Adding metformin to insulin?

[Antje77]

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)

 

[Daibell]

Hi. Metformin may help just a tad and won't do any harm. I take it and also take insulin. My DN thought it's other protective properties worth having

 

[Fenn]

In my very limited experience and knowledge of anything clever.

For some unknown to me reason, after a recent heart bypass, the hospital reduced my metformin from 2g to 1g daily, not sure what if any difference that made as it was a volatile time, my diabetes endo consultant just very recently put it back up to 2g, this as far as I can tell made zero difference to bg or insulin use.

Your graph makes no sense to me but I really like it, maybe because the effort involved far exceeds my patience, good job.

 

[Antje77]

Your graph makes no sense to me but I really like it, maybe because the effort involved far exceeds my patience, good job.

That was about the only conclusion I derived from this ridiculous graph!
Lots of work for no conclusion I can see. At least I use the Libre where I log my insulin, so I could simply look up my daily amount of insulin on LibreView.

Hope your recovery after the bypass is going well!

 

[EllieM]

@Antje77
This is an interesting one. My situation isn't quite as volatile as yours but I often feel like insulin behaves like water and my GP has mentioned that she'd give me metformin if I wanted it. (Am considering having a discussion with my endo at my next annual review.)

The obvious thing to do is to try it and see?

Don't suppose you can get a cpeptide test out of your GP so that you can tell whether honeymoon is still a factor?

Do you have a big rise at dawn?

One more thought. Probably not an issue for someone who hasn't been diabetic for decades, but how confident are you that your injection sites aren't an issue?

 

[Marie 2]

Hi! Metformin if you can handle the possible gastro issues, can bring a lot of benefits to the table.

I never did figure out why my dog varied so much, in her case since I was pretty sure steroids set it off and I wondered if her pancreas would still try to pop in and help off and on. Honeymoon periods in people can last 8 years plus sometimes. Spurts of insulin production could explain drastic changes.

I can tell you a high fat day for me then requires more insulin for the next 24 hours. A fasting day makes me super insulin sensitive for the next 24 hours. A higher exercise day when I snorkel also makes me super sensitive for the next almost 24 hours.
Maybe you can try to add to your graph some stats of fat consumption, exercise etc? Have you tried to fast for a day to see what difference it causes? Maybe it would supply you some more information?

My dog, same food, same exercise, same schedule and she widely varied. There were a few people that had the same issues with their dogs...........I think probably more than was known because only a smaller percent had a Libre on their dog to know. Luckily Libres were catching on to use on them and vets were becoming more knowledgeable about it.

 

[Hopeful34]

Sorry I can't really make any sense of your graph either. Like Ellie sometimes my insulin behaves like water, and then the last vial I used, I kept going to go hypo.

It might be worth trying Metformin to see if it helps. It would be interesting to know the results if you decide to go down this route, and the Endo agrees.

 

[Antje77]

Thank you all for your thoughts already, I hope more will follow!
I think sharing thoughts is very useful. Even if no-one has definitive answers it accelerates our own thought processes and may lead to new ideas.

First I'll wave to my endo/internist in case she followed the link to this thread I sent her earlier today through the hospital messaging system.
Hi Ilse, nice to see you here!
(First name only to protect your privacy, as per forum ethos, not being impolite.)

The system doesn't allow pictures so I thought to just link to this thread in preparation for our appointment and my unusual question with the picture of my ridiculous insulin fluctuations.
It was only later I realised this would lead you to all the replies as well, which made me laugh.

The obvious thing to do is to try it and see?

That's what I was thinking, but I wanted the thoughts of the forum and my endo first!

Don't suppose you can get a cpeptide test out of your GP so that you can tell whether honeymoon is still a factor?

C-peptide would be my endo to order, and I suppose I could get one if I really wanted to.
However, I don't really see the necessity, as just seeing if metformin improves things seems much less of a hassle. Besides, it doesn't really make any difference to my treatment if I still produce insulin, the goal is keeping healthy BG's with as little work as possible.

