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alexg

Extreme Lows and Unknown Cause

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alexg

Hi everyone, I haven't post here in a very long time.  I need to familiarize myself more with my Diabetes as it has been out of hand for nearly 10+ years.

 

For starters, I have never seen an A1c lower than 7 since I have been diagnosed.  I started on pills, went up to insulin, and now on insulin with pills combination.   I barely started to get extreme lows that have made me more cautious about my readings.  I am at about 3 weeks taking Synjardy with my Insulin.

 

For example today, I woke up had a 102 glucose reading, took my Novolog 70/30 60u shot and ate breakfast.  About 3 hours later, I tested again and was at 92.  I then took my Novolog 20u shot, my Synjardy pill, and ate lunch.  2+ hours later before I went to the gym, I checked my glucose and was at 152.  I usually take a Gatorade or something to the gym so I can gradually drink it and my sugar won't go down, but since it was high, I just took water.  I did my exercise fine, no problems, got home and wow I was at 52 and it didn't even feel like that.  I right away took my glucose pills to raise it up and then ate dinner.  I didn't inject my nightly Novolog 70/30 mix since I was low and didn't eat a big meal.  A few hours later, I took my glucose and I was at 82.  

 

My concerns are how my glucose drops from 152 to 52 and my exercise wasn't even an intense one. This similar daily routine has occurred about once to twice a week getting lows like that.

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miketurco

Hi, the reason you're going low is because there's too much insulin in your system relative to the amount of sugar. Lows can be dangerous. I would say take less insulin next time, let yourself run high, and maybe contact the doctor's office. 

 

Once you're past this, there's lots to talk about in your email. Not to be rude, but you've got to learn how to calculate insulin and manage your carbs. You've had diabetes for quite a few years and it's critical to your well being that you learn the actual math of diabetes.

 

I want to point out that I am not a doctor, nobody here is a doctor (that I know of), and there's absolutely no medical advice on this site.

 

First things first, there are two types of insulin. The amount you need in your system throughout the day has little or nothing in common with that 70/30 premix you take however-many times a day. You need to get two kinds of insulin, slow and fast acting, and determine the dose and timing for each of those two insulins.

 

The amount of basal (long acting) insulin is something you just experiment with to learn. You have to do something called "basal testing." Basically, if you get this wrong you can go really low while you sleep. It's rarely deadly but it can be.

 

Second thing you have to do is figure out how to dose the fast acting (bolus) insulin. The amount you take is based on four things: your current bg, when you plan on eating, how many carbs you're going to consume and how many bg points insulin takes your reading down. OK, I lied. There's a fifth thing, which is "how many carbs does a unit of insulin cover." There's more to it, but these are the basics.

 

There's an AWESOME book you should read called Think Like A Pancreas. It goes into great detail regarding the how too of insulin dosing. It's actually pretty readable, don't let the title fool ya :)

 

Last thing: get another doctor. That's my personal opinion, of course. But if your doctor has you on 70/30 "sliding scale" I have to believe that's a problem.

 

Sorry for being harsh. Friend of mine went low the other day ("or something" and is in the hospital. So when I hear you talking about this stuff, I kind of freak out.

 

Wishing you the best

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DeusXM

Have you had any classes at all on using insulin?

 

Exercise can easily cause a large blood sugar drop (even if it's not strenuous), particularly with the volumes in which you're taking it.

 

Have you had any briefing on matching your insulin to your food intake? Your Novolog 20u at lunch should not be at a fixed dose, it should be in proportion to what you are eating. As for the Mix insulin, you are unfortunately stuck with fixed doses for those, but that means you have to eat the same amount for breakfast and for dinner that you do every day, at the same time. You CANNOT miss one of these doses.

 

I would say if you're already on three injections a day, you may as well move onto a four-injection system, where you take a set amount of background insulin every day and then have a fast-acting insulin in proportion to your food every time you eat. 

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alexg

Thanks for the advice.  Sorry to freak you guys out!

 

No I haven't had any classes on insulin.

 

I used to be at 100 u @ breakfast, 36 u @ lunch, and 80 u @ dinner :wacko: before I got put on Synjardy as a trial basis.  With those past doses, I would rarely hit 70's, but had a high A1c due to after meal highs. I did notice that the 70\30 mix would take long to work for those after meal highs, but did eventually go down before my next meals.  I was added Synjardy to improve Insulin resistance if I remember correctly.

