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Sudden change in my response to insulin and food

BooJewels

BooJewels

Well-Known Member
Messages
443
Location
Lancashire
Type of diabetes
Treatment type
Insulin
Good evening, long time no post. I hope everyone is keeping well. I'm currently experiencing an odd phase of reactions to food and my insulin and obviously can't get professional guidance until Monday, but thought maybe someone here might have some ideas in the meantime.

I'm a T2 of almost 25 years and I was put on Insuman Comb 25 insulin twice daily with breakfast and dinner about 10 months ago, when low carbing and meds just weren't managing my levels (perpetually in the 20s). It worked really well at getting control and I did well on it, losing weight, with much improved numbers and bloods generally. I combined it with a lower carb regime - i.e not as low as some here manage, but I found I needed some carbs with the insulin, as a combination regime is always a best guess dose for the day ahead and with too few carbs I'd dip too low as the insulin worked before I'd digested other food stuffs.

After a regular blood test, my HbA1c was rather too low, suggesting that I was having hypos that the tests I was taking (average x 6 per day) weren't showing, probably overnight and as I was sleeping badly and often waking in a sweat or with a bad headache the next morning, we decided this was pretty likely and we cut the dose for a week or so whilst we considered options. I regularly had to eat before bed to get my BG high enough to sleep, which wasn't helping my low carb goals and weight. And I found the hard way that drinking alcohol (just 1 glass) dropped me low all of the following day.

The Insuman insulin is a fast acting and slow release in combination, suggesting that the fast acting and long one were overlapping about 6 hours after the dose. So I was put onto NovoMix 30 the week before Christmas which is a rapid acting and slow acting analog insulin. I started at about 20% less than the Insuman and this was a little too much at first, so I dropped another 2 units per dose to 10 am and 14 pm - my DN said she'd rather I ran a little high for a week or two as she was worried about losing my hypo warnings. I saw her about 10 days ago to review my first 2 weeks on it.

I did really well on this over Christmas with all my readings sitting between 5.7 and 10 - most between 6.5 and 8 - it looked nice and consistent on my graph, with minimal fluctuation - even on the days I was a piggy over the festivities. We were both delighted with how it was looking and agreed to continue just as I was, as once working and returning to exercise after the holiday period, I'd be more active and eating less rich food and I would probably drop a little overall without any need to adjust the doses.

Until the middle of this week. Doing my regular test before bed on Wednesday, I was astonished to see that I'd dropped to 4, with no suggestion of hypo symptoms - I can usually feel when I get below 5.2-ish. The following evening, after a similar style known safe evening meal (in terms of carb load etc,), I was 13 at bedtime - the highest I'd been for months - but was 5.8 the following morning, lower than usual. Today I was 9.7 after my usual breakfast, which is noticeably higher than the same meal and dose usually results in (usually around 7.2 -7.4 - I only usually rise less than 0.5 after breakfast with insulin - today was 3) and we went out to run some errands and do some shopping - nothing too strenuous and returned for lunch. I went to do my usual BG before eating and couldn't remember how to use my meter and couldn't take blood as I was trembling - my BG was 3.7 - the lowest I've knowingly been in 20 years. Yet I only felt symptoms at the last minute - although my husband said I then got very belligerent with him and wouldn't eat and wouldn't sit down and I don't remember any of this. I had my some apple juice and a piece of brioche and then lunch (obviously more carbs than usual) and after it, was now 14. My reactions to both food and the insulin seem somewhat extreme - I haven't reached 14 in many weeks - and a rise of over 10 seems excessive, no matter what you eat. My usual hypo treatment regime would raise me 2 or 3.

I started a new pen on Friday, but this clearly didn't address it (same box/batch as the one first giving me trouble, but also the same batch as the ones I did well with) and I've taken one out of a new box from a different batch to try tomorrow, but I'm clutching at straws really to eliminate any easily fixed variables. I have been very careful with mixing the insulin (I've done approaching 700 injections now) and checking the consistency etc. I use a different spot each time and don't have any flesh issues where I inject.

