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let's go on to another case an eighteen
year old woman is diagnosed with type 1
diabetes three months prior to coming to
see you her initial hemoglobin a1c level
was twelve point three percent she was
started on both a basil and a prandial
insulin regimen her blood glucose
readings now show episodes of both
fasting and post prandial hypoglycemia
with blood glucose levels ranging from
45 to 60 milligrams per deciliter
medications are insulin glargine and
insulin aspart and on physical
examination her blood pressure is 115
over 60 and her pulse rate is 60 beats
per minutes her BMI is 18 kilograms per
meter squared the remainder of her
examination is unremarkable a current
hemoglobin a1c level is 6.2 percent what
accounts for the low blood glucose
readings this young woman has type 1
diabetes that was diagnosed three months
ago manifesting with a very very high
hemoglobin a1c after beginning treatment
with insulin before each meal and
long-acting insulin doses in the morning
and evening her blood sugar levels are
now very low three months later her exam
reveals a very thin patient manifested
as a low body mass index and a
hemoglobin a1c is quite low in fact it
is now half of what it was three months
prior what this implies is that she is
responding very very well to her insulin
dosing which is calculated initially
based on her body mass index at the time
of diagnosis and her calculated
carbohydrate load in her daily diet as
the insulin begins to work there is a
reduced metabolic stress on the
remaining beta cells and reduced
toxicity from prior high glucose levels
on the pancreas some beta cells regain
their ability to produce endogenous
insulin and she is now getting too much
exogenous insulin in the form of her
daily insulin injections so hemoglobin
a1c is low and a premium fingerstick
sugars are also low this
Naaman and is called the honeymoon phase
of type 1 diabetes and its management
and presence is a good sign that the
pancreas and beta cell activity is
recovering the unfortunate thing is that
it only lasts for a very short time the
conclusion to this case is that the
honeymoon phase is accounting for a low
blood glucose and we're now going to go
on to a discussion of the honeymoon
phase the patient's pancreas has
responded to the low blood sugar from
treatment with insulin by resuming
endogenous insulin production and this
has led to in combination with
endogenous and exogenous insulin
hypoglycemia it is likely that this
condition will not be permanent and this
patient would benefit from lower insulin
doses of both a bolus dose and a
prandial dose after insulin therapy for
type 1 diabetes begins the remaining
functioning beta cells Maher gained the
ability to produce some insulin which
explains her low blood sugars the
ability of some beta cells to produce
endogenous insulin and the lower blood
sugars in the short term in terms of her
finger sticks and low blood sugars in
the intermediate term in terms of her
hemoglobin a1c as stated this
unfortunately does not last the next
step as mentioned would be to reduce her
basil and prandial insulin doses so that
hypoglycemia is avoided continuing
insulin however even at low doses is
recommended during the honeymoon phase
this is in order to preserve the beta
cell function as long as possible by
reducing the metabolic stress on those
remaining cells
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you