Should I hold off on insulin?

[Rekarb]

Got my insulin supplies, took my insulin class, stuck myself twice but now my numbers are starting to drop. I've been on Actosplus Met for a week now and I actually would have started on the insulin Friday but I ran low on test strips and thought I should wait until I had a decent supply.
My numbers have been averaging above about 200 over the last month with spikes into the 300's.
Friday night took my first bg and it was 137 had a beer and an hour later it was 164.
Got up that morning - it was 137 and half an hour after breakfast it was 185. 4 hours later it was 146 until I ate and it didn't go above 177.
My fasting rate is about 60 points lower and my spikes nearly 100 points lower. I'm thinking that I need to let this stabilize before I start shooting the insulin?

Mike

[jtausch]

Got my insulin supplies, took my insulin class, stuck myself twice but now my numbers are starting to drop. I've been on Actosplus Met for a week now and I actually would have started on the insulin Friday but I ran low on test strips and thought I should wait until I had a decent supply.
My numbers have been averaging above about 200 over the last month with spikes into the 300's.
Friday night took my first bg and it was 137 had a beer and an hour later it was 164.
Got up that morning - it was 137 and half an hour after breakfast it was 185. 4 hours later it was 146 until I ate and it didn't go above 177.
My fasting rate is about 60 points lower and my spikes nearly 100 points lower. I'm thinking that I need to let this stabilize before I start shooting the insulin?

Mike

No Insulin is designed to help you body lower and stabilize you BS. If you are using a basel LONG LASTING like levimer or lantus definitly take that. on the bolus insulin i woudl try to take those also even if you have to go buy your own strips to check. Are you a type 1 or type 2? Type 2 you could probably get away with out some of your boulus if you eat low carb type 1 i would not even try to skip insulin. If your on insulin its not a good idea tyo skip any poses

[Rekarb]

I'm a 1.5. I haven't started the insulin yet, that's my question. Should I wait until this change stabilizes a bit? I would be going on basal only. This drop in bg is less than 48 hrs. How low can it go? What happens if take insulin and my bg has gone below 120 without it?

Mike

[Subby]

I don't think we can really tell you what to do... here are a couple of thoughts though.

- have you asked your doc?

- speaking for myself, I might let things stabilise a bit, at least see if things stay like this a few days, yes. Look at it this way, your numbers are not high in the sense that it's imperative to get insulin into you, even if it caused dosage problems and lows (and highs). If things are changing a lot right now, it is going to make things more tricky to get it right. The point is, I would still be geared to starting on insulin at some stage (few days, few weeks), but if I feel things are really changing now, I might just watch for a little bit.

- that idea of stabilisation... have you had other examples of significant fluctuations in overall BGs over the months? Because that seems to be something that T1.5s do report, and the real difficulty in dosing insulin for the different body states. So I guess, look into that, and it might means that you are on a slow rollercoaster and will need to develop highly "adaptive" insulin dosaging, whether you start it now or if/when things go higher again. As if it wasn't hard enough in the first place!

- Last point, if you are wary and your BGs relatively stabilised, but want to move on now anyway, don't forget insulin can scale to any dosage. So if you are hesitant because XX units sounds like a lot, start on a much smaller amount and see how that goes. Obviously still taking care, but it might let you start to get a grip on the kind of dynamics you are playing with, so you become more informed and there is a little less darkness. Again, hopefully your doc will be useful in choosing a low dose or a "range" to try.

So to just put that another way: I would either hold of to see a little more data about your current BG trends, or start on a low dose to get more data about how the insulin works.

[BlueSky]

[QUOTE=Rekarb;481672... My numbers have been averaging above about 200 over the last month with spikes into the 300's.
.......[/QUOTE]
Your greatest need for insulin is at mealtimes. And the problem with injecting only basal is that you blood glucose becomes very volatile. It rises very high after meals and comes crashing down between meals, especially at night. This situation doesn't just stabilise. I would hold off on the basal, and inject bolus shots (Humalog or Novolog) at mealtimes. You may find that, in addition to flattening out the spikes, it also keeps your blood glucose between meals in the target range. When your BG no long stays down between meals, you need basal insulin too. A lot of doctors don't seem to get this ... :( .

