Avoiding hypos

[Juicyj]

Twice in the last week I have been told by an NHS nurse that we should be avoiding hypos as much as possible, the latest information I received today from a nurse was that hypos affect the metabolic memory of the heart, however the inevitability of taking insulin and dealing with life's curve balls means that it's a virtually impossible task, I average around 3 hypos a week and although in post analysis I can define why they happened I very often cannot avoid them as I don't have a CGM.

So putting this question out there to all insulin controlled members - how do you avoid hypos ?

 

[tim2000s]

First of all, how are we defining "Hypo"? From what I understand of the clinical literature, the metabolic effects aren't felt by the body until you are below a threshold of about 3.5 mmol/l, so anything above that is not clinically a hypo.

 

[Juicyj]

I wasn't given a hypo threshold from this discussion, personally I follow the rule that anything below 4.0 mmol/l is a hypo and treat as such and I personally do feel hypo around 4. It was more of a concern that NHS guidance is stipulating that we need to avoid hypos when we all know this is incredibly hard, and my point is quite a simple one, what do you do to avoid them ?

 

[noblehead]

So putting this question out there to all insulin controlled members - how do you avoid hypos ?

With the best will in the world hypo's are impossible to avoid, they can sometimes happen for no rhyme or reason despite our best efforts.

I agree Juicy that a CGM must be a game-changer, but from my own experience simple things like basal testing and working at getting the I:C ratio's right goes a long way in reducing both hypo's & hyper's.

I know some type 1's here aim for very tight bg control and if they achieve that without hypo's then good for them, but my aim is to have good bg control and have a good quality of life without the fear of losing my hypo awareness, therefore don't have any desire to spend time in the 4's and I'm quite happy to have bg levels in the 5 -7 range, example being this morning my bg has averaged out at 6.2mmol/l.

Interesting what your Nurse has said @Juicyj , just did a Google search of what she said and found the following if you want to take a look:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784865/

 

[ickihun]

I'd go back to nurse and ask for a better insulin.
Toujeo300 is for insulin resistant sufferers because of it's make-up.
However @Cumberland is type1 on a toujeo basal insulin.
Im not sure if he agrees but far far less hypos on it. Ive only had one compared to humulin m3. It was a 4.2mmol/l so technically not in nhs threshold.
Ask for toujeo for basal insulin? See if it works better for you too?

 

[Snapsy]

how do you avoid hypos

I don't! That's the simple answer.

I try, mind you. I plan ahead as much as possible, I bip my Libre sensor as often as possible and try to head off lows I can see coming........

The night before last I was a pretty flat 6.5ish all night.
But last night I was a pretty flat 2.5ish all night. I had no clue at the time - I woke up this morning 2.7, had some glucose and wondered what on earth had happened to make that happen. Felt fine but a little hungover from it (I hadn't been drinking!). Mr S complained about my 'unusual, even for YOU' snoring. Hmmmmm, now that's a hypo symptom I didn't know about!

As far as I could recall I'd had and done nothing madly different to the previous evening and night! So there was no way any pre planning, aside from setting an alarm or priming Mr S to bip me if I'm snoring 'unusually' - yes, both things that I could have done - could have made me avoid that all-night hypo. But I was 5.4 and steady when I went to bed. I saw no need.

Day to day, for the last thirty one years I have done my best to a) keep my diabetes tightly controlled and b) avoid hypos. In my experience, however, these two aims are very very difficult to achieve in tandem!

My pump helps massively in that I can turn the tap down to ward off a steady drop if I have identified such a drop on my Libre. But even with those two amazing gadgets I cannot avoid hypos.

 

[Juicyj]

I think I was more frustrated at the fact that I was being told to avoid something that is inevitable and that because of cost I know I wouldn't get access to a CGM unless I lost my hypo awareness, which is still good as I told my nurse, but still cannot avoid them. My hypos since being on a pump are generally around the 3mmol/l mark so I rarely go lower. I do use the libre from time to time but in terms of measuring hypo's I consider this to be an inaccurate method to check. I am interested to learn of what the physical effect is though so thanks for this link @noblehead

 

[Juicyj]

Thanks @ickihun but as i'm on a pump it's just quick acting insulin only.

