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THE INSULIN-DEPENDENT DIABETES

- Definition, A few explanations
- Circumstances of discovery, Positive diagnosis
- The complications, Prognosis
- Treatment, Conclusion

TREATMENT

1 – Goal:

To get a normal sugar rate in the blood (glycaemia <1.26 g/l), while substituting both the essential insulin needs and those in relation with the meals.

2 – Means:

a - Insulin therapy

The insulin therapy with doses adapted on the glycaemia self-control (measure by automatic method with strip) and, to a least degree, urinary, is the basis of the treatment of the insulin-dependent diabetes. The purified insulins are of human structure or animal origin. The presentations vary (small bottles or cartridges for pen or for pump). They are classified according to their durationof action:

The treatments are also varied and the number of injections is all the more big because the diabetes is difficult to balance:

• The 2 injections treatment includes an injection before the morning and evening meals of a fast and intermediate insulin mixture,
• The 3 injections treatment consists of a fast insulin injection before the morning and noon meals, and an injection of fast and intermediate insulin mixture before dinner,
• The 4 injections treatment includes a fast insulin injection in the evening before every meal and a slow insulin injection at bedtime. A 5 injections variant consists of a morning injection of slow insulin.

The calculation of the insulin doses is made in an empiric manner of 2 in 2 units in relation to the glycaemic controls, in order to reach the optimum dose permitting to get a normal rate of sugar in blood.

The occurrence of a hypoglycaemia requires to reduce the needs in insulin from 2 in 4 UI according to the seriousness of the hypoglycaemia. The use of an insulin pump permits to assure the normoglycaemia in an elegant manner. Its inconveniences are the psychological constraint, the risk of prolonged hypoglycaemia and the risk of ketoacidosis in case of breakdown (due to an important hyperglycaemia).

The points of injections of the insulin differ every day to avoid the abrasion of the fat layer located under the skin.

b - Hygiene of life: food and physical exercise

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The diet controlled in carbohydrates is the second side of the treatment. It is a diet whose caloric rate must be adapted to the physical activity. It is normally rich in calories in a normal weight patient. It is composed of 50% carbohydrates, essentially slow carbohydrates, is poor in saturated fatty acids and must bring 1g/kg proteins.

The distribution is also different with 3 main meals and 3 snacks. The patient must be warned that he must never miss any meal, nor absorb too important quantities of alcoholic drinks on an empty stomach (risk of hypoglycaemia).

The physical exercise is recommended according to the patient’s physical and vascular state, and a carbohydrate supplement during and after the effort is obligatory. The practice of the physical exercise is fundamental because responsible for a taking of the glucose by the muscles, which is responsible for a reduction of the glycaemia.

3 – Results:

The insulin therapy only rarely results in the perfect glycaemia balance, because of the modification of the metabolism and food.

4 – Surveillance:

The surveillance is regular through the glycaemia and urine self-control, a multidaily control in the beginning, with ketonuria control in case of high glycaemia. The patient is carrier of the diabetic's notebook on which he notes the result of these tests, and of a diabetic's card.

The dosage of the A1C haemoglobin (or of total A1 haemoglobin), or glycosyled haemoglobin, informs on the glycaemia balance of the 2 preceding months, and the fructosamine dosage on the 2 to 3 previous weeks balance.

We shall not come back on the elements of the diabetic's yearly balance.

5 - Therapeutic perspectives:

The detection of the at risk subjects by the HLA groupage (genetic groupage) in the diabetics families will allow a precocious immunotherapy to stop the illness of the immune system and preserve the insulin capital of the pancreas.

Other types of faster or slower insulins are under experimentation.

The double graft kidney/pancreas is reserved to the patients affected by a terminal chronic renal insufficiency.

The grafts of encapsulated islets, the bio-artificial pancreas, the implantable peritoneal pump with glucose sensor are the most promising ways of research.

CONCLUSION