[Rekarb]

At last check, my bg was 116. This is turning into a wild ride! It feels like what you call a "hypo". This is virgin territory for me and it's going to take a bit of getting use to.
Remember, my strange case. I don't have detectable anti-bodies for beta cells and I have a normal c-peptide. Maybe now that the glucose toxicity is going down things are kicking in. Who knows? I'm just going to have to keep an eye on things for a few days.
My endo prescribed the insulin 5 days ago when my bg's were very high (above 200). No way could he have suspected that they would suddenly drop.

Thanks

Mike

[Joder]

If your numbers have been averaging 200, 116 will feel very weird... don't worry it's about acclimatising to the lower bg.

hard to advise anyone really as the others said - a few thoughts:

speak to your doc about what you plan to do

aim to get your bg down progressively - maybe cut out too many huge carb meals (bread/pasta/white rice etc)

try to eat regular meals if you don't already

if you have massive swings, it may be partly due to big carb meals so a basal may take you hypo if you're down to 116 before meals.

I would want to work out from a standard meal (say breakfast) what happens to your BG and get a bolus tailored for that ( some websites can help you calculate the insulin dose needed to manage a certain carb intake) you DSN or doc will help and get the peaks stabilised, then see where you are and introduce the basal gradually

I would definitely do it under close supervision from your doc/nurse, go steady at it and don't try to do it all at once. I wouldn't suggest that holding off on the insulin is a good thing, as the sooner you can get stable on it the better for your remaining beta cells and everything else.

my idea is that the root cause for the swings is in big carbohydrate loads at meals ?

good luck

best

[Rekarb]

Got through a night of tossing and turning, found morning bg at 134 and I feel thoroughly washed out.
I'll be calling the endo tomorrow morning to get further instructions.
Another thing, I'm low carb. My carbs have not exceeded 50 a day in a month. The only thing that has changed is the taking of Actos starting last week. In a way, this makes me feel hopeful cause the only thing that could be bringing these bg's down are my beta cells. Why they would kick in now, I don't know and I'm certainly not going to look a gift horse in the mouth.

thanks again

Mike

[foxl]

Rekarb, in three weeks I MAY be in the position you are in now. Reading your thread with interest ... my blood sugars are so NORMAL right now ... < 100 most of the time, fasting.

BlueSky, Joslin's actually recommends starting basal-only for LADA. You are saying it is too hard to maintain stability? This is interesting -- first I ahve heard this opinion and would like more info / input from you and others.

[lorilei]

welcome to the crazy, bipolar times of 1.5 on the spiral....your best friend will be your meter...take loads of readings and bring to your doctor along with charts of what you are eating to determine the best course for you..the low 100's will feel wicked for a bit...but even if your numbers are now below the 200 threashold anything can happen....

as far as basal vs bolus to start..i agree with Bluesky in my case, my post prandails rocketed firs, so bolus it was..but my fastings were right behind and basal helped to even the spikes for me shortly after...

of course, as i have said throughout, i dragged my feet grudgingly back to the proverbial insulin table...and i wouldn't recommend that to anyone trying to preserve their beta cell function...i do beleive there is much to be said/learned about adding insulin before you are in dire straights...hmm..maybe a poll?

[Rekarb]

I was the one who told my endo that I needed to go on insulin. We had it all set up to start on Saturday and bang, my numbers dropped!
I spent years working with biological systems and the one thing I would tell my people is that systems tend to bounce when a significant input is introduced. You wait until the system establishes its new baseline, document it then make another adjustment. This is how I've been proceeding all along. The change, I admit, totally caught me by surprise. I wrote initially thinking that it would stop at a lot higher bg's than it did. Once I fell below my target number, I pretty much knew I'd have to wait besides I felt like ****.
I fall on the basal side of the argument basically because I think that everything should start from the underlying structure. If I don't have consistency there I don't see how I could adjust anything that starts off from it.
As far as I'm concerned, there is no rush. I'm going to be doing this for a lifetime and I like measured approaches when dealing with complex problems. I'll probably take a week, measure the extent of the changes, talk it over with the endo and then start my insulin.
Here's an interesting thing I noticed. My spikes were greatly reduced. They were tending to be about 40 points above my fasting rate. This seems to indicate to me that if I could bring my basal to a consistent 100 then my spikes would not take me over 140 which is my ultimate goal.
I should be so lucky. Nothing is as it seem with diabetes. Just have to play it by ear and keep an eye out for the main chance.

