Is my BG control OK?

[andrewbristol]

First time poster here....


At my Diabetic review last week, I was told I was running my BG too low for the past three months (HbA1c 5.5%). I'm not so sure and would appreciate views on this.


I've been T2 since 2007, and started insulin (Levemir and Novorapid) in Feb this year after my BG spiralled out of control - max permitted Gliclazide didn't touch it. BMI 21. Cholesterol 3.1 (Atorvastatin). GFR 68.


I test before lunch and dinner (AM fasting readings became pretty constant some time back, so I only check occasionally). Average of my readings for the three months was 6.5 (sorry, I've not got used to new units!)


For insulin dosing, I carb count (15g/unit) then adjust for (a) current BG and (b) expected activity (which makes a big difference). This seems to work OK most of the time.


My nurse said she was concerned about hypos and loss of sensitivity, and wanted my HbA1C nearer 6.5%. She said to aim for BG of 6-8 before meals - but my average 6.5 reading seemed within tolerance to me.


She was concerned about possible lows overnight, so stopped my 7pm dose of 8 units Levemir in the evening. I still take 6 units at 7:30am. Oddly, my AM fasting readings haven't risen much and are about 6.5, which feels absolutely fine to me. I honestly don't think I have been going low at night (I've got enough sensitivity to know, and did this once when I first started on insulin)


After the review, I went home and frequency graphed my 3 months readings to check how many fell into acceptable levels (I wish I'd had this to hand at the review). This showed:


3.0 to 3.4 1 reading
3.5 to 3.9 1 reading

4.0 to 4.9 26 readings

5.0 to 5.9 46 readings

6.0 to 6.9 57 readings

7.0 to 7.9 52 readings

8.0 to 8.9 18 readings

9.0 to 9.9 11 readings

10.0 to 13.5 13 readings


I thought this showed I was managing reasonably well and not at risk of lows - I was actually quite pleased with the profile....

53% are in my nurse's 6-8 range, with only two readings less than 4.0

67% of my readings are in the Diabetes UK/NICE recommended T2 range of 4-7 (but I appreciate DUK say range is subject to individual advice from your healthcare team).​

(I don't normally do postprandial, but did one this morning. 9.5 after 90mins. A bit higher than the Diabetes UK recommended 8.5, but not too bad)


If I adjusted my dosage to hit 7.0 (my nurse's 6-8 target midway), instead of my current 6.5, this would equate to an HbA1C of 6.0% This is lower than my nurse says she wants. So, I'm confused!

My question is whether my control is OK (or even good?), or should I be letting my levels run higher?

Thoughts would be appreciated

 

[GrantGam]

First time poster here....


At my Diabetic review last week, I was told I was running my BG too low for the past three months (HbA1c 5.5%). I'm not so sure and would appreciate views on this.


I've been T2 since 2007, and started insulin (Levemir and Novorapid) in Feb this year after my BG spiralled out of control - max permitted Gliclazide didn't touch it. BMI 21. Cholesterol 3.1 (Atorvastatin). GFR 68.


I test before lunch and dinner (AM fasting readings became pretty constant some time back, so I only check occasionally). Average of my readings for the three months was 6.5 (sorry, I've not got used to new units!)


For insulin dosing, I carb count (15g/unit) then adjust for (a) current BG and (b) expected activity (which makes a big difference). This seems to work OK most of the time.


My nurse said she was concerned about hypos and loss of sensitivity, and wanted my HbA1C nearer 6.5%. She said to aim for BG of 6-8 before meals - but my average 6.5 reading seemed within tolerance to me.


She was concerned about possible lows overnight, so stopped my 7pm dose of 8 units Levemir in the evening. I still take 6 units at 7:30am. Oddly, my AM fasting readings haven't risen much and are about 6.5, which feels absolutely fine to me. I honestly don't think I have been going low at night (I've got enough sensitivity to know, and did this once when I first started on insulin)


After the review, I went home and frequency graphed my 3 months readings to check how many fell into acceptable levels (I wish I'd had this to hand at the review). This showed:


3.0 to 3.4 1 reading
3.5 to 3.9 1 reading

4.0 to 4.9 26 readings

5.0 to 5.9 46 readings

6.0 to 6.9 57 readings

7.0 to 7.9 52 readings

8.0 to 8.9 18 readings

9.0 to 9.9 11 readings

10.0 to 13.5 13 readings


I thought this showed I was managing reasonably well and not at risk of lows - I was actually quite pleased with the profile....

53% are in my nurse's 6-8 range, with only two readings less than 4.0

67% of my readings are in the Diabetes UK/NICE recommended T2 range of 4-7 (but I appreciate DUK say range is subject to individual advice from your healthcare team).​

(I don't normally do postprandial, but did one this morning. 9.5 after 90mins. A bit higher than the Diabetes UK recommended 8.5, but not too bad)


If I adjusted my dosage to hit 7.0 (my nurse's 6-8 target midway), instead of my current 6.5, this would equate to an HbA1C of 6.0% This is lower than my nurse says she wants. So, I'm confused!

My question is whether my control is OK (or even good?), or should I be letting my levels run higher?

Thoughts would be appreciated

Your nurse is right in what she's saying because of the concerns of untreated nocturnal hypoglycemia. If you're permanently going low during the night and not realising, then you'll become hypo unaware which is extremely dangerous.

My opinion, if you are positive that you're not going low during the night - then the lower the HbA1c the better. Within reason of course, it cannot dominate your life nor can the good HbA1c be a direct result of frequent hypos.

There is no such thing as "too good control" when it comes to diabetes. But you need to be very confident in yourself to get there and be positive that you're doing it correctly and safely.

