[Subby]

Originally Posted by dbaratta

why am I not seeing an endo now?

Exactly. Take control and see one now. This guy will get you nowhere from all indications.

[gary.keith]

Good luck with your doctor visit today. Have you written down everything you want to ask him and discuss with him? I find that helpful so I don't forget stuff in the stress of the moment with a doctor I'm doing battle with. Not sure why you're not seeing an Endo now. Depsite the problems I have with mine I feel much better in her care than I did with my PCP. Maybe it would be different with a PCP who was properly educated about D. But, mine is not so an Endo it is.

Please let us know how it went.

[dbaratta]

Originally Posted by Subby

Exactly. Take control and see one now. This guy will get you nowhere from all indications.

I have my 3-month check up in December, at that time if I am not happy with my control I will insist. I need a referral from him to go. For now I will be splitting the Lantus and hoping for the best. I may have some questions for you on that if I have problems.

[Subby]

Poppy, you are a DIABETIC, a newish one and with problems with insulin therapy (and question marks around type and what is actually going on). One particular issue here may be dosages, as you suspect: your current guy seems reasonably clueless: and we in good conscience cannot tweak your dosage for you. You NEED a competent doctor, now.

You have every reason to see an endo ASAP. I would highly recommend you just ask for a referral and go.

[dbaratta]

Originally Posted by Subby

Poppy, you are a DIABETIC, a newish one and with problems with insulin therapy (and question marks around type and what is actually going on). One particular issue here may be dosages, as you suspect: your current guy seems reasonably clueless: and we in good conscience cannot tweak your dosage for you. You NEED a competent doctor, now.

You have every reason to see an endo ASAP. I would highly recommend you just ask for a referral and go.

Okay. Give me a few days on the split dose to see what happens and if I am not happy I will make him give me a referral.

Thanks!

[dbaratta]

Originally Posted by Gordonm

Your Dr. is your coach. You are the main person controlling your diabetes. I have always gone under the rule of I take care of myself. Your Dr. is with you maybe 15 minutes to 1/2 hour per what every couple of months? He is going to be able to wave a miracle over your head and fix it? I always laugh at the ones who won't change anything unless their Dr. tells them. How does the Dr. know what you are going through on a daily basis. They are there to guide you. You have to be in control of your diabetes. I wish you all the luck in the world with your Dr. and maybe he does need to go. I have been through a few myself but learned from each one. Educate yourself, you are the one in control of your diabetes.

LOL yes I have been educating myself for 3 years now. I know exactly what is going on with me but I can't change meds without my doctor. I take excellent care of myself that is how I know something is wrong and I need more help. I would NEVER change the way I take my meds without my doctors advice no matter how silly that sounds. I tell him what I want and he either agrees or disagrees and we battle it out. I believe HE is the one who needs more education on D and my next step is to see and endo which I need him to refer.

[dbaratta]

Last night was the first night that I started splitting my lantus. Doc and me expected to see FBG 300+ this morning. It was 120. I was shocked! 2 hours later, no food, 177. ugh. but, I just took the 2nd shot. I need to adjust the timing to cover for that 2-hour high in the morning, it happens all the time. So,,,,,continue experimenting and hope this works.

I will insist on a referral from him to see an endo.

[Granny Shanny]

From an opinionated old woman who doesn't know jack about using insulin, it looks like this at least gives you something to work with, and if your doc can't see it, I hope you insist VEHEMENTLY on a referral! ((((Poppy))))

[Subby]

Poppy, I'm glad you seem closer to seeing an endo. As an aside, here is what I would be thinking about myself, given I might not know when I'm going to see the endo.

Are you still going high after meals? Getting to the bottom of that would be a next step in assessing whether you have room to move with your basal insulin doses all up (which may help your dawn phenomenon if you have room to move up).

I'm going to suggest you do get more involved that you've claimed interest in. These are just suggestions, and I primarily suggest it not because I think diabetics "should" be more involved in their own management and troubleshooting, but because I think that sometimes we have to. It's our body. We are the ones with vested interest, docs can wash their hands at any point. If you want something done properly do it yourself. And all that gumf. Consider.

How I would progress in your case is to test if your overall doses of basal are enough. I would do a simple form of basal testing. It seems strange to do it for lunch or dinner but that is what I would suggest. Why? Because the morning is typically problematic, obviously problematic for you currently. Often when people don't eat in the morning their BG goes up and up anyway, even with usually good basal. So it's hard to get definite basal testing done for the morning, especially with the issues you are facing. So test if your basal dose is appropriate, for the rest of the day. That will help you decide if you should be changing your overall dose - which will help with the morning if it happened to be upwards. Make sense?

So here is my suggestion. One of these days have a small breakfast and bolus for it as per normal. Eat nothing afterwards. After four hours, given no lows or huge highs, start taking tests every hour. Skip lunch. Continue to take hourly tests and write them all down. Any time you go low or particularly high or don't feel well, abort and eat something. It's ok, you are just looking for indications, as to whether you are even, going low, or going high. The important information is not where you start or the actual number (as long is it is not really unreasonable) but where it goes from there. I don't like to basal test past 8 hours myself (4 hours to set up, four hour of testing).

On another day you could do the same thing but test the evening. Eat and bolus breakfast, eat and bolus lunch (make it a bit early and small), then 4 hours later start testing hourly to discover what your basal situation is doing during that period.

If your BG continues to go up and up, given a pretty typical day and this short term fasting, it is very good evidence that your basal doses are simply not adequate overall. You have talked about these as "liver dumps" - you are right in a way, in that the liver is virtually always "dumping" or converting and releasing a steady stream of sugar into the blood. The question is whether your basal insulin is enough to keep up with the constant process. It should be, that is it's function. And this form of testing really is the only way to get a clear vision on if it really is doing it's job.

