Ashley's Story



My name is Charles, and I am from Toronto, Canada. I am sending this note
out to see if you could share your thoughts on Ashley, my niece. Ashley is
your typical 9-year old--vibrant, bright and playful. Ashley is also
diagnosed with Type II diabetes. Ashley's diagnosis simply devastated us.
However, we were pleasantly surprised to see her conditions bounce back to
normal since the initial diagnosis. We subsequently stopped the insulin
injections and Ashley has been fine ever since, for about two months now.
However, the endocrinologist at Toronto Hospital for Sick Children (THSC)
thinks Ashley is going through her "honeymoon" period.



According to the endocrinologist, Ashley is feeling well now because she is
in her honeymoon period where the leftover beta cells are working extra hard
to produce the necessary insulin and Ashley can relapse in the next 6 months
when her remaining beta cells eventually get destroyed. He advised us not to
get the hopes up and prepare to accept reality. Having researched on the
topic, it became clear Ashley is most likely type II diabetic and she is in
her honeymoon period. However, there are number of things about Ashley that
do not fit well with a typical type II diabetic child. This prompted me to
post this article and solicit more opinions, advice and comments to
demystify Ashley's conditions.





Chronology of Events



Following are progressive events on Sarah's diagnosis, treatment and
progress:



Oct 2005
On a routine blood test slightly elevated blood sugar level (HbA1c =
0.064) was observed. No treatment was recommended and the family doctor told
us not to worry. However, my sister had been checking Ashley's blood sugar
ever since on a weekly basis, and it was very stable and normal.

Feb 24, 2006
Ashley was taken to the family doctor with an intense cough and she had
difficulty breathing (she is not asthmatic).Her blood sugar and insulin was
fairly normal with HbA1c = 0.062 and fasting sugar = 4.6 (glucometer
reading). Suspecting respiratory infection, the doctor prescribed an
antibiotic (Cefzil) and to help Ashley's breathing, he also prescribed an
anti-inflammatory (Prednisolone). Following are the actual dosages of each:

1.. Cefzil 5m(x3), twice a day for 5days (antibiotic)
2.. Prednisolone 10ml(x2), twice a day

Mar 03, 2006

(Following Friday)
Ashley's sugar level shot up to dangerous levels (18-20 in the
glucometer) and Ashley looked very weak. She was rushed to THSC where she
was eventually diagnosed to be Type II diabetic. Some nurse attended Ashley
hypothesized that the diabetes could have been induced/unmasked by the
strong dosage of Prednisolone that she was on. When we brought it up, the
endocrinologist discounted the notion of Prednisolone link. A diabetic
treatment was initiated and her sugar level began to subside.

Mar 08, 2006
Ashley was put on insulin dosage. Her dosage was:

a.. Rapid (M-3 + After 2), Normal (M-7 + After 2)
b.. 14 units (10 units in the morning, 4 units in the evening)
We also put Ashley on a diet where meals were given in regular
intervals and the sugar intake was measured and controlled. We were
instructed to monitor Ashley's fasting sugar level and adjust the insulin
dosage accordingly. Ashley was responding really well and we started
reducing her insulin dosage after 3 days, according to the instructions
given by the doctor. On March 29th, we only gave Ashley N2 insulin.

Apr 18, 2006
Ashley was completely weaned off insulin.




Observations



Following are some of the key observations we were able to make that form
the basis for my questions:

· It is said that exercise does not have any impact on type II
diabetic patients. However, exercise (walking, swimming, and yoga) reduced
Ashley's sugar level noticeably.

· Ashley's beta cell test (anti islet cell test) performed after the
diagnosis was negative indicating Ashley was not loosing any beta cells. The
endocrinologist theorized that Ashley was not loosing any beta cells when
the test was actually administered. Further, he concluded that there is 95%
chance that Ashley was Type II diabetic, meaning there is a 5% chance Ashley
is not diabetic.

· No one from Ashley's family (from both of her parents' sides) is
diabetic. Ashley's illness cannot be hereditary.

· Ashley's siblings are perfectly healthy.

· Ashley did not exhibit any type II diabetic symptoms including:
ketone in blood, excessive thirst, and urinate frequently.





My Questions



Naturally, we have a number of questions regarding Ashley's health. The
staff at THSC has been more than helpful and courteous and I don't intend
disregard or disrespect their assessment of Ashley's conditions. I just have
some unanswered questions and was hoping to get some answers from a wider
forum, while conveying Ashley's story. My questions a

· How can Ashley go from being perfectly healthy (on Feb 24th) and
Type II diabetic in a week (Mar 03rd)? Can the sugar level increase that
rapidly over such a short period of time? Wouldn't you expect the sugar
level to gradually rise if you are diabetic?

· Is it possible that Ashley's diabetes was triggered by
Prednisolone (please see my research in Appendix A)? If so, was Ashley given
a heavier dose that she needed?

· Since Ashley did not show most of the symptoms of a type II
diabetic patient, except for a temporary short sprout in blood sugar level,
is it possible that she was rashly misdiagnosed? Are there any more tests
that we can perform to confirm her diagnosis with a higher degree of
accuracy?

· If there is 5% (according to endocrinologist) chance that Ashley
is not diabetic, what could explain the whole episode?

· Assuming Ashley is in her honeymoon period, is there a way to
extend it? Are her conditions reversible?

· Should Ashley's siblings be worried? Are there any precautions
that they can take?

· How did exercise help with Ashley's blood sugar level when she is
diagnosed with type II diabetes?

· Is there an alternative treatment method to reduce/control Type II
diabetes?

· Does exercise help with Type II diabetes? If so, what type of
exercise?

· Does diet help with Type II diabetes? If so, what type of diet?

· Is there an alternative method to administer insulin than
injections?

