Doctor says this , Hospital says that??

[Adrian1981]

Hi everyone,

I am having trouble with my HB1C being too high. Its currenly now at its highest for 5 years. Although never below 7 , normally 8, it is now creaped up to 9.3.

I get my diabeties monitored at the hospital clinic and at my doctors.

I recently visited the hospital where i was informed of the 9.3 reading. I have not performed carb counting for a while now, seem to eat the same things so inject the same amount, with the occassional correction dose if required. The hospital have now suggested i go back to strict carb counting.

Now my confusion. When my doctor heard of my high HB1C she rang me to discuss my insulin.
She informed me that "her doctors training" stated that carb counting is so' thirty years ago' and that her solution was to ensure that my :-

daily novarapid units total = total amount of lantus units given per day .

My current meal time novarapid units are 4, 6, 8 for breakfast, lunch and dinner respectively.
my lantus units are 15 in the morning and 15 in the evening.
(my reason for my lantus being split is beacuse I was often getting home from work late and having my lantus 2hrs after the due time, so by splitting it, at least one of the doses was on time).

As you can see my novarapid total is 18 but my lantus is double that.

What do people think i shoud do to try and improve my HB1C.

1)If i go with my dr then i have to reduce the lantus to 18 from 30 units. This will surely increase my HB1C.

2) If I go with the hospital, which i am now, the insulin will vary depending on meal content but be a lot less than the lantus amount given.

Any advice and personal experience comments would be appreciated.

Many Thanks

Adrian

26 years type 1 diabetic, aged 28

 

[totsy]

if it were me i think i would go with the hospital as gp,s are general drs whereas hospital diabetic teams are trained in diabetes,
also carb counting does work,i take less novo daily than lantus, have u tried doing a fasting test to see if your lantus is at the right dose? i do it every so often, i miss a meal and see if my bs holds steady, if low then im on too much lantus, if high ..not enough, once your lantus is right it is so much easier to tweak novo,
try it with a different meal over a period of 10days and see what happens,
im sure others will be along to offer advice soon,
this is only what i would do and you MUST do what you feel best doing

 

[timo2]

Hi Adrian,

I agree with what totsy's said. Stick with the advice from your hospital.

Also, as your meal time doses are relatively small, you might also want to check out the half unit NovoPens for a bit of finer tuning.

Regards,
timo.

 

[noblehead]

Hi Adrian,

I'm afraid your doctor is talking utter nonsense! Daily lantus units do not need to match units of novorapid, I really can't believe your doctor said that. Some days I can take as little as 18units of novo and 26 of lantus, other days(special occasions/eating out) I may have 30-32 units of novo and still inject 26 of the lantus.

Lantus is a background insulin, there to keep blood glucose stable throughout a 24 hour period. Novorapid is a fast acting insulin designed to cover food at mealtimes. The best way to know if you are on the correct dose of lantus is to fast. Lets say you have breakfast at 8.00 am, then by 12 your blood glucose was 7, your reading of 7 should not fluctuate much between then and your next meal at say 6-7pm. Should your blood glucose rise, to little lantus, if they fall and you go hypo, you will then need to cut back your units of lantus.

I was on the DAFNE course recently, they cover all this on the course and show you how to match insulin to the food you eat. There is no need to eat and inject the same amount each day, that is 'old school advice' not given out now. The principle of DAFNE is to match insulin to the food you consume. They use ratio's to determine the right amount of insulin to each 10g of carbs, or in DAFNE terms each 1 CP, this being carbohydrate portion. Most find that at each meal you may need a different ratio of insulin per 10g of carbs. I can assure you that carb counting is not 'so thirty years ago', it is still in use and the only way of achieving good diabetes control.

I would suggest that you see your diabetes care team and discuss your control, ask about the DAFNE course and enlist, and tell them what your doctor said so you may clarify the situation. I am sure once you enroll on the course and you go back to carb counting, you will see a big improvement in your hba1c.

Good luck

NIgel

 

[jopar]

And when did your doctor actually do her medical training? Durning the early 90's they did stop carb counting, then wised up and brought it back, slightly different than it used to be as now the diaebtic is trained to use carb counting to be pro-active in there control i.e change there insulin dose to match there needs!

Your GP can't undermine what your consultant has said, and is totally out of order..

I too am in contact with both my hospital team, and my sugery team but my DNS and GP do not interfer with what my hospital team has said, if they think a change might be needed then they discuss this with my hospital team, which is the correct way of doing things..

Me I would phone my hospital team, explain what your GP said and advised you to do, because you are likely to find that your consultant will write a letter putting GP straight about carb counting, and to butt out... Most consultants enjoy writting a snooty letter to GP's

 

[TishTosh]

Hiya

I'm the same as the others and would stick by what the hospital recommends. My GP has a specialist diabetic nurse but even the advise that she gives me is not always the same as my consultant. My management has been much better since i've followed the adivce of the hosptial.

