Treatment

Treatment of DM1 revolves around a management plan that includes client education about the disease, insulin therapy, diet and exercise, and the prevention of complications. It is of great importance that the client learns how to control serum glucose levels because glycemic control is essential to longevity and preservation of health.


Short and Long-Term Insulin Therapy:
Lifelong insulin replacement therapy is needed in the treatment of DM1 and regular dosing schedules should be followed for optimal glycemic control. Subcutaneous injection of insulin is the most accurate way of introducing insulin to the body. On occasion, intramuscular (IM) insulin injection is used for fast absorption, but does not allow for the long-term, steady regulation of glucose levels. Oral insulin formulations have thus far failed to control blood glucose levels because gastric acid in the stomach causes enzymatic breakdown of oral insulin, limiting its absorption into the bloodstream. However, clinical trials for prototype oral insulin formulations are currently underway in India and South Africa, have identified some promising future research avenues, and offer hope to millions of diabetics worldwide that a pill form of insulin is on the horizon (Bio-Pharm International, 2009; Oramed, 2009).

Currently, many types of injectable insulin are available for treatment, yet the majority of DM1 clients inject a combination of rapid-acting insulin before meals and longer-acting insulin at bedtime. An alternative to the subcutaneous injection of insulin is the insulin pump, a small device that is worn attached to clothing delivering a continuous amount of rapid-acting insulin under the skin via a catheter. While there is risk of infection at the insertion site, the insulin pump offers better control of hypoglycemia and hyperglycemia (American Diabetes Association, 2012).

A study investigating the effectiveness of insulin pump treatment on DM1 affected youth suggests that the effectiveness of the treatment, measured by the youth’s HbA sub 1C^levels, is dependent on several factors that create barriers to glycemic control. For instance, youth that showed a decreasing HbA sub 1C^ pattern were more likely to have been sufficiently and repetitively educated by healthcare providers on the importance of maintaining optimal glycemic control. One factor identified for the group of youth that had not potentiated glycemic control with insulin pump treatment was the lack of parental involvement in treatment and care of their child’s disease. Results indicate that more parental involvement in glycemic control is beneficial for children and youth with DM1. Regardless of parental input, this study found that insulin pump therapy was successful in achieving the target glycemic control goal in 60% of the youths participating (Nelson et al., 2009).

Types of insulin that have been approved for use in Canada

(Canadian Diabetes Association, 2012)

Adverse Effects of Insulin Therapy:

• Hypersensitivity: rash, anaphylaxis or angioedema
• Local: allergy at injection site manifested as itching, redness, swelling. Pruritis and lipodystrophy
• Metabolic: hypoglycemia, ketoacidosis
• Respiratory: decline in pulmonary function if insulin is inhaled (Lippincott, 2012)

Interactions:

Hypoglycemic effects are potentiated if taken with MAOIs, beta blockers, salicylates, or alcohol. If insulin is taken with beta-adrenergic blocking agents, there will be delayed recovery from hypoglycemic episodes. The effects of insulin are decreased if taken with corticosteroids, diuretics and atypical antipsychotics. There is an increased risk of hypoglycemia if taken with juniper, berries, ginseng, garlic, fenugreek, coriander, dandelion root, and celery (Lippincott, 2012).

The Role of Diet in Short and Long-Term DM1 Treatment:

For those with DM1, proper nutrition is a key factor in controlling blood glucose levels. DM1 affected individuals should monitor what they eat (carbohydrate counting), when they eat and maintain a regular daily eating schedule. A healthy diet has the full complement of vitamins, minerals, complx carbohydrates, fibre-rich and glycemic-poor foods, and foods low in saturated fats. 
                                


