Insulin use, some frequently asked questions,
Good Hope responses
insulin dose pages from DAFNE
- I test my sugar every morning and it is 7, why should I
- I am happy with my diabetes, but my eyes are bad, my ophthalmologist
- I feel fine but my eyes are bad, my HbA1c is 8.0%
- My sugars are 3 mmol/l first thing in the morning at 7am.
- My sugars are 3 mmol/l at 2am
- My sugars vary at the same time each day, no matter how
hard I try.
- I feel hypo, but when I test my sugar it is 6mmol/l.
- I sometimes miss injections
- I use insulin and want to lose weight
- My sugar level was 1.9mmol/l and I did not know I was hypo
- Mistakes in insulin dose
- My sugars always go up and down, and I use Lantus (glargine)
- My weight has gone up, and I use Lantus (glargine) and
I test my sugar every morning and it is 7, why should I change.
I am OK.
But conversation reveals eyes are getting worse. Tests reveal HbA1c is 11.5.
Our interpretation is that clearly there is a discrepancy here. It is virtually
impossible for your HbA1c and average sugar level to be so different. As
the HbA1c is effectively an average sugar over 8 weeks, your sugar must be
high at times when you are not testing.
Test at other times. Later...sugars are high at other times, 9, 10, 12 etc.
You are using mixtard twice daily. The options for changing the insulin
include, and ultimately it is largely the patients decision that is important:
- no change; serious eye other problems will develop over 2-4 years
- adjusting the mixtard doses to achieve the best level achievable with
mixtard, an HbA1c of about 8.0%. At an HbA1c level of 8.0% the eyes deteriorate
37% faster that if 7.0% could be achieved. More sugar testing will be needed,
but not all that often. An HbA1c of 8% rather that 11.5% represents a 120%
improvement, and eye changes will slow down considerably in the long term.
- Changing to basal bolus (if prepared to test x4/day, the preferred option),
or short /long acting e.g. monotard CHECK /actrapid if not so happy to
test frequently. An HbA1c is achievable, especially if there is no autonomic
- Change to an insulin pump, if you have the money or can get the funding.
I am happy with my diabetes, but my eyes are bad, my ophthalmologist sent
me. I use short/long acting monotard/actrapid, testing now and again.
I understand you are moving house and are about to be evicted, and there
may have other home problems. Changes in insulin regime are best avoided
at this time. As soon as home circumstances stabilize, you will need need
to test and adjust insulin a lot more, perhaps changing to basal bolus. (The
relationship between nurse and patient is crucial, and the timing of the
proposed changes is crucial.)
Regular follow up, with your diabetes specialist or practice nurse, perhaps
every 6 weeks, negotiating the next 6 weeks changes, building on the relationship,
may be the best way to proceed. Shortages of nurses may prevent this.
I feel fine but my eyes are bad, my HbA1c is 8.0%
I use short and long acting monotard/actrapid, and have not changed my insulin
regime for 10 years. I use the monotard once a day, would it be better to
use it twice a day? I do not like testing my glucose.
Yes, recently people have started using monotard twice daily, as it lasts
12 hours, with its peak at 6 hours.
But, in view of your bad eyes, basal
bolus with much more frequent testing
and adjusting may be essential to keep good sight, or even the sight that
you have. Basal bolus generally offers the best control, particularly if
you are willing to test regularly. It means you can have a more erratic lifestyle
and still keep good control. An insulin pump when they become available may
be better still, but these require intensive glucose monitoring, and may
lead to some restrictions, so they should not be regarded as an 'easy option'.
My sugars are 3 mmol/l first thing in the morning at 7am.
This may not be a straightforward situation. Causes may be different in
different people, but here are some ideas. This is also discussed here and here .
Remember, adjustments of your insulin affect your sugar in the future, not
the past, but by identifying what is going on you may be able to adjust your
insulin to avoid a similar situation the next day. But do not chase the tiger;
an example of this is just below.
- You may have needed less long acting insulin the night before. So you
would adjust the long acting insulin that night. Adjusting your pre-breakfast
insulin at 7.15am (breakfast 7.45am) will not be particularly helpful,
because it is the long acting evening's insulin that controls the next
morning's sugar. Were you to adjust the 7.15am insulin you may 'chase
the tiger' and then have problems later that morning. (This is a little
oversimplified; your diabetic nurse will have advice more specific for
- You might have had more exercise that usual the day before. A lot of
exercise in a day may require a lower dose of insulin in the evening
as your metabolism is 'paying off a debt' and building up its stores.
This is particularly so if you take a lot more exercise than usual.
My sugars are 3 mmol/l at 2am.
Again this may not be a straightforward situation, but here are some ideas.
Here's assuming your previous day's activity was completely routine. If you
exercised a lot, expect a hypo at night, see the paragraph above.