Do you have a big rise at dawn?

No. But only because I inject a generous amount of Fiasp before getting out of bed, regardless of breakfast.

how confident are you that your injection sites aren't an issue?

Very confident. For one, I'm fat so I have lots of surface to choose from, and I'm rather flexible too so I'm quite creative in selecting spots to inject
Secondly, there are some patterns not visible in the graph, mainly that if I have a high insulin day it will stay that way over the day and the same with low insulin days, and I inject all over throughout the day.

Honeymoon periods in people can last 8 years plus sometimes. Spurts of insulin production could explain drastic changes.

This is of course a possibility. In which case metformin might reduce my overall insulin needs but won't do anything to stop the fluctuating.

 

[Antje77]

part 2 of my replies, as the forum software started to balk at the amount of quotes.

Maybe you can try to add to your graph some stats of fat consumption, exercise etc? Have you tried to fast for a day to see what difference it causes? Maybe it would supply you some more information?

My dog, same food, same exercise, same schedule and she widely varied.

Most of those 90 days followed roughly the same pattern in activity and macro's. I've added the days I swim to the graph by now (45 minutes in the morning), but apart from reducing my dose for foot on the floor this doesn't make a discernible difference to the over all pattern.
Still it makes me happy to see my diabetes is like your dog's, it makes your dog and I friends through time and space.

It might be worth trying Metformin to see if it helps. It would be interesting to know the results if you decide to go down this route, and the Endo agrees.

I'll definitely share the results, should the endo and I agree to give it a try!
And before I share the results I'll bore you all senseless with nervous questions on how to safely adjust my insulin before taking this first metformin tablet!
To which no-one is allowed to reply for safety reasons...

Let's just hope that if we decide to try the experiment won't be cut short by side effects.

 

[EllieM]

And before I share the results I'll bore you all senseless with nervous questions on how to safely adjust my insulin before taking this first metformin tablet!

I was on the REMOVAL trial a few years back, to see if metformin would reduce vascular issues for T1 diabetics. Never got to find out whether I was taking the tablets or a placebo, but I was given no input on it causing any issues with injections, so am guessing it isn't regarded as too much of an issue.

Here are the warnings they gave me for metformin, basically a warning about lactic acidosis (keep to safe limits on alcohol, oops) and don't take it before having a general anaesthetic or having a test involving iodine injections.

***********very boring boiler plate ******************************
Metformin must not be used by people with moderately or severely abnormal kidney or liver blood tests or too soon after a heart attack. In these situations metformin therapy may lead to lactic acidosis, the build up of lactic acid in the blood which is potentially dangerous. We will make sure that your kidney and liver tests are adequate before proceeding with the study and also on numerous occasions during the study. You should not exceed standard recommendations for safe limits of alcohol consumption while you are on the study medication. Metformin should not be taken for 48 hours before general anaesthetic for an operation. If you need to have any X-ray or angiogram which needs a dye containing iodine (such as a CT scan with „contrast‟), you must stop the study medication 48 hours before the test and alert the doctors wanting to do the test that you are participating in this trial. Before you restart the study tablets (no earlier than 48 hours after the test), you must have a blood test to check your kidney function. The study doctor can arrange this in liaison with the doctor looking after you in hospital. If you are admitted to hospital, please make sure you inform the hospital team of your participation in the study, show them your Patient Alert Card and the information in your Study Diary. It is theoretically possible to develop side-effects to any medication, which, if not treated quickly, could become life threatening. Warning symptoms of the rare but serious side-effect of lactic acidosis include muscle cramps, breathlessness, abdominal pain and a feeling of being very weak and unwell. If you have any of these symptoms, develop a rash or otherwise feel very unwell on the study medication, you should discontinue the treatment and contact your GP or the emergency services for urgent attention. For such serious side effects, please contact the study nurse as soon as you can to report them

 

[Antje77]

Never got to find out whether I was taking the tablets or a placebo, but I was given no input on it causing any issues with injections, so am guessing it isn't regarded as too much of an issue.