We had contemplated a basal/bolus regime, but decided to try this first, but I'm wondering if maybe a combination therapy isn't suitable for me and controlling it myself might be worth the additional effort. I do seem to be receptive to additional insulin as I've kept my BGs decent on much lower doses than the manufacturers suggest according to my weight - yet meds and diet had minimal impact on BG despite my efforts. I want to return to lower carbing as I think I did better overall on it and was doing well losing weight, but having to treat hypos plays havoc with that regime.

Does anyone have any ideas what might cause such a dramatic change in reaction so quickly. I don't think I'm ill or sickening for anything as my husband and I are actively avoiding anyone with bugs as he's having surgery soon and with failing kidneys, they've said they won't operate unless he's fully fit. I'll obviously speak to the DN on Monday, but wondered if there's anything else I might address in the meantime? And my fingers are now really sore with all the additional testing.
 
hi BooJewels. It sounds like you're having a rough time of it with the sugar levels. The only things I can think of is firstly it could be that the mixed insulins you are using do not have the right basal dosage that you need. It may be that you'd be better off using a basal insulin and a separate bolus insulin. I've had type 2 for 17 years and I've been on insulin since 2010. I've not been treated with mixed insulins at all. My endocrinologist has only changed my basal insulin once. I use Lantus for basal and Apidra for bolus. My second thought is you could have something going on in your body that is causing your sugar to be erratic. Eg. for me I've been dealing with a uti for well over a month and it has made managing my sugar levels very hard as mainly I'm getting either higher than my usual readings or I'm just crashing... pretty much like you're experiencing.

I hope whatever it is that you're able to get it sorted and get your sugar levels settled again. I wish you the best. :)
 
Thanks very much Mep. I think the basal is probably the core of the issue, as you say. At the very least the proportion between them isn't right. The problem with a mixed insulin is that you have a fixed proportion of basal and bolus and this doesn't account for differing demands when you eat something different or are more active. Using a fixed dose per day, you're always giving yourself a 'best guess' dose for the next 12 hours. When I started on the Insuman, it did very well getting my BG under control for 6 months, then started going awry once I was settled - it does say in the information that it's not as good for long-term maintenance. The NovoMix is supposed to be a bit better as it's rapid and slow, so the basal and bolus doses don't overlap as much. The DN said it works very well for most people and all her patients on it tolerate it well.

Here in the UK there are guidelines as to the prescribed progression of regimes - and I've been following that recommended path - largely because my DN felt it was worth a try before we made the commitment to basal/bolus. The mixed insulins are simply easier to administer and manage, but I've suspected since it went wrong with the Insuman, that a mixed might not be for me and the DN was a little surprised that I did as well over Christmas on it, hence we decided to give it another two weeks of more normal habits before reviewing again.

It just seems odd that it went suddenly wrong overnight with little else changing in my routine. My BG graph bimbled along rather boringly for 2 weeks, with minimal fluctuations, then goes beserk with massive spikes and dips since last Wednesday. I was 4 at bedtime again last night, so treated the hypo and woke in the night feeling rough and drenched in sweat, so took it again and it was 10.8, but was down around 5 again when I got up. It then spiked up to over 10 after brekkie.

I tried a brand new pen from a different batch with breakfast, but it doesn't appear, after one dose, that will be the answer if I've increased by 5 with breakfast - when it's almost always less than 1 difference. I was going to reduce dose, but then that wouldn't indicate if the pen batch was an issue, so I decided, for today to try my usual dose with the new pen. If the rest of the day fluctuates as wildly, I'll reduce dose tomorrow.

I don't think there's anything else wrong, other than the long-term issues I already deal with, as I've hardly been out and mixed with other people for the last couple of weeks as the weather has been bad and I've had a lot of work on and doing my tax return etc., so I don't think I've been exposed to bugs. I seem to be otherwise okay.