Thanks

Mike

[BlueSky]

... BlueSky, Joslin's actually recommends starting basal-only for LADA. You are saying it is too hard to maintain stability? This is interesting -- first I ahve heard this opinion and would like more info / input from you and others.
Linda, the trick with treating LADA is to supply insulin when it is needed most. Because your beta cells are producing a substantial amount of insulin, it doesn't make sense to provide even more of it between meals. Your body doesn't need extra insulin at these times. And the extra insulin action from long-acting basal shots is likely to cause hypos between meals. Especially at night. Furthermore, the low level of basal insulin action is not suitable for containing post-prandial spikes. Blood glucose is likely to spike very high after meals because of the relatively low level of insulin action. And because we become more insulin resistant at high BG levels, recovering from these spikes becomes problematic.

It is not hard to see why the use of a basal-only insulin for LADA and early T1 diabetics is likely to result in very volatile blood glucose levels. Which is why I am bewildered by the mis-informed belief amongst endos and so-called experts (like Joslin) that this is suitable. When my daughter was diagnosed as T1, she was put onto Lantus immediately. The result was that she had to "feed" the insulin before bed and between meals. And she had post-prandial spikes that didn't come down before her next meal (lunch and supper). It was only after the endo cut back on the Lantus and started bolus Novolog that things settled down.

Because our greatest need for insulin action is at mealtimes, it make much more sense to start with a bolus-only regimen, and to introduce basal insulin when the beta cell function no longer keeps BG down between meals. The practice of starting T1s on long acting insulin comes from the days of conventional therapy (2 injections a day), and it doesn't utilise the potential of modern fast acting insulin.

[foxl]

Thanks, Mark. So you think "starting with basal" is more to do with it being more convenient to the user, rather than advantageous to the beta cells, basically?

[Rekarb]

It's official, my endo wants me to wait to see what we have here. My last bg was 115. We're just going to take a little more time and let things settle.

Mike

[BlueSky]

Thanks, Mark. So you think "starting with basal" is more to do with it being more convenient to the user, rather than advantageous to the beta cells, basically?
Yes, I certainly think so. Doctors make the assumption that new patients want to avoid multiple injections for as long as this is possible. New patients get put on basal because it is supposedly easier for them to handle. There is no need to balance each meal with bolus insulin, which takes some getting used to.

The other issue is that injected insulin needs often decline sharply after insulin treatment is started, because the beta cells are getting much needed support. It sounds like this could be happening to Rekarb. Managing the reduced dosage is more challenging with a bolus regimen, because BG sensitivity to food changes. And the change is not always consistent. A basal-only regimen most likely shortens the honeymoon, during which there is some residual beta cell function. But this removes some of the dosing uncertainty. It makes both the doctor's and the patient's life easier in the short term. But failure to preserve beta cells is unfortunate, especially for someone with T1.5.

[foxl]

So you think there is more rest to the basal cells by bolusing -- even though:

the timing is less-easily predictable (ie, peak matching),

and on a low-carb diet, the need for secretion for peaks may not be as frequent?


Supposedly, about half our insulin needs are basal, the other half are bolus for peaks.

I would think if basal were taken care of by the exogenous insulin, then endogenous would store up, for peak usage, but, maybe not?

Not simply debating, but trying to think through this, out loud as it were.

[Rekarb]

Just taking a preliminary look at my numbers seems to show that my spikes are being limited. They are consistently staying about 40 points above whatever my lastest fasting rate is.
I remember reading somewhere that half the beta cells constantly secrete giving a basal level and that the other half kick in to prevent spikes. I've also read the African American diabetics show a strong tendency to have a problem with the phase 1 part of beta activity. Why this is so I've no idea and neither does anyone else. Just seems to be some statistic that sticks out. Which leads me to think about the different variations of diabetes in different groupings. I think its probably warranted to look at some of this data in terms of one's own diabetes. Of course, North Americans are pretty much mutts so it might be hard to pick anything out of any specific racial grouping.

