Endo says that any A1C under 7 is ok

Type 1 and LADA
#1

And I am struggling. Seven days ago, she asked me to reduce my basal from 10.5 to 8.00. a reduction of .1 to each hourly basal. I admit, that I had some lows, but now, all I am is high. 213 this morning and averaging 160 all day. Bolus is 1/2 food and 1/2 correction--her goal is to hit 50/50, and she seems to think corrections really count as bolus doses. Carelink average BGs seem relatively ok, but the high readings scare me.

BIG FEAR: I am about to come up for new scrips for pump and cgm. If she dumps me as a patient, I am in real trouble. Last A1C was 5.5.

Appreciate some feedback. Thanks all.

Happy, Healthy New Year!!

#2

This seems to be a new obsession among some. Why is the 50/50 split so important? What is the advantage to you? In over 40 years of T1, that ratio never worked for me. I usually took about twice as much basal as bolus.

I can see cutting back on the insulin if you are going low often, but why the artificial goal? And also, where was the basal cut? At certain times of day or just across the board? Were your lows at certain times of day only? That could be a basal problem, or an I:C problem too. My I:C ratios varied in a way similar to my basals (I had 3).

Sorry for all the questions, but to my mind, you need to be the ultimate decision maker on your dosing although I get that you need to at least appear to cooperate in order to get your scripts.

Oh, one more question. Exactly what do you mean by "some" lows? An a1c of 5.5 is certainly attainable with a pump, but I personally wouldn't have been able to do it without a lot of lows. I settled for low 6s and more comfort.

#3

Why is she threatening to dump you? Has she threatened to not write you scripts? They make empty threats sometimes. I always call their bluff and I have never had anyone actually refuse me scripts. But, I have heard the threat many times. Its nerve wracking, I'll admit, but don't panic.

#4

Oh, you think she's gonna pull your pump for running too low an A1c, eh? Is that it?

#5

Spock - I notice that you use a CGM. If so, how much time on average, each day, do you spend below 70 mg/dl? I think 5% of time below 70 is an acceptable amount of hypoglycemia. In one study, the CGM trace of non-diabetics showed 5% of time each day below 70.

What portion of your time below 70 is actually below 60 mg/dl? If you spend 5% of your time below 70 and only 1% below 60 then I think the doctor is over-reacting to your management style.

Have you had any severe hypos that left you passed out or you needed the help of someone else? Are you hypo-unaware?

Safety is # 1, but there's no need to consistently err on the side of hyperglycemia. That might make your doctor sleep easier but I don't think it's good for your health.

I wouldn't worry too much about your big fear. There are other doctors that will respond to your needs. Doctors should never threaten patients. Inspiration works better.

Good luck. I'd be interested to your answers to some of the questions I've posed here.

#6

My basal/bolus proportions range from 58%-42% (basal-bolus) to 55%-45%. I sometimes have days at 50/50, but not typical. I don't think there's anything special about the exact basal/bolus split.

#7

I agree with you that there is nothing special about the 50/50 basal/bolus. It only makes sense when you eat the high carb ADA recommended diet. If you eat a diet higher and lower in carbs then you will deviate from 50/50. That is just the way it works out and will like vary daily if you are carb counting no matter what diet you choose.

There is a lot of growing thought that what really matters is time in range. And certainly one part of that is capturing the amount of time you spend low, but it also captures how much time you spend high. I don't know if you end would be willing to consider this approach but it might help.

In either case your endo is probably concerned about your lows and wants you to loosen your control. I think any of us who use insulin and have A1cs below 6% are likely to he "the talk" with our endo about this. It goes with the territory. And it is likely that your endo is asking you to loosen your control the only way she knows how, by getting you aligned with the 50/50 rule and establishing your ICR and ISF based on the standard rules (like the rule of 1800). It is likely all she knows.

In this case she will want you to set your targets before meal higher (perhaps 120 mg/dl) and after meal higher (like 160 mg/dl). All of which will result in your A1c rising to 7%. Presumably with your level of control you will eliminate hypos which is probably what she wants. But I doubt it is what you want.

In the end you will need to address your endo's concern about hypos or you will continue in conflict. I think you should come back to her with a real plan on this. Cora's suggestion is a good one, if you can diagnose the areas where you have been at greatest risk of hypos and address/loosen your control on just those areas you may be able to achieve a reasonable compromise.

