Adding metformin to insulin?

[Antje77]

Yeah, I’ve been having similar woes with Tresiba.

I don't really think it's the Tresiba, seeing the flattish lines I can usually achieve, although it's not impossible of course.
My gut feeling is that it's either fluctuating insulin resistance or, less likely, my pancreas doing some random spluttering.

If it is due to Tresiba I have a problem, because there is no way I'll go back to Lantus/insulin glargine and with Levemir you need to keep a very close eye on the time you inject, which I wouldn't like at all.

 

[StewM]

I don't really think it's the Tresiba, seeing the flattish lines I can usually achieve, although it's not impossible of course.
My gut feeling is that it's either fluctuating insulin resistance or, less likely, my pancreas doing some random spluttering.

If it is due to Tresiba I have a problem, because there is no way I'll go back to Lantus/insulin glargine and with Levemir you need to keep a very close eye on the time you inject, which I wouldn't like at all.

Why’s that not work for you? Like obviously flexibility is better than rigidity but beyond that.

My issues with fluctuating Basal needs predate Tresiba so in fairness it isn’t really the Tresiba that is the issue. It’s more than I “naturally” (if that’s the right word) have dramatically different Basal needs not just day to day but hour to hour. Obviously the Pump’s been the main solution suggested by my doctors but still waiting to start on that at present.

All that said, I find your experience and numbers very similar to my own.

 

[Antje77]

Why’s that not work for you? Like obviously flexibility is better than rigidity but beyond that.

I found injecting my basal in bed before I go to sleep works very well to not forget it. If I'd need to take it at the same time every day (or even twice, as would be likely with levemir) this means I'd lose that easy routine and I would have to start carrying my basal pen like I do my bolus and keep an eye on the clock all the time.
None of those are good enough reasons for a definite no, but it sure would complicate diabetes for me.

If switching to Levemir would mean my bolus needs would become very stable, yes, it'd be worth it!
But I think that's rather unlikely, especially now you've explained you had the same issue on a different basal, that suggests the problem doesn't lie in the Tresiba

I am interested in getting Levemir added to my prescription though, so I would be able to add some basal on high insulin days instead of chasing with my bolus, so I plan to ask that too when I have my appointment.

 

[StewM]

I found injecting my basal in bed before I go to sleep works very well to not forget it. If I'd need to take it at the same time every day (or even twice, as would be likely with levemir) this means I'd lose that easy routine and I would have to start carrying my basal pen like I do my bolus and keep an eye on the clock all the time.
None of those are good enough reasons for a definite no, but it sure would complicate diabetes for me.

If switching to Levemir would mean my bolus needs would become very stable, yes, it'd be worth it!
But I think that's rather unlikely, especially now you've explained you had the same issue on a different basal, that suggests the problem doesn't lie in the Tresiba

I am interested in getting Levemir added to my prescription though, so I would be able to add some basal on high insulin days instead of chasing with my bolus, so I plan to ask that too when I have my appointment.

I had about ten good years on Levimir (less said about the last year on it the better )

What works for me (as I have similar issues as a sleep-deprived parent), is setting reminders on my phone to take my Basal. The native IOS reminder app is pretty good for this as you need to mark it as complete for it to go away. So I never do that until I’ve actually taken the Insulin.

I’ve also always carried my Basal with me as, even with Tresiba, it covers you if something completely unexpected happens which prevents you from going home.

 

[JoKalsbeek]

The amount of insulin I need fluctuates pretty wildly. A while back I made a graph of the amount of bolus insulin used every day over 3 months, determined to finally find the pattern. Couldn't find one. By far the most of my days follow comparable eating and activity levels at the moment, still, the amount of bolus I need fluctuates heavily.

I also need rather high doses of insulin (114 of basal and anywhere between 18 and 70 of bolus on a mostly lowish carb diet) so I have quite a bit of insulin resistance going on.
Some 6 months back I discussed adding metformin for the IR with my endo through email. Her advice was to leave things as they are, seeing that my hba1c and time in range are very nice, and while high insulin doses might have some detrimental effects, this is in no way a certainty.
Seeing as I'm fine with my high doses, I agreed.

