Low A1c means lots of hypo's?

[sofaraway]

I had a bad experience on tuesday ended up in A&E for over 24 hours with a blood sugar of 1.x (can't exactly remember).

I had my A1c done while I was there and it was 5.8% down from 5.9%. The DSN that i saw said that I must have alot of lows to get that A1c, I let her look through my meter (around 5 tests a day) and she could see that I don't have many lows, around 1 a week and not serious lows.

I don't test at night, last test 10pm and first test 6am. She thinks that I must be going low overnight. So i'm going to have a blind CGMS in the next few weeks to see what is happening overnight (and i have to test a couple of times overnight for the next week). Before the A&E experience I would have argued that i don't have lows very often and my A1c is good because simply I just have pretty tight control.

So I've been told to relax my control and reduce my insulin so that I can get my A1c above 6%.

I've reduced my insulin and am now seeing 7-9 before meals and before bed last night I was 13. i have to say i don't like it at all. I'm so used to my blood sugars being better than that I don't feel great when I go above 10.

I wonder If I am setting too unrealistic expectations, if my control really is too tight. I wouldn't have thought so before, but that shock of the admission has knocked my confidence.

Do any of you guys have a 5.x A1c and not have alot of lows?

any other thoughts would be appreciated

(apologies if anyone has already read this, i admit I did cross post on another diabetes forum)

 

[Trinkwasser]

So i'm going to have a blind CGMS in the next few weeks to see what is happening overnight (and i have to test a couple of times overnight for the next week). Before the A&E experience I would have argued that i don't have lows very often and my A1c is good because simply I just have pretty tight control

A CGMS would be useful to see what your BG is actually doing. But BLIND??? You mean they are concealing the information that you need from you? I don't get that.

 

[sofaraway]

It is blind in that the CGMS that you can get (generally used in the US alongside pumps) show on the screen every 5 minutes what your blood sugars is, alarms when it's below or above certain set levels.

The one I will be using will be hooked up but I will be unable to see the readings, the information will be downloaded afterwards and we can look at the results and see whats going on. I will need to test as normal during these 3 days

 

[jopar]

It is most likle one of the older type of GMS...

My hubby is also T1, and his HbA1c's normallys come in around the 6-7% mark... Our surgery DNS is always pleased with this, and she was saying that when she said this at a meeting of DNS's she was told that he was getting too aggresive treatment?

He does get the odd low though...

But if you feel that you are getting hypo's or lows (where you just dip below the 3.9mmol/l mark) and I assume that you would be aware that you are getting low... Then the only other period of getting low that you may not kow about is durning th enight while you're asleep...

I sleep through night-time hypo's I generally know that I have had at least one durning the night, because I feel like poop in the morning... Depending how low I've gone the symptons will range from a sluggish feeling, to having a hang over effect and if I had a really bad one it effects my eye sight and I can't basically see.... and my moring BG will be slightly higher than my bedtime one...

 

[hanadr]

A non-diabetic would have an Hb A1c of about 4.5% without ANY night time hypos. So why should your nurse assume you are having them? That assumption is based on a false premise.( i.e. that a diabetic cannot maintina non-diabetic blood glucose levels. Look through the Bernstein book for the relevant passage. It's on pages 52 and 53 of my edition. Phottocopy it and give it to your nurse.

 

[iHs]

I think in general people are worrying way too much about trying to achieve ultra low hba1c such as what Bernstein recommends in his book.

It should take many years for complications to manifest from poor control. I have more or less always had an a1c around the 7 mark for over 42 years with only a few problems that were fixed fairly easily. I would say that if people can aim to get their a1c between 6.4 and 7.0 then in general they should be able to live a good life with diabetes.

The hba1c is not a very good test anyways as it can mask poor control by allowing someone to have very high bg and then very low bg so the up down zigzag occurs. What does make a huge difference is to 'eat to your meter' and try using food to keep bg balanced out with insulin every 2-3 hours. You then can overcome all the highs by not eating so much food and if you are going low, you can eat a carb snack or protein or fat.

Hopefully, another ultra fast insulin will come about within the next 2 years called Viaject and that should help eliminate high bg after food is eaten and will disappear from the body within 2-3hrs from when it is injected. This will also help those who experience mid morning or mid afternoon hypos.

