Becoming Hypo Unaware

[Stuboy]

Recently (well, sinse diagnosis) I've been having lots of Hypo's... usually at least 1 or 2 a day, yesturday i had 4.

With an increasing occurance of these Hypo's i've started to become hypo unaware, like today and last night i tested at 2.8mmol/L and i didn't even know... at all.

Quite frankly it's starting to worry me. Is there anything you can do to stop becoming hypo unaware?

Or at least are there any other tell tale signs of a hypo, other than... going pale, acting like a idiot, feeling shakey, cold sweets, blurred vision, etc.

I j ust want to avoid any passing out!! Especially as my hypo's are usually happening at work!

Thanks guys n gals.

[Cyborg]

If you run your bg higher than normal for awhile it should help with the hypo unawareness.

[SueM]

you need your blood sugars to run a little higher for a few days to stop this.
As you were only diagnosed in July there is a good chance you are going through the honeymoon period so chances are you need to cut your insulin by a fair amount ring your diabetes nurse tell them you have major problems with lows which are affecting your work.Also point out as you are on a crappy mix you have no means of getting any reasonable control while honeymooning so you want a change.

A small tip if you want off that crappy insulin go into the clinic and demand do not ask demand a change. If they try to say no chuck your insulin in the bin in front of them and tell em to keep it then.
That tactic works wonders :-

[Stuboy]

i can't do that!! lol

My nurse is nice and she did say i will probably go onto B&B but she said i should be educated on dieting and counting carbs etc before i can B&B.
I wish i could be like that and just through it in the bin, but i'd feel bad after lol. Although it is something that i will mention everytime i see her.

But the thing is, i wont see her for a while now because im not gonna see another nurse untill after the last session of this group they've put me in, which is in feb 2007! I guess i specifically ask for an appointment i guess.

[spike]

Consider getting an insulin pump. I have nowhere near the problem with severe hypos that I did on MDI. Otherwise your only option may be to curtail carbs drastically and use very small boluses. The smaller the bolus, the less likely you will make a mistake. However, that does no good if you need to take a shot of long acting insulin which may not control your bg's optimally throughout the day and night. An insulin pump's basal settings allows you to fine-tune your basal insulin to an amazing degree--nothing like the poor results many get from MDI.

[corwin]

im not gonna see another nurse untill after the last session of this group they've put me in, which is in feb 2007!

:topic: Please tell me you will at least get an a1c done before feb. It's 5 months from now and you were just dx'ed, you need to be on top of your levels.

[SueM]

If you are going hypo like that there is a good chance you could crash your car. Then bang goes your licence.
Counting carbs is easy. You do not need to go to education classes to learn carb counting numbers are on all food products so if you are cooking from scratch work out the carb value for the whole made up item ie if it's cake then divide it into portion sizes same as spuds a spud was always 10gms for the size of a hens egg etc but there are plenty of web sites with carb values on.
It's your condition learn to manage it.
Be insistant you want a change of insulin whether the nurse is nice or not she doesn't have to live with it you do.As you have been going low I hope you have been cutting back your insulin.

[SueM]

Consider getting an insulin pump. I have nowhere near the problem with severe hypos that I did on MDI. Otherwise your only option may be to curtail carbs drastically and use very small boluses. The smaller the bolus, the less likely you will make a mistake. However, that does no good if you need to take a shot of long acting insulin which may not control your bg's optimally throughout the day and night. An insulin pump's basal settings allows you to fine-tune your basal insulin to an amazing degree--nothing like the poor results many get from MDI.

Spike he isn't on MDI

An insulin pump rflmao you are joking arn't you? He lives in the UK

[Stuboy]

do we have to pay for pumps in the UK? Or are they available on the NHS?

[DeusXM]

Or at least are there any other tell tale signs of a hypo, other than... going pale, acting like a idiot, feeling shakey, cold sweets, blurred vision, etc.

I j ust want to avoid any passing out!! Especially as my hypo's are usually happening at work!

The Mixtard regime makes it a bit complicated. You're on Mixtard 30, which means that it's 30% fast-acting and 70% long acting. Now, it depends on when you're having your hypos. If you're having them throughout the day, then you are taking too much insulin in total. If you're having them in the first couple of hours but hardly any afterwards, then you will need to switch to a different Mixtard, one with a lower portion of fast acting. If they're happening later, then you'll need to change to a Mixtard with more fast-acting.