 

[tim2000s]

With the best will in the world hypo's are impossible to avoid, they can sometimes happen for no rhyme or reason despite our best efforts.

I agree Juicy that a CGM must be a game-changer, but from my own experience simple things like basal testing and working at getting the I:C ratio's right goes a long way in reducing both hypo's & hyper's.

I know some type 1's here aim for very tight bg control and if they achieve that without hypo's then good for them, but my aim is to have good bg control and have a good quality of life without the fear of losing my hypo awareness, therefore don't have any desire to spend time in the 4's and I'm quite happy to have bg levels in the 5 -7 range, example being this morning my bg has averaged out at 6.2mmol/l.

Interesting what your Nurse has said @Juicyj , just did a Google search of what she said and found the following if you want to take a look:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784865/

Thanks for that. That particular study is interesting in that it uses the now discredited ACCORD study as a key pillar of the argument that Hypoglycaemia is a cause of heart related issues. At least they acknowledge more study is needed.

What I note in all of these things is that "Severe Hypoglycaemia" is always stated as what causes the physiological effects, and this is normally in the 2.0-2.5 mmol/l range.

But in response to @Juicyj 's original question, I use OpenAPS to achieve that. If you are a pumper, one of the things I've learned from using this technology is that most people have their DIA in pump set incorrectly. Many of us like to think that we have a DIA of 3 to 4 hours, which might be the point at which we think we aren't seeing any action, yet the models that APs run off are more sensitive to DIA and therefore insulin stacking has a pronounced effect. I think many of us would get better Bolus Calculator results and fewer hypos if we tended towards 5 hours for DIA.

 

[Robinredbreast]

It's can be a difficult task at times and we can only do our best, because upset and worry affects me. Also going out walking with a group last year and and taking the right amount of Insulin for the return journey to find out it is much longer, doesn't help, so = hypo. If only we were all perfect ...................
@Juicyj it can be frustrating.

 

[GrantGam]

Tough one...

In all honesty, if I'm doing something that would be dangerous/unacceptable for me to hypo (motorbike, exercising, dangerous tasks at work, etc) - then I'd run my BG higher than I'd usually like to. Instead of aiming for low 5's, I'd sit at 8 or 9. I achieve that by taking less insulin with meals, snacking or taking less basal in the morning.

The way I manage my diabetes is basically the opposite of what is advised. Lots of small corrections, micro-treating lows and advance bolusing. Although this is an effective means to manage T1, it does mean that hypos are more likely. Certainly I've found that to be the case.

I had a slight disagreement with my DSN about my BG's at my last visit. She was concerned at the amount of 4's and occasional 3.8 in my logs. I said that I still have all my hypo awareness (albeit I'm not a shaking sweaty mess and 4.0, but I know I'm not right). I am however, a sweaty shaking mess before I pass out from low BG, which is something I cannot afford to lose. It really boils down to what a hypo is defined as and also the situation you're in.

I'm currently walking the tightrope with a CGM and even then it's tough. Will all the fancy alarms and predictive algorithms in the world, there is still every chance of not catching a hypo.

I'd like to add that <3 hypos per week is possible if you're doing absolutely everything correctly. Throw some heavy exercise, a few nights out, couple of large meals and the general hectic nature of life... then I find 3 hypos in a week an EXTREMELY hard figure to get to.

For all of those out there who are almost always above 3 hypos per week, it happens

 

[noblehead]

Many of us like to think that we have a DIA of 3 to 4 hours, which might be the point at which we think we aren't seeing any action, yet the models that APs run off are more sensitive to DIA and therefore insulin stacking has a pronounced effect. I think many of us would get better Bolus Calculator results and fewer hypos if we tended towards 5 hours for DIA.

