Type 1 diabetes is an autoimmune disease, and the pathophysiology of the disease itself is not fully understood. It is known that there must be a genetic predisposition and that some environmental factor must exist to initiate the entire process. It is also worth mentioning that the genetic predisposition is relatively weak, since only about one in sixteen people who are at risk actually develop diabetes.
Over time, the focus has somehow shifted toward viruses. Again, it is not entirely clear which viruses are involved or why they trigger diabetes in some individuals but not in others. In any case, diabetes remains a major scientific unknown, and the therapeutic approach is largely experience-based.
What is particularly important to emphasize from clinical experience is the fact that if hyperglycemia is brought under control very quickly with insulin therapy, the need for insulin rapidly decreases. If doses are reduced wisely, avoiding hypoglycemia, several weeks after diagnosis it is possible to achieve remission—a temporary reversal of the disease—and discontinue insulin therapy, or remain on very small doses or a single dose. The faster and more effective this process is, the longer the remission lasts. Interestingly, remission can be achieved more than once.
It is also important to know that when insulin therapy is reintroduced, a person may remain on very small doses or a single dose for a long time, sometimes even longer than 10 years.
The presence of endogenous insulin production in the pancreas is significant not only because of the small doses and fewer injections, but also because insulin produced by the pancreas is preserved while exogenous insulin from injections is active. It can then be utilized in cases of dietary mistakes or other increased needs, so that glycemic profiles remain stable despite an inadequate dose administered by injection.
For a long time, it was believed that remission was a characteristic only of type 1 diabetes. Type 2 diabetes is a completely different pathophysiological problem. Insulin resistance exhausts the beta cells that produce insulin, their functional number decreases, and blood glucose levels rise. It was long believed that these cells are lost permanently, but it turned out that they are only nonfunctional, and active work is being done on ways to restore their function.
It has been shown that good glycemic control is one of the simple ways to achieve this. Several years ago, Chinese researchers demonstrated that a similar remission effect after good glycemic control also exists in type 2 diabetes. If a person with high blood glucose is given temporary insulin therapy and euglycemia is rapidly achieved, these individuals will also achieve remission and can then be treated with oral therapy for many years.
This is the reason why every person who presents to healthcare services with high blood glucose should receive insulin therapy for at least some period of time. Once glycemia is normalized, if it is assessed that type 2 diabetes is present, oral therapy should be initiated as recommended by the ADA and EASD consensus.
Author: Miodrag Đorđević
