I've been told to increase HbA1c to improve hypo awareness

[dancer]

After an HbA1c of 46, with 16% of a fortnight's test results hypo and 34% below target but above hypo, I was told to reduce my basals (I'm on the pump). I haven't lost my hypo awareness but have been as low as 2.1 with no symptoms.

My DSN said I should reduce each of my daytime basals by what amounts to a total of 8.6% but as I'm insulin sensitive I decided to only reduce by 4.3%.

I've just had a result of 12.3, two hours after lunch (I've been told only to correct at meals). I don't mind raising my test results but don't want them to go sky high for a long period of time. Can anyone tell me how long I should have these raised sugars for? I have asked but don't yet have an answer. I presume it's at least 8 weeks but just want to know what others have experienced.

 

[Spiker]

It's forever. They want your control to be less tight because of your good hba1c because they are scared of hypos. The title of this post is a misunderstanding I think. They want you to increase your hba1c. This is in line with NHS policy. Alas.

 

[Spiker]

They are ignoring your meter data that shows you are not going hypo. Or just they don't believe it.

 

[dancer]

It's forever. They want your control to be less tight because of your good hba1c because they are scared of hypos. The title of this post is a misunderstanding I think. They want you to increase your hba1c. This is in line with NHS policy. Alas.

Yes, sorry about the title!

I have even asked what the new NICE guidelines are for the target HbA1c for those prone to hypos but still haven't been told.

My DSN is wonderful but I'm stressing over this.

 

[noblehead]

They are ignoring your meter data that shows you are not going hypo. Or just they don't believe it.

Dancer says 16% of a fortnight's readings were hypo which is a lot.

You need to start with the basics @dancer and get your basal rates right, once you do that you can then look at your insulin-to-carb ratio's, if you get that sorted this should go a long way in reducing the amount of hypo's you are experiencing and preserve your hypo awareness.

The following explains how to do a basal test on a pump:

http://www.salforddiabetescare.co.uk/index2.php?nav_id=1007

 

[Spiker]

Dancer says 16% of a fortnight's readings were hypo which is a lot.

Sorry I mis-read that. Yes, fair enough, that's not good and she does need to ease back on the insulin in that case.

 

[dancer]

Thanks Noblehead, I've been doing nothing but basal tests for months. When my dancing was reduced from 5 or 6 days per week to only 1 or 2, my blood sugars crept up. I expected my basals to come back down when my husband was able to do more dancing but I still had to increase basals.

I then went on a fortnight's holiday, using a different basal pattern as I normally do. With a few tweaks, all was fine. Then I went back home, changing back to my Basal 1. It was then the hypos started - so more basal testing, reducing basals where necessary.

Now I've been told not to basal test but run on this new reduction of all daytime basals. I've to keep in touch with my DSN but just wondered how high my BGs should go and for how long, before my hypo awareness improves. I take it, as usual, everyone is different.

 

[noblehead]

The usual advice when someone loses or starts to lose their hypo awareness symptoms is to run bg levels slightly higher than normal for several weeks to restore the awareness, it's probably best that you go along with your DSN recommendations @dancer, just mention that your not happy with running bg levels of 12mmol and see what they have to say.

 

[iHs]

Try to alter yr bg targets to be no lower than 6.5mmol before a main meal and allow for a rise of 3mmol mid way at 2hrs, then that should allow for bg to return back to 5-6 mmol after 4.5hrs so hopefully no low bg or hypo feeling. Why are trying to control so tight as you are anyway?

 

[dancer]

Try to alter yr bg targets to be no lower than 6.5mmol before a main meal and allow for a rise of 3mmol mid way at 2hrs, then that should allow for bg to return back to 5-6 mmol after 4.5hrs so hopefully no low bg or hypo feeling. Why are trying to control so tight as you are anyway?

My target is actually 6 - 8 which was OK till my dancing was reduced then things went haywire, first hypers then hypos. It just happened and now this.

 

[iHs]

Try using the target bg of 7mmol allowing a rise of 3mmol, falling back to 6 to 7mmol again by the time the bolus has finished it's action. Have you lost weight at all?

 

[dancer]

I put on 3lb when doing less dancing but lost 2lb before going on holiday. When I came back I'd put on 1/2 a stone but the hypos started before I started trying to lose the holiday weight.

I am following my DSN's instructions, only not reducing my daytime basals as much as she wanted.

I've just returned from dancing where my BGs were certainly quite stable, around the 12.3 mark. I am now having a snack and have given myself half the bolus plus half the correction (this is what I normally do if snacking after dancing which normally works but who knows now).

 

[donnellysdogs]

You know your body.. 12.3 is uneccesarily high to increase hypo awareness...

You need to keep them in the higher levels of 6-8 (ish) for around 6-8 weeks.