Must admit my DIA (or action time on my pump) is set at 4 hours, I've not noticed a lowering effect after this time but interesting what you've said above Tim.

 

[Deleted Account]

I am sure it is possible to avoid hypos whilst keeping your BG within approved limits most of the time.
However, doing that whilst living a full, fun and interesting life is not possible.
If you really want to avoid hypos completely, eat the same thing every day, don't do a stressful job. don't get ill, do exactly the same amount and type of exercise every day, don't go on holiday, don't alter your daily routine, ....

But that's my opinion and I'm not a trained doctor/nurse ... I just live with type 1 diabetes every day of my life.

 

[therower]

As much I don't like dropping down to 4 and below , I think it's inevitable to achieve overall good control. There isn't much leeway between a BS of 4 and a BS of 7.
I think it's a balancing act, good control and a happy life.
As long as we are happy with our control, that's all we can ask for.
The one thing that really annoys me ( I'm off again @Snapsy ) are people who lecture and or advise on anything hypo related. I believe only an insulin controlled diabetic will ever fully understand hypoglycaemia. I appreciate the fact these "experts " can forewarn us, but just saying avoid hypos is far to easy.

 

[GrantGam]

I know some type 1's here aim for very tight bg control and if they achieve that without hypo's then good for them, but my aim is to have good bg control and have a good quality of life

Absolutely agree.

I had a sub 40mmol/mol HbA1c once, but it almost killed me to get there. I was absolutely obsessed with testing and could not stop thinking about "what my BG might be". There was little quality of life, although at the time it felt sound - it really wasn't.

I had an interesting discussion with my diabetologist at my last visit about HbA1c values and complications. She told me that there is little evidence to suggest that an HbA1c in the low 50's would cause more complications/greater liklihood of complications than an HbA1c in the low 40's. Basically, the difference is negligible. But, she did say that you would be three times more likely to suffer recurring bouts of hypoglycemia with an HbA1c in the 40's. Apologies if I'm misquoting you Doc!

What I took from that is that creeping your HbA1c closer to 50 will not cause you much more issues than busting a gut to keep your HbA1c super-low. With a higher HbA1c there is more room to relax and not worry about dropping low which in itself, is enough to make the quality of life much greater.

 

[tim2000s]

I appreciate the fact these "experts " can forewarn us, but just saying avoid hypos is far to easy.

They're just "Specialists"... Those who live with it are the "Experts"....!

 

[ickihun]

Thanks @ickihun but as i'm on a pump it's just quick acting insulin only.

Im not savy with pumps @Juicyj .
So no basal at all in your regime?
How much is your imput to pump control? Is it still as effective as it used to be? Anything changed to cause you more hypos?

 

[therower]

They're just "Specialists"... Those who live with it are the "Experts"....!

That's a great way of describing the difference between us and them.
Thanks for the different slant on the situation.

 

[Scott-C]

Without cgm, I suppose being aware of the roughly two hour peak action, and the occasional surprisingly hard kick down in the tail end 4 or so hours make those points in time which are worth paying attention to, especially if there had been some unexpected physical activity in the afternoon, and even more so if there's any insulin stacking going on from a late afternoon snack.

I think it can take a while for newly dx'd to appreciate that insulin acts over time in that way and can easily catch us on the hop if it's not accounted for.

 

[Juicyj]

Hi @ickihun - Pumps use quick acting only, so your basal is quick acting insulin which is drip fed continuously, however you have a basal setting which you would periodically check via basal fasting. I pretty much analyse my readings every day and also with my DSN who can check reports I download and send her, so my pump settings are pretty accurate. However it's life's events which affect control, so stress, exercise, hormones and unexpected events which can cause hypos/hypers and this is what we cannot control. I think as @helensaramay has said unless you live a sedentary lifestyle and eat the same thing all the time with limited stress then maybe you could limit the number of hypos you have, but as we all know that's impossible..