Some questions

TigerBao said:

Hi all. As mentioned elsewhere, I'm a type 1 diabetic, treatment by insulin (humalog and lantus.)

My questions:

I can never remember the ideal before and after readings I should aim for. Is 6 -7 a good target to generally aim for at any time?

As a Type 1 your levels according to the NICE 2011 guidelines are this :
Fasting (waking)........between 4 - 7 mmol/l.
2 hrs after meals.......no more than 9 mmol/l.

What's the ideal hb1ac reading? My last test I think was last year and was something like 11.7, I know that's incredibly not good, but I don't know HOW incredibly not good (and yes I'm taking measures to get my thumb out of my orifice and take it back.)
NICE guidelines presently say 6.5% is good however it should be individually agreed with your HCP to suit your own circumstances.

And a not so quickie: Do you find that mood affects your sugars? I have, to put it PCly in this modern world, "emotional imbalances" and am often either angry or depressed, and I find when I can find nothing else at fault (I've injected the right amount, worked out how much I need, injected on time, etc) my being angry or otherwise "off" is often the only reason I can find for my sugars being off kilter.

It's actually the other way round.....'sugars' will affect your mood. It is well known that both high and low blood sugar levels will have an impact on your moods, aggressive, weepy, depressed etc........all sorts of effects.

Also related to the previous, does anyone know if antidepressants affect sugars? I was on zispin several years ago, which my doctor prescribed me, obviously, but the leaflet inside said it's not suitable for diabetics, coz they're made of sugar to dissolve on the tongue. Experiences shared would be appreciated. I don't want to go back on the antidepressants but lately my depression has been, well, winning.

Thanks everyone.
Tiger

Click to expand...

As regards the AD's........the coating is only a minimal amount so shouldn't really have a significant impact on Bg levels. The known side effects of Zispin are as follows :

increased appetite, weight gain, dry mouth; postural hypotension, peripheral oedema; drowsiness, fatigue, tremor, dizziness, abnormal dreams, confusion, anxiety, insomnia; arthralgia, myalgia; less commonly syncope, hypotension, mania, hallucinations, movement disorders; rarely myoclonus; very rarely blood disorders (see Cautions), convulsions, hyponatraemia (see Hyponatraemia and Antidepressant Therapy), suicidal behaviour (see Suicidal Behaviour and Antidepressant Therapy), and angle-closure glaucoma

Click to expand...

Hi There, ref: your question about what your BG should be, it's a very personal thing. You have the NICE guidelines above but some people find 7's and 8's too high and others find 4's and 5's too low. You need to find a level which works for you and then aim to maintain it by adjusting your insulin accordingly, depending on what you are eating. Personally, my target is 6 and I aim to stay above 4.5 at all times and below 8. I have a pump so am able to be that specific! But even without a pump, with the right knowledge and attention to carbs and ratio's etc, it's totally possible to stick to your targets. Good luck!

Personally, I have had a huge variety of anti depressants and the main two that have hugely lowered my readings are citilopram and duloxitine. I too am on a pump but had to hugely alter everything from my hourly basal ratings to my carb ratio's for these two drugs.

However, neither Doctor of Pharmacist told me these facts, infact I think duloxitine leaflet warns about levels going up!! Needless to say though, not everybody will have them lowering their levels, we are all individuals and what affects some doesn't afffect others....

cugila said:

NICE guidelines presently say 6.5% is good however it should be individually agreed with your HCP to suit your own circumstances.

Click to expand...

cugila, I thought it was 7.5 from NICE, and 6.5 from DUK. If you have a link to the NICE stuff you got this from please would you post it? I'm collecting HbA1c recommendations for my study at present (they are all different!) and would be great if you could point me in the right direction for that figure. Ta.

Snodger said:

cugila said:

NICE guidelines presently say 6.5% is good however it should be individually agreed with your HCP to suit your own circumstances.

Click to expand...

cugila, I thought it was 7.5 from NICE, and 6.5 from DUK. If you have a link to the NICE stuff you got this from please would you post it? I'm collecting HbA1c recommendations for my study at present (they are all different!) and would be great if you could point me in the right direction for that figure. Ta.

Click to expand...

Oops.....shows I'm a Type 2..... That is the figure for them, however what is quoted for Type 1 is this :

Blood glucose control
Blood glucose control should be optimised towards attaining DCCT-harmonised HbA1c targets for
prevention of microvascular disease (less than 7.5%) and, in those at increased risk, arterial disease
(less than or equal to 6.5%) as appropriate, while taking into account:
• the experiences and preferences of the insulin user, in order to avoid hypoglycaemia
• the necessity to seek advice from professionals knowledgeable about the range of available
meal-time and basal insulins and about optimal combinations thereof, and their optimal use.

Click to expand...

