CONTROLLING YOUR DIABETES, FOLLOWING THE PROTOCOL,
AND USING LANTUS INSULIN

TIME

• Inject Lantus once daily in the morning, at the same time every day. Eat breakfast right after you inject your insulin. Do not vary the time of your injection. This is very important. Lantus lasts for 24 hours. Set your clock if you need a reminder. So if you injected at 8 AM yesterday, you will inject at 8 AM today, then eat breakfast. Congratulations-you are now a regular breakfast eater!

SITE OF INJECTION

• Although, according to the company, you can inject into other sites, I would prefer you give yourself your injections only in the abdominal skin around the umbilicus (belly button). Occasionally you will see some bruising, as small veins (inferior epigastric) run through this area. This is bruising is cosmetic only and will heal.

EATING

• Do not skip any meals while on insulin. You must eat three times per day. Each meal should contain some protein (meat, milk, etc.) If you skip a meal for any reason you may become hypoglycemic. This can cause you to be dizzy, fatigued, sweaty, lose consciousness or have a seizure. If you eat three times per day and follow my instructions carefully you will never become hypoglycemic.

YOUR IDEAL DOSE

• My method involves starting a dose of Lantus insulin which is BELOW your actual need. Your dose is gradually increased every 1-2 days until your blood sugar reading is in a controlled range, often 100-130 mg% .
• When your true (optimal) insulin need is found, you will begin to require less insulin over the succeeding weeks. We will then lower your insulin dose (gradually, by approximately 5 units per day, depending upon your daily blood sugar readings). During the process of reducing insulin dose, your fasting morning blood sugar should remain between 100 and 130 mg%.
• If your blood sugar drops (at any time during the day) below 100 mg% this is a signal for you to reduce your insulin by 5 units the next morning, whether or not you can contact me.

DON'T BE IN A HURRY

• This is a gradual process. Don't "chase" high blood sugar readings by giving yourself doses of short-acting insulin. This is extremely dangerous, as it may induce hypoglycemia. The consequences of hypoglycemia range from fatigue and tremulousness to loss of consciousness, seizure and death. Follow the guidelines meticulously and hypoglycemia will be avoided.
• If you are taking even a small dose of 24-hour active insulin and drinking enough fluid you will NOT go into diabetic ketoacidosis or hyperosmolar coma. You do not need to go to the Emergency Room or Urgent Care if your blood sugar reading is high and you feel well. Drink "sports drinks" like Gatorade, not clear water. You need electrolyte replacement (salt and potassium) which plain water does not provide. If you become concerned send me e-mail (the best method), go to my diabetes website, or call the answering service and explain that you are one of my diabetic patients.

EXERCISE

• Exercise daily for about 20-40 minutes, depending on your tolerance.

DIET

• Reduce the amount of carbohydrate in your daily diet. (No refined sugar. Avoid products made with white flour. Avoid rice, potatoes and bread.) You may eat these, but I prefer you reduce the amount you consume of these foods. Increase your protein, vegetable and fruit intake. After the first three weeks, you can have more carbohydrates, but concentrate on following an "Atkins-style" diet at the outset. (Information about these diets can be found by searching the Web, or asking at your local library or bookstore.) Avoid drinking alcohol to excess. Alcohol damages the pancreas. Do not drink alcohol every day and never to excess.

KEEPING IN TOUCH

• Send me e-mails daily (robertovilla@pol.net) if you cannot come in. List your name, medications you are taking, the # of units of Lantus insulin you are injecting daily, and if you are experiencing any symptoms. Also list other medications you are taking.

RECORD KEEPING

• Check your blood sugar twice daily. First test: Just before you eat breakfast. Second test: Just before you eat dinner. Bring your glucose meter to EVERY visit with me. I download information from your meter every time you come in. This information guides me in deciding on changes to your medications. If you have any symptoms (weakness, dizziness, tremulousness or sweating) test immediately (as many times as this happens) and report these symptoms to me. If you have had diabetes for more than one year or have ever had a blood sugar in excess of 500 mg% you should test your sugar more often initially. For example, add after breakfast and after dinner testing, for a total of four readings per day. Once your diabetes comes under control you may reduce this to three times daily, and then to twice daily.