In an ideal world you'd be placed on MDI but I can understand your nurse's concern with regards to carb-counting. Although MDI gives more flexibility with your life, it also gives you more flexibility to really screw things up and I think at this early stage, your nurse is right to be cautious. However...

...whilst everyone moans about NHS waiting times, the dirty little secret is that the people who work within it are just like you and me. In other words, they like having a quiet life. What they don't like is being bugged constantly. If that happens, they'll do whatever they can to get you to stop bugging them. Much like people in customer service get a bit more panicky and proactive if you start making their lives difficult, so do people in the NHS. So start forcing your way through the system. Keep calling them and asking for an earlier appointment. Really keep bugging them and make it politely but catagorically clear that you aren't going to stop until you get what you want from them.

Remember, the constant hypos part is going to really help your case. Back in January, I was having 8-10 hypos a day on Insulatard and I really couldn't go on like that. So I went to see the nurse and explained that I needed to change my insulin. Given my problems with both Levemir and Lantus, she wanted me to consult the diabetologist first, which I was ok with. But she said I'd have to wait two weeks. I bluntly told her that wasn't good enough and if I carried on like this, it might not be a diabetologist I'd need to see, but an undertaker instead. I may have exaggerated on this point. But the fact still stands, I needed to make a change ASAP - much like you do. I managed to bully my way into a next-day, emergency, first-thing in the morning appointment, which was fine by me. 24 hours after my initial nurse's visit I was on a new insulin. So being firm does work. I doubt you'll get onto a carb-counting course straight away, but you can certainly try to bully your way onto the earliest possible one, or even maybe get put on MDI in advance with a brief 'one-to-one' explanation of what you need to do.

[DeusXM]

An insulin pump rflmao you are joking arn't you? He lives in the UK

Insulin pumps are available in the UK. It's a common misconception that you can't get a pump in Britain. Of course you can get a pump in the UK; it's just that you'll have to pay for it, much like our American pumpers do. I'll have top check but I'm pretty sure the insulin supplies for pumps are covered by the NHS - it's just the pumps themselves that aren't.

do we have to pay for pumps in the UK? Or are they available on the NHS?

Both. Pumps are available in the UK both to purchase yourself, and they're also free on the NHS to those who qualify for them. Sadly I can tell you straight off that you don't qualify for a free pump and as such I'd really recommend you don't get one yourself. A pump isn't the solution it's been presented as; it's a **** of a lot of work and you'll need to know how to handle MDI and carb-counting before you can even think about looking at a pump. A pump will be no use whatsoever to you until you know your basal insulin needs and your carb ration, which you'll need for MDI anyway.

[Stuboy]

Before i went on holiday she did suggest a different mixtard, but didnt' want to do it untill after my holiday, to save complicating things and to also see if my body was still settling down. Last appt. she said she'd found out that mixtard has actually taken the other mixtures off the market, so as far as mixtard is concerned... it's 30 or nothing now.

The course that she's put me on she said would teach carb counting and lots of other things. and im on the earliest course going, starts 10th Oct, then the 4 group meetings are spread out untill feb 07.

[RLK]

My nurse is nice and she did say i will probably go onto B&B but she said i should be educated on dieting and counting carbs etc before i can B&B.


Don't let them feed you that garbage.... Carb counting is not difficult to learn. My doc put me on MDI (B&B) about 3 days after diagnosis. Sure, I had some highs and lows, but I learned a lot about how carbs affect me.

I just had a similar conversation yesterday with a co-worker who has been on Lantus only for 3 years (Type 1, mind you!) and eating a very regimented diet. His doctor tells him that "Things look good- keep doing what you're doing.". But good numbers don't necessarily mean that things are "working" if you can't enjoy your life a little bit and still obtain good numbers. It becomes a quality of life issue.

I'm convinced that no doc or nurse will ever push you to make changes in your care as long as the numbers are good. You have to be willing to politely demand what you think is better for you.

Ok, I'll get off my soapbox now....thanks for listening to my mini-rant.

[stacey21]

I had a problem controling my bg but since i have been given the freedom to decide how much background insulin i should take i have dramatically lowered my bg and it is running between 8.0-4.0 at the moment. Once you are cofdent enough i would suggest asking if you can decide for yourself. I have never been so happy with the diabetes.
I hope you get sorted soon! :)

[Lorna]

If you run higher, for about a week you should get your hypo symptoms back. I have recently enquired about a pump, and was told that nobody in the region I live has one on the NHS (criteria in Scotland are even more strict than in England). I was also told that, if self financing the pump I would need to self finance the consumables at cost of approx £1000 a year and also the additional test strips required. On the positive side, I did speak to a consultant who thought pumps would be available to all on the NHS sometime between the next 5 -10 years.