· Are there any emerging/promising (clinical) treatments for Type II
diabetes?

· Can the beta cells be harvested from Ashley's twin sister and
transplanted to Ashley?





Thanks for your time and kind words. Take care.



Truly

Charles





Appendix A: Link between Diabetes and Prednisolone



I found a solid link between Prednisone and diabetes. Google gave me a
number of search results:

a.. 1,270,000 for Prednisone diabetes.
b.. 372,000 for Prednisolone diabetes


Here are a few interesting links I found that seem to link Prednisolone to
diabetes:



http://www.diabetes.org/live/transcript.jsp?chatid=19

Question: My son is a Type 1 Diabetic. He has a rash on his arm that
continues to get worse. Originally we took him to his family physician who
prescribed prednisone which seemed to be helping the rash, however when he
visited his endocrinologist, he told us this medication was contributing to
his high blood sugars. He prescribed Ketoconazole (2 tablets) however it
still isn't any better, and seems to be getting worse. We call his Endo and
he suggested a dermatologist. I just wanted to know if you have any
suggestions or opinions.

ADA: We would agree that the prednisone can cause your son's blood glucose
levels to be elevated and since the antifungal (Ketoconazole) is not helping
the rash get better it would be in your son's best interest to be evaluated
by a dermatologist. A dermatologist is trained to treat conditions of the
skin and can consult with your son's endocrinologist to determine the best
treatment option for the cause of the rash without increasing his blood
glucose levels.



http://www.medinfosource.com/expert/exp4052702b.html

Q. I am a legal assistant in Missouri. I have a client who was given 40 mg
of Prednisone for swelling in his wrist. He started noticing harsh side
effects immediately Five days later he was diagnosed with Diabetes type 1.
One of Prednisone's side effects is diabetes, but it doesn't state what type
of diabetes it can cause. Have you heard of anyone having this same case?

A. Prednisone is indeed a powerful drug, and can be life-saving but must be
used cautiously. It is one member of the group of drugs commonly called
steroids or cortisone. As a group, they are the strongest form of
anti-inflammation medications available so common uses would include the
treatment of severe asthma, allergic reactions, and various strong
auto-immune diseases such as rheumatoid arthritis.

Persons taking these drugs on a long term basis are monitored for side
effects such as the development of ulcers. They do indeed interfere with
glucose (sugar) metabolism but this is usually not so severe. In rare cases
an acute case of diabetes can occur which requires immediate treatment as
you describe. Some of these cases will resolve if the Prednisone can be
stopped, but some cases persist. It is thought that the Prednisone has
unmasked a diabetic tendency when the condition fails to resolve.