Carb counting really does work well for me but I have to admit I slip away from checking the labels of everything that I eat. It's always a good idea to check the labels as the carb values can be quite different (eg same sandwich from different shops) and these will effect your blood readings.

My novorapid is different from day to day depending on what I am eating and the amount of exercise I have done. What ever dose I take it is nowhere near the same amount of Levemir that I inject. Even if you have changed your life style a little it can sometimes change your glucose reading which can be a real pain :roll:

I agree with Totsy though, you have to do what is right for you. Try not to worry about your HbA1c result too much as you can work at bringing it back down to your usual value

Tish Tosh

 

[Adrian1981]

HI all,

Thanks for your posts and advice.

Can i double check what you all mean with regards fast testing/ fasting.
Do you mean skip and meal completely and its insulin and see if the blood still remains the same at the following meal time?

I have been doing my blood tests in between meals. I'll give one example.I had lunch and then approx two hours later did my blood test. The result was 4.0. Then about twenty mins later it was 3.2.

Does this mean the lantus dose is too high? I was going to check again in an hour from there but I ate due to the 3.2 reading.
How rapid is the novarapid? Should i be seeing the effects of the novarapid two hours after the injection or has it done bit long before.

'noblehead mentioned the DAFNE class they have attended. I have recently attended a simular thing with the diabeties nurses and some other diabetics. We studdied the insulin, carb counting, correction does and how much are sugars are effected by 1 unit of insulin and exercise etc.


Thanks again all.

 

[timo2]

Testing somewhere between the two/two and a half hour mark should give you a good gauge of how your NovoRapid is doing, Adrian.

If your after-meal sugars are good, but your next pre-meal sugars have risen, then this may be an indication that your basal is too low. Waking, pre-meal and pre-bed sugars will tend to be where any problems with your basal dose will show up.

Personally, I've found Levemir slightly better than Lantus. Its action is a bit milder and more predictable - which is all we ever ask from a basal insulin.

Regards,
timo.

 

[noblehead]

Adrian,

You need to skip both your meal and insulin to see if you have the correct basal dose, in your case lantus. During and after my course I tried fasting at different times. First I had my evening meal at 6pm then ate nothing till the following morning at 7am. A couple of days later I ate breakfast at 7am and fasted until my evening meal around 6pm. I fine tuned my dosage by only 2 units, but 2 units can and does make a difference. This method is one that is suggested by the tutors on the course to establish that you have the correct basal dose.

Novorapid has a profile of no more than 4 hours. Meaning that is almost certainly used up after this time. It is most active between the 1-2 hour mark, but still continues (albeit at a slower rate) to lower blood glucose up to 4 hours after.

Have a chat with your DSN about what has been discussed before you proceed any further, your DSN is more suitable to offer advice on a more personal level.

Regards

Nigel

 

[moonstone]

Noblehead you're exactly right about everything except one thing, which I have to point out. Novorapid has a profile of 2-6hrs. If I'm going to hypo due to accidentally having too much Novorapid (eg from a bad estimate on my carb intake) it will normally be between 1.5hrs and 3hrs afterwards. This doesn't happen often, I hasten to add! 4hrs is a good average to work off, but we still need to bear in mind the potential for a 6hr action - eg two big doses at 4hrs apart could overlap, resulting in a hypo.

To the original poster, I think your GP may be confused with terminology - 30yrs ago the procedure was to be allowed a fixed amount of carbs per day, and that's why you had to carb count. But that's not what people are talking about these days when they use that phrase, it's a completely different concept. As everyone here has said, listen to your hospital instead. Even though you've been on a carb counting course, still get on a DAFNE course as soon as you can, it's the gold standard - you've said one or two things that I know would be more than covered on DAFNE.

 

[noblehead]

Hi Moonstone,

The insulin profiles I studied lately, was that novorapid lasted no longer than 4-5 hours, 4 was the figure I was given on my DAFNE course. Of course it would be ill-advised to inject insulin twice in such a short space of time (within 4 hours) as there is a potential for a overlap, hence why it is advisable to leave enough time between meals for the previous insulin dose to expire.

Thanks for pointing that out!

Regards

Nigel

 

[lilibet]

Agree with all other posters

You can't as a matter of course match basal and bolus as bolus depends on what you eat,and that varies across the day! Basal needs are also independent of food
At present my split is almost 60/40 but on some days can be less, on some days more.

As for the hypo at two hours twenty - most likely to be Novorapid but in saying that, if your basal is set wrong it will make meal times harder to fathom. For me, I need to watch about the 90 mins mark, sometimes a bit before, or a bit after but there and thereabouts. Although Novo has done it's 'best' by that point, it will still drop a wee bit thereafter, but I feel ok about injecting 4 hours after again because although the insulin is stacked, its not potent enoug at that time to leave me in 'danger'.

Of course , we are all different. Yesterday I had 16 u Levemir, and 12 unit Novorapid
Day before I had 16u Levemir and 24 u Novorapid