You may need a lower dose of insulin at night, but also it could be helpful
to have a snack at bedtime, perhaps a salad sandwich.
Once you have taken corrective action, a snack at bedtime, or reduced your
insulin, or both, it would be wise to test your sugar in the middle of the
night a couple of times to see all is well, setting your alarm.
To prevent night time hypos, aim for a sugar above 6 mmol/l at 10pm, before
bed. If lower than this, you will need a snack before going to sleep. Some
people will need a snack if their sugar is lower than 9mmol/l...everyone
Some people have all their insulatard (once daily insulatard) before they
go to sleep. Some prefer twice daily insulatard, that is half the dose twice
a day approximately, and that may help some people. But now once a day glargine
(Lantus) may be best.
Once you have had a night time hypo, the next night you would be wise to
test your sugar at 2-3am the next night to stop it happening again, and continue
to test during the night until you have no hypos.
My sugars vary at the same time each day, no matter how hard I try. At
11am on Monday they were 7mmol/l, Tuesday 11mmol/l, Wednesday 4mmol/l
This this situation always requires expert advice. Here are some ideas
- Your injection sites may be the problem. You may need to change your
sites in a more methodical way, or use other sites; ask your nurse to
- Check you are not 'chasing the tiger', as in the example 2 paragraphs
above. Your sugar level advises you more for the next day.
- Is your lifestyle regular? If you exercise for 3 hours on a Tuesday
and Thursday, but not other days, this can make your diabetes very difficult
to control. Start by having a regular lifestyle, with the same exercise
each day, and learn how to control your sugar accordingly.
When you are reasonably proficient at controlling your diabetes with
a regular lifestyle, with expert advice, you can still exercise 'erratically',
adjusting your insulin, and have controlled diabetes.
- Do you have an infection, or other condition, such as hypothyroidism?
- Unfortunately if you have had diabetes for many years this situation
may develop; the diabetic clinic nurse should advise. If you have had
reasonably well controlled diabetes less than 15 years your diabetes,
in theory, should be controllable, and often a lot longer.
- Irregular eating is a common problem. Some people have a smaller meal
or even miss a meal if their sugar is high; do not do this as it will
not help your control. The high sugar is an indication that you may need
to adjust the next days insulin. For example, a high 11am sugar is related
to your morning insulin dose, so if you did need to adjust your insulin
you would adjust the dose the next morning; if you did not eat your usual
lunch your control will be poor in the afternoon (you may get a hypo),
and you may enter a vicious circle, continually making adjustments that
make your diabetes even more difficult to control.
I feel hypo, but when I test my sugar it is 6mmol/l. I have been adjusting
my insulin to try and improve my control to help my eyes.
You have an altered threshold of symptoms, as you have had a high sugar
level for so long. Your body is so used to high sugars that it thinks 6mmol/l
When you feel this way and your sugar is 6mmol/l, you will feel better if
you eat (3 dextrosol in an emergency).
Your body needs longer to adjust to this lower sugar. All you can do is
to persist, perhaps aim for a slightly higher sugar for a couple of weeks,
then gradually aiming for a lower sugar. 8. I changed to basal bolus insulin,
but feel terrible.
You probably have an altered threshold of symptoms. You would be best seeking
advice from your practice nurse. Test your sugar often to see is you can
work out what is going on until you get chance to speak to your diabetic
I sometimes miss injections
10% of young men and 25% of young women have an eating
disorder at sometime,
and sometimes deliberately miss insulin injections to use weight. If you
do this it is important to mention this to your doctor and nurse.
If you miss your insulin often, there are various psychological therapies
that may help. If you do not make any progress with you doctor or nurse,
ask if you could be referred to a psychologist expert in this field.
Similarly if you become bulaemic or anorexic, vomiting your meals or missing
them, you will need expert help. This help is available if you ask.
I use insulin and want to lose weight
This is discussed in type
2 diabetes; insulin certainly helps you to put weight on. You have
to eat what you need to gradually lose weight, an then adjust your insulin
levels if your sugar levels getting low. Exercise is crucial.
If you have type 1 diabetes, you will know that being overweight often represents
lack of regular exercise, as well as eating slightly too much over the years,
often fattening foods. You will need to tackle both of these to lose weight.
See diet. May be your diet has too
much high calorie food. This would include full fat dairy food (especially
cheese), cakes, large portions of meat, large portions of fish (some fish,
the size of half of weetabix if you are trying to lose weight, is helpful
as part of your diet. Meat, if you do eat it and want to lose weight, should
be of similar volume.)
This will mean changes to the way you think about food, not eating leftovers,
asking others not to encourage you to eat second portions, not having certain
foods in the house (reserve them for treats outside the house) are examples
of the changes you may need to make.
