Change in insulin behaviour

[andrews]

Hi,

I have found my blood sugar control very erratic over the past few weeks and was wondering if anybody here could help out with an explanation.

I am finding that my Novorapid appears to be working more aggresively than before for the first 2 hours but then hardly at all for the next 2-3 hours.

I am also injecting much less than I used to, almost half, as I have found myself going low soon after injecting and eating.

Example:
This morning my blood sugar was 9.9, I injected 10units and had breakfast , bowl of fruit and toast.
After 2 hours it was down to 4.9, I then had a small ceral bar 15g carbs, 2 hours later it was 11.7.

It's almost like there is a delay from when I eat to when the blood sugar level starts to rise causing the initial low then the delayed high.

Can anybody help, this is very worrying.

Cheers
Andrew.

[Subby]

Hi andrews. What kind of diabetes do you have? I can guess, but it's best not to assume. :) How long have you been diabetic and injecting insulin? What kind of BGs and A1cs do you get? Any other changes in diet, exercise, lifestyle habits, stress, work, these past few weeks?

I know that seems a lot of questions, but sometimes working things out is like being a detective, and we're happy to help you with gathering information.

There is a delayed-gastric-emptying condition called Gastroparesis (http://digestive.niddk.nih.gov/ddiseases/pubs/gastroparesis/index.htm) - it might explain things, or it might be the wrong track. I don't have personal experience with it or how it might come, or go.

[AngelKitty]

Hi Andrew and welcome to the forum.
Subby has asked some good questions to try and hash out your problem.
Also, have you lost weight recently and / or increased your exercise -if so, that may explain why you need less insulin.

:) AngelKitty

[mortis505]

Are you injecting to cover the number of carbs you are eating? Or just set amounts as prescribed by a physician?

[andrews]

Hi,

I am Type 1, have been for 14 years, am 38 years old.
My control has been pretty good in the past, Hba1c typically in the low 7's. I used to take around 18units of novo with breakfast, lunch and dinner, adjusting slightly depening on the meal content and 25 units of lantus overnight.

I exercise regulary and am of average weight for my builld.

have lost a little weight over the last couple of months and blood pressure has been slightly high 120-140/80 due to some stress recently.

Wondering if the injection site can make a difference, injected in my thigh this morning and stomach at lunch. Had a sandwich and apple for lunch at 1:20pm BS was (12.0) and blood sugar was at 13.5 around 3pm and is now still 8.3 after 3 hours since lunch. Haven't eaten anthing since lunch.

So behaviour at lunch is very different from breakfast and I injected more insuilin at lunch (15units)

[Subby]

I'm going to go off on what might seem a bit of a tangent here Andrew, sorry if it doesn't feel like it applies.

I've noticed, through my own experience and through chatting on these forums, that sometimes the whole terrain can change and suddenly the insulin therapy we've been using becomes out of date. Of course, this can be from something short term happening, such as illness or lifestyle change, (and we may or may not be aware of all the factors, it has to be said). It also sometimes seems to be like a tectonic shift in body dynamics, that means we need to go back to basics and rebuild our control again.

At this stage, I'm actually suspecting (and I could be wrong) that what might be going on for you is a bit of both. You mention weight loss and stress, both of which could require some adjustments to doses that you may not have completely allowed for, yet. And especially as a long term diabetic, other factors do seem to kick in, a change in the way your body works, that requires going back to the drawing board, so to speak.

Where to go to from here? Putting aside getting tested for Gastroparesis, which may be worthwhile if you suspect it is occurring for you at times, (and which I imagine may be possible given your length of having D) I think that the absolute best thing you can do is discover and use some new tools for dosaging, techniques to find out what your body is doing through the day, and inform choices for dosages and tactics.

These are the two areas I would look at right now, to gain better tools to work with, plus gain insight into what is actually happening for your doses:

- The fixed dose approach you are using - well, I used it for 15 years, and it was a revelation to move to a carb counting method of dosaging instead. It means that, you are applying a fixed, logical rule to your bolus amounts, it can be so much more accurate, and so much easier to troubleshoot. It GIVES you something to troubleshoot, rather than largely guessing. It gives you a system that will be more accurate and more fixable, even if you start eating more snacks and eating more eractically - because it involves simple rules to calculate a dose given any situation.

- So the upshot: move to a carb counting system. This is not hard given a bit of application. It would be good to see your endo or a new DE willing to help you, to get you started. If you are pretty switched on as you seem, I would not worry about such things as courses to learn it. It's pretty simple given a careful approach to learning it.

- Without good basal coverage, boluses can be a mess. And basal doses that were good enough for years - may have changed - and one may not be able to cut it, either. It might be that a single shot is not sophisticated enough for you, if for example you are developing resistance through the day but less so at night. As a contrast to someone happily getting by on a single shot of Lantus, I use around 8 different levels of basal through the day, some as much as 30% more than my lowest, on the pump - this has finally given me a chance for reasonable control. In general, many pumpers use 2 or 3 at least - it's not unusual to have different ebbs and flows of basal requirements. Pumping does provide more control that also gives a window or a spotlight into how your basal is going - but people on injections can get insight and work better with basal reqs too, given the knowhow. And if you reveal your basal problems, there are a few tricks you can try on injections, such as splitting your Lantus dose between a morning shot and a night shot, to better suit your needs.

So, the upshot is: use basal testing (the only technique that will peel back the covers to scrutinize basal control hour to hour) to see how well your Lantus really is giving you basal coverage, and to inform on dosaging, timing and techniques.

As someone who struggled with BG instability for years, but did not have such tools, I spend so much fruitless time trying to make sense and patch up a house that was constantly falling down. To me it's too hard to make sense of what might be going in in the morning and why your lunch boluses are leaving you high, etc etc... without going back to something like basal testing to separate out basal and bolus issues, and careful meal/bolus testing after better basal coverage is established. I do know without doubt is that if you take up the challenge to revise and re-educate yourself with some of the fundamentals, such as carb counting and basal testing, you have every chance of making progressive headway in your control and improving your quality of life.

I'm aware how I've just suggested things you may not be familiar with - please do search around the internet, these forums, ask your endo and DE, ask here. Phew, sorry for putting people to sleep with such a long winded message :)

[Gary_W]

I agree with Subby on this.

Another thing to keep in mind is this: the general rule of thumb for a basal to bolus ratio is 50:50. This is only a starting point, and most people will vary from this. But if you vary a huge amount from 50:50 AND you're having problems then start to suspect this.

As you are putting in 25u of basal insulin and 54u of bolus, you are quite some way off the 'average'. If it works for you, great. But it isn't :)

Get some basal testing done as already suggested. Also, keep in mind that if you are high at the point you eat, you'll be hard pushed to get your numbers down no matter what. Once you go much above a 10 or 11, your body becomes resistant to the insulin and the usual sensible calculations get completely thrown out of the window. Nothing makes sense when you get up there. For this reason, eating when your BG was already 12 (216 for those in the US of A) wasn't too sensible IMO. I know that sucks, but if you throw petrol on a barbeque then expect to lose your eyebrows :)

Good luck. This place can help you.

Gary