I didn't mention earlier that I have already eliminated meter or test strip issues by using others and I did squirt three 15 unit doses out of the pen onto a surface, to ensure that they all looked the same size, just to eliminate the rather unlikely possibility of a mechanical/dosing issue.

I hope that you can get your UTI sorted, I've had them in the distant past and they're very unpleasant.
 
Hi @BooJewels .
I'm too on mixed insulin. Humulin m3.
I've experienced your symptoms over xmas.
I was low carbing then xmas eve I was offered pasties and Christmas cake. I'd been extremely strong up til then but received bad news and it stressed me right out. Carb eating was the result.
Hense, messing up my lower bgs so on occasion I overcompensated for them with addition insulin.
The thing is that I didn't realise is the carbs had a knock on effect for days not hours for me. I tried to correct with insulin but I didn't quite judge the full effect and up and down my bgs went.
My only advice is to try not to increase your well diagnosed need for low carbing. Food wise or insulin.
Try and mimic the diet you were on when steady and same amount of insulin too. The key is steady and controlled amounts - of both.
Try it again for a few days then tweek small and steady if still not perfect. Steady food plan is essential. No high carbs out of the blue or increased/decreased insulin in extreme.
This worked for me. But only a suggestion I'm not medical trained- at all.
I hope it helps. :-)
 
Thanks for the reply @ickihun

I think the converse is true in my case, my numbers were very good over Christmas, rather surprisingly so, to the extent that I allowed myself to indulge more than I would have done a month or two earlier. I was sensible, but not manic about restricting my diet - but I was manic about testing and timing of meals and injections etc. My numbers were good during this period - I started on NovoMix on 21st December and was strict with diet until the Christmas Eve evening meal.

If anything, I've lost control whilst being better with my diet again, trying to get back to a better regime after slacking a bit. I don't tend to tweak my insulin to meet diet requirements, as that would feel like cheating to me and I'd never know what worked. I don't ever want to get into the mindset of thinking its okay to have a slice of chocolate cake as I can add a bit of extra insulin to compensate - I think that's a slippery slope I don't want to even contemplate.

If anything, I've come down a little from what was prescribed - at the time I went onto it I was supposed to inject 12 units am and 16 units pm, but I've settled on 10 and 14. This worked over Christmas and the fortnight since, then from Wednesday, it all went awry, with no obvious explanation for it.

Yesterday I plummeted to 3.7 before lunch, yet today, after the same breakfast, insulin dose and time period (yesterday I did some shopping, today I've moved furniture around in my office), I was 8.9 before my lunch. In 25 years as a diabetic, I've never had unpredictable patterns like this - my meter is seemingly spewing out random numbers at the moment.
I'll see what the DN has to offer tomorrow.
 
Hopefully the nurse can throw some light on it.
Rather scary if your insulin is always the same. No increase or decrease to your carbs. Your right to be concerned.
In my experience ive never known an insulin user not to change insulin doses to their dietery needs. Chocolate cake is never a winner for type 2s as of Christmas cake which I know that is why insulin doesn't solve bad dietary choices. Only the glucose high.
For me the knock on effect is for days not hours.
I hope I can resist next Christmas. Especially since I'd prefer Chocolate cake to heavy gritty fruit icing topped cake. I don't know why I ate it. (Maybe pastry carb gave me a sugar craving?)
Your post just reminds me how different us type 2s are. One size doesn't fit all. ;-)
 
I just had my most serious hypo I was at 8.6 before lunch, 8.8 at two hours after lunch and less than two hours after that reading, when I was due for my next injection with dinner (i.e. I normally start going up again as the earlier dose tails off), I realised that I couldn't see properly and felt very funny and as my vision started to blacken, I grabbed my old meter I keep as a back up in my office and was down at 3.2! My husband had to get my glucose tabs and orange juice. 20 minutes after that I'd gone to 9.4!

