What is type 3 diabetes?
Type 3 diabetes is any form of diabetes diagnosed outside the usual diagnostic criteria of type 1 and type 2. So it is an umbrella term describing lots of different types of diabetes. Diabetes in its literal translation means sugary urine. Therefore, any condition causing high glucose levels induces a form of diabetes. However, there are lots of different types.
For example, one form of type 3 diabetes is when continuously high glucose levels are associated with the onset of cognitive deterioration. This results in conditions such as Alzheimers and/or dementia developing. Another type of type 3 diabetes is caused by cystic fibrosis.
However, when most people refer to type 3 diabetes they are usually referring to type 3c diabetes. Alongside, cystic fibrosis, type 3c is the most common type of diabetes we treat in hospital. Type 3c diabetes is an induced form of diabetes following pancreatitis or pancreatic cancer. Injury to the pancreas can lead to problems with how it normally releases it’s hormones and enzymes.
These hormones known as insulin and glucagon help to regulate blood glucose levels. Enzymes help to digest food so nutrients can be taken from it.
Normally, type 3c is used interchangeably with type 3 diabetes and therefore from this point forward we will refer to type 3c as just type 3.
Cause of type 3 diabetes
There are many causes but the main culprits are alcohol excess, smoking, pseudocysts, blockages in the pancreatic duct or pancreatic cancer. Each can damage the pancreas in their own way. If you suffer with pancreatitis and continue to drink and smoke, it is advisable that you stop as soon as possible to prevent things worsening.
What are the symptoms of type 3 diabetes?
With type 3 diabetes you can still be prone to the symptoms of diabetes if your blood glucose are high. Symptoms include include weight loss, thirst, dry mouth, blurred vision, genital itching, tiredness and fatigue amongst others. You are unlikely to experience such symptoms without knowing the cause. This is because your team will inform you of the symptoms and you will regularly test your glucose levels.
Different types of treatment for a partial pancreatectomy
Following pancreatic problems or surgery, you may need to start insulin if your glucose levels are frequently above 11mmol/L. Insulin lowers glucose levels in the body. Usually, your body releases just the right amount of insulin to help keep glucose levels in a specific range. Currently insulin tends to be the only treatment option in type 3 diabetes patients. This is because the pancreas has lost some or all of its insulin production capabilities. Therefore, treating this with other conventional diabetes medications such as tablets, will not work, as we need to replace the insulin that is lost.
Most of the insulin producing cells in the pancreas are located in the tail end of the pancreas. Therefore, surgery or injury to this end makes it more likely you will require some insulin treatment but it does not guarantee it.
Some patients will only need a once daily insulin to help stop glucose levels creeping up.
This type of insulin is called a long acting, a background or a basal insulin. These insulins stop your liver releasing too much glucose into your blood and therefore prevent a high baseline glucose level. This is usually measured by looking at your waking glucose levels.
Background insulin provides 24 hours of insulin coverage and needs to be taken every day. This can be taken once or twice a day depending on the insulin and your personal circumstances.
If you are started on a long acting insulin you will need to test your blood glucose levels once or twice a day with a finger prick test. This helps to keep an eye on things. However, your GP will also conduct diabetes check ups at least annually.
Basal Bolus Insulin
Once commencing a background insulin you and your medical team may notice your glucose levels start to increase after eating. This shows your pancreas is also struggling to release extra insulin to compensate for the food you eat. Luckily, there is a type of insulin designed to help this. Rapid acting or bolus insulin is used to stop glucose levels spiking too high after eating.
Using a background insulin with a rapid insulin is also how type 1 diabetes is managed. If you have been prescribed a rapid insulin I’d encourage you to check out our type 1 section. The treatment plan is almost identical for type 3 and type 1.
When background and rapid insulin are used together, it is called as a basal bolus regimen. A basal bolus insulin regimen is a bit more involved than a once daily insulin. You will need to check your glucose levels several times a day, usually before meals and before bed.
You will be taught how to adjust your rapid insulin based on what you are eating. If you want more information on this, check out the link above or the type 1 section on this site for more info.
Sometimes it will be necessary to remove a patients entire pancreas. If there is no pancreas remaining, unfortunately, there are no longer any insulin producing cells. So this procedure means you will need to take insulin lifelong. The preferred insulin regimen to treat a total pancreatectomy is a basal bolus regimen as above.
This is because this insulin regimen most closely resembles how your body releases insulin naturally. It is also the most flexible approach because you don’t have to eat to suit the insulin. Some insulin regimens, like a twice daily mixed insulin regimen, require you to eat for the insulin to prevent low blood sugars. Whereas, a basal bolus regimen can be much more easily matched to your lifestyle and eating habits.