From what I've occasionally encountered without really looking for it (as I haven't, so far) on diabetes groups on Facebook is that insulin doses went down substantially for a lot of people starting metformin.
I'm thinking, but I may be wrong, most of those people had high BG's to begin with, giving them a buffer for the effect of the metformin.
But what will happen if you add metforming to your normal dose of insulin when your numbers are in the 4's and 5's on a regular basis? Not much room for error there...

Here are the warnings they gave me for metformin, basically a warning about lactic acidosis (keep to safe limits on alcohol, oops)

That's one I dug into quite deeply earlier this year.
When I was first diagnosed with diabetes, 5 years ago, my GP practice nurse wanted to start me on metformin first, which I declined based on my having read the leaflet online already and seeing that alcohol is a contra-indication because of the risk of lactic acidosis. So I got started on gliclazide instead.

Earlier this year I looked into the connection between alcohol, metformin and lactic acidosis a bit deeper, because I wanted to ask my endo if it would be an idea to start metformin because of my high insulin doses.

I was very surprised to find there is not much to connect the two, and the warnings in the leaflet are mostly based on assumptions!

 

[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)

You know how I feel about Metformin, personally. But hey... What harm can it do to try? You won't really know anything until you do, anything's an educated guess up until now, and everyone responds differently so.... That educated guess doesn't mean much when it comes to a one-of-a-kind Antje. Who knows, whether you respond to it the same explosive way I did or if it'll make a marked difference to your insulin needs... I'd just give it a go, see what happens. Your CGM should make things clear enough. Just stock up on bog rolls just in case. And vaseline.

 

[JohnEGreen]

Earlier this year I looked into the connection between alcohol, metformin and lactic acidosis a bit deeper, because I wanted to ask my endo if it would be an idea to start metformin because of my high insulin doses.

I was very surprised to find there is not much to connect the two, and the warnings in the leaflet are mostly based on assumptions!

Metformin seems to coexist quite well with my odd glass of whysky and has not caused a problem over the last year or so.

And as met works for T2s who produce their own Insulin why should it not work for those who inject they work indipendantly of each other met works to reduce glucose produced by liver and insulin does what insulin does for all people generally.

 

[Antje77]

Who knows, whether you respond to it the same explosive way I did or if it'll make a marked difference to your insulin needs... I'd just give it a go, see what happens. Your CGM should make things clear enough. Just stock up on bog rolls just in case. And vaseline.

If I do try, and if my side effects are even a 10th of yours, the experiment will be cut short faster than I can run to the bathroom!

One more thought. Probably not an issue for someone who hasn't been diabetic for decades, but how confident are you that your injection sites aren't an issue?

When I was taking my Tresiba last night another (rather unlikely) possibility came to mind.
What if my Tresiba doesn't absorb the same every day? It being such a very long acting insulin this could account for the slightly wavy pattern of lower insulin weeks and higher insulin weeks.
I don't expect this to be the issue but I'll inject in my bum for the next two weeks instead of my arms to see if this makes a difference. (No legs, I absolutely hate injecting in legs!)

 

[StewM]

If I do try, and if my side effects are even a 10th of yours, the experiment will be cut short faster than I can run to the bathroom!

When I was taking my Tresiba last night another (rather unlikely) possibility came to mind.
What if my Tresiba doesn't absorb the same every day? It being such a very long acting insulin this could account for the slightly wavy pattern of lower insulin weeks and higher insulin weeks.
I don't expect this to be the issue but I'll inject in my bum for the next two weeks instead of my arms to see if this makes a difference. (No legs, I absolutely hate injecting in legs!)

I experience similar patterns to yours, and I also take Tresiba. I also didn't experience these patterns until I began to take Tresiba.

