who also have say, flat feet, should be roughly equivalent to the percentage of people with flat feet in the general population.

Why would the condition of insulin resistance be at a much lower percentage in the population of people with type 1 diabetes than in the general populations? Or perhaps it only seems that way? I believe science thinks that there is almost certainly a genetic component in type 2 diabetes and, of course, we know that obesity and a sedentary lifestyle are at least risk factors, but I don’t understand what would exclude people with type 1 diabetes from those same genetic and lifestyle issues.

I understand that there may not be an answer for this – or perhaps there is! But again, when you have time I would appreciate your take on the issue.

Thank you,
Zazzy

Zazzy –

I personally believe that there are two unrelated factors at work. Insulin resistance itself is a genetic thing. It probably gave some advantage during feast-or-famine periods of prehistory. Folks who are predisposed to insulin resistance and Type-2 are really good at putting on weight. And of course we are a really fat nation, so anyone who is predisposed is also placed in a high-risk factor environment.

But being fat, even hugely fat, does not cause insulin resistance if the genes are not set up for it.

And for whatever reason, those of us with T-1 genes tend to run on the skinny side. Something about the disease process, according to an endo I used to know. I was quite heavy before I got diabetes, but have been anywhere between painfully skinny and trim every since. And I don’t think I eat all that different.

I know at least three fat Type-1s personally. They all seem to have the same insulin to carb ratios that I do, so even though their body mass is much greater we all use about the same amount of insulin.

Soooooooooooo, I’m not sure that was totally clear, but what I’m trying to say is that the genes for T-2 are also the genes for insulin resistance; while the Type-1 genes are either garden variety for insulin resistance (in other words non-insulin resistant) or maybe even insulin senstive. And going out on a limb here, it just this second occurred to me that it would make sense that genes set up for insulin production problems would logically also be connected with increased sensitivity as a built in protection. After all, we still don’t know what causes the onset of the autoimmune process of T-1. If we lived in a lower carb environment maybe our systems wouldn’t get so stressed. But this last part is just intellectual exercise, I’ve never seen any studies or anything like that.

One of the things I learned from searches based on Wil’s information, was that they are, under rare circumstances, using Metformin to treat people with type 1 who are also insulin resistant. Most of what I read stated outright that since insulin resistance is so exceedingly rare in people with type 1, they weren’t even going to discuss it. A NCBI study, however, reported that in the early stages of type 1 diabetes, insulin resistance plays a larger role than is currently recognized. Interestingly, they state:

Intensive diabetes management is associated with both improved insulin sensitivity and beta-cell function.

I wonder if this intensive management, which is not generally a part of the early treatment of people with type 2 diabetes, is responsible for the much greater sensitivity to insulin that Wil describes in people with type 1? It might also explain why someone like me, who has been on a very restrictive diet, seems to be much more sensitive to the insulin my body still produces than I was previously.

At any rate, I very much appreciate Wil taking the time to answer this question. There is a lot to think about here and I feel I understand some of the issues that go with Type 1 Diabetes as well as the issues that surround insulin resistance with Type 2 Diabetes a little better.


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