Dinner was ready by now, so I ate first and I've given myself only 5 units of NovoMix - usual evening dose is 14. I don't know what the implications are of not taking any when it's expected, so I decided that a small dose might be the best compromise.

Clearly I need to speak to the DN tomorrow - unfortunately, she only works 2 days a week, so I hope she isn't taking a day off.
 
I hope it gets sorted soon. I wish I could have helped somehow. Sorry. :-(
 
Yeh I think your mixed insulin isn't working for you. Also I'm not sure if it has been explained to you... but my endocrinologist explained to me that basal insulins all have a profile and they're not all the same. So if one doesn't work,, they give you a different one based on the profile of that insulin. He showed me a profile chart where it shows how the insulins work and the differences in profiles. I got the idea what he was saying. For example he put me on protophane to start with and it didn't work well for me, so I've been put on lantus. I hope that your diabetic team there can help you get on the right insulin you need. It is hard to manage sugar if the basal isn't right.
 
Thank you @ickihun - the moral support is appreciated. I'll report back tomorrow when I find out more.

I think it's safe to say that I've eliminated any potential external transient causes, like faulty meters, test strips or pens, so it must be down to how my body is reacting to this particular insulin. The only thing I haven't changed is injection site and I use my big fat belly, so that should be the fastest, as I understand it. Yet I seem to be getting a delayed response.

@Mep - we were obviously typing at the same time. I was aware of the nature of different insulin profiles. When it became evident that the Insuman Comb was causing un-seen nocturnal hypos, we looked at the profiles and times of my results and decided that the profile of both the fast acting (relatively slow in insulin terms) and slow one of that insulin were causing them to both be active and peak at about 6 hours after taking - which coincided with my numbers. Hence moving to a 'rapid' combo - so that hopefully the rapid would be tailing off before the basal peaked. In theory, the peaks of these two don't overlap by as much - in that one is tailing off as the other gets going.

The funny thing is that it worked really well for three weeks and then went totally bonkers overnight. You'd think it would be evident fairly quickly that it wasn't going to work for me. I need to look more carefully at the numbers and times before I speak to her tomorrow, but at the moment, I can't see an obvious pattern, yesterday my hypo was 4 hours and a meal earlier than todays. My insuman ones were only ever overnight and mostly without me knowing, I just wondered why I wasn't sleeping well. 6-7 hours after my morning dose I'd had an extra meal with lunch of course - and was on a lower morning dose to allow for my extra daytime activity. So the pattern I experienced was at least plausible and could be explained. I'm at a loss with this current non-pattern, you'd think my meter was just plucking random numbers out of thin air.
 
Just a quick update as I now have a family emergency and need to spend a few days away dealing with it.

Before I spoke to the DN, I was trying to fathom if there was a pattern in the numbers and did notice when looking at earlier numbers, that when my insulin dose was too high (eg the time we realised my HbA1c was too low and I must be having nocturnal hypos), I rebounded back and forth much more, the lows were lower and the highs were higher.

When I reduced the dose, the band of variation was much narrower - which seems counter-intuitive, but when I looked back at old graphs I'd printed for appointments, each time we decided to reduce the dose (which we did as I lost weight and added more exercise in), my control was tighter after a reduction and it seems to go erratic, rather than just low, when I'm having too much insulin. I must rebound back and forth much more if I start to get lows.

So as I'd reduced my doses to 5 units as an emergency precaution, we've decided to stick with that for several days to see if I get more even control again and that this insulin works at all for me, then titrate it up to get my levels right, very slowly indeed. But even on 5 units (10 per day as opposed to the 25 I was on) my figures haven't yet gone wildly up, I'm 5.6 this morning which is low for me at this time of day, so maybe it lasts much longer in my system than the charts suggest, or maybe I'm very sensitive to this one. Maybe I just had seemingly better control over Christmas due to the richer food and less activity.