Charles Antony wrote in message ...
>Ashley's Story
>
>
>
>My name is Charles, and I am from Toronto, Canada. I am sending this note
>out to see if you could share your thoughts on Ashley, my niece. Ashley is
>your typical 9-year old--vibrant, bright and playful. Ashley is also
>diagnosed with Type II diabetes. Ashley's diagnosis simply devastated us.
>However, we were pleasantly surprised to see her conditions bounce back to
>normal since the initial diagnosis. We subsequently stopped the insulin
>injections and Ashley has been fine ever since, for about two months now.
>However, the endocrinologist at Toronto Hospital for Sick Children (THSC)
>thinks Ashley is going through her "honeymoon" period.
>
>
>
>According to the endocrinologist, Ashley is feeling well now because she is
>in her honeymoon period where the leftover beta cells are working extra
hard
>to produce the necessary insulin and Ashley can relapse in the next 6
months
>when her remaining beta cells eventually get destroyed. He advised us not
to
>get the hopes up and prepare to accept reality. Having researched on the
>topic, it became clear Ashley is most likely type II diabetic and she is in
>her honeymoon period. However, there are number of things about Ashley that
>do not fit well with a typical type II diabetic child. This prompted me to
>post this article and solicit more opinions, advice and comments to
>demystify Ashley's conditions.
>
>
>
>
>
>Chronology of Events
>
>
>
>Following are progressive events on Sarah's diagnosis, treatment and
>progress:
>
>
>
> Oct 2005
> On a routine blood test slightly elevated blood sugar level (HbA1c =
>0.064) was observed. No treatment was recommended and the family doctor
told
>us not to worry. However, my sister had been checking Ashley's blood sugar
>ever since on a weekly basis, and it was very stable and normal.
>
> Feb 24, 2006
> Ashley was taken to the family doctor with an intense cough and she
had
>difficulty breathing (she is not asthmatic).Her blood sugar and insulin was
>fairly normal with HbA1c = 0.062 and fasting sugar = 4.6 (glucometer
>reading). Suspecting respiratory infection, the doctor prescribed an
>antibiotic (Cefzil) and to help Ashley's breathing, he also prescribed an
>anti-inflammatory (Prednisolone). Following are the actual dosages of each:
>
> 1.. Cefzil 5m(x3), twice a day for 5days (antibiotic)
> 2.. Prednisolone 10ml(x2), twice a day
>
> Mar 03, 2006
>
> (Following Friday)
> Ashley's sugar level shot up to dangerous levels (18-20 in the
>glucometer) and Ashley looked very weak. She was rushed to THSC where she
>was eventually diagnosed to be Type II diabetic. Some nurse attended Ashley
>hypothesized that the diabetes could have been induced/unmasked by the
>strong dosage of Prednisolone that she was on. When we brought it up, the
>endocrinologist discounted the notion of Prednisolone link. A diabetic
>treatment was initiated and her sugar level began to subside.
>
> Mar 08, 2006
> Ashley was put on insulin dosage. Her dosage was:
>
> a.. Rapid (M-3 + After 2), Normal (M-7 + After 2)
> b.. 14 units (10 units in the morning, 4 units in the evening)
> We also put Ashley on a diet where meals were given in regular
>intervals and the sugar intake was measured and controlled. We were
>instructed to monitor Ashley's fasting sugar level and adjust the insulin
>dosage accordingly. Ashley was responding really well and we started
>reducing her insulin dosage after 3 days, according to the instructions
>given by the doctor. On March 29th, we only gave Ashley N2 insulin.
>
> Apr 18, 2006
> Ashley was completely weaned off insulin.
>
>
>
>
>Observations
>
>
>
>Following are some of the key observations we were able to make that form
>the basis for my questions:
>
>· It is said that exercise does not have any impact on type II
>diabetic patients. However, exercise (walking, swimming, and yoga) reduced
>Ashley's sugar level noticeably.
>
>· Ashley's beta cell test (anti islet cell test) performed after
the
>diagnosis was negative indicating Ashley was not loosing any beta cells.
The
>endocrinologist theorized that Ashley was not loosing any beta cells when
>the test was actually administered. Further, he concluded that there is 95%
>chance that Ashley was Type II diabetic, meaning there is a 5% chance
Ashley
>is not diabetic.
>
>· >
>· Ashley's siblings are perfectly healthy.
>
>· Ashley did not exhibit any type II diabetic symptoms including:
>ketone in blood, excessive thirst, and urinate frequently.
>
>
>
>
>
>My Questions
>
>
>
>Naturally, we have a number of questions regarding Ashley's health. The
>staff at THSC has been more than helpful and courteous and I don't intend
>disregard or disrespect their assessment of Ashley's conditions. I just
have
>some unanswered questions and was hoping to get some answers from a wider
>forum, while conveying Ashley's story. My questions a
>
>· How can Ashley go from being perfectly healthy (on Feb 24th) and
>Type II diabetic in a week (Mar 03rd)? Can the sugar level increase that
>rapidly over such a short period of time? Wouldn't you expect the sugar
>level to gradually rise if you are diabetic?
>
>· Is it possible that Ashley's diabetes was triggered by
>Prednisolone (please see my research in Appendix A)? If so, was Ashley
given
>a heavier dose that she needed?
>
>· Since Ashley did not show most of the symptoms of a type II
>diabetic patient, except for a temporary short sprout in blood sugar level,
>is it possible that she was rashly misdiagnosed? Are there any more tests
>that we can perform to confirm her diagnosis with a higher degree of
>accuracy?
>
>· If there is 5% (according to endocrinologist) chance that Ashley
>is not diabetic, what could explain the whole episode?
>
>· Assuming Ashley is in her honeymoon period, is there a way to
>extend it? Are her conditions reversible?
>
>· Should Ashley's siblings be worried? Are there any precautions
>that they can take?
>
>· How did exercise help with Ashley's blood sugar level when she is
>diagnosed with type II diabetes?
>
>· Is there an alternative treatment method to reduce/control Type
II
>diabetes?
>
>· Does exercise help with Type II diabetes? If so, what type of
>exercise?
>
>· Does diet help with Type II diabetes? If so, what type of diet?
>
>· Is there an alternative method to administer insulin than
>injections?
>
>· Are there any emerging/promising (clinical) treatments for Type
II
>diabetes?
>
>· Can the beta cells be harvested from Ashley's twin sister and
>transplanted to Ashley?
>
>
>
>
>
>Thanks for your time and kind words. Take care.
>
>
>
>Truly
>
>Charles
.. . . .(snip). . .


You have made a variety of medical statements in your post which are
inconsistent with Type 1 and Type 2 diabetes as I know them. I'm not
trying to be sarcastic or even ironic when replying at a time in which
Ashley's condition must be devastating to you. However, I am afraid that
your research has not been deep enough and/or you have been too anxious and
too intent in looking for "some way out".

Some remarks from my side (Research Engineer with diabetes, not a medical
person)

1. Ashley is exhibiting symptoms quite typical of a Type 1 (Type I)
diabetic.

Although thirst, excessive urination and the like are symptoms of
developing diabetes, the acceleration effect of prednisone could easily
have masked them.

FWIW, I did not experience any of the classical physical symptoms other
than blurred vision and, of course, high blood sugars.

2. A juvenile Type 1 diabetic can go from "no physical symptoms" and normal
blood sugar to sky-high sugars and DKA coma in a week.

As a parent of a suspected Type 1 diabetic child, you must be aware of the
symptoms of DKA. Please read and try to understand these medical papers:

http://www.ispad.org/clin-2.htm

http://www.emedicine.com/EMERG/topic373.htm

Please memorize the symptoms and/or post them in view somewhere.

The first symptom of approaching DKA is high blood sugar. Since DKA can
cause rapid-onset death, please, please, please continue to monitor her
blood sugar.

Pay special attention to her blood sugar at 2 hours after a meal. A
non-diabetic would be expected to be at 5 mmol/L or lower at that time.

It is not clear to me why you "weaned" her from insulin injections. The
first treatment for DKA is insulin injection. Daily insulin injections are
a preventative against DKA.

3. Type 1 diabetes is genetically induced and mildly hereditary. It is an
autoimmune disease triggered by "something or other".

"Something or other" can be a variety of stress factors, ranging from a
virus to a food allergy to personal stress. A Type 1 diabetic can have
no known diabetic relatives of any Type (like me, for instance), or be
part of a family in which every child and grandchild of a T1 is also T1.

In contrast, Type 2 (Type II) diabetes is almost always strongly
hereditary.

Sorry, but your statement:

". . . No one from Ashley's family (from both of her parents' sides) is
diabetic. Ashley's illness cannot be hereditary. . . ."

is totally in error.