Edited by alexg

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NoraWI

That 70/30 is a mix of slow and fast insulin in a preset dose. There is no way it will match your body's needs. The Synjardy is a mix of metformin and empagliflozin. Metformin is one of the oldest and safest T2 medications; empagliflozin is a newer one that reduces blood sugars by processing them faster through the kidneys. That puts a lot of pressure on your kidneys. There is a warning about taking it with insulin here:

 

https://www.synjardy.com/how-it-works

 

You say nothing about what you eat. It is very important in maintaining control of your BG. As they said above, you have to learn more about diabetes control and probably find another doctor who loads you up with information rather than medication.

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Uff Da

I agree with others above who implied that the 70/30 mix of insulin was likely part of your problem. I've never been on it personally, but I was caregiver for my late husband for years and he was on it. It doesn't give one the flexibility that a true basal plus meal time insulin does.

 

If you don't have access to classes on diabetes/insulin use, the book miketurco mentioned above is a very good substitute. In fact, when I was first put on insulin, my endo expressed regret that the local hospital was no longer offering such classes. My reply is that that didn't bother me at all, since I learn much better from reading than from a class. With a book, I can go back over things I find hard to understand or if I forget something, whereas I can't do that in a class.  I got the book Using Insulin by John Walsh, used it as my "insulin bible," and have had an A1c between 5.5 and 5.9 ever since. The book Think Like a Pancreas by Gary Scheiner covers much the same territory.  

 

The modern long-acting insulins are Lantus, Levemir, Tresiba and Toujeo. They are much improved over NPH insulin, but are also much more expensive. You might want to check what one(s) are covered by your insurance, and what your price would be before asking your doctor to make a change in your prescription. 

Edited by Uff Da

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alexg

Thanks for the explanations, I am already with the insulin and medication. I know the Novolog mix is my main problem because I personally had to lower it from 80 to 60 because of the lows.  One of my typical meals is grilled fish over a bed of some white rice with a side of mixed vegetables (broccoli, corn, peppers) .  Other times its grilled chicken with two sides or homemade chicken soup or beef soup.  I don't drink sodas nor do I eat stuff like ice cream, candy, etc.  I rarely eat potato chips, but do eat popcorn.  I snack on sugar free jello with some fruit or low carb yogurt.  When I go out, I usually get anything that is grilled not fried and stay away from sides like french fries, mash potatoes, bake potatoes, etc., but I do get corn, rice, vegetables.

 

I always rotate between Humalog and Novolog depending on my insurance, but will have to look into those other brands.  I will go ahead and find those books and get some more information.  Thanks everyone for your imput.

Edited by alexg

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Kit

I think you are eating significantly more carbs than you realize.  Corn and rice are pretty carby and a lot of people here have troubles with rice, even if brown.  So is most fruit for that matter.

 

Have you gone through and checked the actual carb counts in your meals?  How much are you eating?

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Uff Da

I always rotate between Humalog and Novolog depending on my insurance, but will have to look into those other brands.  I will go ahead and find those books and get some more information.

 

Just to make sure we are on the same page, those other brands of insulin I mentioned would substitute for the NPH in your 70/30 mix. 

 

If you have the time to do so, you might want to log some of your meals into the FitDay website (or another site that does the same thing) to tally up just how many carbs you are eating. Although these sites are basically designed for losing weight, I just used one for the tally of nutritional information. As far as rice is concerned, all I'm able to eat in one meal without my BG going well over 200 is 2.5 to 3 ounces, which is a mighty small portion. But people are different. Men, who typically weigh considerably more than my 132 pounds, might be able to get away with more. Just do a check after some of your meals to see what your individual tolerance is.

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meyery2k

alex - Welcome and I think you will see there is a lot of good "real world" advice here.

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alexg

Thanks!

 

Before lunch I was at 102, then 1 1/2 hours later I am at 124.  This is with 70/30 @ 60 and taking the Synjardy pill.  I had chicken with broccoli in lemon butter sauce.  That was only estimated at about 10g - 15g Carbs.

 

I am doing research on the Lantus, Levemir, Tresiba and Toujeo insulin and have found that my insurance does cover them.  Wonder why my doctor has never tried me on those.

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Uff Da

Before lunch I was at 102, then 1 1/2 hours later I am at 124.  This is with 70/30 @ 60 and taking the Synjardy pill.  I had chicken with broccoli in lemon butter sauce.  That was only estimated at about 10g - 15g Carbs.

 

That's great! However, do watch for a possible low later, depending upon how your medications affect your BG over how much time. For me, Novolog had a very long period of action. One time my BG dropped another 59 points after the 4.5 hour mark after bolus!

 

What the timing will be of the Novolog plus NPH plus Synjardy is anyone's guess. And how it works will also likely be changed by the fat/protein/carbohydrate content of an individual meal. So you'll have to watch what happens and compare it to what happens with a different meal content. Keep good notes. Sometimes this can get to be quite a research project. But over time you'll have a better idea of what to expect and can adjust size of bolus or timing of bolus for better results on those that don't work out as desired.