DON'T DO STUIPD THINGS

• Do not inject any other kind of insulin from any other source. Remember: if you are on Lantus, you will not go into ketoacidosis even with a blood sugar as high as 600 mg%-if you are hydrated. Drink lots of fluids, but this must be GATORADE or similar sports drink or fruit juice, not plain water.

MEDICATIONS TO AVOID

• Hydrochlorthiazide (HCTZ). This medication may elevate your blood sugar. If you are in remission, this medication may cause you to relapse. This is a commonly used mild diuretic and is often combined with antihypertensive medications (medicines that reduce blood pressure).
• Corticosteroids. The most common oral forms of this type of medication are Prednisone and Medrol. In certain cases you may need to take this type of medication, but be aware that your blood sugar will rise. A form of corticosteroid is often injected into the back to treat disc disease or into tendon or joint spaces for pain by certain specialists. This may cause a transient rise in the blood sugar which may last several days.
• Atypical Antipyschotic medications. These medications may cause alterations in the immune system which then predispose the patient to diabetes. This indirect effect would be consistent with the observation that only a very few patients taking these medications develop diabetes. Examples: Zyprexa (Olanzepine), Risperdal (Risperidone), Seroquel (Quetiapine), Geodon (Ziprasidone), Clozaril (Clozapine), Abilify (Aripprazole).
• Beta blockers. The mechanism of the development of diabetes on this group of medications may resemble the mechanism for the atypical antipyschotics. Examples: Atenolol, Metoprolol, Labetalol, Inderal. However, Coreg (Carvedilol) is an exception and appears to be an ideal beta-blocker for diabetics with hypertension. However, there is a report that it can, like other beta-blockers, predispose a patient to the acquisition of diabetes mellitus (Cardiovasc Drugs Ther., 2003 May; 17(3):295). In most patients, however, it does not seem to elevate the blood sugar or block symptoms of hypoglycemia.
• Metformin (Glucophage). Do not take this medication if you are on insulin or you have had diabetic ketoacidosis in the past. Abdominal pain and diarrhea are common side effects with this medication. " Combination medications: Examples: Avanda Met. Actoplus Met. Each patient's need for a particular medication will vary over time, and the susceptibility of each patient to a particular side effect will vary from person to person. The safety of each component of these combinations is not equal. Combining medications in fixed combinations ignores these facts, and is done for marketing purposes by business people in the pharmaceutical companies. It is not done by doctors for the betterment of the patient's health. Never take combination insulin (mixed insulin) preparations such as 70/30 or 75/25. Doing so multiple times per day or with other insulins will cause hypoglycemia.

POSSIBLE REMISSION OR CURE

• If you have not had an adverse reaction to thioazolidinedione medications (glitazones) like Actos or Avandia, I will start you on one of these early in your course. Doing so will make it possible for you to go into remission, because these agents have been proven to "rejuvenate" the cells in your pancreas that make insulin. So it is possible for you to be temporarily "cured" of your diabetes. This is more likely if you have come in soon after the discovery of your diabetes. For these drugs to work properly your blood sugar must be maintained in a normal range. Most people who go into remission (that is, they maintain normal blood sugars with no medication) will, from time to time, experience a relapse and they will need medication again. However, during their relapse their blood sugars do not go up as high as they were before and, in most cases, remission can be re-established with a short course (weeks) of thiazolidinedione medications (e.g. Actos or Avandia).

DON'T FORGET TO CHECK FREQUENTLY

• As you improve, your need for insulin will drop gradually, although in some cases the drop may be rapid. We may have to lower your insulin dose by 5-10 units per day. Ultimately, you may not need insulin at all.
• The treatment of diabetes is a dynamic process. The epidemic form of the disease, the most common, is probably due, in large part to a viral infection. One or more than one virus may be involved.

Roberto Victor Illa, M.D.
Internal Medicine,
Board Certified
Diabetes/Hypertension