There is no known, reliable preventative therapy for approaching Type 1
diabetes. There is no "restorative" therapy (transplant from sibling)
There is no way to protect other family members.

Type 1 is an autoimmune disease. Researchers are experimenting with immune
suppressive drug therapies but there is nothing available outside of the
clinical trials.

4. Prednisone unmasks developing diabetes of any type. It "orders" our
livers to produce extra glucose. If our beta cells have been damaged by
some form of diabetes, they cannot handle the extra glucose and our blood
sugars rise.

There is a theory that the extra work load produced by the release of extra
sugars can accelerate an existing diabetic beta cell destruction mechanism.
Therefore, in theory, prednisone can accelerate the arrival of developing
diabetes. That is not the same as "induce" or "cause" diabetes.

4. An HbA1c of 0.064 is not "slightly elevated" It is high, and
consistent with approaching full-blown diabetes.

My HbA1c has not been that high since I switched from old-fashioned
insulins to modern insulins several years ago.

(Think about the above statement if your doctor prescribes "old-fashioned"
insulins when and if the time comes. The modern insulins: Humalog,
Novolog, Apidra; Lantus and Levemir are much easier to use. Easier to
use means better control which means lower chance of diabetic
complications.)

The best study of HbA1c I have seen is the U.S. Third National Health and
Nutrition Examination Survey (NHANES) which reports an average of 5.0% for
non-diabetics. NHANES is a large study with enough subjects to produce an
expectation of accuracy.

(Note that most of us use the percentage version of HbA1c, i.e. 6.4%)

5. Exercise helps control blood sugar in any and all diabetics.

When I was in my honeymoon stage, the only way I had available to knock
down a high blood sugar was riding a stationary bike. A 4-minute mile
would knock my sugar down by an average of 1.1 mmol/L.

6. Injection, either by syringe, pen or insulin pump is the most reliable
and accurate method of delivering insulin. There is an experimental
"inhaled" insulin being tested. I cannot imagine using it on either a
child, or any Type 1 diabetic.

Please investigate the costs and capabilities of an insulin pump. It is
the most powerful and reliable insulin therapy available right now.

Most insulin therapies for children are "second-best" therapies, used
because the child has limited understanding and is unavailable to the
parents during much of the school day. Pump therapy is capable of
sidestepping these limitations.

7. "is it possible that she was rashly misdiagnosed?". I cannot
believe that (except for the fact that Type II is being mentioned so often
when applied to a child with clear Type 1 symptoms). Non-diabetics do not
experience blood sugars much above 8 for any reason at any time. Two
readings of 11 or more are considered sufficient for the diagnosis by most
docs.

I commend whoever put Ashley into Emergency care when she spiked to 18
mmol/L. She was in serious danger at the time.

The gentleman who put together this web site

http://www.rajeun.net/gtt.html#Diabetes and Hypoglycemia

http://tinyurl.com/c5xqo

has harvested responsible medical citations of blood glucose readings for
non-diabetic and diabetics when stressed by glucose ingestion.

Note that he uses the U.S. notation of mg/dL. ( 18 mg/dL = 1.0 mmol/L.)
Ashley's 18-20 mmol/L correspond to U.S. blood sugars of 324 - 360 mg/dL.

Mr. Toussier is not a doctor but, as I stated, he quotes responsible
medical sources.\

Good luck and please, please test her blood sugars frequently. DKA is
dangerous.

Regards
Old Al

Old Al,

Great response, and well written!

What kind of engineer are you? I'm a software engineer, and would love
to work in the field of diabetes with it, despite the advice of mentors
telling me that I shouldn't go into a field that is also part of my
life. *sigh*

JasonJayhawk wrote in message
. com>...
>Old Al,
>
>Great response, and well written!
>
>What kind of engineer are you? I'm a software engineer, and would love
>to work in the field of diabetes with it, despite the advice of mentors
>telling me that I shouldn't go into a field that is also part of my
>life. *sigh*
>

Chemical engineer, 35 years in Research.

Some of the diabetes therapies are less intimidating if you are used to
dealing with polymerizations in 10,000 gallon kettles. (A runaway can put
a load of stink on the CEO's roof 15 minutes after you first notice
something is wrong. I met our CEO a couple of times; I sometimes think
that kind of incident would have caused him to personally rip my head off in
preference to firing me)

I was diagnosed Type 2 then finally settled into the profile of an
adult-onset Type 1. I have a grandchild and a daughter-in-law at risk for
future T2; as well as a brother-in-law, and both "other" grandparents in
full-blown T2. All reasons to really crack the books on both Types.

"Being sentenced to hang focuses your mind".

AFAIK, the leading user of diabetes-knowledgeable software engineers is
Medtronics. I expect them to be the first with the artificial pancreas:
an insulin pump and implanted bG sensor with automatic feedback from the
sensor driving changes in instantaneous doses of insulin from the insulin
pump.

Regards
Old Al

>
> You have made a variety of medical statements in your post which are
> inconsistent with Type 1 and Type 2 diabetes as I know them. I'm not
> trying to be sarcastic or even ironic when replying at a time in which
> Ashley's condition must be devastating to you. However, I am afraid
> that
> your research has not been deep enough and/or you have been too anxious
> and
> too intent in looking for "some way out".

Actually, you are right. I typed in Type II, instead of Type I. I meant to
say Type I. It must have been the exhausting night. Thanks for your
response. I really appreciate you taing the time.

