The morning high-low

DSC02260-1.jpgUp until about a month ago I had big problem controlling my post-breakfast and pre-lunch blood glucose. I would take 18 units of Levemir and 6 units of Novolog, wait 15 minutes, and then eat breakfast. Breakfast for me is a rotation of whole wheat toast, egg beaters, Morning Star meatless breakfast patty, steel cut oats, or Scottish oatmeal.

None of my portion sizes exceeded 60g of carbohydrate but my post-breakfast 2 hour BG would almost always be high; between 160 and 200 mg/dL. My pre-lunch BG would almost always be too low; between 60 and 70. I discussed this with my endocrinologist on my last trip ( I was being fitted with a trial Dexcom unit ) I mentioned this ti him. After “yelling” at me about the hypoglycemia, he recommended splitting my Levemir dosage into two; 8 in the morning and 10 in the evening.

I tried that for a week and my pre-lunch BG was much better ( between 80 and 90 ) but my post-break 2 hour BG was still high. I returned to the endocrinologist at the end of a week ( the length of time the Dexcom sensor was good for ) and we tweaked things further. He suggested waiting a full 30 minutes after taking the Novolog before eating. Within a few days my post-breakfast BG was within the 120-150 range and my pre-lunch BG was still within the 80-90 range. Success!! By carefully controlling the amount and timing of my insulin dosing I have achieved good BG control. My estimated A1c is 5.4 but I will wait for a doctor visit and test to confirm.

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High low! High Low! It’s up and down we go!

Recently I have been noticing some odd BG behavior. Last weekend while on the way to my daughters dance recital (she’s 6 and a little princess) I experienced a low of 37. I normally check my BG before and about two hours after each meal but I started to feel odd about an hour after eating. My wife was driving and I noticed that I was feeling hot and sweaty even though the car A/C was set for 60. My thinking felt fuzzy. I pulled out my glucometer (my hands had started shaking by this time ) and stared at the reading for a moment. 37. My wife must have noticed something was wrong because she said, “Everything OK?”. “No”, I said, I need sugar.

We scrambled around to find some hard candy. We have two young kids and yet there was no candy to be found in the car. I normally carry a backpack with my glucometer, test strips, lancets, Novolog Flexpen, flex pen needles, and BD glocose tablets. I carry the backpack everywhere. That day I decided to take the meter and leave everything home. My wife found a packet of sugar from her last trip to Dunkin’ Donuts and saved the day.

This has never happened before. The previous day I had a similar experience after eating dinner. My BG was down to 49. Today, it’s happening again, about two hours after lunch. BG is 85. Wait! No. It’s now 100. Wait no!!

Did I take too much insulin? Not likely. I took the same amount I always take for this amount of food.

Too much fat in the meal? No more than any other meal. 11.7g. I had a Weight Watchers meal, Texas Toast and an Apple.

Lunch June 23 2007

I am tracking my insulin and BG readings on the SugarStats.com web site and will be able to create some interesting reports that may help shed light on what’s going on.

SugarStats.com

Diabetes survival gear

Shortly after I was diagnosed I was given a free meter by the hospital. It was a big bulky thing that required a bucket of blood and a day to register a reading. Since them I have purchased the FreeStyle Flash Blood Glucose Meter (one for home and one for travel) from Abbott Laboratories. It take readings in about 7 second and require but a tiny drop of blood for a reading. My endocrinologist has software into which he can download the data and graph my blood glucose over time ( albeit snapshots in time ).

Novolog FlexPenI also purchased a backpack in which I carry my Apple MacBook, FreeStyle test strips, FreeStyle Sterile Lancets, a Novolog Flexpen insulin pen, and NovoFine needles for the FlexPen. I use the OS-X version of the Calorie King Exercise and Nutrition Manager to track and chart my daily food intake and also lookup the occasional restaurant meal. My kids thinks it’s cool that I have a backpack just like theirs.

SimpleShot

David Pogue, a tech writer for the New York Times, reports on a new invention called the SimpleShot. The device provides an injection of glucagon, a hormone produced by the pancreas that stimulates an increase in blood sugar levels. Diabetics on insulin are often at risk for hypoglycemia, an abnormally low level of glucose in the blood. Normally administering the glucagon involves mixing a powder and a solution. The invention was a finalist in the Modern Marvels Invent NOW Challenge.