A quick look at my notes shows in the past two months.

I do see great variance day to day in the required amounts of Insulin. I only change my Carb Ratios if I see a consistent pattern. However, I do make corrections if required. The overall trajectory of my Insulin requirements has been an increase in Insulin Sensitivity by 40% for Bolus, and 20% for Basal. This has happened with almost zero lifestyle changes regarding diet and activity levels within those months.

Back to the variance, despite the general trend of increasing insulin sensitivity, there are days where it takes a lot more Insulin or less Insulin to achieve the same results. What does this look like in real terms? In the past two weeks, whilst my average insulin to carb ratio has been 1unit to 11.25 carbs, I have had zero "average days". The ratio has varied from 1 unit to 9.25 carbs to 1 unit to every 11.75 carbs*. My Basal dose remained consistent during that time, but I have seen some nights where the Basal is just not doing what it's supposed to (a flat line). I achieve on target Basal results on 9 out the 14 days, with lows or highs happening through the night on the other days. Thanks to Libre alarms I was quick to correct any problems that did occur.

*This might look small, but I'd encounter almost zero variance in my overall ratio whilst taking Levemir.

 

[ROE100]

Hi Antje

Feel your issues - I don't have the details anyalsis as not on Libre.

On my last call with the consultant I have been told I am insulin sensitive but then in the next breath told to inject earlier before eating to stop the spike & no you can't have a half unit basal pen.

I have also thought that tresiba may not release flat/same through out the whole 36 hours.

I have also thought I may be insulin resistant and should sugest met. to the consultant but from past experience when ever I have requested/ask for something it has always been a no and then over time it become of the the norm and often a few years later get what I initially asked for.

 

[DisFanJen]

Wow! Those are some crazy numbers!

Well, I can't comment on if it would help to stabilise the insulin amounts as while I'm on insulin and metformin, I'm at the point where I'm thinking of talking to my specialist about coming off the insulin (down to 6u basal and no bolas while eating around 90 - 120g carbs a day).

I will say that I have major gastro issues if I go more than 1g of metformin a day (which is one of the reasons I've not pulled the trigger with them about coming off basal, I think they'll try and up the metformin again).

I do seem to need less insulin because of the metformin, but the ol' weight loss and exercise made a bigger hit (I know, who'da thunk that stuff about staying healthy, etc. really does make a difference? ) and apart from having to keep the amount under control to avoid gastro issues it seems to not cause me any other side effects.

Bottom line, I don't see any special reason not too if it doesn't give you any side effects.

 

[Antje77]

I'll inject in my bum for the next two weeks instead of my arms to see if this makes a difference. (No legs, I absolutely hate injecting in legs!)

Did that yesterday. Reminded me of how I dislike bum almost as much as legs.
I'm a wimp. But I'll try to stick (in)to bum for two weeks in the name of science.

 

[Antje77]

Did that yesterday. Reminded me of how I dislike bum almost as much as legs.
I'm a wimp. But I'll try to stick (in)to bum for two weeks in the name of science.

I've been very good and have injected my basal in my bum now every day for 10 days now. As expected, it doesn't seem to make a difference. I'll finish the 2 weeks but I'll be very happy to go back to arms after that!
The amounts of bolus I've used in the last 9 days are
44
43
50
52
48
43
18
22
so just as erratic as before.

 

[StewM]

I've been very good and have injected my basal in my bum now every day for 10 days now. As expected, it doesn't seem to make a difference. I'll finish the 2 weeks but I'll be very happy to go back to arms after that!
The amounts of bolus I've used in the last 9 days are
44
43
50
52
48
43
18
22
so just as erratic as before.

Yeah, I’ve been having similar woes with Tresiba. My Badal requirements have dipped, peaked and dipped again since you last posted (confirmed by Basal Testing).

Glad you’ve got the option of arms that never worked well for me at all.