I'll have my yearly (first in two years) review in two weeks. I've already done the labwork for it, everything's fine, so I expect her to want me to keep doing what I do.

While I can work well with the ridiculous fluctuating of the amount of insulin I need, it means a lot of hard work, never knowing if that slice of low carb bread needs 5 units or 14 today.
I'm assuming it's due to my IR being different on different days, although a long honeymoon is a possibility as well (diagnosed 5 years ago, but had symptoms 2 years before that, in hindsight).

So now I'm wondering if metformin might help to stabilise things a bit but I have no idea if this is a logical thought.

Below is a picture of my graph of bolus insulin used over 3 months
Left are the insulin units, top are the dates, three days for every vertical line, every dot is a day.
Ignore the spike on the 3rd of august, had Chinese take-away that day .

So I'd be happy to have your thoughts added to mine!
Doesn't matter what type of diabetes you have, as my diabetes has enough T2 traits to take into account as well as the T1 aspects.
It's of course a bonus if you have experience with adding metformin to insulin, but I'm happy with your thoughts if you're diet controlled only as well.

(Tagging in @Hopeful34 , @Marie 2 's beloved dog, and @becca59 who've all experienced fluctuating insulin needs)

How'd the appointment go? Did the endo advise a "steady as she goes", or are you going to hoard some loo rolls and start Met?

 

[Antje77]

How'd the appointment go? Did the endo advise a "steady as she goes", or are you going to hoard some loo rolls and start Met?

Got everything on my wish list!
Not only metformin to try, but also another DSN (don't like my current one at all and asked if I could change, no problem at all!) and Levemir to experiment with!

I was thinking to have a go with the metformin first, dropping my basal by 5 to 10% on the advice of my endo to stay safe and see what happens.

Once I know what that does, I can use the Levemir: reduce Tresiba by 10-15 units to make room for the Levemir, and adjust the dose on a day to day base depending on needing more or less insulin. Hopefully this will lessen the amount of mini corrections with my bolus insulin on days I need more.
Agreeing to this took some deep thinking, but in the end we agreed that 'we don't really do that, it's very unusual' was not a very sound argument. I was very happy to hear "Oh well, go ahead but don't mix up your pens!"

She also told me reading her name in this thread made her smile, and she wrote a very, very nice letter to my GP informing him on the changes in approach and my nice numbers, she sounded rather proud of me in that letter, with added exclamation marks (2 of them!!) after my time in range!

On the downside, BP was up, not sure if it's a true reading or white coat syndrome so I'll get to experience the joy of a 24 hour reading next week...

 

[JoKalsbeek]

Got everything on my wish list!
Not only metformin to try, but also another DSN (don't like my current one at all and asked if I could change, no problem at all!) and Levemir to experiment with!

I was thinking to have a go with the metformin first, dropping my basal by 5 to 10% on the advice of my endo to stay safe and see what happens.

Once I know what that does, I can use the Levemir: reduce Tresiba by 10-15 units to make room for the Levemir, and adjust the dose on a day to day base depending on needing more or less insulin. Hopefully this will lessen the amount of mini corrections with my bolus insulin on days I need more.
Agreeing to this took some deep thinking, but in the end we agreed that 'we don't really do that, it's very unusual' was not a very sound argument. I was very happy to hear "Oh well, go ahead but don't mix up your pens!"

She also told me reading her name in this thread made her smile, and she wrote a very, very nice letter to my GP informing him on the changes in approach and my nice numbers, she sounded rather proud of me in that letter, with added exclamation marks (2 of them!!) after my time in range!

On the downside, BP was up, not sure if it's a true reading or white coat syndrome so I'll get to experience the joy of a 24 hour reading next week...

Those 24-hour things are a bit of a pain, but it should rule out white coat rather effectively. But on all other counts I am so pleased for you. I hope your experiments work out wonderfully!

 

[Japes]

Last time I had a 24 hours blood pressure reading the GP was highly entertained by the explanations of two raised points in the reading, but also the fact when the know workplace stressors were not in play, and I've not walked up the hill to the surgery, I had absolutely perfect blood pressure!