Taken from: www.onlinelibrary.com

  

The Role of Exercise in Long-Term DM1 Treatment:

Regular moderate exercise can help to both control and improve blood glucose levels by enhancing the body’s response to insulin. Regular moderate exercise can:

• Reduce LDL cholesterol by removing lipids from general circulation and storing it, thereby reducing the amount of cholesterol available to form plaques in blood vessels
• Potentially lower A1C in children and adolescents
• Reduce the risk of cardiovascular disease (CVD)
• Reduce hypertension
• Reduce the risk of colon cancer
• Reduce weight and prevent obesity
• Prevent osteoporosis
• Increase life expectancy
• Increase CV endurance, muscle fitness and flexibility
• Increase whole-body insulin sensitivity
• Enhance self-esteem and sense of well-being

Vigorous exercise however can have negative consequences on those with DM1. These include:

• Hyperglycemia
• Hypoglycemia
• Musculoskeletal injury
• CV accident (angina, myocardial infarction, dysrhythmia, sudden death)
• Deterioration of underlying retinopathy and nephropathy

(Riddell & Perkins, 2006)

Treatment of Acute Conditions:

• Mild to moderate hypoglycemia: Oral ingestion of15g of carbohydrates such as orange juice
• Severe hypoglycemia in a conscious person: Oral ingestionof 20g of carbohydrates such as glucose tablets
• Mild to moderate hyperglycemia: Administration of orals fluids, however, often no treatment is required

Emergency Treatment of Acute Conditions:

• Ketoacidotic diabetic coma: administration of intravenous fluids, insulin, potassium and sodium
• Hyperosmolar diabetic coma: administration of intravenous fluids, insulin, potassium and sodium given as soon as possible.
• Hypoglycaemic diabetic coma: administration of the hormone glucagon to reverse the effects of insulin, or glucose given intravenously.
• Hyperglycemia: immediate administration of insulin and IV fluids

Treatment of Chronic Microcirculatory Disorders: Neuropathy, Retinopathy and Nephropathy

Diabetic neuropathy, retinopathy and nephropathy cannot be reversed once the damage has been done, however, further deterioration may be prevented by early detection of diabetes and effective management of the disease. In an experimental study conducted by Albers and colleagues, intensive insulin treatment in patients with DM1 prevented or delayed the development of neuropathy for more than 6.5 years after completions of the study (Albers et al., 2010). This shows promising results for the treatment of neuropathy. 

• Neuropathy: Chronic, uncontrolled blood glucose levels in diabetics often leads to damage of nerve cells (transmission of impulses) particularly in the extremities. Neuropathies affectsboth micro and macrocirculation and can lead to reduced sensitivity in the legs and feet and result in what is commonly described as a feeling of “pins and needles” in the extremities. It is important for diabetics to monitor their feet for cuts and wounds regularly, treat affected areas promptly and protect the feet by wearing quality socks and shoes. In the event that a cut or wound doesn't heal and and an ulcer develops, immediate medical attention is warranted. Non-healing ulcers that cause severe damage to underlying tissue of the feet may require amputation. Additionally, males with DM1 may develop erectile dysfunction as a neuropathological complication. Although its recommended that prevention of such complication is applied from the onset of DM1, some solution to this problem do exist. These involve administering erectile dysfunction medication (requiring higher dosage than the general population), surgey, vaccum pumps and medications for retrograde ejaculation.  



Taken from: http://wwwgem.triinalneuralgiatreatment.info/348/diabetes-and-foot-neuropathy/


                                          





Taken from: www.science photolibrary.com

                                    

• Retinopathy: Severe and poorly controlled blood glucose levels can cause damage to the blood vessels that supply the retina. If left untreated, deterioration of the retinal blood vessels can lead to blindness. Treatment involves controlling blood glucose and reducing blood pressure and serum chosterol levels, but does not cure retinopathy; rather, it prevents further progression of the disease. People with DM1 should have their eyes examined by an ophthalmologist at least once a year to avoid progressive ophthalmic complications. If the condition worsens, several surgical procedures are available:
• Photocoagulation is laser eye surgery that is used to burn tiny perforations into the retinas of clients whose retinas are surrounded by abnormal vasculature. Photocoagulation either keeps blood from leaking into the surrounding tissue, or eliminates abnormal and fragile blood vessels. It is also used in the treatment of macular edema.
• Panretinal photocoagulation is laser eye surgery used to treat larger areas of the retina.
• Vitrectomy is a surgical procedure used to treat hemorrhage of the eye and to repair retinal detachment.
• Injection of corticosteroids into eye tissue to prevent the growth of abnormal vasculature is an experimental treatment currently being investigated.
  