So yes, would be between 6.5% for those at increased risk and 7.5% for others, although it is subject to agreement between Patient and HCP's. Personally I would aim for the lower figure as we know that complications can set in if the figure is above 7% for any length of time. The same old story that they tell us we should lower our HbA1c to avoid complications and then here tell us that 7.5% is OK ?

Not in my book it isn't...... lower has to be better whilst avoiding the hypo's. Balancing Insulin and Carb intake should avoid that mostly. This bit as well :

Advise that any improvement is beneficial, even if target HbA1c levels are not reached
(and the greater the improvement, the more the benefit)

Click to expand...

It's a bit like a Diabetic Course I was on recently they are telling all the T2's that 10 mmol/l is OK everyday...yet the guidelines clearly state that for a T2 no more than 8.5 mmol/l and a T1 no more than 9 mmol/l. Where is the sense in that........ :roll:

I have no idea what DUK quote as I stick with NICE figures.

http://guidance.nice.org.uk/nicemedia/l ... /29391.pdf

ta.
The DCCT showed significantly reduced risk of long-term complications in their intensive therapy group, who had an HbA1c of 7.3 I believe (presumably NICE just rounded it up!). HOWEVER if you count hypos as complications, and I certainly do, then it becomes a much more complex story - the intensive therapy group had three times as many severe hypos as the control group.
That's why I am always a bit wary of these figures as targets for type 1s. It's easier for you type 2s... but increased risk of severe hypos is not to be taken lightly.

having said all that - the DCCT was pre-DAFNE and it's quite possible that if they repeated it with DAFNE style education for the intensive therapy group, they might be able to manage the lower bg without the increased hypos.

But I just wanted to sound a note of caution when it comes to recommending these targets across the board for all diabetics.

That's what I always see as a problem.

I know many Type 1's who have HbA1c's lower than 6.5% and who also do not hypo all the time. Why accept a higher level that may cause you problems later on ? That seems illogical to me. Get a balance with Insulin and Carbs consumed and that will help avoid those complications rather than sticking to what has to be flawed information regarding levels. Too much Insulin or too much Carbs has to be bad for anybody. If you have a HbA1c of 7.5% that means your average daily Bg levels are around 9 mmol/l. That to me is not a good number to aim for, lower has to be better.

I once had a HbA1c of 7%, during that period of time I had levels which varied from 2.4 to 24.6 mmol/l. That was not good control in anybody's book.....yet according to the guidelines it was good ? Should I have gone along with that I would be well on the way to complications by now......

I have Type 1's who I have helped get better control, reduce their high HbA1c's and yet still can avoid hypo's........when they drop too low they immediately do something about it. We won't go into hypo awareness or lack of as the case may be.......

We keep being told by the so called 'professionals' (DCCT etc) that intensive therapy significantly reduces the risk of long term complications, retinopathy, neuropathy etc etc......that is what complications are. A sound hypothesis which is borne out by those who achieve good control and yet still can avoid complications, avoid too many hypo's and have a better quality of life.

A Hypo is NOT a complication with the same long term effects like those mentioned above, it is something that all Diabetic's whether Type 1 or 2 can get and deal with at the time. They can for the most part be avoided. You do NOT have to run high levels to avoid them either, just keep the levels at the lower end of the scale above the point where you get hypo warning signs/symptoms. It is hyper levels which can cause complications so lower levels must be better......

As has been shown here lower HbA1c levels have to be better to avoid the complications so there is no way I would accept that levels of 7.5% are good targets whatever anybody tells me.

As for recommending things to people....if we had listened to those who stick to the recommended target Bg and HbA1c levels many Diabetic's would already be suffering those complications. Look at the stories of those who ignore the so called 'professional' advice handed down from on high and see what their results are. Less or no complications, reversal of any symptoms, better quality of life, better all round health, better fitness levels........

Personally I prefer to recommend what I think is more helpful......HCP's have been shown to give out loads of advice that frankly doesn't help many Diabetic's.......just put's them on a slippery path to ruin.

I will never agree with anybody who advocates higher HbA1c or Bg levels as a control measure......I will never agree with a target level (7.5%) which I believe encourages poorer health and possibly complications. What targets people wish to aim for is a matter for them, I don't think you can give just one figure, hence the 'agreed' with the Patient caveat.

Just my view ........

One other thing I should mention which is aimed at ALL Diabetics is this from the NICE Quality Care Standards (25/03/2011). The latest information which I think is very relevant and tends to support my view regarding the levels to be aimed for :

Quality statement

People with diabetes agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia.

Quality measure

Structure

Evidence of local arrangements to ensure that people with diabetes are able to agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia.

Click to expand...

This is how the standards are arrived at.........

Derived from the best available evidence such as NICE guidance and other evidence sources accredited by NHS Evidence, they are developed independently by NICE, in collaboration with the NHS and social care professionals, their partners and service users, and address three dimensions of quality: clinical effectiveness, patient safety and patient experience.

Click to expand...

http://www.nice.org.uk/guidance/quality ... ontrol.jsp