>
> Some remarks from my side (Research Engineer with diabetes, not a
> medical
> person)
>
> 1. Ashley is exhibiting symptoms quite typical of a Type 1 (Type I)
> diabetic.
>
> Although thirst, excessive urination and the like are symptoms of
> developing diabetes, the acceleration effect of prednisone could easily
> have masked them.
>
> FWIW, I did not experience any of the classical physical symptoms other
> than blurred vision and, of course, high blood sugars.
>
> 2. A juvenile Type 1 diabetic can go from "no physical symptoms" and
> normal
> blood sugar to sky-high sugars and DKA coma in a week.
>
> As a parent of a suspected Type 1 diabetic child, you must be aware of
> the
> symptoms of DKA. Please read and try to understand these medical papers:
>
> http://www.ispad.org/clin-2.htm
>
> http://www.emedicine.com/EMERG/topic373.htm
>
> Please memorize the symptoms and/or post them in view somewhere.
>
> The first symptom of approaching DKA is high blood sugar. Since DKA can
> cause rapid-onset death, please, please, please continue to monitor her
> blood sugar.

We do monitor her blood sugar level twice a day, everyday. Thanks for the
wonderful links.
>
> Pay special attention to her blood sugar at 2 hours after a meal. A
> non-diabetic would be expected to be at 5 mmol/L or lower at that time.
>
> It is not clear to me why you "weaned" her from insulin injections. The
> first treatment for DKA is insulin injection. Daily insulin injections
> are
> a preventative against DKA.
>
The doctor told us to reduce the dosage of insulin if her sugar level
consistently drops, and it did. I'll check with the nurse.

> 3. Type 1 diabetes is genetically induced and mildly hereditary. It is
> an
> autoimmune disease triggered by "something or other".
>
> "Something or other" can be a variety of stress factors, ranging from a
> virus to a food allergy to personal stress. A Type 1 diabetic can have
> no known diabetic relatives of any Type (like me, for instance), or be
> part of a family in which every child and grandchild of a T1 is also T1.
>
> In contrast, Type 2 (Type II) diabetes is almost always strongly
> hereditary.
>
> Sorry, but your statement:
>
> ". . . No one from Ashley's family (from both of her parents' sides)
> is
> diabetic. Ashley's illness cannot be hereditary. . . ."
>
> is totally in error.
>
> There is no known, reliable preventative therapy for approaching Type 1
> diabetes. There is no "restorative" therapy (transplant from sibling)
> There is no way to protect other family members.
>
> Type 1 is an autoimmune disease. Researchers are experimenting with
> immune
> suppressive drug therapies but there is nothing available outside of the
> clinical trials.
>
> 4. Prednisone unmasks developing diabetes of any type. It "orders" our
> livers to produce extra glucose. If our beta cells have been damaged by
> some form of diabetes, they cannot handle the extra glucose and our
> blood
> sugars rise.
>
> There is a theory that the extra work load produced by the release of
> extra
> sugars can accelerate an existing diabetic beta cell destruction
> mechanism.
> Therefore, in theory, prednisone can accelerate the arrival of developing
> diabetes. That is not the same as "induce" or "cause" diabetes.
>
> 4. An HbA1c of 0.064 is not "slightly elevated" It is high, and
> consistent with approaching full-blown diabetes.
>
> My HbA1c has not been that high since I switched from old-fashioned
> insulins to modern insulins several years ago.
>
> (Think about the above statement if your doctor prescribes "old-fashioned"
> insulins when and if the time comes. The modern insulins: Humalog,
> Novolog, Apidra; Lantus and Levemir are much easier to use. Easier
> to
> use means better control which means lower chance of diabetic
> complications.)
>
> The best study of HbA1c I have seen is the U.S. Third National Health and
> Nutrition Examination Survey (NHANES) which reports an average of 5.0% for
> non-diabetics. NHANES is a large study with enough subjects to produce
> an
> expectation of accuracy.
>
> (Note that most of us use the percentage version of HbA1c, i.e. 6.4%)
>
> 5. Exercise helps control blood sugar in any and all diabetics.
>
> When I was in my honeymoon stage, the only way I had available to knock
> down a high blood sugar was riding a stationary bike. A 4-minute mile
> would knock my sugar down by an average of 1.1 mmol/L.
>
> 6. Injection, either by syringe, pen or insulin pump is the most
> reliable
> and accurate method of delivering insulin. There is an experimental
> "inhaled" insulin being tested. I cannot imagine using it on either a
> child, or any Type 1 diabetic.
>
> Please investigate the costs and capabilities of an insulin pump. It is
> the most powerful and reliable insulin therapy available right now.
>
We are in the process of procuring one

> Most insulin therapies for children are "second-best" therapies, used
> because the child has limited understanding and is unavailable to the
> parents during much of the school day. Pump therapy is capable of
> sidestepping these limitations.
>
> 7. "is it possible that she was rashly misdiagnosed?". I cannot
> believe that (except for the fact that Type II is being mentioned so
> often
> when applied to a child with clear Type 1 symptoms). Non-diabetics do
> not
> experience blood sugars much above 8 for any reason at any time. Two
> readings of 11 or more are considered sufficient for the diagnosis by most
> docs.
>
> I commend whoever put Ashley into Emergency care when she spiked to 18
> mmol/L. She was in serious danger at the time.
>
> The gentleman who put together this web site
>
> http://www.rajeun.net/gtt.html#Diabetes and Hypoglycemia
>
> http://tinyurl.com/c5xqo
>
> has harvested responsible medical citations of blood glucose readings for
> non-diabetic and diabetics when stressed by glucose ingestion.
>
> Note that he uses the U.S. notation of mg/dL. ( 18 mg/dL = 1.0
> mmol/L.)
> Ashley's 18-20 mmol/L correspond to U.S. blood sugars of 324 - 360 mg/dL.
>
> Mr. Toussier is not a doctor but, as I stated, he quotes responsible
> medical sources.\
>
> Good luck and please, please test her blood sugars frequently. DKA is
> dangerous.
>
> Regards
> Old Al
>
Thanks a lot. Take care.
>
>

Charles Antony wrote in message
>...
>
>>. . . (snip). . .
>>
>> Please investigate the costs and capabilities of an insulin pump. It is
>> the most powerful and reliable insulin therapy available right now.
>>
>We are in the process of procuring one
>
>. . .(snip). . .