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alexg

That's great! However, do watch for a possible low later, depending upon how your medications affect your BG over how much time. For me, Novolog had a very long period of action. One time my BG dropped another 59 points after the 4.5 hour mark after bolus!

That is exactly what I have noticed.  The Novolog Mix takes long to act compared to the fast acting one.  That is also where my lows come from as my reading is fine, but then the insulin kicks in later.  I will keep a watch more closing.

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alexg

Had another excellent day.  Woke up with 86, ate breakfast, then had 76 before lunch.  After noon was steady at 80's taking a snake as well.  Right now before dinner, I have 78. 

 

Yeah I think my doc was unaware exactly what I was going through having my insulin dosages really high.  Seems I am evening out at 60 units both breakfast and dinner... and yes manually adjusting the lunch dose from 10 - 20 u depending on carbs of lunch meal.

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alexg

How serious is it to look out for lactic acidosis from the Metformin medication? I read on all the symptoms and well some symptoms are like normal like sweating, so I am curious how would you know when to seek medical emergency.

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miketurco

Sounds like your numbers improved a lot, congrats! 

 

Lactic acidosis? I think this is only a concern for those with significant/chronic kidney and liver problems. I could be wrong on that. Are you just wondering because it's a possible side effect, or do you feel as though you may be heading in that direction?

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alexg

Thanks yeah my numbers have been great.

 

I'm just wondering cause its a major side effect of Metformin.  I really want to control my numbers without the help of extra meds added to my insulin as they just add more side effects to be concerned about.  I really don't know if its the Metformin or the Jardiance helping my numbers out from the Synjardy pill, but I don't like the side effects of Jardiance which is still considered a fairly new drug.  Metformin has side effects like the lactic acidosis, but I keep reading everywhere its one of the most popular first-line of defense for type 2 diabetics.  

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miketurco

Metformin... there are some difficulties people have with their stomachs and also b12 metabolism. I had concentration problems when I was talking 2500mg/day. Cut back to 500 and that helped. I hope to get off it, and insulin, some day. Anyway, the b12 and stomach problems are the main concern. The stomach stuff goes away on its own, usually. The b12 thing is important to look at. Many people, including myself, take b12 supps.

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alexg

Well guys I got my lab results today and my A1C dropped to 6.2%, WOW!  I am still getting random lows in the mid 40's but catch them right away.  Still going to talk to my doctor next week about those lows.  Overall I happy with the results that Synjardy pill has done, but still don't want the Jardiance part and only want to keep Metformin if at all in an extended release form.  Will see what my Doc says next week.  Keep you posted you all!

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Fraser

Another option could be to reduce your insulin and also your carb load. Both create swings in BG

 

6.2 is a great number but if your BG ranges from 40 to 200 to get there, damage can be done.

Edited by Fraser

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alexg

Another option could be to reduce your insulin and also your carb load. Both create swings in BG

 

6.2 is a great number but if your BG ranges from 40 to 200 to get there, damage can be done.

Thanks!

 

Actually I get those occasional (1-2 per week) lows because I don't eat enough carbs and yes I should decrease my insulin, but since I already lowered the Mix from 80 \ 80 to 60 \ 60 myself, I am going to see what my doc says.  The 20 Rapid at meal time, I vary from 10 units to 20 units depending on what I am going to eat.   My fasting numbers range from 80 - 105 and my 2 hr after meals are less than 140.  I haven't seen any reading higher than 170+ and that is rare.

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mystiquarte

hi alex I think your having hypo's because your not eating enough and then working out expecting your body to behave as normal...
it can't without the right fuel..if your eat breakfast at 8am, test at 10am eat morning tea (not lunch) test at 12noon eat lunch test at 2pm eat afternoon tea 5 test eat tea after shot 7pm test eat snack

 

when you go to the gym have your gatorade and take another snack with you for a top up if you need it and make sure to test before and after your workout!

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alexg

Well i went to the doctor today and he was impressed with my all time low A1C of 6.2.  He was indeed concerned with the lows that he took off my Novolog short acting isulin and only left me on the 70\30 mix.  He also got me off Syngardy and only gave me 10mg of Jardiance instead.  He said we would evalute my glucose readings this way and ajust as needed. 

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alexg

Well I hate to say this but I am averaging 150 in my fasting reads and higher through the the day.  I am going to send my readings to my doctor and hopefully he stops screwing me cause I thought I was doing so good. I felt life was better living with readings below 100 and actually having to monitor not going too low.  I don't know what to tell this doctor anymore, he keeps changing my meds routine.

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