[spike]

Spike he isn't on MDI




Are you positive?

[Stuboy]

i am definatly not on MDI. Im on mixtard (see new signature)

I know full well that i wont get a pump for a very long time, i was just asking because i was interested whether they were available on the nhs or not.

I would like to go B&B though, but as im so new to all of this i will go with what my nurse suggests... she really doesn't seem like the sort to just fob you off on something if it's "working enough", and i will certainly push for it when i think im ready also.

At the moment im taking 12 units of mixtard twice a day. and have been OK in the morning, sometimes a little high on my after breakfast reading(2 hours) but then about an hour before lunch i seem to go really low. Im also going low after my evening meal (2hour reading) sometimes before the 2 hours. But the odd thing is, when i was taking 16 units twice a day, i was higher after lunch and didn't hypo so much after dinner, if anything after dinner were good - high readings.

just confusing the **** out of me...

Im supposed to be assessing the results and insulin amounts every three days, but they just having been making sense to me so i've left it a bit longer to assess the results, it's been 5 days so far and im still reluctant to make a decision to up the insulin or lower it.

[Stuboy]

:topic: Please tell me you will at least get an a1c done before feb. It's 5 months from now and you were just dx'ed, you need to be on top of your levels.

Nurse said that i would probably get an A1c during the course. Late october early november time. Because if we did it now, where my sugars were so ridiculously high it would be a high A1c and wouldn't reflect how well im controlling my levels realistically.

[spike]

MDI, as in Multiple Daily Injection...

You are taking more than one injection of insulin per day, correct?

[corwin]

Stuboy, that's good, I agree with your nurse. Getting an a1c too soon after diagnosis is pointless because it will just be very high. I just wanted to make sure you didn't mean you are going to wait another 5 month which is way too long.

Spike, I was under the impression that 2 shots of mixed insulin a day isn't considered MDI. I'm guessing SueM and Stuboy also regarding it as such.

I also started with Lantus and Novo since day one, at first my targets were really high and it was lowered as I gained experience and confidence with what I'm doing.

[spike]

Stuboy, that's good, I agree with your nurse. Getting an a1c too soon after diagnosis is pointless because it will just be very high. I just wanted to make sure you didn't mean you are going to wait another 5 month which is way too long.

Spike, I was under the impression that 2 shots of mixed insulin a day isn't considered MDI. I'm guessing SueM and Stuboy also regarding it as such.

I also started with Lantus and Novo since day one, at first my targets were really high and it was lowered as I gained experience and confidence with what I'm doing.

Mixtard is a combo insulin, and the OP is taking it several times a day. If that doesn't fall under the definition of MDI, what does? ONLY a long acting insulin taken separately from a short acting insulin? C'mon folks, that's no different than when I put regular and Lente in the same syringe and injected several times a day.

[DeusXM]

Mixtard is a combo insulin, and the OP is taking it several times a day. If that doesn't fall under the definition of MDI, what does? ONLY a long acting insulin taken separately from a short acting insulin? C'mon folks, that's no different than when I put regular and Lente in the same syringe and injected several times a day.

No, no, no. This is not MDI. He is injecting twice a day with a mixed insulin. Multiple Daily Injections refers to what's also known as intensive insulin therapy, whereby you take one or two injections a day of a basal insulin and then take an injection of a bolus insulin every time you eat. With Mixtard you have only two injections a day, before breakfast and before dinner, and you do not inject at any other meal time or at any other time during the day.

That's the crucial difference between MDI and mixed insulin therapy. Mixed insulin therapy does not technically cover all meal times and as such cannot provide good A1C results to the same extent that MDI can.

Technically yes, you are gramatically correct in saying any form of insulin therapy that requires more than one injection a day is 'multiple' daily injections. However, the term MDI very specifically refers to the basal-bolus system that mimics the action of a non-diabetic pancreas. Mixtard and your mixing R and Lente do NOT mimic the action a non-diabetic pancreas. Be aware that your previous regime of mixing R and Lente yourself is a very unusual insulin treatment regime - presumably this was suggested to you during the transition period when MDI was first being trialled but the necessary action-profile insulins were not available. Regular insulin acts too slowly to be used in modern MDI treatments.