Taken from: www.eastbayeye.com

                                  

• Nephropathy: Treatment goals are to prevent kidney disease from progressing. Controlling blood pressure (<130/80) is one of the best ways to retard further damage to the kidneys. Pharmaceutical drugs may be prescribed to lower blood pressure and protect the kidneys from further damage These include angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB's) (US National Library of Medicine, 2012).

Taken from: http://treatmentofdiabeticneuropathy.com/what-is-diabetic-nephropathy

                                            

Treatment of Chronic Macrocirculatory Disorders: Atherosclerosis and Arteriosclerosis

The treatment of atherosclerosis/arteriosclerosis is effective if combined with healthy lifestyle choices such as smoking cessation, regular exercise, intake of healthy diet, maintainance of a normal weight, and stress reduction. Common drug therapies for atherosclerosis include cholesterol lowering drugs, blood pressure lowering drugs and blood thinning drugs.

Atherosclerosis treatment recommendations.

In addition to drug therapy, non-surgical techniques may be used. These include angioplasty (the widening of narrowed arteries by inflating a balloon into the target site allowing for improved blood flow) and atherectomy (the direct removal of plaque from the arteries). Surgical techniques for the treatment of this condition include bypass surgery (using a blood vessel from another body part and re-sectioning it to the affected area), minimally invasive bypass surgery (in place of a larger incision made during conventional bypass surgery, this surgery involves using a smaller incision to perform the same surgery), and endarterectomy (removal of plaque in the carotid or peripheral arteries) (University of Maryland Medical Center, 2011).

The Use of Vitamins and Herbs to Treat Arteriosclerosis and Atherosclerosis


                                   

The use of vitamins and herbs may be contraindicated in certain diseases and in conjunction with certain medications. Many pharmacists and some physicians are becoming increasingly aware of research on natural substances, and are good resources for individuals attempting to incorporate natural preventative measures into their disease management programs. Research in the area of vitamins and herbs is limited and has a fraction of the financial backing of pharmaceutical drug research. As a result, there are few studies specific to DM1 treatment with vitamins and herbs. The long term complications of DM1 are both microcirculatory and macrocirculatory CVD, thus most of the research stems solely from the field of heart disease.

• B vitamins: Homocysteine is an amino acid that appears to increase the risk of heart disease and stroke due to elevated levels of homocysteine in the vasculature. One theory purports that amino acids might contribute to the damage of blood vessel walls and be involved in clot formation (Veldman et al., 2005). Recent studies utilizing high doses of B-vitamins resulted in a reduction in early stage subclinical atherosclerosis (Universityof Maryland, 2012). To reduce atherosclerosis, this vitamin therapy might be implemented if a DM1 patient’s homocysteine levels are high.
• Omega 3 Essential Fatty Acids (DHA & EPA): There is a growing body of evidence to support the use of omega 3 essential fatty acid oils (and the end products of DHA and EPA in particular). Omega 3’s have been shown to be effective in the prevention and treatment of atherosclerosis by preventing blood clot and plaque formation (University of Maryland, 2012). Those at risk for atherosclerosis might preventatively incorporate more cold-water fish, such as salmon, into their diet two to three times per week. It is important to note that since Omega 3’s also have blood-thinning properties, the effects of pharmaceutical blood-thinners may be potentiated by consumption.
• Coenzyme Q10: Coenzyme Q10 is a substrate that we produce naturally in our oxidative pathway and is associated with metabolic and general energy. As we age coenzyme Q10 production tends to decrease. Research on Q10 and cardiovascular disease indicates that it may increase levels of overall intrinsic antioxidants and decrease clot formation (University of Maryland, 2012). One study also has shown that in acute cases of MI, supplementing daily with Q10 within three days post MI were much less likely to experience successive heart attacks (University of Maryland, 2012). Research indicates that CoQ10 inhibits hyperglycemia-induced proinflammatory gene expression. Also the antioxidant N-acetyl-L-cysteine prevents endotheial cell apoptosis associated with hyperglycemia. Together, these antioxidants limit reactive oxygen species production, leading to reduced endothelial cell damage associated with hyperglycemia (Funk et al., 2012).
• Hawthorn Berries: Like many other berries, Hawthorn berries (Crataegus monogyna)  contain concentrated antioxidants. Research suggests that these specific antioxidants can be used for plaque build-up prevention. Use of Hawthorn has also been shown to decrease blood pressure and lower cholesterol (University of Maryland, 2012). As Hawthorn acts on the cardiovascular system, discussion with a pharmacist or physician who is knowledgeable about herbs is important if one is already on medication for the same or similar conditions. The University of Maryland Medical School states that160mg-1800mg in divided doses were suggested for therapeutic effects.
• Garlic: There is mixed research on the effects of garlic (allium sativum) on cardiovascular health. However, many studies suggest that in specific concentrations or strength, garlic may reduce cholesterol, destroy plaque formations and reduce the formations of blood clots. Garlic has blood thinning properties thus a person taking any medication for cardiovascular health must be counselled.