Just wondering

Mike

[foxl]

I have not read a racial or genetic association with the loss of that early insulin peak, might it be your interpretration of a remark in the literature?

Because loss of that peak is associated with early D, in general, a point which sticks out in MY memory, I know it is in Blood Sugar 101. SOMEWHERE. But not sure where the author found it in the literature.

It is true Americans are mutts -- I am in the genographic project, and we are a true melting pot!

[Subby]

So you think there is more rest to the basal cells by bolusing -- even though:

the timing is less-easily predictable (ie, peak matching),

and on a low-carb diet, the need for secretion for peaks may not be as frequent?

Supposedly, about half our insulin needs are basal, the other half are bolus for peaks.

I would think if basal were taken care of by the exogenous insulin, then endogenous would store up, for peak usage, but, maybe not?

Not simply debating, but trying to think through this, out loud as it were.

A few pop answers:

Ease doesn't inform on requirement. Just because it's hard doesn't mean it may not be the best course.
If low carb solved your pp spikes it wouldn't even be a question for you: if you spike, the need may be there. If you want to go Bernstein levels and aim to virtually remove meal requirements, by all means, that's an option.
Half/half is for no pancreas contribution and high carb diet, not your situation, and hard to overlay your situation. As per your next point, we do not know what your pancreas is doing - humming away providing basal needs, or shunting it all into "boluses"? And what amounts of each? Don't know.
Storing up: interesting question. No idea if anyone can truthfully answer it. Or whether it's info that can be put into practical use.

If I were you, I'd do some analysis of when my worst BG times are (if you don't feel 100% sure how you "rank" your BG issues). Fasting or post meal? Depending on which is worst, would be where my own pitch with the doctor, would be going.

You've mentioned both fasting and obviously, post prandial problems (at least at times, while on the forum). As such the obvious answer for "which is better?" is.... probably both. But do you really need both? No idea. It could be that one will contribute or alleviate the other. I guess I return to my own thought which is... try one, and see what happens. Once you've adjusted (for example, basal, to get good fastings and no lows) you can easily answer if you are still spiking after your mealtimes, or at other times of heightened insulin needs through the day.

[foxl]

Subby, thanks for your thoughts!

I am thinking ... I might just get bolus to cover occasional excursions, at this point.

I would love to understand, how long it takes beta cells to recover and build back up?

I have had NO FBGs over 110 since about June ... well, okay, TWO that were 120! I really need to input all of this and GRAPH, this weekend for the Endo ... I have had some post-prandial spikes but now I am looking at it, none over 135!

Variables here include: new meter, which definitely runs lower, and eating more carefully since I know eating this low-carb will not be forever.

... so mutter mutter mutter, d'ya think she will laugh me out of her office?

[SB_Krista]

BlueSky/Mark,

I understand your reasoning that basal-only provides insulin when you don't really need it (between meals and overnight), however, what about someone like me whose BG readings never fall below 120? It seems to me that my basal set-point is about 120 and I go up from there with every meal. Low carbing keeps my post-prananials in a reasonable range, considering where I start. I've always thought my high basal set-point is due to my liver....releasing glucose and/or not being down regulated properly by the presense of enough insulin. Thoughts?

[Rekarb]

There's actually a whole bunch out there. If you google "ADM" "African" and "first phase" a whole group of citations pop up.
It's a genetic fluke that was once thought to only exist in American Blacks but it seem it's every where.

Mike

[/url]
[url=http://www.utdol.com/online/content/abstract.do?topicKey=~uSyJ4hk7W7N3.9y&refNum=2-22]Medline Abstracts for References of 'Syndromes of ketosis-prone diabetes mellitus' (http://care.diabetesjournals.org/content/23/3/335.full.pdf)

[foxl]

There's actually a whole bunch out there. If you google "ADM" "African" and "first phase" a whole group of citations pop up.
It's a genetic fluke that was once thought to only exist in American Blacks but it seem it's every where.