There is something wrong to have levels of 12... The changes in basal are wrong... Too much.

I don't know how long you have been on a pump or why you are strictly being guided by your DSN but 12 is too high and the only real way to see whats going on is basal testing.

You need to basal test around the time of dancing if this is causing you problems. You need to check the times of eating around these times to get any boluses correct.

I'm sorry to say but in your situation I would do a few basal tests and not tell the DSN.

Its your life, your control at the end of the day.

Please do not run your levels too low for activities...

For me I found that I knew my body and life better than someone who saw a 30min glance of my levels. I knew when I needed to change things and also when I needed to come off the pump.

For me hypo unawareness has mainly been due to having swiftly changing levels... Ie too much bolus or not enough food. The fast occuring drops were much more troublesome than drops that happened gradually. Activities also increased the speed of drops in levels.

If I were you I would be doing basal tests but not mentioning them...

 

[Spiker]

I agree that 12 is too high unless it's a brief after-exercise peak. Even then, it's not good.

 

[dancer]

I always reduce my basals before and during dancing so I'm not sure how I could basal test at this time.

I've been on the pump for 5 years and my consultant said I should speak to my DSN when I told him my hypo recognition was getting worse.

I've told my DSN that I don't want BGs in double figures for any length of time and I did wonder what kind of results I should be aiming for. She did tell me to stop basal testing. I don't actually know why - maybe I'm becoming obsessive? It's not as if I make basal changes at the drop of a hat. I always wait until I'm absolutely sure I need to increase or decrease. For almost 30 years I've had inconsistent BGs. I can be high at the same time for several days in a row (eating and doing the same things) and then drop back to target or below target. It all started with my last pregnancy. And apparently the fact I'm now on a total daily insulin total of around 20 units makes things more complicated.

 

[Spiker]

I don't think you are obsessive and I don't think you should stop basal testing and making conservative changes.

 

[Spiker]

To get hypo awareness back your BG just needs to remain in the normal, non-hypoglycemic range. Can be for as little as 2 weeks and you will get awareness back. Your BG does not need to be hyperglycemic. That sounds like an unhealthy way to get hypo awareness back.

I would guess the reason you got hypos on your normal Basal 1 pattern after you came back from holiday is that during the 2 week holiday you adapted to a lower level of activity (and lowered your basal). When you resumed your normal level of activity you were not as used to it, it was more strenuous, and hence the hypos. That's what I find anyway whenever I increase my activity level, I get hypos, at least until I have re-adjusted to the higher activity level.

I suppose a key issue is what caused you to lose hypo awareness. But even more important than that is getting hypo awareness back.

 

[dancer]

To get hypo awareness back your BG just needs to remain in the normal, non-hypoglycemic range. Can be for as little as 2 weeks and you will get awareness back. Your BG does not need to be hyperglycemic. That sounds like an unhealthy way to get hypo awareness back.

I would guess the reason you got hypos on your normal Basal 1 pattern after you came back from holiday is that during the 2 week holiday you adapted to a lower level of activity (and lowered your basal). When you resumed your normal level of activity you were not as used to it, it was more strenuous, and hence the hypos. That's what I find anyway whenever I increase my activity level, I get hypos, at least until I have re-adjusted to the higher activity level.

I suppose a key issue is what caused you to lose hypo awareness. But even more important than that is getting hypo awareness back.

Sounds good Spiker but I've been doing the same thing after every holiday since I got the pump and haven't gone hypo. It must have something to do with all the hypers I was having for months, with the necessary increased basals. I reckon that whatever caused those highs must have disappeared, hence the hypos. No one seems to know what the cause was.

I've got no intention of having BGs in double figures for weeks on end (till my next HbA1c?) I'll contact my DSN next week and ask her what the plan is. If I'm not happy, I'll just increase my daytime basals (or some of them) again. Having said that, I could easily be in single figures tomorrow. Who knows?

 

[Spiker]

Sounds good. Good luck tomorrow, @dancer.

 

[donnellysdogs]

One thing.. Why is a dosage of 20 units a say making things complicated? Heck, it doesn't matter what your dosage is providing you can get good levels.

I know what you mean by fluctuating levels.. My levels could swing for a number of reasons..
A) days of getting up early or late... (Due to hubbys shifts) I had two basal rates for this and switched over the night before his shift changed)
B) I have slow colonic transit and know that at times when my stomach struggles my levels would shoot up for days. Flaxseed remedied this
C) days off to days working.. Again needing a different profile due to being a gardener daytime workwise and still busy when off but slightly less.

Have you been offered a CGM or a freestyle libre at all?

When dancing do you literally dance for hours at a time? Or do you have any break etc?

I don't understand why your consultant has not consudered a cgm to enable you to do dancing without fear of hypo's etc.