One of the reasons an insulin pump is a powerful therapy is the training
which pump users must take. Insulin Pump training is about the best
DAFNE-type* course available on our side of the Pond. You will really
understand insulin therapy** by the time you are up and running with a pump.
Unlike her peers**, a "pumping" Ashley will enter her 20's with a thorough
understanding of the relationships between her insulin input, her diet,
and her blood sugars.

I have seen the statement (by an ex-pumper) that: "All insulin users should
wear a pump for a while in order to really learn how to use insulin"

(* DAFNE: Dose Adjusted For Normal Eating)

(** insulin therapy: The majority of insulin users have a poor
understanding of insulin therapy. One reason is lack of good training.
In some cases, it's almost as somebody opened a door, threw a vial of
insulin at the diabetic, and slammed the door in their face with barely a
word. I am currently mentoring a T2 lady whose training consisted of
little more than the statement "Here, try this".

That lack of know-how means that many of the comments about insulin-using
diabetics that you see in newspapers and magazines are based on observations
of people who have suffered diabetic complications from high blood sugars
produced, in many, many cases, by their inadequate training and inadequate
insulin regimes.)

Regards
Old Al

Charles,

It sounds like you do not yet have all the pieces to solve the puzzle, but
with time you will.

I don't want to interfere with what your docs are doing, and it sounds like
they are giving you good advice. I don't have all the facts that they do, so
if anything here conflicts with what they are telling you, I would go with
what they say.

In interest of time, I'll comment on some but not all the issues.

>
> · It is said that exercise does not have any impact on type II
> diabetic patients. However, exercise (walking, swimming, and yoga) reduced
> Ashley's sugar level noticeably.

Whoever said this is wrong. Exercise impact both types.

>
> · Ashley's beta cell test (anti islet cell test) performed after
> the diagnosis was negative indicating Ashley was not loosing any beta
> cells. The endocrinologist theorized that Ashley was not loosing any beta
> cells when the test was actually administered. Further, he concluded that
> there is 95% chance that Ashley was Type II diabetic, meaning there is a
> 5% chance Ashley is not diabetic.

You need to be careful with the some of the commercially available tests for
islet cells, as you can see false negative results. IMHO, the best tests in
this family are the Anti-GAD and IA2 antibodies. Negative Anti-GAD and IA2
would suggest no type 1 (see below).

>
> · No one from Ashley's family (from both of her parents' sides) is
> diabetic. Ashley's illness cannot be hereditary.

It can still be hereditary. Most children with type 1 have no family
history, just like Ashley. But when you carefully look at the families, many
of them have other autoimmune diseases such as thyroid disease. And if you
wait a while, it is very common to see more autoimmune disease sprout up in
family members.

>
> · Ashley's siblings are perfectly healthy.

That's good news. But if Ashley is positive for Anti-Gad or IA2, you should
consider checking the siblings for antibodies too. They can be positive for
several years BEFORE the diagnosis.


> · Ashley did not exhibit any type II diabetic symptoms including:
> ketone in blood, excessive thirst, and urinate frequently.

Reminds me of the 17yr old I saw Friday who claimed no symptoms with his 550
mg/dl glucose. We diagnosed him that day with type 1.

>
> My Questions
>

> Naturally, we have a number of questions regarding Ashley's health. The
> staff at THSC has been more than helpful and courteous and I don't intend
> disregard or disrespect their assessment of Ashley's conditions. I just
> have some unanswered questions and was hoping to get some answers from a
> wider forum, while conveying Ashley's story. My questions a
>
> · How can Ashley go from being perfectly healthy (on Feb 24th) and
> Type II diabetic in a week (Mar 03rd)? Can the sugar level increase that
> rapidly over such a short period of time? Wouldn't you expect the sugar
> level to gradually rise if you are diabetic?

No, this is the way children often present.

>
> · Is it possible that Ashley's diabetes was triggered by
> Prednisolone (please see my research in Appendix A)? If so, was Ashley
> given a heavier dose that she needed?

Prednisolone unmasked a previously occuring glucose intolerance, but likely
made it look even worse.

> · Since Ashley did not show most of the symptoms of a type II
> diabetic patient, except for a temporary short sprout in blood sugar
> level, is it possible that she was rashly misdiagnosed? Are there any more
> tests that we can perform to confirm her diagnosis with a higher degree of
> accuracy?

>
> · If there is 5% (according to endocrinologist) chance that Ashley
> is not diabetic, what could explain the whole episode?

There is the entity of childhood "transient hyperglycemia".

Four of my former teachers at Joslin Clinic published a paper on this in
1993. The reference is
J Pediatr. 1993 Sep;123(3):347-54.