[spike]

Regular insulin most certainly was used in "MDI" therapy. It wasn't ideal, but it was what we had at the time. I was so glad to get onto a pump with fast acting insulin. When I first started pumping, there was no Humalog either, so the improvement, while worthwhile, wasn't as dramatic as when I got ahold of my first bottle of Humalog!

[Stuboy]

well... i dont class mixtard as MDI, so no, im not on MDI treatment. im on mixtard.

back to the question at hand... are there any other tell tale signs of a hypo that others have come across that I could also look for?

[SueM]

Everyone has different symptoms that change the longer they have diabetes. :)
Your priority is to lower your insulin levels to stop your hypo's.
Basicly your pancreas is havng a final fling before it packs up all together.

[spike]

Basicly your pancreas is havng a final fling before it packs up all together.


LOL! I love the way you described the honeymoon period, Sue.

[Stuboy]

I really need some good advice with this.

Im reluctant to run high because i want to get my levels controled as best as i can.

Taking 12 units twice a day over the last 5 days has... improved my morning levels, starting to see an improvment in my after breakfast levels, and before lunch, with the exception of today. but im still going hypo after dinner... but if i take my insulin down for the evening it'll make my morning numbers high :(

here's my results spreadsheet i made when i was diagnosed... i changed the way i log after the hospital appt. where the yellow line is slightly.

http://www.cruise-pompey.co.uk/bloodtestresults.xls

[spike]

How is a "mix" insulin going to give you good control after meals AND all night long? ANSWER: IT ISN'T!! Nearly as bad a regimen as I was on for 18 hellish years. (Regular and various other insulins such as Lente, Ultralente, and Semi-Lente (not all during the same period)). You need a basal insulin separate from your boluses. and if you have DP, you basically can only control it well with a pump. Shots are too iffy for nighttime bg's for some diabetics (myself included).

I suggest you go over your concerns with an endo ASAP. why suffer?

[Stuboy]

what's an endo anyway?

[SueM]

what's an endo anyway?

The so called diabetes specialist you see at the hospital.
As spike says you are on a hiding to nothing with mixatard there is no way on earth are you going to get control with a premixed insulin.
As I said before demand a change before you end up in hospital or a coffin.
You need to run high if you can't tell you are going hypo.
It only need be for a week and we are not talking about sky high numbers either.
In the UK if you become hypo unaware it is ilegal to drive a car so you need to sort this quickly.

[Stuboy]

I always check my levels before i drive, if im in the 4's and know that im heading down the scale i'll have a glucose tab before i drive.

Im going to drop my evening insulin to 10 units and keep morning at 12, my levels up untill lunch seem to be ok it's just the evening the screws up.

[Belinda]

Nurse said that i would probably get an A1c during the course. Late october early november time. Because if we did it now, where my sugars were so ridiculously high it would be a high A1c and wouldn't reflect how well im controlling my levels realistically.


OK....you should have one at the first to see how ridiculously high they were and to see the next time you go (usually 3 months) how they have dropped. I am sorry that you have no IDEA how your A1C is....I get mine done every 3 months (just had one done yesterday but lab work wasn't in before I left since I waited until after appointment to get my blood drawn......should have been earlier at the appointment but the snooze button is just sooooooooooooooo nice). When I switched docs at one time before I found the Endo of the world.....the doc had my A1C test done and then had me back once a month checking it to see if it was coming down at all. He also changed my meds and finally thought about a pump for me when I had asked and told me I would have to go to an Endo......so that is where I am today.....



Had the hypo problem too and was told to run BS 150-200 for a few days. Flabberghasted....I know but he said...lighten up and eat some sugar.....

[sandyhandz]

What blood glucose # does 2.8 equal?

I'm also a new insulin dependent diabetic (since beginning of July). When my sugars drop into the 70's I start having symptoms. Even at 79! Luckily though I can feel the symptoms, even in the middle of the night.

[Funnygrl]

2.8 is 50. Not extemely low, but low enough.

I was also the impression MDI only meant basal/bolus with shots, or 3 plus shots a day.


MDI
Multiple daily injections (of insulin). One of several terms that are used to describe insulin programs that are designed to obtain tight control of blood sugar by giving several shots every day.

from: http://www.childrenwithdiabetes.com/dictionary/m.htm

I don't know anyone who considers mixtard "tight" control. But the details of terminology don't matter.

