I went to the endo this morning with 4 weeks of meticulously created spreadsheets delineating every hourly sensor reading, meter readings, insulin for bolus and correction, and basals. Last time I took Carelink reports and he threw them in the trash. They did an instant A1C and it was 5.3, down from 5.8 in May.
He really wants me raise my A1Cs/ blood glucose levels. His case is that maintaining such a low A1C is dangerous for me, as it has meant a lot of low BG levels-- some really horrible. I just cut all my basal down by .05 (1.2 units per day) after making cuts over the summer of about 2 units per day and now take 8.6 daily. I changed my correction from 1/65 to 1/80, as instructed. I had already changed my I/C from 1/10 to 1/15 last winter. He even asked me "Are you really a diabetic?" Well yes--for 51 years!!!!
I am going to try for a while, but I will be like a recovering alcoholic trying not correct everything over 100.... (I am 137 now--2.5 hours after lunch and have itchy fingers...) He was actually sweet today--understanding, sympathetic--told me he felt more like a coach than a doctor with me.
I see his point. My life, and my family's were a lot easier when I did not obsess about BG levels. I seem to be ultra sensitive to insulin--daily totals for basal and bolus around 12-15 units. And I have had three devastating lows in 2013.....
I have been struggling with some similar things too.
Doc has long advised that I probably only need 18 units of basal a day but I like (decades of habit) to do closer to 20 units of basal a day and then eat snacks to keep from going low. I mean, 20 units a day was my basal was in college, and I like nice round numbers, too!
Now that I'm past middle age though I'm starting to put on a few pounds and that snacking doesn't make sense.
This past weekend I was particularly active with the kids and around the yard and was just doing 18 units of basal a day and still had lots and lots of lows. It would be like 50 then I would eat a big snack thinking "oh, this is fore sure gonna shoot high" but then an hour later I would be low again.
If you are having a lot of lows, then you need to be less aggressive. Those great A1Cs won't help if you're dead from going too low. The game needs to be to keep it from going too high and too low. Maybe a CGM would help, and raise the point at which you are going to make corrections.
I am curious, did your sensitivity to insulin increase after you started running so low?
I'm glad to read that your endo was sympathetic today and also viewed his role as more of a coach.
One person's obsession is another person's diligence. It's all perspective and balance. You can't just live life to manage blood glucose. There has to come a point where all your logging efforts and BG management actually make your life easier. This is your call. You should know if you're spending too much time and effort for the benefit received.
I would be concerned, however, about "horrible low BG levels." We play this game with live ammunition and you want to live to fight another day! My BG decisions usually err on the side of aggressive control but one must remain cognizant of the dangers.
I use two measurements to provide overall guidance to my BG management: average BG and standard deviation over a 14 day period. I shoot for my average minus 1 SD to be >/= 70 mg/dl. For example, if my 14-day average is 105 and the SD is 40, then 105-40 = 65, which is too low. I would then back off on insulin delivery, either I;C or basal rates, whichever seem appropriate.
Your high sensitivity to insulin makes your insulin dosing tricky. I wonder if diluting insulin in your case would be a workable tactic.
Do you factor in IOB when you do correction boluses? I would only do a correction to a 100 if I had zero IOB. Sometimes a 20 minute walk is perfect to knock down a 137 to a sub-100 reading. Just a thought.
Your tactics in moderating both the I:C and the basal rates sound very reasonable to me. Good luck. A course change now seems like a good idea.
Man I wish I had your sensitivity... you must be type 1. I'm 1:10 correction, 1:3 I:C. I'm hoping to double both of those with weight loss (carrying about 30lb excess) and getting a regular exercise regimen in place. But that's off-topic...
Your endo is worried about a heart attack. How low are your hypos? If you're not going below 50-60 it's probably paranoid (but note: I'm not a doctor). However, if you're heading further south than that on a semi-regular basis there is plenty of good reason for concern. There are been several studies in the last decade pointing hard to cardio issues with repeated severe hypos, enough so to have cast some doubt (or at least some caution) on the tight control recommendations from the DCCT.
I'm trying to achieve tight-control to the point of non-diabetic stats. That would be an A1c in the 5-6 range. However, I'm being very very careful about hypos, and focusing on the other side instead, trying to keep the highs tamed, and then keep my fasting BG in the 90s.
Gotta have a pump to do it, though. It simply isn't possible to compensate for Dawn Phenomena, big differences in glycemic index of meal composition, etc. I just started pumping, and after trying to do this for the last two months with MDI (and succeeding, but at an enormous psychological cost), there's no doubt in my mind that a pump is an essential tool for successful tight control.
