Endo Visit Today..Differing Opinions

[gettingby]

Ok, had my 3 month endo appt today. My A1C is a little high at 8.2 (and no, I'm not ashamed to say it. Ashamed I let it get there but intend to get it down).

Endo told me today that he believes I should get my A1C's between 7.5 and 8.2. He thinks that since I've had it for 24 yrs, I would be pushing it close to too many hypos if I go any lower than the 7.5. This is where the disagreement comes in. I have had my A1C down to 7.3 in the past with very few hypos. He and I consider my hypos to be any readings below 70. He says that since I have had 59 hypos in the past 3 months (403 bg readings), I should just strive for an A1C no lower than 7.5.

Opinions? And don't say "ditch this guy". He is the only one that has really been trying to help me. He's the one who persuaded me (with the help of df members) to start pumping. He really wants to see me succeed.

Wonderful news tho. My total cholesterol has dropped another 4 pts (180) so he says to stay on the Simvastatin for now but we may end up decreasing the dosage.

Ok guys and gals. Give me your thoughts. Don't hold back but please keep it respectful and civil.

Thanks!!

Edit: He also assured me that I made the right decision with the temp basal the night before my labs. This fasting was higher than the last (122 compared to the 96 last time) but he still says I made the right choice. So, that made me feel a little better.

[notme]

Well Cin.... I disagree with your doctor. My HBA1c is 6.5 (too high in my thinking) and I have told my doctor that I am pushing for 6.0 next time. He was all for it and gave me some help in how to achieve that number.

Your doctor seems a bit old school in his thinking. 7.0 was a number that we would strive for when we had NPH and Regular insulin to work with and not many other tools. Today we can keep a much closer range without going hypo. The pump, Lantus, Humalog, Novalog and all the other fast acting and non peaking insulins. We also have carb counting.

I think what you could do to prove this to your doctor is to go ahead and lower your A1c. Keep your logs and your numbers so he can see that you are not going hypo to achieve those numbers. The proof is in the numbers. You may just get your doctor to rethink his stand on those incredibly low standards he is setting for his patients.

[Funnygrl]

I think keeping your a1c between 7.5 and 8.2 would be doing your body an unnecessary disservice. Especially being on a pump, with frequent glucose testing, I'd think you'd be able to safely get it lower. How is your hypoglycemia awareness now?

You're too young to have to deal with organ failure from diabetes.

[gettingby]

Thanks Nancy and Funny.

My hypoglycemia awareness is really good (most of the time). I do hit periods where a 40 or 50 slips right by me virtually unnoticed but not too frequently. And Nancy, my Ultra Smart keeps everything right there for him to see. I think, like you said, that I need to prove to him that I can accomplish it.

Again, thanks ladies.:)

[davef]

Cin,

I think that we are the ones who know best what we are capable of and that you are in the best position to decide what "too many hypos" means.

Not being on insulin, I can't give and informed decision as to whether or not 14.6% of your readings being below 70 equates to too many lows.

I say follow you gut and go for it.

[xMenace]

Better control means better control. You get fewer hypers and fewer hypos.

Recipe:
- basal test
- profile meals
- low carb
- exercise

[lorilei]

ok Cin,...newbie answer here...but one to consider, i think...

you mentioned that you consider hypos to be anything below 70...and that you have recorded 59 hypos in the past three months..so 10 per month average...( seems most ppl have 1 or 2 episodes per week easily??)

I'm wondering how these hypos fall out on the range..ie..if 9/10 hypos were in the 60-70 range and you had no problem detecting them...then his advice seems to err quite a bit on the side of caution...

However, if 90% of your hypos were numbers that dropped below say 60 or any other number causing you serious issues as a result...then he has some more merit to his argument ...

sorry just thoughts here...but i think lowering your personal parameters a tad may be okay IF you FEEL okay and recover easily....

[duck]

I think bouncing high and low is probably worse for us than staying high at 170 all the time or staying lower at 70 all the time...But if I had a choice, I would stay consistently lower around 100 all the time. Now, if I can only get dialed in.

Your endo sounds like s/he is trying to be supportive and pragmatic. I say through a bit of pragmatism to the wind when you are ready and work on getting to a more stable lower point.

--duck

[Tattoo azz]

Hey Cin, i say try little steps until your satisfied. Hope you're not too stressed girl. I take it you've been tweaking your dosage as well? I know it's not much help but you know more about your own situation than i do, i know you'll figure it out along with your doc. Keep on keeping on
Azz

[cherokee_psh]

Cin,
I always thought that lower numbers meant less possibility for damage. Then the Duck's post made sense too....stability. Possibly the doctor just want to stabilize first then step down slowly later while maintaining stability.

[Subby]

YOU are completely right when you mention you've been lower that 7.3 and had greater stability. As someone who obviously makes the effort each day, you have the tools in place to keep getting your body to respond better with better BGs, as per what Nancy and John are saying.