 

[hanadr]

Bernstein comments on the fact that HbA1c doesn't show up the person whose BG goes up and down a lot, but also says that it's the best we have. He also says somewhere that your chance of getting complications depends on a lot of things including genetics. Having seen eye and feet and kidney problems in my T1 husband and amputations followed by death from a stroke in his early 60s by a colleague, not to mention my own stroke at age 56, I am not taking a risk on it. I am trying for those 4s.
If you don't get complications, thank your great-grandparents

 

[Trinkwasser]

The hba1c is not a very good test anyways as it can mask poor control by allowing someone to have very high bg and then very low bg so the up down zigzag occurs. What does make a huge difference is to 'eat to your meter' and try using food to keep bg balanced out with insulin every 2-3 hours. You then can overcome all the highs by not eating so much food and if you are going low, you can eat a carb snack or protein or fat.

That's very true. My Reactive Hypoglycemia was mostly "only" giving me numbers between 10 or so and 4 or so and my A1c was still in the low fives.

Beacuse I was evidently doing this for around 50 years, believe me when I say "non-diabetic" numbers which are not NORMAL can produce neuropathy of both types, **** lipids, high BP and numerous other forms of damage.

Do you feel lucky, punk?

(I made a nice typo just then, neropathy - a burning feeling in your forum)

 

[Katharine]

Low aics and hypos can indeed go together like a horse and carriage but the link can be broken.
some tips:

1. low carb diet = less blood sugar = less insulin injected = less error (Bernstein's law of small numbers)

2. 7 unit rule. No more than 7 units in one shot (you can have multiple shots though) results in the insulin working over the time it is meant to eg regular is finished by 5-8 hours, rapid acting by 3.5-5 hours, so less carry over of effect.

3. What is happening overnight? If you adjust your basal insulin for your morning bs levels and not your 2-4am levels and you have an appreciable dawn phenomenon you WILL get night hypos.

4. Match the insulin to the meal and be particularly wary of the "pizza" effect. Say you eat three slices of an Italian base pizza at 30g a slice and cover it with a rapid acting insulin. The pizza takes 6-8 hours to digest but the insulin peaks at one hour. Result a hypo soon after eating and a corrected hypo and then another surge in blood sugar as the pizza comes onstream. You may need to use regular insulin for pizza and split the bolus. What Steven is doing for pizza is: taking 3 boluses of regular insulin for the total carb + carb weighting calculation + protein estimation sum. Splitting this into about three. First jag 15 mins before eating, second jag when pizza eaten, third jag one hour after the second jag.

I hope you can find out what has caused the hypo. Then you have an opportunity to prevent the same thing happening.

I think it is worth aiming for normal blood sugars but agree that unpredictable hypos can be a limiting step. I have done a lot of work in trying to get tight meal to insulin matching and I just wish diabetics were taught more about this so they could decide for themselves if the effort is worth it or not.

 

[lionrampant]

So I've been told to relax my control and reduce my insulin so that I can get my A1c above 6%.
forum)

Sweet merciful ****...

 

[hanadr]

Dear iHHs
complications don't always come on slowly. Sue Townsend, the writer, is almost totally blind and was diagnosed in1999. that' not all that long ago.
Anyway, it makes sense to keep as near "normal" as possible.
Many of us on here and Bernsein's patients prefer a little self discipline and keeping low.

 

[Trinkwasser]

1. low carb diet = less blood sugar = less insulin injected = less error (Bernstein's law of small numbers)

That works for RH as well, when you're relying on your own rather than injected insulin.

I hope you can find out what has caused the hypo. Then you have an opportunity to prevent the same thing happening.

I think it is worth aiming for normal blood sugars but agree that unpredictable hypos can be a limiting step. I have done a lot of work in trying to get tight meal to insulin matching and I just wish diabetics were taught more about this so they could decide for themselves if the effort is worth it or not.

Yes I know several Type 1s who have better A1cs than me. On the other hand some (Type 2s also) just never seem to have stable systems whatever they do.

Just a thought if you normally have excellent control and suddenly throw a major hypo for no apparent reason could you have shot into a vein? Or used bolus instead of basal? DO NOT TRY THIS AT HOME <G>

 

[sugar2]

sofaraway,

Sorry to hear about the A&E incident! I was told the same about having a low HA1C, but I am skeptical. It cn of course be true, but it doesn't have to be. If you genuinly have good control, and your BG only raises as much, or a little more than a non diabetic, then she should be finding out from you how you achieve the results you do!

Alas, my HA1c is now 6.5...but I am working on it! The other thing that was true for me in my 5.8 days was that I started to lose sensation of having a hypo...I avoided A&E, but did end up in the back of an ambulance. So, didn't have many hypos...but when I did, occassionally I didn't know about it. This is my quandary. I do not want to have hypos that knock me for 6, but I want to aim foe a good HA1c. I would like to ask anyone, who has had HA1cs in th 5s for an extended perod f time, did they experience this? Did the sensation return, or do they not et hypos?

Cheers,
Jill