As I said this is just a suggestion. I do recommend you take things into your own hands a little in reasonable and safe observation of how your insulin is working in your body (as I said, you should test hourly or 2 hourly, not just for data, but to be safe. If you do basal test, do it when there is no undue pressure on you). I can't solve whether the doctor would go with you on this ride, or how you might use the knowledge if you are not prepared to have a say in your dosages. That fact, currently puts you at a huge disadvantage. I can understand where you are coming from with it. I just don't know your chances of finding good control staying with that protocol.

[Subby]

What I didn't get to in there, was that you mention adjusting the timing of your Lantus to deal with a strong spike in the morning. Maybe, but it's very unlikely it is an issue of Lantus timing. Lantus is sloooow. Your DP or morning spike is fast. It is probably just the wrong insulin for the wrong job. Or, as per above, it may be that you need more overall, which could also help.

To deal with DP, what some have to do (I used to have to do this) was take more long acting at night than they need for most of the night, so that by the time the morning comes there is enough action to help mitigate the DP spike. To do this, an important part is that the right long acting snack needs to be eaten before bed to prevent the stronger action causing lows during the period that there is no spike.

Yes, there are lots of variables in there, and I'm not just suggesting this willy nilly, it's an illustration that there are ideas and tactics out there that may be useful to you. Another may be a strategic rapid bolus at the right time before the spike. Apart from doing what you feel comfortable doing on your own steam (which may be very little, I accept that) the endo should be keyed in to helping you form safe tactics to directly deal with highs in the morning. You current doc really did fail you on this. Splitting isn't a bad idea for you to bring to the table at all, you were more useful than him that's for sure, but it's just one small part of overall dosage consideration and potential tactics.

[dbaratta]

[quote=Subby;519790]What I didn't get to in there, was that you mention adjusting the timing of your Lantus to deal with a strong spike in the morning. Maybe, but it's very unlikely it is an issue of Lantus timing. Lantus is sloooow. Your DP or morning spike is fast. It is probably just the wrong insulin for the wrong job. Or, as per above, it may be that you need more overall, which could also help.

QUOTE]

Wow, you invested a lot of time in this response which I am very grateful. The DP for me is 2-hours after rising. I could be 67 at dawn, 2-hours later 180-260. Just a cup of coffee which I don't use sugar and I bolus a few units for. One thing I have not tried is giving up caffeine. I have read that it is much easier to control D with no caffeine. Not sure.

Basil testing, didn't know exactly what it was but I have been watching. Now that you suggest this I will test more. Here is what I have found.

Lunch: healthy: bolus what I need: 2-hours post 120-138

No more food for 6 hours: BG 210

Dinner: healthy: bolus what I need: 2-hours post 110-120
Before Bed: 110-115

Overnight pretty good most nights 70-120

2 hours after rising, no food, 180-260

Was told to do my full dose (when I was on once a day) 25units now before bed. Now I am doing 12 morning 13 evening.
What I was saying about times is that Lantus kicks in about 4-hours after injection? That is what they told me, I suppose everyone is different, but then once we start dosing it doesn't matter does it? It is all so confusing and having a doc who is clueless is not helping,,,,but, I will insist on the endo in Dec wether or not I am better.

I will do more basil testing as you suggest. I can do that today because I am making dinner for the family at 3:30 so I won't eat now from 8am till 3:30 and see what happens.

Also, I would never do anything I had not discussed with my doc first so dont' worry about me taking your input and running with it. Your thoughts are greatly appreciated!

He has given me the okay to play with dose by 3 units if I am not doing well.

Okay, off to start the turkey dinner

[ShottleBop]

How long are you going between Lantus shots? Dr. Bernstein says that, despite Lantus' claims to be 24-hour stuff, it's not.

[dbaratta]

Originally Posted by ShottleBop

How long are you going between Lantus shots? Dr. Bernstein says that, despite Lantus' claims to be 24-hour stuff, it's not.

AH I believe that!!! I am splitting my dose now and dose every 12-hours. I am upping my dose by 1 each dose. I did a basil test yesterday and never went over 156 fatsing, but I was busy around the house. I will test again while I am sitting at my desk tomorrow. That desk job is killing me.

Today I woke up high, 209, but I had a high carb meal yesterday which I normally do not do because I always dump a lot more when I eat simple carbs....my bad. We will see what tomorrow morning's reading is. I have had my usual 45 carbs today. It should be okay.

Todays readings were all good, I even went hypo after a 2-mile walk, so, I am pretty happy so far with the split dose. It has only been 2 days though. We will see.

[xMenace]

Originally Posted by dbaratta

Today I woke up high, 209, but I had a high carb meal yesterday which I normally do not do because I always dump a lot more when I eat simple carbs....my bad. We will see what tomorrow morning's reading is. I have had my usual 45 carbs today. It should be okay.

I've never found that meals affect my basal action. Exercise, stress, sickness, etc do, but never food. Just be careful assigning blame. We're often wrong.

Be very careful about your midnight to 4am numbers. Please do some basal testing here too. You're looking for your pattern which should be pretty consistent: drop, flat, or rise. All three are common.

Another critical time is mid afternoons from about 3pm to dinner. Nearly all of us tend to drop. It's not much of a concern when running high, but when you tighten up your control, it may bite you.

Just for review I've been 911'd nine times in my career, and I've had many more severe hypos on top of that. My worst have been by far the middle of the night including seven 911's and dozens where DW had to treat me. I drop hard. The next worse is mid-afternoons where I've had many sneak up on me over the years. I've never had to have anyone help me, but I've been close. The rest were just being stupid.