Mike

[/url]
[url=http://www.utdol.com/online/content/abstract.do?topicKey=~uSyJ4hk7W7N3.9y&refNum=2-22]Medline Abstracts for References of 'Syndromes of ketosis-prone diabetes mellitus' (http://care.diabetesjournals.org/content/23/3/335.full.pdf)


Aha! So it is ... interesting! Thanks, Mike! You always have to know the right terms, don't you? Before I ever heard of LADA, I had a gut feeling, but it was not too easy to find at first.

[BlueSky]

So you think there is more rest to the basal cells by bolusing -- even though:

the timing is less-easily predictable (ie, peak matching),

and on a low-carb diet, the need for secretion for peaks may not be as frequent?


Supposedly, about half our insulin needs are basal, the other half are bolus for peaks.

I would think if basal were taken care of by the exogenous insulin, then endogenous would store up, for peak usage, but, maybe not?

Not simply debating, but trying to think through this, out loud as it were.
The bottom line is, if BG is going up after meals, you need to bolus. Blood glucose rises above normal when the beta calls can't cope with the demand being made of them. In other words, they are being stressed. If BG is going up after meals, there is not enough stored insulin to cope with the extra requirement. Insulin being produced between meals is not adequate to deal with the extra demand. And if increasing basal causes hypos, this doesn't help either. Blood glucose becomes more volatile, and the amount of time that BG is elevated rises. Only pre-meal bolusing will provide the relief that is required.

The longer BG stays above normal, the more severe beta cell stress is. So, reducing stress on beta cells requires supplying supplemental short-acting insulin at meal times.

I realise that matching insulin requirements with bolus insulin is difficult. But ignoring the problem won't make it go away. We just have to do our best.

[foxl]

Thanks, Mark! Your response makes great sense to me.

Somewhere in another thread, I posted my last month worth of highs and fastings and was shocked to find -- I need to review the data, more! I may not be ready for any further therapy, at ALL.

Yet. Of course.

[Rekarb]

[QUOTE=BlueSky;484412]The bottom line is, if BG is going up after meals, you need to bolus. Blood glucose rises above normal when the beta calls can't cope with the demand being made of them. In other words, they are being stressed. If BG is going up after meals, there is not enough stored insulin to cope with the extra requirement. Insulin being produced between meals is not adequate to deal with the extra demand.

I actually agree with what you're saying but I think it should be added that bg rises in normal individuals after eating as well. How big that response is should determine what should be worked on.
My fasting numbers are still terrible but my spikes continue to diminish. Now they are in the range of 20 to 30 pts above fasting. This improvement goes hand in hand with my fasting rate dropping. My testing is indicating that as my basal drops my bolusing beta cells are becoming far more active. If this is a real trend, if my basal gets good I won't hardly spike at all.
One thing we can all agree on, however, is the importance of testing all aspects of bg behavior.

Mike

[Rekarb]

It's been a week since last post but finally the bg is finding some sort of range. My basal got down to 100 for a couple of days but now seems to be hanging around 130 - 140. I have a definite DP but I can't really see how it is different from the rise I get in BG after any prolonged fast. 5 to 6 hours after my last meal, I will start up.
Spikes went up slightly too. I tend to be 40 pts on average higher than basal rate unless I try to do something like watermelon. This is the one thing I truly miss! I'm thinking about downing a quarter cup of olive oil before to see if I can stop that spike.
By the way, thinking of spikes. Somewhere I heard that if you spike less than 50 pts above your basal then that food is probably ok. Is this true?

Thanks

Mike

[foxl]

It's been a week since last post but finally the bg is finding some sort of range. My basal got down to 100 for a couple of days but now seems to be hanging around 130 - 140. I have a definite DP but I can't really see how it is different from the rise I get in BG after any prolonged fast. 5 to 6 hours after my last meal, I will start up.
Spikes went up slightly too. I tend to be 40 pts on average higher than basal rate unless I try to do something like watermelon. This is the one thing I truly miss! I'm thinking about downing a quarter cup of olive oil before to see if I can stop that spike.
By the way, thinking of spikes. Somewhere I heard that if you spike less than 50 pts above your basal then that food is probably ok. Is this true?

Thanks

Mike

Mike -- how long have you been on the actosplusmet, refresh my memory, please? Because ... metformin specifically takes care of glucosneogenesis, productio nof glucose by your liver. A fasting rise would be due to that gluconeogenesis. Are we sure you have given the metformin enough time to take effect?