 

[slip]

What a well written and informative post, wish I only had 2 lows in 3 months!

I agree with what Grant says, keeping ultra low will have a knock on affect to your hypo awareness - but I don't think you're near that scenario, but night time hypos added in then maybe, but as you say you don't think you are having them and the fact you've dropped your evening levemir completely then theres no reason for you to have them unless your pancreas decides otherwise.

If your DSN is concerned about night time hypos then ask for a free trial Libre?! to prove it one way or another.

Well done.

 

[CherryAA]

First time poster here....


At my Diabetic review last week, I was told I was running my BG too low for the past three months (HbA1c 5.5%). I'm not so sure and would appreciate views on this.


I've been T2 since 2007, and started insulin (Levemir and Novorapid) in Feb this year after my BG spiralled out of control - max permitted Gliclazide didn't touch it. BMI 21. Cholesterol 3.1 (Atorvastatin). GFR 68.


I test before lunch and dinner (AM fasting readings became pretty constant some time back, so I only check occasionally). Average of my readings for the three months was 6.5 (sorry, I've not got used to new units!)


For insulin dosing, I carb count (15g/unit) then adjust for (a) current BG and (b) expected activity (which makes a big difference). This seems to work OK most of the time.


My nurse said she was concerned about hypos and loss of sensitivity, and wanted my HbA1C nearer 6.5%. She said to aim for BG of 6-8 before meals - but my average 6.5 reading seemed within tolerance to me.


She was concerned about possible lows overnight, so stopped my 7pm dose of 8 units Levemir in the evening. I still take 6 units at 7:30am. Oddly, my AM fasting readings haven't risen much and are about 6.5, which feels absolutely fine to me. I honestly don't think I have been going low at night (I've got enough sensitivity to know, and did this once when I first started on insulin)


After the review, I went home and frequency graphed my 3 months readings to check how many fell into acceptable levels (I wish I'd had this to hand at the review). This showed:


3.0 to 3.4 1 reading
3.5 to 3.9 1 reading

4.0 to 4.9 26 readings

5.0 to 5.9 46 readings

6.0 to 6.9 57 readings

7.0 to 7.9 52 readings

8.0 to 8.9 18 readings

9.0 to 9.9 11 readings

10.0 to 13.5 13 readings


I thought this showed I was managing reasonably well and not at risk of lows - I was actually quite pleased with the profile....

53% are in my nurse's 6-8 range, with only two readings less than 4.0

67% of my readings are in the Diabetes UK/NICE recommended T2 range of 4-7 (but I appreciate DUK say range is subject to individual advice from your healthcare team).​

(I don't normally do postprandial, but did one this morning. 9.5 after 90mins. A bit higher than the Diabetes UK recommended 8.5, but not too bad)


If I adjusted my dosage to hit 7.0 (my nurse's 6-8 target midway), instead of my current 6.5, this would equate to an HbA1C of 6.0% This is lower than my nurse says she wants. So, I'm confused!

My question is whether my control is OK (or even good?), or should I be letting my levels run higher?

Thoughts would be appreciated

My thoughts would be -

what diet were you on when you spiralled out of control? what diet are you on now ? if your blood sugar was out of control and you were already on a strict LCHF diet at the time, then that a completely different scenario from a standard diet.

Are you sure if you get the diet part sorted out, you actually need the insulin at all?

 

[andrewbristol]

My thoughts would be -

what diet were you on when you spiralled out of control? what diet are you on now ? if your blood sugar was out of control and you were already on a strict LCHF diet at the time, then that a completely different scenario from a standard diet.

Are you sure if you get the diet part sorted out, you actually need the insulin at all?

Many thanks for your thoughts/comment. There's no change in my diet from when it spiralled out of control to now, so that's not a factor. I don't do LCHF (i tried it for a while a few years back). I just eat a sensible balanced "normal" diet, but avoiding things which spike BG, and dose for the carbs I eat.

The start of my BG going out of control was picked up in my Jan 2017 review when my HbA1C rose from mid 6's to 7.9. Nurse switched me from 40mg/day Gliclazide to 2 x 500g Metformin/day. I wasn't self testing at that time. Three weeks later I was concerned about very blurry vision, so I tested. I was 20.8, so something was seriously broken!!

Surgery were great - emergency appt later that day, checked for ketones (OK). Switched off Metformin and back to Gliclazide at 80mg/day. No change. Increased to 240g/day. No change. Pretty scary - within a couple of days I was put on insulin, which was quite a learning experience, but a huge relief.

I gradually and carefully got my initial dosing established and have been refining it since. Yes I am definitely T2 - no doubt.

 

[andrewbristol]

What a well written and informative post, wish I only had 2 lows in 3 months!

I agree with what Grant says, keeping ultra low will have a knock on affect to your hypo awareness - but I don't think you're near that scenario, but night time hypos added in then maybe, but as you say you don't think you are having them and the fact you've dropped your evening levemir completely then theres no reason for you to have them unless your pancreas decides otherwise.

If your DSN is concerned about night time hypos then ask for a free trial Libre?! to prove it one way or another.

Well done.

Thanks Slip
As luck would have it, I signed up to a project at Bristol University where they want volunteers to use continuous monitoring for one week and compare it with the food intake and activity. I'll be a guinea pig back end of next month - so it will be a great opportunity to find out once and for all what is going on with my BG. My DSN is keen to see the results.

I did see the Libre and I'm very tempted by the free trial. I heard the ongoing cost is about £100pm, and although NHS is going to support it, our CCG haven't made a decision on it. I really think it would be good for DSNs to have a few to lend out to patients when she wants to find out what is really going on (like myself!)