[corwin]

Im reluctant to run high because i want to get my levels controled as best as i can.

here's my results spreadsheet i made when i was diagnosed... i changed the way i log after the hospital appt. where the yellow line is slightly.


Impossible! you want tighter control? get off the mix. I have diabetes for twice as long as you (still a very short time) and you already beat my record low 3 times, your numbers are running all over the place. It's not your fault, you don't get the insulin you need to get it right. If it was me I would probably gave up at this point and just wait to win the draw for normal treatment (don't take my advice, it's just me). You are taking the same amount of insulin every day and you don't correct, how can you possibly get good control? You have to understand that and be active demanding B&B, asap, it's your health, the current treatment is messing up your life style and health, do whatever it takes to change that. With good control your hypo awarness will come back, you won't run the risk of loosing your license or worse, get into a bad accident, your life will basically be 100% better. There is no other solution to your problem, sorry.

[Stuboy]

at the moment i am not excercising either... before diagnosis i was a gym goer.

I really wanna get back into the gym and start lifting weights again and do some cardio, but i dont know how well that would boed with mixtard... even with "reasonable control". when i start excercising it'll probably blow it all out again.

Do you guys find that B&B is good with excercise in the gym too?

[DeusXM]

It certainly would be good for you to get back in the gym - as well as all the usual benefits of exercise, it's great for keeping your BGs normal, but if you're having hypos a lot already you're going to have to do a lot of experimenting.

MDI will give you more flexibility about your exercise in as much as you can know you only have low levels of insulin in your system. For instance, if you exercise 2 hours after injecting bolus insulin, you will know that you will have lower levels of insulin than if you'd injected one hour ago.

Another way in which MDI can help with exercise is that it allows you to dynamically alter your insulin intake according to your needs. Currently on Mixtard you take a set amount, right? Perhaps varying slightly according to meal size? The problem is once you start varying your Mixtard dose, you not only alter the amount of fast acting in your system but also your slow-acting. I'm going to try and explain why this can be a problem, so bear with me thought this...

When you exercise, generally you will reduce your blood sugar levels. This effect will also last for some time as your muscles restore their glycogen supplies by using your blood glucose. So after exercise, you BG will continue to drop for up to 24 hours. Now, this means two things: 1 - you need less background insulin to compensate for the glucose your liver releases, and 2 - you need less insulin to cover your food because your muscles will be absorbing the glucose generated far more quickly.

On MDI, I can deal with both these things. I will take less of my bolus insulin when I eat after exercise, and I may also alter my basal insulin too. This way I can exercise at any time of day and avoid hypos.

With Mixtard, you can't do this. Say you have your normal breakfast and exercise later in the day. You have two options - you can either take the same amount of Mixtard that you normally would, or you can take less. If you take the same amount, you will cover your usual day-to-day needs, but once you exercise you will run the risk of having hypos. If you take less, you reduce this risk of having hypos, but you will probably have high BG until you exercise.

What I would suggest with exercise and Mixtard is that you exercise at the end of your injection cycle. In other words, if you are injecting at breakfast and at dinner, I would exercise a couple of hours or so before dinner (or breakfast) and then take a lower amount of Mixtard for dinner (or breakfast). This way you exercise when your insulin levels are at their lowest, minimising hypos, and you can safely reduce your next insulin injection, because you will use up the glucose from your food more quickly (so you'd need less fast acting) and you'll use up your liver output more quickly too (so you'd need less long-acting).

This should help minimise your risk of hypos but what I would also suggest is that, if you start going to the gym again, you take your BG monitor, test before exercising, test during your work out (maybe once every 15 minutes) and then test every hour for a few hours after your workout. Plot the results on a graph and then you'll be able to see precisely how exercise affects your personal blood sugar. This will let you know by how much you need to reduce your insulin intake when you work out.

I'm not sure how clear I've been in explaining myself here so please let me know if there's anything I can help clear up.

[Stuboy]

some of it makes sense, but i will re-read it again so the infomation sinks in bit by bit lol. Thanks for all the info this is really helpfull!

The nurse did suggest not to go to the gym untill i've got my levels steady and im not getting so many hypo's.

I've got a health club lined up for joining, it's ace! So Laura and I are rearing to go, just waiting to see less hypo's!

... im Hypo right now at 3.2 before lunch (aware).