[Rekarb]

I've been on the actosplusmet for about 3 weeks. You're on the same med and I was wondering how long it took before it fully took hold?
I've just went through a mean false hypo and it just seems as if a war is going on inside of me and all I can do is sit and take it.
When my numbers were mostly up, I could clearly correlate what I felt with those numbers. Now, I feel lousy when their up and down with brief moments of wellness. If I had to choose again, I would definitely do insulin first. I think it is a far more straight forward way of addressing bg. The body needs insulin so supply as needed and skip all this messing around tweaking other functions trying to meet this insulin need.
I'm committed to letting this play out even though I have to put up with the ball in a match of bg ping-pong.
There is one correlation that has shown up. If my morning bg is above 150, I'm going to have a bad time of it. The rest of the day is my basal bg working its way down over time.

Guess what? Suddenly, I'm feeling good! Gonna go outside and cut the grass.

Striking while the iron is hot!

Mike

[foxl]

Mike, I never noticed when the actosplusmet started working, and it is not at all obvious retrospectively in my blood sugar records. In fact since I am a 1.5, maybe ... it never has? I suspect I have some insulin resistance but not sure how much. One of my first ideas is to go off the actos at least (I do not care for risking the side effects, if it is not really working ...). Met supposedly takes 4 - 5 weeks or more to start working though.

I was on Glimepiride (Amaryl) for supposedly the first couple weeks, but went off it due to crashing lows after 7 days or less. But, I also began low-carbing before 4 weeks.

If it were my choice, I would say, if you can get thru the next couple weeks you might have a more solid for making a decision on insulin use, without too much roller-coastering!

[Rekarb]

Thanks for the reply, Linda.
It's definitely the Actos that's working. I tested without meds while low carbing and doing exercise and I can definitely see where it kicked in. I guess I'll have to wait another couple of weeks for the Met to work. It's a hassle since my energy levels are yo-yoing like mad but diabetes is a hassle anyway.

It isn't like nothings happening. My bg's are still going down, though more slowly now. So I'm getting there. I'm guessing that by end of next week I should be seeing bg's consistently in the 120's which was where my target was for insulin, anyway. I'm not going to be satisfied, however, until all my bg's are safely nestled below 140.

Mike

[Rekarb]

Bg's are under my target number. So I guess no insulin.

My only question is: now what?

Mike

[foxl]

My question, too! Did you get that article, BTW?

Funny we are going in opposite directions ... I am going OFF Actos, tonight actually. I am very interested to see if there is an observable difference in my numbers!

I think for now my plan is to go onto insulin when it become apparent I need to (based on C-peptide and A1c), and stay on Met as well ...

[Rekarb]

My question, too! Did you get that article, BTW?
Article? On what? Did you send me something?

Are you going off Actos to go on insulin? I'm seriously thinking about doing that myself. It just seems to be more straight forward. As it is right now, my bg's are still going lower. It would be problematic to inject insulin while I've got this wild card messing around in my system.

If I am an A-B+ then I might have got better and faster results with insulin. Of Course, I've only been on these meds for 5 weeks and I'm starting to see near normal readings.


We are going in different directions in one way but the same way in another, we are both getting healthier. The one test that would truly pick this up is a c-peptide. If those numbers are going up then that would be a pretty sure sign.

Mike

[foxl]

Mike, I went to PM and sent you via email a newer article by the Texas group on therapy in KPD ... do you use the email account you gave when you registered here ... ? I will need to find it again to re-send, hang on ...

Not going on insulin yet, my numbers are too low! I am going off actos and on 1000 Met BID (was on 850, BID, so not a huge change, there). I am in the process of editing my profile in a bit. b/c I just changed my meds last night!

My goal is to minimize use of meds to control this ... and maybe go on insulin later when my BGs go up a little ...

[Rekarb]

I can't access it though. I explained the problem in my email.

"Can't go onto insulin because your numbers are too low" That is a hoot! Could you imagine saying something like this a few months ago?

What aren't you getting that you think insulin might bring you?

Mike

[foxl]

Nothing right now ... just seems my MD does not think using insulin in ealry LADA to support beta cells is worthwhile?

You cannot access a PDF, even? Sorry!