When I was first diagnosed (in 1962) I took LOTS of insulin--150 units per day. After I delivered my son, my insulin requirements decreased dramatically and have ebbed lower with age--over 40 years. The pump also had a big impact on my need for insulin.
I am overweight (a lot...) and eat about 50 carbs per day, which means my basal dose is much higher than my bolus.
How bad were your lows? Were you unconscious,required helps etc? I had some lows that scared me, one was my fault I had stacked insulin, the other just came out of the blue so I think my pancreas decided to work for some reason. My endo said to back off bolus by 1 unit and basal by 1 unit I think. But when I did that I just woke up at 160 again or went too high.. now I am being more careful never to stack and just watching things more and so far so good.. the worst for me is if I wait to long to eat and then go low, or sleep too long and then go high usually.. timing is everything. I think when you get to 120 you can correct maybe? That is what I do. Maybe you can try going for a walk, water or some exercise instead of correcting? I have been doing that too. Or just give tiny, tiny corrections. You're lucky to have an endo who actually looks at all that, mine doesn't, not sure if anyone looks at my stuff, lol.
In your situation, I don't know what a "devastating low" is. If the paramedics are involved, I would look at that as a sign for change. My last one of those was in 2011 and my A1C has been lower since then so I have been pleased but am always sort of on my guard about it.
I use the CareLink reports, particularly the sensor overlay by meal report, to see where changes might be useful. If there's a bunch of "off" numbers that show a big wedge, I consider what's going on at that time, and maybe the time or two before. If I run low after lunch, I can see highs before dinner and lows after dinner as the chasing the dragon gets sort of carried away. If I then can nudge a lunch tick to get rid of that, sometimes it will "flow" down the line and clean up a whole bunch of stuff. It bothers me that your doc would chuck your reports, for some theatrical purpose or whatever. If that's the only broad-based statistical analysis you get, he should be able to help you come up with a solution out of it, not throw it out and make you write your own logs, more detailed but more time consuming.
The "pie charts" are also useful because it's a way to look around the low here and there and see "clusters" of lows or highs and find solutions in more data that may, in the end, help you make a decision like "I can just change this, I don't need to yutz all day...". I tried to go from .8U/ hour to .775 recently, not a huge change (and I kept some bumps in, but we can leave DP out of it..haha...) and it didn't work at all so I just went back to .8 for most of the day. It's easier for me and seems to work well.
Don't trust those instant Bayer A1c Now tests. I was at AADE week before last and had a Bayer A1c Now test at the Bayer booth and another lab quality test at another booth. The A1cNow was off different by 0.6%. Maybe your A1c was actually 5.8% and your doctor is asking you to raise your A1c. In my view, if you are going to make treatment decisions based on a test, you shouldn't use a known to be inaccurate.
My low times are overnight--12-5. My pump overnight basal has been lowered for .4 to .1.5 from 12 to 5. I have DP and have a much higher basal from 5 am-9am-noon: .45, .95, which incorporates the lowering basal by.5.
If I have a problem during the day I have probably over corrected which is why the correction was lowered to 1/80.
Honestly, I have become totally OCD about this and need to calm down--15 years--to an easier place.
My bolus wizard accurately calculates corrections with IOB used in the formula. I know that over 200, I usually need an extra kick, but I do become aggressive about it.
My lows usually have nothing to do with corrections. As GinaY said, it is just so complicated. It changes constantly--I can be OK with everything for days and then completely tank out with lows.
I am currently 161, 2 hours after my meal, and am itching to correct....Like I said, it is a very new mindset.
I have been as low at 10--still awake and communicating. The paramedics did not believe me until they tested. My last one I was below 40 for a while.
Paramedics have been involved over the last 10 years--maybe 6 times. Only twice was I non-communicative in any way. Never transported.
And yes, I have a diligent and loving husband who helps me when needed. I am very lucky about that.
Actually, AR, the spread sheet really made me pay attention to every hour, every day, and every reading. I think it really changed my attitude about BG levels when I reviewed the collected data.
I think Terry gives you very excellent considered advice (he usually does!). I agree that if you feel stressed a lot of the time than you are probably in need of a bit of letting go. I usually have a knee jerk reaction to doctors telling those of us with A1Cs in the 5's that we are too low, but in your case it sounds like it is right. I had the unique experience of having two 5.7's in a row and one was the result of quite stable numbers, the second one of lots of highs and lots of lows. I was proud of the first one, not so happy with the second.
Was there any pattern involved with the lows, or is there any pattern involved with your lows? Would having higher BG goals have avoided those emergency situations? If not, what would have avoided them?
They can be very random. Last one, I got up at 8:00 am at 115, small no carb breakfast and was out of it by 10:30. Nothing unusual--food, weather, etc. There can be an ocassional handle of over correction,,,