Low blood sugar risk with a total pancreatectomy
People having a total pancreatectomy are at high risk of low blood glucose levels. This is because the pancreas is not only responsible for releasing insulin to help lower your glucose levels. It also is responsible for releasing an opposing hormone to insulin called ‘glucagon’.
Unlike insulin, which lowers glucose levels, glucagon increases glucose levels. Usually, these 2 hormones work very well together to maintain glucose levels between a set range. Unfortunately, glucagon has not yet been developed as a treatment for people with type 3 diabetes and therefore patients are only treated with insulin. This is despite the fact, they produce no insulin or glucagon. The technology just isn’t there currently.
This has one serious implication. Following a total pancreatectomy your body has a reduced ability to raise its glucose levels should they drop too low. This becomes particularly significant if you are injecting insulin. Low blood glucose levels are always a risk when injecting insulin but it is a much greater risk after a total pancreatectomy.
However, try not to worry too much. Being aware of this goes a long way to helping prevent low glucose levels. Also, the liver helps out if glucose levels drop too low by releasing extra glucose.
Therefore, your diabetes team may set your glucose targets a little bit higher compared to some of your diabetes counterparts. This is just to stop low blood sugars occurring. For a guide on low glucose levels click here.
Glucagon is available as a one time injection if your glucose become too low. This is designed as a kind of rescue treatment to help with severely low blood glucose levels. Often this is administered by someone else other than the patient. This is because at this point, the patient is unable to self treat their low blood glucose level.
A glucagon injection is different from an insulin injection. Insulin can be adjusted and administered with many different types of insulin. Glucagon on the other hand is a set dose one time injection. Glucagon sends a quick surge of glucagon through your body.
A glucagon injection causes the liver to empty its stores of glucose. This is a last resort and quite rarely needed. Taking a glucagon injection increases your chances of further hypos over the next 24-48 hours. This is because it leaves you with little glucose reserves in the liver after an injection. As a result, the liver can’t contribute additional glucose to the blood for circulation. Therefore, further hypo’s are a risk until the liver can replenish its stores.
It is unlikely you will administer this yourself. Therefore, keeping your glucagon kit in a place where it is most likely to be needed and where someone else can help is good practice.
Your GP should prescribe a glucagon kit for you if you do not already have one.
Pancreatic enzyme replacement therapy
The pancreas also has another major function. In fact releasing hormones like insulin and glucagon is only 1% of the pancreas job.
The main job of the pancreas is to release digestive enzymes to help break down food. These are released via the pancreatic duct and into the small intestine. With pancreatic conditions, these enzymes can become blocked in the pancreatic duct and thus are unable to help digest food. This is known as pancreatic insufficiency. With a total pancreatectomy, there is no pancreas to release enzymes and so the patient will have a complete deficiency.
The symptoms of this can range from no symptoms to excruciating pain. The most common symptoms include unexplained weight loss, pain in the abdomen, bloating, loose, oily, discoloured and foul smelling stools (particularly after eating a fatty meal), burping and gas.
Treatment with PERT
Pancreatic enzyme replacement therapy (PERT) is used to replace the enzymes your pancreas is no longer releasing or producing. These come either in capsule or powder form and need to be taking with meals. The main consideration with these tablets is to help digest fat. However, you may need to take these for protein and carbohydrates, especially if you have a total pancreatectomy.
Your medical team will teach you all about PERT and how to manage them. The principle is quite easy. If you are having a large or fatty meal, you will need to take more. If you are having a low fat meal you will likely require less.
The good thing about PERT is you can’t really take too many. If symptoms persist you can always take more enzymes. For reference your body will produce around 750,000 units of pancreatic enzymes at a meal. Typically, PERT comes in 10,000, 25,000 or 40,000 unit preparations and a normal starting dose is anywhere between 50,000 – 100,000 units with meals. Each patient will have a unique requirement and your team can help advise you on this.
Going forwards, you will receive regular diabetes health checks with your GP. These are usually a yearly test. One of these tests is called a HbA1c test. This measures your average glucose over the previous 3 months and helps support the glucose tests you have been doing every day. We have discussed HbA1c in more detail here.
As you can see, type 3c diabetes can take a lot of effort to manage. If you need a basal bolus regimen and PERT, there can be a fair amount of work to do each day to manage your condition.
This doesn’t make it impossible though. Finding a routine with it helps and over time you’ll find your stride with it.
There is also an abundance of support to help you through managing your blood glucose levels and enzyme replacement therapy.
For more information on living with type 3 diabetes, check out Ali’s story filmed by diabetes UK.
Need more help
If you need more support we offer a range of 1:1 consultancy services and online programmes focused on helping you improve your glucose control and health for the long term. These include our type 2 diabetes recovery programme, type 1 glucose stability programme and winning weight loss programme. Go to the pages using the links above or in the headers or get in touch if you have questions.