I'll be interested in the experiment with metformin...

 

[becca59]

@Antje77 have just seen this thread. (Holidays) Apologies for not engaging sooner. As I only access the forum via the app and not the website, I do not get notifications.
Anyway not a lot to add. You seem to have clicked with your new DN and there is nothing wrong doing a bit of experimenting. Let’s face it that’s how new innovations often begin.
Yes I have wild fluctuations with my bolus insulin needs, but to be honest I take very small amounts of both basal and bolus insulins in comparison to yourself. So in the main it is not too bad to deal with. I have thought of Levemir rather than Tresiba but I like the once a day flatter line of Tresiba. It is my 3rd basal over the years and I love it. Would rather adjust the bolus.

 

[jape]

I use 40 units of Tresiba daily, but my need for Novorapid fluctuates wildly from day to day. However, in my case, it is the result of me sinning by eating some carb rich food. When I abstain from eating carb rich foods, it would seem that my need for Novorapid is very little. I have been a good boy for the last 3 days, consequently no Novorapid for these 3 days. This morning I woke up with BG level of 3.7.

Concerning Metformin, I have been taking it for the last 13 years. Honestly, I don't think it does anything for me (positively or negatively), but my endocrinologist keeps telling me it is a wonder drug, and it is good for me!

 

[Antje77]

I have thought of Levemir rather than Tresiba but I like the once a day flatter line of Tresiba. It is my 3rd basal over the years and I love it. Would rather adjust the bolus.

I fully agree, I definitely don't want to swap my Tresiba for anything else.
I'm so happy my endo (reluctantly) agreed to let me experiment with using a little Levemir on top of the Tresiba on a day to day need base! It might well be I'll find it's too much of a hassle, but being allowed to try means I'll be happy with any conclusion after some experimenting.

Those 24-hour things are a bit of a pain, but it should rule out white coat rather effectively.

I'm rather hoping it will rule IN white coat, not out. I much rather have white coat than true high bp, if given the choice!

Today I got a phonecall from a very confused pharmacist who received the order from the endo to send me some Levemir and metformin. I explained, she agreed, and I hope she's managed to work out a way around the computer system which doesn't really accept 3 different insulins instead of two.
She was very interested in my experiments, partly because she's sure she'll be asked questions on her messing with the computer system, looks like I've created a lot of work.

Delivery is planned for friday night, so I think I'll reduce my Tresiba a little on thursday and friday, and start the metformin saturday morning.
Wish me luck!

 

[Antje77]

If it was morning coffee, it may well be the biggest part of the rise was from getting out of bed, not the coffee.
Many of us need insulin when we get up, even without breakfast. For some this is only 1 or 2 units, for me it's anywhere between 5 and 16 units (which also covers the splash of milk I have in my coffee).

That’s very interesting, they don’t tell you that. I am way too volatile to inject without food at the moment, feel better being a bit high than crashing, but that’s off topic sorry op

edit: sorry, how do you know if it is 5 or 16 if not associating it to food?

Hi @Fenn , I took your question to this vaguely related thread as to not derail the other one.

It's complicated, and some of it comes down to intuition, although there are quite a few specific factors helping me to decide on my morning dose as well.

First is my overnight graph on my Libre. If I rise throughout the night, sometimes to the point of waking from an alarm and giving a small dose to prevent rising further, I can be reasonably sure I'll need more insulin than average on this day. Not only for my morning dose, but for my meals as well.

Second is the trend over the past couple of days. It's usually not as if I need 5 units today and 16 tomorrow, it's a gradual thing throughout the weeks.
So if yesterday and the day before were relatively low insulin days, chances are today will be as well.

Third: I hardly ever take more than 12 units for getting out of bed, and even that's pretty rare. I usually vary between 5 (rare too) and 10, and top up after an hour or 2 (still way before my first meal) if I'm still on the higher side.
Yes, that's stacking, and if I do I keep that dose in mind when injecting for my first meal which usually happens somewhere in the following 2 hours.

4th: Plans for the day. Twice a week I swim in the morning, starting an hour after getting out of bed. On those days I reduce my dose.
If I have a car ride or other unusual activity my dose will be lower than when I'm at home, with all the time in the world to keep a close eye on my numbers and react to them before I go below 4.

