Ask D’Mine: Insulin Overdose and What to Do About Dry Skin

Happy Saturday, the last of 2012! The year may be ending, but don’t worry, our weekly advice column Ask D’Mine isn’t going anywhere.  We’re just tickled to keep on truckin’ with veteran type 1, diabetes author and educator Wil Dubois — who’s never shy to tackle the tough questions.

Today he’s talking about why exactly PWDs (people with diabetes) have hypoglycemia, and what the deal is with dry skin on the feet and legs. Read on!

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

Dan, type 3 from Massachusetts, writes: Love your column! I’m a dad to a type 1 son (diagnosed 1 year ago) and son to a type 1 father (50 years on). My question that I haven’t found an answer to yet: It’s obvious why BG rises in a type 1 — lack of insulin to help it get into the cells and out of the bloodstream. But why all the problems with lows? Why can’t the natural mechanisms of the body kick in (is glucagon the only mechanism at play?) to keep a diabetic from going low, as happens with non-diabetics? Is there so much more injected insulin in a diabetic than naturally occurs in a non-diabetic person that it overwhelms that response?

Wil@Ask D’Mine answers: You pretty much had it figured out on your own, Dan. When the type 1 body deals with artificial insulin it has brought a knife to a gun fight. A fire extinguisher to a bonfire. A fly swatter to deal with condors. A mesh net to catch a shark. You get the idea.

Real-life trivia: Betcha don’t know how long insulin from a sugar-normal like yourself stays effective in the blood. The answer: About five minutes. Not very long! How long does modern “rapid” acting analog insulin last? Four hours!

So the main problem with type 1 lows is an issue of supply and demand. The sugar-normal’s pancreas mainlines insulin straight into the blood stream via the rather large portal vein. Because the commute is so short, not that much insulin is needed to do the job. On the other hand, those of us using our primitive pumps, pens, and syringes are shooting into the layer of fat between our skin and muscle. Sure, the insulin gets taken up by the blood system, but it takes quite a while for that to happen. That’s one reason the half-life of injected insulin is about twenty-four times longer than the half-life of endogenous insulin; it has to last long enough to get to the job site.

Realistically, we type 1s are taking controlled overdoses every time we shoot up. When we don’t control the shot well, which is often, we go low. That’s because despite our very best efforts at carb counting, insulin tracking, paying attention to our level of exercise and stress, even on a good day we’re basically using stone knives and bear skins to try to build a space station. Our best technology falls woefully short of the elegance of the properly functioning human body.

As for the body’s response to insulin, several factors are at play. First off, in the absence of an artificial source of extra insulin—such as an injection of insulin manufactured in an Eli Lilly plant, or a medication designed to increase insulin production—it’s unlikely your pancreas would produce much more insulin than needed. Still, the body is a system full of checks and balances. Hormones and counter-regulatory hormones. And the counter-regulator for insulin is glucose. The chemistry is pretty simple. Too much sugar, add insulin. Too much insulin, add sugar. They are poison and antidote to each other.

Wait a sec, you say, what about the glucagon? Where does that come into play? Glucagon, either the body’s own, or from an emergency kit purchased at Rite Aid, is simply a means to an end. It’s a signaling hormone. The stuff itself doesn’t lower sugar. It just makes the liver cut loose with some of the glucose it’s been hoarding. (For you detail-oriented freaks… err… folks… glucagon signals the liver to convert glycogen to glucose and release it.) And that glucose from the liver is what reverses the low.

The problem with type 1 is that we’ve added so many artificial layers that the natural system isn’t equipped to deal with our artificial reality. So the body’s internal defense mechanisms can’t keep up.

Secondly, in those of us with type 1, the response to hypos gets blunted. There are a number of theories as to why this is, among them that long-term elevated blood sugars can create a slow-onset progressive neuropathy that fries the system; that the immune system attacks the Alpha cells in the pancreas (which seem to have a role in glucagon signaling); or that the system simply gets worn out from overuse.

You also asked if glucagon was the only mechanism at play. Um, no. There’s also epinephrine (a.k.a. adrenaline) in some cases. Think of it as the body’s Plan B. If the whole glucagon, glycogen, glucose thing isn’t doing the trick and blood sugar is still falling, the kidneys try to ride to the rescue, and the body cuts loose with the sugar-rich epinephrine—the body’s natural Red Bull—to give you wings. Actually, if you “feel” a low, what you’re feeling isn’t the low blood sugar, or the glucose release from the liver. You’re feeling the cascade of adrenaline through your body. So when you feel the symptoms of a low, Plan A has already failed.

And of course both Plan A and Plan B often aren’t enough. The body simply isn’t equipped to deal with an overdose of insulin that lasts 24 times longer than evolution built it for. That’s why we need to use yet another artificial solution to an artificial problem: a pocket full of fast-acting glucose tabs.

Alan, type 1, from Illinois, asks: Man do I have severe dry skin, especially on my legs and feet. I use lots of “diabetic cream” but that doesn’t seem like enough. Any suggestions?

Wil@Ask D’Mine answers: I’m sure glad you asked me for “any” suggestions, rather than “any good suggestions.” So, of course you know that dry skin is more common among D-Folk than sugar-normals, and the longer you’ve had diabetes the worse the problem is. And of course you know that if your blood sugar control sucks, the dry skin is worse because hyperglycemia dries out your skin.

And I assume you know the much-publicized basics: avoid long baths; soaking in water actually robs the skin of hydrating oils. Use warm rather than hot water when bathing. Be alert that many soaps have a skin-drying effect. Avoid lotions with alcohol in them. When drying off, “pat” dry, don’t rub. The best time to put lotion on is right after bathing. Drink lots of water. Put a humidifier next to your bed. Note I said humidifier, not humidor. A humidor is a sexy box for keeping your cigars from drying out, too. Arguably, an equally tragic event.

Of course, visit your doc to ensure that you don’t have some funky fungus or yeast that might be making the drying worse. But then, here’s my last-ditch advice: When you go to bed, slather your feet with Vaseline and then cover your feet with socks. I know. It’s messy and not particularly sexy. But severe dry skin isn’t sexy either. This goopy sock method works for a lot of d-Folks in your boat. Your skin will bask in healing moisture all night.

You’ll probably need to do it for a number of days, maybe even for a full a week at first. After that, hopefully just now and again.

Oh, and be careful when you take them off in the morning. I don’t want you slipping and falling in the shower. Drowning is not considered the best cure for dry skin.

Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.