Lantus problems and going round in circles

And on and on and on...

When we began writing about our experiences of living with Diabetes it was, at least in part, in response to a nasty overnight hypo brought on (I suspect) by the action of Lantus glargine. From some reading I have done since it appears I am not alone in this. That there are other people with diabetes using Lantus and injecting their dose at night time (recommended by the manufacturer and for most people the best option) who find they sometimes go low overnight, or wake up low in the morning.

One of the difficulties in managing diabetes with MDI (multiple daily injection) basal-bolus is that if you don't get your basal (background) dose correct then everything else becomes incredibly difficult to manage. You have no firm footing on which to start your day.

I think the late-at-night injection timing is suggested because it puts Lantus's onset period (perhaps an hour two until full strength) at a time when you have finished eating for the day and are usually if not actually asleep, then pretty much at rest. When I moved my injection to the morning, though my overnight levels were suddenly very steady and reliable, I had problems with high blood glucose spikes after breakfast. In response I began to split the dose, morning and evening, having a little just before bed, and the rest at breakfast. My hope was that this would spread the activity more evenly over the day. Sadly though, after a few months I can see that this has caused more problems, and not really solved anything. I found I was waking up low again, or waking slightly clammy having gone hypo overnight. On several occasions my liver then took matters into its own hands and began dumping glucagon into my bloodstream as it's own emergency measure. I would wake high, inject rapid-acting insulin and wait until my levels dropped before eating breakfast. After 2 hours or so I would give in, my levels still stubbornly high, eat a fraction of my usual breakfast and wait to see how things were going at lunch. Not only that but if the smaller Lantus dose didn't send me hypo overnight, then it had run out of steam by breakfast anyway and I was heading for spike central again after breakfast. Smaller doses you see, tend to act over a shorter time. With no Lantus hanging around, and anything from 15-45 minutes for Humalog to get going even a fairly low GI breakfast was going to cause problems. What my neice might describe as an #epicfail.

So I've gone back to Lantus in the morning. Suppertime and pre-breakfast readings are more constant. The post-breakfast problem still exists, of course, but at least I've lost the overnight hypo and liver-dump double whammy. Last time I didn't spend much time experimenting with the timing of my breakfast bolus (rapid-acting) doses. My hope is that with enough time between injecting and eating I might be able to stay out of the teens between breakfast and lunch.

Maybe.

Walking the line (or why I don't like Mondays)

The other day I was reading on a forum where a fellow type 1 diabetic was struggling with a GP who was unhappy that they were testing too often.

Testing too often...

Someone else's GP had made a suggestion that anything more than two or three times a day was really a bit much. Actually I think they had talked their GP up from a prescription of 50 strips for 2 months. That's not much more than once a day. And certainly doesn't seem to acknowledge the DVLA guidelines for testing before (and every two hours during) any driven journey.

Sometimes it seems GPs just don't understand what it's like to live with diabetes day to day. Here's how it feels:

In the southwest of the UK there is the busy 'North Devon Link Road', for much of its length overtaking is forbidden by a pair of white lines down the middle just a few inches apart. Being a diabetic is like being asked to walk along that line. Blindfold. And backwards. As it twists and turns you'll have to avoid straying into the surging hypo-traffic rushing up on you from behind, or the thundering diabetic-complication lorries bearing down on you from ahead. A few times a day you are allowed to peep out from under the blindfold to see where you are and make a correction. Though if you look more than 6 or 7 times a day your GP may well say that you are looking a bit too often, and they have read a report that said it makes your walk more difficult. You just need to try a bit harder. Or you are trying a bit too hard. You should try walking a bit more towards the lorry side for a while. In fact what you really want to be able to do is to cut some little holes in the blindfold. But unfortunately those CGMS scissors are far too expensive. If you are lucky you might get one for a week, but if it's an old pair the doctor would look though the holes at the end of the week, then sew them up again.

Sometimes for all of us the road is wigglier than others. The traffic is especially heavy. The strategies and methods you usually rely on don't seem to work at all. Or work way too much. The road-walking equivalent of a dizzy spell.

The current cloud on my weekly horizon is Mondays. I seem to need a different set of insulin:carb ratios to avoid drifting teen-wards all day. Especially bad in the mornings, by evening meal while trying to correct I can overdo it and then drift low. Monday is the day furthest from a usual gym session, which might have something to do with it - exercise has a knock on effect for me for quite some time. I'm still having a tricky time of things working out what the current Monday ratio needs to be. I could tell you what it was a few months ago, but that doesn't work at the moment.

And that dear GPs is why we need to test so often. Very sorry if that is slightly financially inconvenient for you.

Canine CGMS - dogs trained to detect hypoglycaemia

No really. I'm not making this up.

I saw fascinating snippet on BBC Breakfast today featuring a mum and her young type 1 daughter. They are one of the first families in the UK to benefit from a specially trained 'assistance dog' which can detect hypo- and hyperglycaemia by changes in the scent of the diabetic.

Yup that's right! Amazingly the dog can sense when the girl's blood glucose levels are either too high or too low and alert her. In one instance at a family disco where the girl had been dancing away with her brother, on returning to the table the dog began licking and nuzzling her before rummaging under the table and fetching her blood glucose meter. Her bg level had dropped to 2.5mmol/l. The dog sleeps in the girl's bedroom and will go to fetch her parents if her blood glucose levels drop too low overnight.

