www.diabeticretinopathy.org.uk

General

Insulin use, some frequently asked questions,
Good Hope responses

David Kinshuck

 

  1. I test my sugar every morning and it is 7, why should I change.
  2. I am happy with my diabetes, but my eyes are bad, my ophthalmologist sent me.
  3. I feel fine but my eyes are bad, my HbA1c is 8.0%
  4. My sugars are 3 mmol/l first thing in the morning at 7am.
  5. My sugars are 3 mmol/l at 2am
  6. My sugars vary at the same time each day, no matter how hard I try.
  7. I feel hypo, but when I test my sugar it is 6mmol/l.
  8. I sometimes miss injections
  9. I use insulin and want to lose weight
  10. My sugar level was 1.9mmol/l and I did not know I was hypo
  11. Mistakes in insulin dose
  12. My sugars always go up and down, and I use Lantus (glargine) and rapid
    acting insulin
  13. My weight has gone up, and I use Lantus (glargine) and Novorapid
    insulin

 

1

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:

 

2

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.

 

3

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'.

 

4

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.

 

5

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 is different.

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.

 

6

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

 

7

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 is low.
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 team.

 

8

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.

 

9

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).

 

10

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

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.

 

11

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 future mistakes.

 

12

My sugars always go up and down, and I use Lantus (glargine) and rapid acting insulin

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.)

graph of glucose fluctuations in uncontrolled diabetes

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 at professionals:

  1. 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.
  2. Check injection technique
  3. is he using short needles, (now 5 or 6mm are recommended and occasionally 8mm, never 12.5mm)?
  4. is he rotating sites?
  5. is storing his insulin correctly etc?
  6. Check his injection sites..what are they like?
  7. Does the patient really understand what affects his b/g readings i.e. food, exercise hypos illness etc. Stress can affect blood glucose readings ++++.
  8. If he is having laser treatment will probably be very stressed.
  9. 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 insulin dose.)
  10. I would ask for a 2am blood glucose readings to find out what is happening before adjusting Lantus
  11. Is he over compensating and chasing his tail? Does he react to every reading without looking for trends.
  12. I would discuss diet, ask him to keep a food diary and refer to Dietition if necessary. Consider carbohydrate counting and work out insulin:carbohydrate ratio.
  13. As he is overweight, consider introducing Metformin which may keep insulin dose down and hopefully stop further weight gain.
  14. Don't exclude deliberate mishandling of insulin.
  15. Group educational sessions can be very helpful.
  16. 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.

 

13

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.