On Diabetes, and Thinking Outside the Box, by Dr. Cynthia J. Koelker

A thoughtful EMT wrote me to ask:

Dr. Koelker:
What effect could you have on blood sugar for a diabetic (type 1) through blood transfusions? I am a paramedic, and our field treatment for high blood sugar is IV fluids until the hospital can give them insulin to lower the blood sugar. In a SHTF scenario, there is no hospital. The thought process got me thinking though….My questions are these:

1) What, if any effect could you have on lowering blood sugar through transfusions? i.e., basically finding a non-diabetic donor match, and swapping a couple pints of blood…the non-diabetic can process any sugar, and the diabetic gets blood sugar lowered by dilution.

2) Could you time a high sugar meal for the non-diabetic to manipulate the blood you were donating? Could you get enough glucose and insulin transfused to affect the diabetic’s intracellular glucose?

3) If the science and idea are valid, would it be able to have any appreciable effects or would you be re-arranging deck chairs on the Titanic?

The idea intrigues me, because blood transfusion gear can store a lot longer than insulin.

Thank you- Eli
Here is my reply:
Excellent questions, Eli.  I’ve pondered the possibility myself and will offer my preliminary conclusions.
First, theoretically, the answer is yes, it could work. 
For example, in a scenario where, say, identical twins would essentially share the same pancreas, IV lines could be connected in a continuous system, allowing the diabetic’s blood to enter the non-diabetic’s system, with the “treated” blood being returned in equal amounts from the non-diabetic to the diabetic. 
This is not quite the same as swapping a couple pints of blood, as I’ll address below.
Eli’s preliminary questions raise several more:
1.      Who is a suitably-matched donor?
2.      Would a non-diabetic be the best donor? 
3.      How much blood would need to be transfused?
4.      How long would this arrangement work?
5.      Should the non-diabetic receive blood back in return?
6.      Should serum be used instead of blood?
7.      Could the blood be administered via a different route?
8.      Could non-human blood be used?
9.      Could God have left us a simpler answer for treating diabetes Type 1 than we’ve discovered to date?
To begin with the end, I believe #9 above could well be true.  Though science has investigated pancreatic transplantation, islet cell transplants, stem cell manipulation, and other high-tech options, no simple solutions have been found, but they yet may be out there.
And so, at TEOTWAWKI, what to do? 

(Before I go on, let me say don’t miss the March 13, 2013 SurvivalBlog article by AERC regarding Insulin Dependent Diabetics.  The author offers many excellent suggestions along with personal experience as a diabetic.)

But the question remains: what to do if no insulin is available?  Would transfusion work?
A few calculations will help explain:  In the non-diabetic, serum insulin levels average <30 microUnits/ml (that’s 0.000030 Units/ml), or 0.003 Units per liter of blood or serum.  (In a type 2 diabetic with insulin resistance, the serum insulin level may actually be higher than normal.)  If a type 1 diabetic requires 24 units of insulin/per day, that’s 1 unit/hour, or 0.0427 Units per minute, if my number-crunching is correct (and let me know if it’s not).    The calculations are actually quite complex, in part due to the half-life of insulin, along with multiple other factors. 
To simplify the computation enormously, if it takes a serum insulin level of around 10 microU/ml to metabolize a serum glucose level of 100 mg/dL, it would take about 5 times that much insulin (or non-diabetic blood) to regulate a serum glucose level of 500.  To treat a diabetic’s blood sugar of 1000 could require all the insulin within a non-diabetic’s circulatory system – and clearly you can’t donate all your blood multiple times a day (except in the shared-pancreas arrangement described above).
If a diabetic’s blood glucose level of 900 were suddenly diluted 50:50 with a non-diabetic’s blood (which isn’t really possible), this would decrease the level to around 400 mg/dL to start, then perhaps 50 points further due to transfused insulin . . . but only for a very short time, on the order of hours at best.  And in order to administer this much blood, an equal amount would have to be removed via blood-letting.

Given an unlimited blood supply and ICU-level nursing, perhaps this could be accomplished, but considering factors likely to be present at TEOTWAWKI, the challenges appear to be insurmountable.

Additionally, to answer a few more of my own questions above:
1.      In the identical twins shared-pancreas scenario, with blood going in and out of each person, blood typing is not a problem.  However, for others to share blood back and forth, both the diabetic and non-diabetic would need to be compatible to both donate and receive blood.  Simple ABO/Rh typing does not prevent all transfusion reactions, and of course even correct typing does not eliminate the possibility of infection or fluid overload.  Still, in a life-or-death situation, with a supply of insulin expected to be available shortly, it could be considered.  (Make sure to obtain a blood donation compatibility chart if you would consider transfusion for any reason.  You’ll either need to know everyone’s blood type ahead of time, or learn how to crossmatch it yourself.)
2.      Theoretically a normal weight or an overweight person, even a mild Type 2 diabetic with insulin resistance, could serve as the donor.
3.      Serum alone is not likely to work because transfusion alone is not really feasible.  The only way I see transfusion working is the shared-pancreas scenario already described. 
Next, what about non-human blood?
Animal-to-human blood transfusions have been tried hundreds of years ago, but were often fatal, and assuredly would be fatal using large volumes of blood.
But could the insulin within, say, a gallon of cow blood be put to use some other way?  
Theoretically, maybe so.  The blood would need to be centrifuged promptly to remove the cells, since the blood cells themselves remain metabolically active until they begin to break down.  The serum could be further concentrated by evaporation at room temperatures (with careful attention to sterile technique).  The resulting insulin-containing liquid should not be given intravenously but might be effective via a rectal infusion, high in the anus (see Oral Insulin (Swallowed) and Rectal Insulin Suppository for Diabetics by T.R. Shantha, MD, PhD, FACA).
Although insulin does not degrade when given rectally as it does when given orally, absorption is a potential problem.  Although some insulin is absorbed rectally, I can find no answer to whether bovine insulin would be – but it might work.

Another possibility would be an enema of blenderized bovine (cow) pancreas, though the pancreatic enzymes might irritate or even perforate the colon – perhaps a reader would like to try this experiment on rats or rabbits before trying it on themselves.  Allergic reactions are also a concern.

The earliest treatment of hypothyroid patients involved implanting (not transplanting) sheep thyroid tissue into a patient.  Surprisingly, it worked.  So could the same idea work with insulin-dependent diabetes?  Again, I don’t know, and again the pancreatic enzymes could be a problem.  But it might work, to a degree.  Perhaps a curious reader would be interested in trying this experiment on their diabetic pet.  Answers simply cannot be obtained without experiments (some of which end badly for the subject). 

Transdermal insulin use has also been studied, but requires ultrasound or iontophoresis for transport through the skin.  Could a slurry of pancreas be used on the skin?  We just don’t know – I doubt it’s been tried.  The pancreatic enzymes may irritate the skin.  Alternatively, the same enzymes may aid insulin absorption.  Insulin itself has some deleterious effects when applied topically.  But if the choice is death or experimentation, necessity becomes the mother of invention. 

In summary, the analogy of re-arranging deck chairs on the Titanic is probably valid regarding using transfusion to lower blood sugar, but if I had a child with Type 1 diabetes, I’d be motivated enough to start experimenting, maybe even learn how to follow Banting’s recipe for insulin.  And I’d do some hard praying about stem cells – the answer to a new pancreas lies within our bodies; how to unleash it is the only question. 

About the Author: Dr. Cynthia Koelker is SurvivalBlog’s Medical Editor. her web site is www.ArmageddonMedicine.net.