In the news                  August 1, 2020

The other diabetes – a new scenario

You may have read that the lethality of the current coronavirus increases dramatically in persons with diabetes. Several countries have reported that more than half of those who died had diabetes, overwhelmingly type 2, which had previously been known as adult onset diabetes.

As I have noted in past blogs, pediatricians have recognized for decades that when a disease such as mumps occurs in genetically susceptible persons they sometimes develop type 1 diabetes (juvenile onset). It appears that the virus not only destroys insulin-producing cells within the pancreas, it releases fragments of those cells that trigger an immune response that finishes off the cells that are left. When the production of insulin ceases, daily injections are necessary to sustain life.

The mumps virus is just one example but other viruses can also be the villains. In 2002 the SARS virus and in 2012 the MERS virus, both coronaviruses, were found to be capable of destroying insulin-producing cells. Italian physicians were among the first to report that some SARS-CoV-2 patients had type 1 diabetes (T1DM) and that in many cases the condition had not previously been diagnosed. This raises the disturbing possibility that SARS-CoV-2 actually causes T1DM and that because of the sheer numbers of infected persons throughout the globe we are going to see an epidemic of the disease.

The picture is far from clear and it is much more complicated than the simple explanation that I offer here. Besides genetics other factors come into play including the mechanism by which viruses attack those insulin-producing cells, the details of the patient’s immune response, the effect of antiviral drugs or other medications that might halt or slow down the process and how physicians can manage the complex biochemical abnormalities that result from the combination of a life-threatening viral infection and an equally lethal metabolic disorder.

The big question for those who have type 1 diabetes or have a family member who does: will COVID-19 increase the risk of dying? It appears not. In fact, physicians in Italy suggest that the risk of acquiring the infection and of having severe complications appears to be lower in persons with type 1 disease. However, the numbers observed so far are very small, the explanation may have nothing to do with the virus itself and systematic analyses are only now getting started.

Stay tuned as we experience one more surprising element of this unusual pandemic.

Lifestyle

Annoyances of aging: that pesky intestinal tract.

This week we’ll start from the top with GERD (GastroEsophageal Reflux Disease) that can be as mild as heartburn or as severe as bringing up stomach acid that you can taste. This happens when the valve-like apparatus between the esophagus and the stomach becomes relaxed and incompetent as we get older. Sometimes the cause is a hiatal hernia, a defect in the diaphragm, the sheet of muscle that separates the chest from the abdomen.

In most persons the symptoms of GERD are mild and can be relieved by taking a Tums or two. When the acid-induced irritation of the lower esophagus becomes frequent and severe it’s time to see your local gastroenterologist. He or she may determine that the cause is related to a prescription medication, to a hiatal hernia or simply obesity. It may be necessary to take a look or to do other tests in order to rule out specific conditions such as Barrett’s esophagus, which carries a low but real risk of cancer.

Medications that lower the production of stomach acid include PPIs (Proton Pump Inhibitors) and H2 blockers but both of these prescription drugs are associated with side effects that include a greater risk of cancer, dementia and fractures. One of these, ranitidine (Zantac), has been removed from the market by the FDA. Stomach acid is necessary for the proper processing of vitamin B12 and medications that reduce it can induce anemia as well as damage to the nervous system.

You can take some consolation from the fact that you have lots of company: about 20 percent of Americans have GERD and even more have simple heartburn. Most of us can handle it well with antacids but when the symptoms are severe it’s another one of those annoyances of aging that in reality are indicators of a more serious problem.