"Distinction between transient hyperglycemia and early insulin-dependent
diabetes mellitus in childhood: a prospective study of incidence and
prognostic factors." by Herskowitz-Dumont R, Wolfsdorf JI, Jackson RA,
Eisenbarth GS. . Joslin Diabetes Center, New England Deaconess Hospital,
Boston, Massachusetts. (These are some of the foremost researchers in the
cause of type 1 diabetes)

Here is the abstract

"We prospectively studied 63 children with transient hyperglycemia to
determine their risk of acquiring insulin-dependent diabetes mellitus (IDDM)
and to evaluate the predictive value of immunologic markers of prediabetes
and of the intravenous glucose tolerance test. Children with transient
hyperglycemia were identified by a prospective systematic review of the
laboratory reports of a large children's hospital and an office-based
pediatric practice and by referral from pediatricians. Transient
hyperglycemia occurred in 0.46% of children seen in the children's hospital
and in 0.013% of children attending a pediatric office practice.
Insulin-dependent diabetes mellitus developed within 18 months of
identification in 32% of children in whom transient hyperglycemia was
discovered in the absence of a serious illness, compared with 2.3% of
children identified during a serious illness (relative risk, 13.9; 95%
confidence interval, 1.56 to 123.5). Islet cell antibodies and competitive
insulin autoantibodies each had a 100% positive predictive value for IDDM;
the negative predictive value of islet cell antibodies and competitive
insulin autoantibodies was 96% and 98%, respectively. The stimulated insulin
release during an intravenous glucose tolerance test, adjusted for age, had
the highest overall accuracy of prediction. All children less than 6 years
of age with stimulated insulin release levels < 85 pmol/L (12 microU/ml)
subsequently had IDDM, as did an 11-year-old child whose stimulated insulin
release level was below the 1st percentile of 170 pmol/L (24 microU/ml). To
date, no child whose stimulated insulin release level was above the 5th
percentile has had IDDM. We conclude that when transient hyperglycemia
occurs during a serious intercurrent illness, the risk of progression to
IDDM is low. In contrast, one third of children in whom transient
hyperglycemia is identified without a serious illness can be expected to
have IDDM within 1 year. A combination of islet cell antibodies, competitive
insulin autoantibodies, and stimulated insulin release levels during an
intravenous glucose tolerance test can accurately distinguish children with
prediabetes from those with presumed benign transient increases in plasma
glucose concentrations."

Thus, you could consider doing an IV glucose tolerance test to measure the
insulin output. These authors are still working in the field, and your endo
could call them to see if they would have an updated recommendation. Rich
Jackson is still at Joslin Diabetes Center in Boston, Joseph Wolfsorf is at
Children's Hospital in Boston, and George Eisenbarth is at the Barbara Davis
Center at Univ of Colorado in Denver. They are all extremely nice & helpful
docs, and I bet they would be willing to talk to your endo on the phone if
he/she were to call.



> · Assuming Ashley is in her honeymoon period, is there a way to
> extend it? Are her conditions reversible?

If this is a honeymoon, you can actually extend it with insulin. I realize
this sounds odd, but insulin seems to reduce the immune attack from the
islet cells, and reduces the stress on the islets.


> · Should Ashley's siblings be worried? Are there any precautions
> that they can take?

If Ashley has type 1, they have a small ~5% risk themselves.

>
> · How did exercise help with Ashley's blood sugar level when she
> is diagnosed with type II diabetes?

It helps everyone's BG.

>
> · Is there an alternative treatment method to reduce/control Type
> II diabetes?

In early Type 1 there are preventative treatments being developed with
TrialNet.

If you mean alternative, such as health foods, etc, don't waste your time.


> · Is there an alternative method to administer insulin than
> injections?

Inhaled insulin is being released in the US next month.


> · Can the beta cells be harvested from Ashley's twin sister and
> transplanted to Ashley?

Twin ??!?

Is this an identical twin?

At this point, islet cell transplantation is promising, but not yet 'there'.

Since Ashley's glucose is back to normal, this is a moot issue. She would
not be needing islets if her BG is normal, and the risks to your daughters
are too great.

Summary:

Ashley could have transient hyperglycemia of childhood triggered by her
respiratory illness. The magnitude of the BG elevation was made worse by the
prednisolone. The issue that you have hit upon is how to identify whether
this is early type 1 diabetes vs. transient hyperglycemia.

You may want to consider checking anti-GAD and IA2 antibodies if they were
not the ones already done. Negative antibodies are about 96- 98% predicitive
that she does not have type 1. If negative, you can either wait and continue
to monitor Ashley, or consider doing the IV glucose tolerance test which
would have even more predictive value.

For what it is worth, I have had one similar case in the last 20 years. A 14
year old with a BG of 250 (13.8 mmol/l) , trace ketones, & repeatedly
negative antibodies. I watched her for about 6 years before she moved away,
and still had no recurrence of any glucose intolerance. We discussed doing
an IV glucose tolerance test, but decided not to.

Good luck. Let us know how it goes for you & Ashley.


William C Biggs MD FACE

You could find some interesting information about Type I and Type II
diabetes on this website :