And last: Completely unscientific, but I take my gut feelings serious when it comes to dosing. Apparently I know things I don't know that I know.
If I have a sudden feeling I need to take a couple units more or less than logic tells me, I'm inclined to follow that feeling. Works for me, but don't ask me how.

I guess the main take away is keeping a very close eye on my numbers and spotting patterns. And a bit of luck as well.

 

[Fenn]

Hi @Fenn , I took your question to this vaguely related thread as to not derail the other one.

It's complicated, and some of it comes down to intuition, although there are quite a few specific factors helping me to decide on my morning dose as well.

First is my overnight graph on my Libre. If I rise throughout the night, sometimes to the point of waking from an alarm and giving a small dose to prevent rising further, I can be reasonably sure I'll need more insulin than average on this day. Not only for my morning dose, but for my meals as well.

Second is the trend over the past couple of days. It's usually not as if I need 5 units today and 16 tomorrow, it's a gradual thing throughout the weeks.
So if yesterday and the day before wore relatively low insulin days, chances are today will be as well.

Third: I hardly ever take more than 12 units for getting out of bed, and even that's pretty rare. I usually vary between 5 (rare too) and 10, and top up after an hour or 2 (still way before my first meal) if I'm still on the higher side.
Yes, that's stacking, and if I do I keep that dose in mind when injecting for my first meal which usually happens somewhere in the following 2 hours.

4th: Plans for the day. Twice a week I swim in the morning, starting an hour after getting out of bed. On those days I reduce my dose.
If I have a car ride or other unusual activity my dose will be lower than when I'm at home, with all the time in the world to keep a close eye on my numbers and react to them before I go below 4.

And last: Completely unscientific, but I take my gut feelings serious when it comes to dosing. Apparently I know things I don't know that I know.
If I have a sudden feeling I need to take a couple units more or less than logic tells me, I'm inclined to follow that feeling. Works for me, but don't ask me how.

I guess the main take away is keeping a very close eye on my numbers and spotting patterns. And a bit of luck as well.

Thank you so much, gives me loads to think about.

I appreciate your answer (and all the good you bring to this place) thank you

 

[Antje77]

Thank you so much, gives me loads to think about.

I appreciate your answer (and all the good you bring to this place) thank you

Thank you, that's so kind!

 

[EllieM]

Did you reach any conclusions about the metformin @Antje77 ? Did it help? Are you still taking it?

 

[Antje77]

Did you reach any conclusions about the metformin @Antje77 ? Did it help? Are you still taking it?

I'm still taking it (1000 mg once a day).
Hard conclusions? Not really.
I use slightly less insulin than before, and the amount I need to stay stable fluctuates slightly less wildly.
But data are a bit muddled because:
A: I also add Levemir on an as needed base to my fixed dose of Tresiba. Which might account for at least some part of the reduced fluctuations in mealtime insulin.
B: I likely had covid at about a month (6 weeks?) in, and I suspect that increased the amount of insulin I need a bit without dropping again This really messed up my thought out experiment.
C: We're 6 months further, so who knows how my insulin needs would have changed during this time without the changes in treatment.

At a guess, it helps a little bit, but if I want to know for sure I'd need to stop it again and see what happens. I might do this at some point in the future, but not now. But results are in no way conclusive enough to suggest others try it too.

 

[Antje77]

sorry, how do you know if it is 5 or 16 if not associating it to food?

And sometimes I guess completely wrong!
Looks like today is one of those days where I suddenly need less insulin, so my morning dose has so far dropped me from 5.9 to 4.4, and I'm about to go out for a day of sailing so I'd have preferred to stay around 6.
The insulin hasn't even reached its peak of action yet.

Annoying, but no problem, I have some very tasty juicy pears in the kitchen for the guinea pigs, so I'll have a bite of pear to nudge it up a bit before driving, yum!
The sailing will be relaxed, so with my pear on hand I expect I'll be able to stay between the lines, catching drops with a bite or two before going too low. Or maybe not, we'll see!