There are currently 10 dogs in the UK, trained by small charity 'Cancer and Bio-detection Dogs'. The dogs have been placed with type 1 diabetics with poor hypo-awareness. The work still seems to be in its early stages, but it is hoped that the trained dogs will be allowed to register with Assistance Dogs UK and granted the same status as guide dogs for the blind.

Dorcasdog - I will be expecting great things from you next time you come to stay...

Dishing Up

I've been trying to concentrate much more on Mike's needs, when it comes to meal times, over the last few months. We are lucky enough as a family, to be able to all sit down together for both breakfast and tea. When the children were younger, sitting together did not mean eating the same food, Mike and I enjoy spicy food, and our kids (like most kids) like to separate out ingredients and have both gone through a variety of picky phases, which drives me mad. Friends round to tea, adds another interesting dimension to what I can or can't present at meal times, forward planning is impossible when you may get a vegetarian home on a spaghetti bolognaise day. Even so, I've always enjoyed cooking for the family because it feels like such a worthwhile thing to do well, much more essential than cleaning (which I only do when we're about to have visitors); and it's a good job I enjoy it because when the kids were small I would end up cooking all afternoon to be able to cater for everyone's needs.

The hardest thing is dividing carbohydrate in a measured way. We all eat a similar quantity of food now, but when the kids ate less, dividing the pasta to ensure that Mike had approximately 60grams of carbs for his meal was tricky. In the baby/toddler phase, I just cooked two completely separate meals, one for us and one for the kids. When they were a little older, I cooked simple food, enough for three portions, and divided one of those portions between the kids, then I'd cook an extra veg dish which I could spice up to make the meal more interesting for me and Mike. The next stage got harder, and the measuring less accurate, and with appetites varying, we would often find ourselves finishing the things off which are hard to resist, (like fish fingers) but it can play havoc with your levels. It is a relief now to know that the kids have good appetites and I can just divide everything equally between the four of us.

It does mean that we all have a calorie controlled diet, as a neccessity. I'm sure the kids aren't really aware of that yet. It can make for a rather odd looking meal. The portion of pasta we allow ourselves looks pitiful, but I add a lot of veg to everything to boost the quantity of stuff on the plate. New potatoes present a whole other problem, delicious though they are, to ensure Mike has enough carbs he has to pretty much fill his plate with them, though Mike will allow for that and use less insulin, he doesn't have to have exactly 60grams of carbohydrate at every meal of course, but it's the way we've always done it and it seems to work. You get used to all the measurements, 3oograms of rice is enough for the four of us, 400grams of pasta etc. it makes life easy. I've managed to get back to buying only wholewheat pasta, and there have been no complaints, and I have gone back to trying to vary the type of carbs much more, which was something I read in a Balance magazine years ago. It makes sense to me, if only because too much of anything can be bad for you.

I am aware that I have spent quite alot of the past thirteen years preparing and cooking food, and that not everyone has the time available to do that, (or would want to). To me it has been a luxury I'm grateful to have been afforded, though it is extremely nice when someone else offers to cook for a change. Maybe one of these days I'll be all cooked out and hopefully I'll be able to hand the baton to someone else and then and only then will I offer to do the washing up.

Jane

Basal driving me bonkers

This is ridiculous.

Perhaps I've brought it on myself with a few smug posts about feeling that I'm doing a little better lately, and how I finally seem to have wrestled Lantus into submission, but diabetic readers will be unsurprised to know that it's gone a little pear-shaped over the last few days.

Most annoyingly of all, my recent successes with Lantus have evaporated and I've been waking to early morning test results around 3.5mmol/l again. Starting the day a little low invariably has a knock-on effect for my control for the whole rest of the day for me, and I've been struggling to rediscover my recent run of good form. Diabetes is like walking a tightrope with complications on one side and hypo-induced coma on the other. Tricky enough if your balance is good to start with, but if you start out wobbly you're in for a difficult time.

So I'm basal testing again to see if I can discover the new magic numbers.

The technique I've come across goes like this:

1. Choose a day when you are not doing anything particularly strenuous and your fbg is in range
2. Take basal and any other medication as usual but miss breakfast and don't inject any bolus insulin.
3. Don't eat anything and drink only water until lunchtime and test every hour or two
4. If your basal dose is correct you should remain within 1 or 2 mmol/l of where you started
5. Repeat the test for another 2 days (they don't have to be consecutive)
6. Then move on to missing lunch, then evening meal
7. If you are really hardcore you can also test every hour or two overnight (I confess I've never quite managed this part of the process, and have always been able to convince myself that my dose must be about right, surely?)
8. If you notice a consistent rise or fall in bgs during the tests consider making (or talking to your doctor about) a modest change in your basal dose, perhaps 1 or 2 units up or down
9. Then start the testing process again
   

Not a perfect day to start the test today as fbg was 3.5, but I'm going for it anyway. I also had coffee rather than water which will also muddy the waters a bit (lactose in the milk will push bgs up a bit).

I'll let you know how it goes.

Update: Day 1 test went well despite the wobbly start. Completely solid bgs from mid-morning onwards. Now, do I sloppily move on to lunchtime? Or do it properly and complete the morning test a few more times? Hmmmmmmmmm...

Update: Lantus problems and going round in circles