http://metabolic-syndrome-institute.org

olivier


Charles Antony a écrit :
>> You have made a variety of medical statements in your post which are
>> inconsistent with Type 1 and Type 2 diabetes as I know them. I'm not
>> trying to be sarcastic or even ironic when replying at a time in which
>> Ashley's condition must be devastating to you. However, I am afraid
>> that
>> your research has not been deep enough and/or you have been too anxious
>> and
>> too intent in looking for "some way out".
>
> Actually, you are right. I typed in Type II, instead of Type I. I meant to
> say Type I. It must have been the exhausting night. Thanks for your
> response. I really appreciate you taing the time.
>
>> Some remarks from my side (Research Engineer with diabetes, not a
>> medical
>> person)
>>
>> 1. Ashley is exhibiting symptoms quite typical of a Type 1 (Type I)
>> diabetic.
>>
>> Although thirst, excessive urination and the like are symptoms of
>> developing diabetes, the acceleration effect of prednisone could easily
>> have masked them.
>>
>> FWIW, I did not experience any of the classical physical symptoms other
>> than blurred vision and, of course, high blood sugars.
>>
>> 2. A juvenile Type 1 diabetic can go from "no physical symptoms" and
>> normal
>> blood sugar to sky-high sugars and DKA coma in a week.
>>
>> As a parent of a suspected Type 1 diabetic child, you must be aware of
>> the
>> symptoms of DKA. Please read and try to understand these medical papers:
>>
>> http://www.ispad.org/clin-2.htm
>>
>> http://www.emedicine.com/EMERG/topic373.htm
>>
>> Please memorize the symptoms and/or post them in view somewhere.
>>
>> The first symptom of approaching DKA is high blood sugar. Since DKA can
>> cause rapid-onset death, please, please, please continue to monitor her
>> blood sugar.
>
> We do monitor her blood sugar level twice a day, everyday. Thanks for the
> wonderful links.
>> Pay special attention to her blood sugar at 2 hours after a meal. A
>> non-diabetic would be expected to be at 5 mmol/L or lower at that time.
>>
>> It is not clear to me why you "weaned" her from insulin injections. The
>> first treatment for DKA is insulin injection. Daily insulin injections
>> are
>> a preventative against DKA.
>>
> The doctor told us to reduce the dosage of insulin if her sugar level
> consistently drops, and it did. I'll check with the nurse.
>
>> 3. Type 1 diabetes is genetically induced and mildly hereditary. It is
>> an
>> autoimmune disease triggered by "something or other".
>>
>> "Something or other" can be a variety of stress factors, ranging from a
>> virus to a food allergy to personal stress. A Type 1 diabetic can have
>> no known diabetic relatives of any Type (like me, for instance), or be
>> part of a family in which every child and grandchild of a T1 is also T1.
>>
>> In contrast, Type 2 (Type II) diabetes is almost always strongly
>> hereditary.
>>
>> Sorry, but your statement:
>>
>> ". . . No one from Ashley's family (from both of her parents' sides)
>> is
>> diabetic. Ashley's illness cannot be hereditary. . . ."
>>
>> is totally in error.
>>
>> There is no known, reliable preventative therapy for approaching Type 1
>> diabetes. There is no "restorative" therapy (transplant from sibling)
>> There is no way to protect other family members.
>>
>> Type 1 is an autoimmune disease. Researchers are experimenting with
>> immune
>> suppressive drug therapies but there is nothing available outside of the
>> clinical trials.
>>
>> 4. Prednisone unmasks developing diabetes of any type. It "orders" our
>> livers to produce extra glucose. If our beta cells have been damaged by
>> some form of diabetes, they cannot handle the extra glucose and our
>> blood
>> sugars rise.
>>
>> There is a theory that the extra work load produced by the release of
>> extra
>> sugars can accelerate an existing diabetic beta cell destruction
>> mechanism.
>> Therefore, in theory, prednisone can accelerate the arrival of developing
>> diabetes. That is not the same as "induce" or "cause" diabetes.
>>
>> 4. An HbA1c of 0.064 is not "slightly elevated" It is high, and
>> consistent with approaching full-blown diabetes.
>>
>> My HbA1c has not been that high since I switched from old-fashioned
>> insulins to modern insulins several years ago.
>>
>> (Think about the above statement if your doctor prescribes "old-fashioned"
>> insulins when and if the time comes. The modern insulins: Humalog,
>> Novolog, Apidra; Lantus and Levemir are much easier to use. Easier
>> to
>> use means better control which means lower chance of diabetic
>> complications.)
>>
>> The best study of HbA1c I have seen is the U.S. Third National Health and
>> Nutrition Examination Survey (NHANES) which reports an average of 5.0% for
>> non-diabetics. NHANES is a large study with enough subjects to produce
>> an
>> expectation of accuracy.
>>
>> (Note that most of us use the percentage version of HbA1c, i.e. 6.4%)
>>
>> 5. Exercise helps control blood sugar in any and all diabetics.
>>
>> When I was in my honeymoon stage, the only way I had available to knock
>> down a high blood sugar was riding a stationary bike. A 4-minute mile
>> would knock my sugar down by an average of 1.1 mmol/L.
>>
>> 6. Injection, either by syringe, pen or insulin pump is the most
>> reliable
>> and accurate method of delivering insulin. There is an experimental
>> "inhaled" insulin being tested. I cannot imagine using it on either a
>> child, or any Type 1 diabetic.
>>
>> Please investigate the costs and capabilities of an insulin pump. It is
>> the most powerful and reliable insulin therapy available right now.
>>
> We are in the process of procuring one
>
>> Most insulin therapies for children are "second-best" therapies, used
>> because the child has limited understanding and is unavailable to the
>> parents during much of the school day. Pump therapy is capable of
>> sidestepping these limitations.
>>
>> 7. "is it possible that she was rashly misdiagnosed?". I cannot
>> believe that (except for the fact that Type II is being mentioned so
>> often
>> when applied to a child with clear Type 1 symptoms). Non-diabetics do
>> not
>> experience blood sugars much above 8 for any reason at any time. Two
>> readings of 11 or more are considered sufficient for the diagnosis by most
>> docs.
>>
>> I commend whoever put Ashley into Emergency care when she spiked to 18
>> mmol/L. She was in serious danger at the time.
>>
>> The gentleman who put together this web site
>>
>> http://www.rajeun.net/gtt.html#Diabetes and Hypoglycemia
>>
>> http://tinyurl.com/c5xqo
>>
>> has harvested responsible medical citations of blood glucose readings for
>> non-diabetic and diabetics when stressed by glucose ingestion.
>>
>> Note that he uses the U.S. notation of mg/dL. ( 18 mg/dL = 1.0
>> mmol/L.)
>> Ashley's 18-20 mmol/L correspond to U.S. blood sugars of 324 - 360 mg/dL.
>>
>> Mr. Toussier is not a doctor but, as I stated, he quotes responsible
>> medical sources.\
>>
>> Good luck and please, please test her blood sugars frequently. DKA is
>> dangerous.
>>
>> Regards
>> Old Al
>>
> Thanks a lot. Take care.
>>
>
>