Checkup

Last week, I strolled into my endo’s office feeling good about my numbers and presented him with the news that I have been honey-mooning without insulin since my last checkup. At my last checkup ( sometime in January or February) he had instructed me to quit the morning insulin ( one unit of Novolog ). I was experiencing a lot of lows ( is 65 considered low?). He gave me a stern look and told me that the results of my last A1C were 7.1 and he would prefer my numbers were lower. My average BG reading was 114. I thought I was doing well.

So…I am back on the insulin. I started taking one unit of insulin before each meal. I fully expected lots of lows. Surprisingly I had the opposite experience. My blood glucose appeared to be bouncing around. I would test two hours after a meal and the BG would be 96. Then four hours after the meal it would be 150. WTF? So I started thinking to myself, “Is the insulin raising my BG?”. Irrational, I know.

I increased the dosage to two units and started getting the results I expected. The rational part of my brain continued to search for an explanation. Then today it dawned on me. In a few weeks it will be June 14; the anniversary of my diagnosis. Perhaps the honey moon ( what a stupid phrase ) phase is over. Perhaps I am entering the phase where I spiral down toward full insulin dependence.

This sucks. Sorry. That’s how I feel. I guess soon I will be shooting up Levemir as well. I just hope I don’t get the pens mixed up. One of the sucky things about taking insulin is storing it when I am not at home. I bought a backpack and keep my supplies in the front zippered and somewhat insulated compartment. But now I have to remember to carry it with me out of the car during the summer and winter. Insulin does not like extreme hear or cold. Well…neither do I.

Insulin Honey Moon

Wow! It’s been over 3 months since my last post. December was the last time I saw my endocrinologist. I was experiencing a lot of “lows” so he recommended cutting out the morning insulin ( I was on one unit of NovoLog ) and taking blood glucose readings two (2) hours after each meal. I instead chose to cut out all insulin and hold my carbohydrate intake to 50g or less per meal. I have been doing this for about 3 months and except for a few mistakes ( incorrectly reading labels ) things have gone quite well. My before meal numbers have been between 90 mg/dL and 100 mg/dL with after meal averages of 150 mg/dL.

I eat mostly whole grains (oat, bulgur wheat), vegetables and lean meats (chicken, fish). I was doing this before diabetes so this was not a drastic change. I occasionally indulge in junk food (Cheetos are awesome!) and my favourite ice cream is Häagen-Dazs Rum and Raisin. I keep track of my food intake using the excellent Calorie King Nutrition and Exercise Manager.

Honey Moon Period

I finally had my appointment with an endocronologist after waiting for over 8 weeks.  He explained how the pancreas and insulin work to control blood glucose.  In a normal functioning system the pancrease is able to product sufficient insulin on demand to cover the glucose in the blood.  He suggested that my pancrease may have been declining for quite some time.  However, under extreme stress ( e.g a viral infection), the pancreas can no longer keep up with demand and blood glucose rises.  As the blood glucose rises the pancreas works harder and harder but…eventually gives up.  In my case I had an upper respitory infection just a few weeks prior which may have triggered the stress on my pancrease.  Once I began insulin therapy my pancreas was able to recover a bit.

He said that right now I am doing well controlling my “sugars” but that is to be expected during the “honey moon” period. During this “honey moon” my pancreas is producing insulin almost at full capacity and I can reduce my insulin dosages to match. In fact the doctor suggested that I may even be able to eliminate the insulin altogether.

For example before each meal I was originally taking 1 unit of Novolog for every 15g of carbohydrate and my nightime basal (Lantus) dosage was about 3 units. My blood glucose before each meal was about 105. Now I notice that I can take 1 unit for each 20g of carb and I have eliminated the night time basal dosage. My bloog glucose before each meal is now abouy 88. That’s quite low and I think I may need to lower the Novolog to 1 unit per 30g of carbohydrate.

What scares me ( yes, I am afraid ) about all this is that I am basically guessing at the dosage amounts for each meal which can lead to taking too much insulin and risking hypoglycemia. For dinner last night I had slightly more than 60g of carb and 3 units of Novolog. My blood glucose before the meal (around 6 PM) was about 76 ( I tested twice to be sure ). By 10PM my blood glucose was 79. So obviously I took too much Novolog. I ended up eating a late night snack (20g carb) which I had eliminated when I droppred the basal (Lantus) dosage to zero. My blood glucose this morning was 95. This is a very scary honey moon.

My doctor suggest that in about 6 months to 2 years ( what a huge friggin range ) this will change I will need more insuling to cover my meals etc. I now understand why this is called “medical practice’.