In practice it is helpful if the rest of the family have the same healthy
diet, perhaps having larger portions if they have a lot more exercise.
Once you start the diet, you will need to test your sugar and reduce your
insulin. Aim to lose 1/2 -1 pound a week (0.5kg).
My sugar level was 1.9mmol/l and I did not know I was hypo
This is hypo unawareness. Questioning reveals
that the patients was resting at home and then when back to work in a very
busy job (a teacher). His sugar was well controlled at home, but as soon
as he went back to work the did not reduce his insulin but kept getting hypos,
4 times a day. He was advised
- to reduce all his insulin doses 4 units
- he phoned his nurse that day he reported the problem and was given advice,
and an appointment was arranged for that week. Some clinics run 'unawareness'
- He was asked to test 6 times a day.
- Depending on the high sugar levels that may result, he would gradually
increase his insulin, but not aiming for the very low levels that he
had at home.
- Gradually his body would learn to recognise the hypos again. As an example,
one person's body may recongnise one hypo a week, but if that person
gets more than one a week the body would run out of (counter-regulatory)
hormones, and not recognise other hypos. Once that person only gets one
hypo a week, his body's hormones will warn him.
Thus hypo-unawareness can be expected to occur
when you get frequent hypos, even if you do not know, and this is one reason
it is so important to test.
Mistakes in insulin dose
Do you make mistakes with your insulin dose? Read this
to see what mistakes are made and how your nurse can help you prevent
My sugars always go up and down, and I use Lantus (glargine) and rapid
This regime is new and can be extremely effective, but things can still
go wrong. This patient reported that his sugars were always changing between
very high, sometimes 20 mmol/, and low, sometimes 3 mmol/ with a hypo.
Further questioning identified he (age 40y) was getting hypos between 4
am-8 am. He perhaps should have measured his sugar every 2 hours for 3 days
to see what was happening, but instead he was given a glucose sensor for
3 days. This is a small machine with a tiny needle inserted under the skin.
At the end of 3 days the needle and machine are removed and the data is printed
off from a computer. (This version does not give an immediate result, may
be the next will.)
these are the results (the 3 days were very similar)
His diabetes nurse knew the problem. He was having hypos or low sugars 3
times a day, between or before meals (4 am, 11.30 am, 6.30pm). He was having
too MUCH Lantus. This produced the hypos, and then his body 'overcorrected',
and then the sugars went up. This is a common problem. The other insulin
was a rapid acting, I believe.
Further ideas, from a colleague in Harrogate, comments are really aimed
- It may be best to restart the educational process at the basic
level, as although the patients has been diabetic for many years, he may
not be familiar with current recommendations. Some clinical consultations
are used for measurement rather than education.
- Check injection technique
- is he using short needles, (now 5 or 6mm are recommended
and occasionally 8mm, never 12.5mm)?
- is he rotating sites?
- is storing his insulin correctly etc?
- Check his injection sites..what are they like?
- Does the patient really understand what affects his b/g readings
i.e. food, exercise hypos illness etc. Stress can affect blood glucose
- If he is having laser treatment will probably be very stressed.
- Does he test regularly and know how to alter insulin appropriately,
that is following advice on the rest of his page. (For example, except
for planned activity changes, generally insulin doses are adjusted if there
is a pattern...if the 7am blood glucose reading is high/low, this relates
to the previous insulin dose, so there is no point in adjusting the 7.30am
- I would ask for a 2am blood glucose readings to find out what
is happening before adjusting Lantus
- Is he over compensating and chasing his tail? Does he react
to every reading without looking for trends.
- I would discuss diet, ask him to keep a food diary and refer
to Dietition if necessary. Consider carbohydrate counting and work out
- As he is overweight, consider introducing Metformin which may
keep insulin dose down and hopefully stop further weight gain.
- Don't exclude deliberate mishandling of insulin.
- Group educational sessions can be very helpful.
- Consider other medical causes of the fluctuations (thyroid, Addisons, Coeliac, infections, malabsorption, etc). This will need more
than one session as a lot to cover. Involving the partner may help if possible.
My weight has gone up, and I use Lantus (glargine) and Novorapid insulin
If you use insulin and your weight
is going up or down, this suggests your
diabetes is not perfectly controlled.
In fact this is the same patient as 13 above. His ophthalmologist had noticed
background diabetic retinopathy beginning, that is tiny haemorrhages in the
retina, and he was very worried. He therefore tried to improve his diabetic
control, and was put on the new regime above.
However, this caused hypos or near hypos, which he had correct by eating,
and 'was eating to feed his insulin'. By reducing the Lantus as above, and
continually improving his control, and by sticking to a diet, he should be
able to lose weight without too much trouble.