Honeymoon period (diabetes)

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The honeymoon period for patients with Diabetes mellitus type 1 is the period that often follows diagnosis and initiation of insulin treatment. It is often suggestive of remission, but it is important to note that the two are unrelated - it is not a cure for type 1 diabetes.[1] During this period some of the insulin-producing beta cells of the pancreas have not been completely destroyed yet and produce unpredictable amounts of endogenous insulin. This period does not occur in all patients.[2] If the honeymoon period does occur, it lasts for varying lengths of time and can affect diabetics differently.

Contents

Importance of insulin therapy

When patients are first diagnosed with Type 1 diabetes, they are immediately started on exogenous insulin injections to control their blood sugars. Patients who experience a honeymoon period will notice that they experience hypoglycemia (low blood sugars) due to some of their own endogenous insulin working additively with the injected dose (calculated by their endocrinologist, usually as a carbohydrate-to-insulin ratio for each meal). Since this honeymoon period does not last forever, rather only for a short period of time, over time patients will notice fewer lows as their residual beta cells lose function. Eventually, the possibility for hyperglycemia (high blood sugar levels) arises due to the complete inactivity of their beta islet cells. At this point, patients will have to adjust their insulin-to-carbohydrate ratios.[2]

It is important to maintain insulin therapy during the honeymoon period.[3] Immediately prior to diagnosis, diabetic individuals have excess glucose in their blood that their tissues are not able to absorb but which decreases the activity of any viable islet cells in the exocrine pancreas. This is commonly believed to be caused by a phenomenon called glucose toxicity but current research also suggests a major role of the immune system.[4] Once insulin therapy is started, the excess sugar inactivating the beta cells is removed and remaining viable beta cells produce and release some insulin throughout the honeymoon period. This period may last for weeks or months but not indefinitely and the amounts of insulin released are not consistent nor reliable to base exogenous insulin doses on. Type 1 diabetics, therefore, cannot eliminate regular insulin injections. It is also believed that injecting exogenous insulin daily at every meal allows the surviving beta cells of the pancreas to rest and this may allow viable beta cells can produce a small amount of insulin.[4] Eventually, these viable beta cells will be destroyed, however and a complete insulin deficient state occurs. Therefore, if insulin injections are completely omitted during the honeymoon period, the possibility of the patient developing diabetic ketoacidosis is high.[1]

Patience is key

The honeymoon period may be a very frustrating time for diabetics since tight control of blood glucose levels is very difficult and ever changing insulin demands are required. To decrease the amount of lows experienced due to additional endogenous insulin production, their endocrinologist will re-calculate insulin dosages often via the insulin-to-carbohydrate ratio method. This is to accommodate for the extra insulin production but can happen on a weekly basis. Upon the completion of the honeymoon period, the patient will suddenly notice elevated glucose levels, although insulin doses and amounts of carbohydrates consumed are kept consistent. Again, their doctor will have to adjust their insulin dosages accordingly (increasing the injection doses) and each time continue closely monitoring their glucose levels for a week or two, to observe how their body is reacting to the changing insulin availability (both exogenous and endogenous).[1]

Length of honeymoon periods

The honeymoon period may last anywhere from weeks to months, and sometimes up to a year. Rarely will patients experience this period for prolonged lengths of time, more than a year. Unfortunately, there is no possible way to remain within the honeymoon period or to extend it.[1] Diabetics must continue their prescribed insulin therapy as directed by their doctor to maintain normal glucose levels (4.0-10.0 mmol/L) during and post honeymoon period.[5] Big fluctuations in glucose levels (hypoglycemia and hyperglycemia specifically) may cause the honeymoon period to end sooner than if the glucose levels were tightly managed. Individuals who are diagnosed later in life, like teens and young adults, experience a longer honeymoon period than young children (early onset type 1 diabetes) because their beta islet cells lose function and are destroyed more slowly.[1]

What not to do during a honeymoon period

It is very important to remember to not stop injections of exogenous insulin during a honeymoon period as it is not a case of disease remission, rather unpredictable residual insulin production. Patients must maintain a very tight grasp on their glucose levels and be in constant communication with their doctor, reporting all glucose levels (high, low, or normal), symptoms and steps taken to treat any hypo- and hyperglycemic events, as they need to deal with it accordingly. Never forget that the honeymoon period will come to an end eventually and a much tighter grasp on glucose levels as well as a more consistent insulin routine will be established.

References

  1. ^ a b c d e The Honeymoon Phase
  2. ^ a b HealthCentral: The Honeymoon Period in Type 1 Diabetes
  3. ^ Jay H. Stein, M.D. et. al., ed. 1998. Internal Medicine, Stein. Printed in the United States of America. Mosby, Inc. ISBN 1071-3964
  4. ^ a b Aly, Hanan and Gottlieb, Peter. "The honeymoon phase: intersection of metabolism and immunology", Current Opinion in Endocrinology, Diabetes & Obesity, 2009. 16:268-292.
  5. ^ Bao, Jiangson et al. "Improving the Estimation of Mealtime Insulin Dose in Adults With Type 1 Diabetes", Diabetes Care, 2011.