In part 1 and part 2 of this series, we discussed the different types of diabetes and their complications. In this article, we’ll discuss what the medic’s treatment strategies should be for diabetic family or group members in times of trouble.
Finding yourself as the end of the line with regards to control of diabetics in the uncertain future will be difficult. You may have learned how to splint a fracture or clean a wound; treating chronic medical illnesses like diabetes, however, will be quite a challenge even for medical professionals.
Your goal for diabetics won’t be the same as it is in normal times. Tight control of sugar levels involves aggressively expending items that will be in short supply in times of trouble. When the grid’s down, your goal should be to balance the available insulin and other supplies with glucose control, especially in type 1 diabetics.
Here’s the tough part: This must be done in such a fashion, not necessarily to keep glucose levels normal, but to keep them below that seen in “diabetic ketoacidosis,” something we discussed in earlier articles. This condition occurs as a result of extreme high blood sugars due to lack of Insulin, as you would see in a societal collapse. Diabetic ketoacidosis (DKA) is usually characterized by a serum glucose level over 250.
I have absolutely no scientific proof for the above strategy other than plain logic. Insulin, like most liquid medications, will lose potency relatively quickly after it expires. A power source is needed to maintain insulin pumps, glucometers, and other paraphernalia needed to tightly control blood sugars. What happens when the batteries run out? What happens when you run out of test strips and have to go by physical signs and symptoms?
If the you-know-what hits the fan, you will find yourself in the unenviable position of making decisions as to how to dispense precious and limited commodities. Therefore, unless the disaster scenario is a short-term one, you can’t afford to expend supplies in the usual manner necessary for tight diabetic control.
This hard fact leaves you with having to accept the possibility that you will have to keep your type 1 diabetics at higher glucose levels than you would like. If you’re unable to check blood sugars, your only guide will be to keep your diabetics from showing signs of deterioration. Their glucose will not be normal, but you might be able to keep it at levels low enough to avoid emergencies like DKA. Even a few months of less-than-optimal control may be survivable and give time for society to re-stabilize.
Diabetic ketoacidosis symptoms may occur at different blood levels in different individuals, so you should always be aware of visible signs and symptoms, which often present quickly. These signs and symptoms include:
- Excessive hunger and/or thirst
- Frequent urination
- Nausea and vomiting
- Abdominal pain
- Weakness or fatigue
- Shortness of breath
- Fruity-scented breath (also called “ketosis”)
You have to watch your diabetics closely, especially the type 1 patients, for the above signs and symptoms. In normal times, low sugar reactions (also called “hypoglycemia”) from too much insulin or physical activity comprise more than 90% of diabetic emergencies. These patients improve rapidly from receiving a small amount of sugar or honey under the tongue. As the insulin runs low, however, high sugar reactions, such as diabetic ketoacidosis, will become more common.
The product labels recommend that insulin be stored in a refrigerator at approximately 36°F to 46°F. Unopened and stored properly, it maintains potency until the expiration date on the package (usually about a year). Opened vials kept at room temperature are thought to last only 28-42 days, depending on the insulin type. That doesn’t necessarily mean that it’s useless the day after, but, unlike longer-shelf life meds in pill or capsule form, loses strength rapidly.
So what would you do when a disaster leaves you with a limited amount of insulin and no ability to get any more? That’s a difficult situation, and there is no CDC recommendation (as far as I can tell) that addresses it. Therefore, the following is purely my opinion.
One option is to take the insulin as usual until it runs out. This will assure normal control for the time being. The insulin is still potent; you can even continue to check glucose levels if the batteries are still good. This is the simplest (and, certainly, most optimistic) strategy. Hopefully, society will restabilize in time for insulin manufacture to restart. If it doesn’t, rapid deterioration of your diabetic patients may occur once your insulin runs out. This may be noticeable within days after the last dose.
Another option is to “ration” insulin. Your goal would be to give just enough to prevent diabetic ketoacidosis (DKA). If you were able to measure blood glucose levels, you would shoot for a value of closing in on 200. This level is much higher than normal but lower than usually seen in DKA. Rationing is a grim strategy, however, because you will be decreasing your patient’s lifespan even if it works to improve the short-term situation.
Insulin adjustments will be difficult to make. There are no studies that evaluate what the effect of withholding part of an insulin dose would be. The same goes for using expired insulin. By the way, insulin that is clear when new should not become cloudy, change color, or accumulate debris in the bottom of the bottle. These could be signs that it has degraded or contaminated.
An additional strategy for diabetics, especially type 1, would be to strictly regulate diet and subsist on a diet almost entirely comprised of protein and fats. The key is to restrict caloric intake, especially from carbohydrates: Give barely enough to maintain normal weight. This is yet another unhealthy practice in the long run, but frequent, small, high-protein meals may keep glucose levels below ketoacidosis levels for a time.
(An aside: Diabetics have increased sugar levels in their saliva and a decreased ability to fight infection, so careful attention to dental hygiene is important. Ill-fitting dentures are more likely to cause mouth sores that won’t heal.)
With regards to type 2 diabetes, it’s most often seen in older, heavier, and less active individuals. Weight control and limitation of the amounts of dietary carbohydrates (which the body turns into sugars) is important. Regular exercise also decreases blood sugar levels, thus improving glucose control.
In survival settings, dietary restriction and increased physical activity may be exactly what the type 2 diabetic will experience. I suspect that a number of type 2’s will find their condition doesn’t worsen, especially if they started off overweight. Eating small, frequent meals and staying active may even improve some of the minor cases. Here’s where careful attention to appropriate food storage for diabetics will help. Plan for a balanced diet high in fiber, low in saturated fats. and (of course) low in concentrated sugars.
The most popular medication used for treatment of type 2 diabetes is called metformin. It works in various ways, including increasing the cells’ sensitivity to insulin. In tablet form, it is a good candidate for long-term medical storage. Other oral medications for type 2 include sulfonylureas and others. Metformin and sulfonylureas may have a synergistic effect: That is, they may have more effect on lowering glucose levels when used together than alone.
Be careful to watch your type 2 diabetics on Metformin as they lose weight during the struggle for survival; they could easily become hypoglycemic. if so, you may have to adjust the oral dosage downward. Dosages of medications vary according to several factors, such as weight, age, severity of condition, etc.
Although controversial, there are a few studies that indicate that Metformin may help with type 1 diabetes. In 2018, researchers published a report that concluded that metformin decreased glucose concentrations and required insulin dosage more than insulin therapy alone. These effects were seen even one year later. Patients still require insulin, but may need less. If you’re considering alternative strategies, testing glucose levels would be wise before a disaster occurs.
Remember, any diabetic for whom you will be responsible should be evaluated now by a physician. Make sure that they are well controlled before a disaster occurs. The better the diabetic control early on, the less organ damage and the higher the chance for survival.
(Aside: New therapies are always under investigation that may one day eradicate Type 1 diabetes. One discovery, made at UT Health San Antonio, increases the types of pancreatic cells that can be made to secrete insulin. It claims to have cured diabetes in mice. To my knowledge, the research on this option and others remains in clinical trials.)
Next time, we’ll examine the potential of natural substances to improve the situation for diabetic patients when the you-know-what hits the fan.
Joe Alton MD
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