So before we go basal/bolus, we decided to try this one a bit more yet on a very low dose and see if it settles into a better pattern.

Thanks for the support.
 
Can I please ask. My sugar levels went up to 18.9 the other day is this really high or has anyone had higher.
 
alicemason said:
Can I please ask. My sugar levels went up to 18.9 the other day is this really high or has anyone had higher.
Click to expand...
I have been off the meter several times over 33.0 and hospitalised with 59.6

See your GP or A&E if your readings are constantly on the high side make a fuss

It might be better to start a thread of your own and give a bit more detail of your circumstances like insulin amounts you inject, diet etc does being hyper happen a lot to you or was the 18.9 a one off!!

Best wishes

Not nice being high
 
BooJewels said:
Just a quick update as I now have a family emergency and need to spend a few days away dealing with it.

Before I spoke to the DN, I was trying to fathom if there was a pattern in the numbers and did notice when looking at earlier numbers, that when my insulin dose was too high (eg the time we realised my HbA1c was too low and I must be having nocturnal hypos), I rebounded back and forth much more, the lows were lower and the highs were higher.

When I reduced the dose, the band of variation was much narrower - which seems counter-intuitive, but when I looked back at old graphs I'd printed for appointments, each time we decided to reduce the dose (which we did as I lost weight and added more exercise in), my control was tighter after a reduction and it seems to go erratic, rather than just low, when I'm having too much insulin. I must rebound back and forth much more if I start to get lows.

So as I'd reduced my doses to 5 units as an emergency precaution, we've decided to stick with that for several days to see if I get more even control again and that this insulin works at all for me, then titrate it up to get my levels right, very slowly indeed. But even on 5 units (10 per day as opposed to the 25 I was on) my figures haven't yet gone wildly up, I'm 5.6 this morning which is low for me at this time of day, so maybe it lasts much longer in my system than the charts suggest, or maybe I'm very sensitive to this one. Maybe I just had seemingly better control over Christmas due to the richer food and less activity.

So before we go basal/bolus, we decided to try this one a bit more yet on a very low dose and see if it settles into a better pattern.

Thanks for the support.
Click to expand...
I wish you well
Been reading your thread with interest
 
Thank you @Cumberland I'm back home this evening and trying to catch up with chores etc.

To update my progress, I dropped to 5 units per dose for a few days and it was evident that this wasn't going to be making much difference - my numbers were much the same as when I was on the 25 units/day when I first started having unexpected hypos. I still had several on 5 units a day, so in discussion with the DN, we've decided to drop the insulin entirely for a little while to see how it settles down. I'd already decided that for myself and missed 2 doses by the time I spoke to her.

I'd personally like to go med-free for at least 2 weeks to see what my current natural pattern is. I last had insulin on Thursday and have had 3 hypos since and spiked at about 15 after meals. So at the moment I have no idea what is going on, the DN thinks the insulin has stimulated something to change in me. I've been diabetic for almost 25 years now and never fluctuated anything like this, I've always been fairly stable (fasting to post-prandial variation in the 4-5 range), even when far too high, it was consistently high. Until 2 weeks ago, I could probably count the times I'd gone under 5 on my fingers, but I've been 4 or less on waking every day lately.

The DN wants me to go back to taking gliclazide when I feel I've gone too high after meals, but I am reluctant to go back onto meds as they made me feel horrible and didn't work well enough to justify it. I want to stay treatment free for long enough to understand a pattern, as this is all new territory.

It is also true that the last week has been far from normal, with significant stress, erratic meals, inappropriate food and little sleep, so hardly a fair time to make assessments. I'm absolutely livid, as I was very happy on insulin for the first 8 months, it suited me well after years of battling a number of unsuccessful treatment regimes. I was low carbing, losing weight and experiencing good control and feeling better. It feels like I've thrown all of that away in the last fortnight. So I want to try and get back to a better routine from Monday if I can.

Has anyone else experienced a sudden change of their patterns in this manner?
 
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