Homeopathy:

• Homeopathy is an ancient method of treating symptoms with remedies whose origins stems back to the German physician Samuel Hahneman. Many medical clinics in Europe, India and the U.K. incorporate homeopathy alongside conventional treatment. A study done by the Ministry of Health and Care Services in Norway (Norges,1998) examined the use of complementary and alternative therapies (CAM’s), which include vitamins, herbs and homeopathy, and found that homeopathy was the most frequently used CAM therapy in 5 out of the 14 countries surveyed in Europe and 11 out of 14 countries surveyed outside of Europe.
• Homeopathy treats each patient as a unique person presenting a unique symptom picture. There is generally no standard homeopathic remedy for acute or chronic symptoms in DM1 patients. As an example of how a homeopath would approach a patient, please connect to the following link:
• http://hpathy.com/clinical-cases/homeopathic-treatment-of-type-1-diabetes-mellitus-insulin-dependent-diabetes-mellitus-patient/

Experimental Treatments:

Although it has preserved countless lives for almost a century, exogenous insulin administration does not offer full control over glucose regulation. Consequently, diabetic patients normally suffer from long-term complications, namely cardiovascular, neuropathy, retinopathy, and nephropathy. With the advent of technology, new surgical techniques have been developed. Promising therapies include pancreatic organ transplants, islet and stem cell transplantation.

Organ Transplantion:

A pancreatic organ transplant is major surgery performed on patients with a matched donor. The normally functioning transplanted pancreas can reduce or eliminate the need for exogenous insulin in diabetic patients. However, pancreatic organ transplant recipients must undergo immunosuppressing treatments for the remainder of their lives. This, in and of itself, can lead to any number of complications including risk for infection, immunodeficiency, cancer, thrombosis and pancreatitis (U.S National Library of Medicine, 2012).

Islet Cell Transplantation:

Another technique that has been successfully introduced is islet cell transplantation. This treatment involves the implantaton of healthy islet cells to damaged cells. The advantage of islet transplantation versus pancreatic organ transplantation is that it’s a less invasive and repeatable treatment (Hori, 2009). The disadvantage to this method is the chronic shortage of donors. The islet cells are isolated from a donor and introduced into the portal vein of the liver. The procedure must be repeated 2-3 times and requires short term hospital stays over 2-3 months. Also for patients who are simultaneously getting a kidney transplant the prevention of graft rejection by immunosuppressants has been a challenge in medicine. Consequently, only 10% of patients who have undergone this procedure have successfully been labelled as insulin independent by the International Islet Cell Transplantation Registry (Serup, Madsen, & Mandrup-Poulsen, 2001). An indicator of successful islet cell transplantation leading to functional beta cells is the β-score which encompasses glycemic control, diabetes therapy, and endogenous insulin (Ryan et al., 2005).

Taken from: Elements for Health, 2010

                                    



Embryonic Stem Cell Transplantation:

One way of inducing the production of pancreatic islet cells and beta cells in DM1 patients is by way of embryonic stem cell (ESC) differentiation. ESC has a number of factors that limit its implementation. The factors are the lack of reliable methods for generating specific lineages, the difficulty of purifying specifically differentiated progeny, and once transplanted, lack of control over the differentiation of ESC's into the preferred cell lineage (Hori, 2009).

The technique of stem cell transplantation (Hori, 2009)