The whole "keep a high A1c" to avoid hypos just doesn't address what's going on in the situation. It's treating A1 like a water level to cover up the rocks. Whereas, for those who makes an effort to keep in control (and therefore test, correct, strive to get it under control) a high A1c is probably more indicative of very big, and sometimes dangerous, waves. As John said, and you said, the better the general control, the less the waves are likely to put you on the rocks.

For those that test a couple of times a day, and don't care/notice if they are sitting high most of the time, and are unlikely to change this approach, it might make sense to say "well, better to stay higher anyway, because you are a risk running at a good A1c". I don't think you fit in that boat. Do you?

In the end Nancy has it. Just go ahead and keep trying tactics to improve your daily BG control, you've got the condition, you'[ll pay the price for a higher A1c, NOT your doctor. I think this whole thing about "aiming" for an A1c is a little superficial anyway, sure it's a target, but aren't you aiming for good BG as many hours of the day you can? That's how it should work on the ground, in my book.

[Subby]

Cin,
I always thought that lower numbers meant less possibility for damage. Then the Duck's post made sense too....stability. Possibly the doctor just want to stabilize first then step down slowly later while maintaining stability.

I could understand this approach working for certain type 1s, and especially many type 2s where there is an amount of pancreas providing stability, or IR is a kind of "layer on top" effect, and progressing with control is a case of shunting the numbers down slowly.

For a type 1, it's a whole other scenario. You need to create the numbers from scratch. You need to keep aiming for good numbers, because that's the way you get the body to partake in "the stability game". And if you are someone with stability issues, such as myself or I would guess Cin, you REALLY need your body to respond well and learn what good numbers feels like.

I'm not trying to make grand statements about the differences in type - just trying to get to what the process really is here. I think the idea of a type 1 getting stability should be about seeing the right numbers more and more, not aiming for generally high numbers and therefore suffering more instability.

[duck]

I should add when I am "stable", I feel "better". The days/weeks when I am bouncing up and down, I get beat-down myself. I wish I could find some study that backs me up at least a bit, but I now that I have a CGM I have more proof, for me at least, that stability makes a big difference in how I feel and my overall energy levels.

However, I think most of us know the lower we can get and stay safe, the better off we are in the longer run.

But ultimately, it's about us and our personal goals and how we feel. I think Cin will be fine. We all need that break from the constant numbers game (unless you are a crazy mathematician).

[IrishJoe]

You could always say 'thanks doc' and then when you're next A1C is say 5.8 and you have the same/less hypos he might see it your way?

[TommyC1]

I don't see where we have too many options.
We have to keep the A1c as close to heathy as we can AND avoid the hypos as much as possible.

No I would not be willing to use 7 to 8 as target A1c's.
I'm shooting for 6. With no hypos.
Hey! It's a goal.
We'll see what the reality is.

Tommy

[gettingby]

Thanks for all of the replies.

I am starting to think more on this. I do wonder if by taking small steps, I can get down below what he has said but in a safe manner. I'm sure gonna try.

And yes, Duck, I will be fine. You've "known" me for almost 5 yrs now and in that time, I don't think I have given up fighting yet. I will prove it to him, to myself, and to all of you who show me your support on a daily basis.

Again, thanks !!!!

[Jan B]

Hi Cin,

I went from an A1c of 8 to 6.1 in three months, after my doctor told me not to go below 7.5 or I'd have too many lows.

I knew when he said it that it was not entirely true -- he is the opposite of the type docs who make you feel bad about your higher A1cs. I'd been on DF for a while, I had started pumping again, and I knew that getting my basals right, and testing a lot would get me where I needed to be (I hoped anyway!)

Three months later, my doctor was elated at my 6.1. I explained that I'd had some lows, but that I was always equipped to handle them, and that I was feeling sooooo much better.

Maybe your doc is a little like mine? Respects that you are an adult, and doesn't want to push too much?

This is what I looked at a lot when I decided that the standard of an A1c of 6 (not 7) was a GOOD idea:

A1c of 8 = avg bg of 180
7.5 = 165
7 = 150
6.5 = 135
6 = 120
5.5 = 105
5 = 90

[soso]

Hi Cin
I totally agree with Duck about the stability aspect...
recently I got an ipod touch and a little app called Glucose buddy, wherein I input my readings and it shows a high and low graph..DH immediately pointed out how my highs and lows were always together in clumps..

So my take is that if you can tame the highs, you will automatically have less lows...if you are anything like me, you will notice how many of those lows are related to correcting the highs...
I am pulling for you anyway..though also sure you will be fine.. you seem pretty thoughtful and grounded to me..

[yannah]

great news on the cholesterol!!! good job!!!

[gettingby]

great news on the cholesterol!!! good job!!!
Well, I didn't do it on my own but am hoping to be off of the Simvastatin soon.

Thanks everyone for your replies and encouragement.:) Like my sig says, I am not gonna let myself and my self worth be defined by my A1C !!!