#8

The 50/50 rule was just pulled from thin air many years ago when the first pumps came on the market. They needed a starting point,and this was also during the Regular insulin days. Buy the time new fast acting insulin's hit the market it was old news that TDD ratios where anything but 50/50 and new rules where developed for correction factors based on the basal/bolus ratio. When the 1500 rule was changed (because the new insulin's dropped BG faster and farther then regular insulin) they came up with a sliding scale of 1600-2200 based on your basal/bolus ratio.....numbers smaller than 1800 will work better when basal insulin doses make up less than 50% of the TDD, while a number higher than 1800 works better for those whose basal doses make up more than 50% of their TDD.

This is very old news but many practitioners are not going to take the time necessary to fine tune your pump...they use a one size fits the ones in the middle of the curve program. What ever keeps your BG within your specific target range most of the time is your correct settings.

#9

The endo feels that an A1C of 5.5 is just too low, so she asked me to reduce the basal for every hour of the day by .1 I have 7 different basals each day.

She has only alluded to me as a non-compliant patient. My last endo got dumped by me because he told me if I came to him with another 5.1 A1C, I would no longer be his patient. I may just be extrapolating him to her.

Over the last 4 weeks, I have spent 16% of my time below 78. However, some of the 16% was 55 and below--not much--4%. Same with high numbers--16% over 140, but some of those were above 250. I went to see her because I was bouncing on a BG trampoline. Besides this new overnight high pattern, the lows have not been consistently at specific time periods.

After making the changes, I am running really high overnight, so I am correcting at 3 AM for readings ranging from 206 to 360, after stadium food at the Winter Classic, being out in the cold weather, etc.

The 50/50 is really hard for me. I average only about 50 carbs per day. So, I usually average a 60/40, often even 75/25. I have been trying to eat more, so I can bolus higher doses which will bring me closer to the 50/50, but can't handle that much food. The only day I made 50/50 was after the 360 overnight. It took hours and multiple corrections to bring it down, which raised my bolus.

I agree with all of you. I am forming a new plan. THANKS!

#10

One more question: Do you correct between meals? Endo also told me to only correct at meals to avoid stacking, and never before or during bedtime. (I wanted to yell "I am on a pump and the wizard considers BOB when calculating the bolus amount!")

But when I get over 200, I would correct, no matter what time of day. After hitting 360 at 3AM, I would certainly correct.

Thoughts on this pearl of endo wisdom?

#11

Too many variables in the system. It may be unmanageable. Who came up with these 7 basal rates? Her? Or, you? Its crazy to call someone with 7 basal rates 'non-compliant.' If anything, you are hyper-compliant and that's whats ruining you. I'm suspicious about how hard you are working to control this system. That might indicate its all out of wack. The best I could ever do, on a pump, was targeting the mid to high 6's for A1c. My quality of life was poor in the five range, poor from passing out all the time. My doc is a real 'how low can you go?' Doctor. She advocates bringing the A1c as low as you feasibly can.

Here's the thing. I get the feeling that you are correcting a lot, like more than once or twice per day, which makes me concerned that you might have a lot of variability in blood sugar and that you might be stacking those correction dosages. DO NOT STACK CORRECTION BOLUS. Only deliver one correction bolus, every four hours. I have never understood that rule, because why should correction have a half life of 2 hours, when meal bolus has a 1/2 life of 1 hr? Never made any sense to me, but its darn true. I drop continually for 4 hours after correction, and more rapidly in the last 2 hours of the four, so stacking on a pump never did anything good for me. If your baseline is out of wack, that will make everything self destruct. Start by finding a conservative dose for which you do not wake up higher than your comfortable with in the mornings. Increase only a small amount, per night, and get a weeks worth of data that proves to her (but, more importantly, to you), what the best overnight dosage is. Dont rely on the BOB, its worthless. Barely anyone uses that. You sound like me. You sound a little hyper-sensitive about the highs. I'm suspicious that you are having a lot of serious lows in order to achieve an A1c = 5, specifically, because you haven't mentioned a pattern of lows. She might be right about needing to increase the average overall, but what she's REALLY trying to say, I think, is that she suspects too many serious lows. Do you 'feel' low ever? If so, what bg do you definitely start to 'feel low' at?

Maybe you should wipe the slate clean and tell her that 7 different basals is impossible to control and that your going back to one. Could you do that? Do you think you could you establish one trustworthy basal that controls you over night numbers? Do you follow her dosing instructions 100% or do you jump around and deviate and set your own dosages day-to-day? I was never much of a pumper and your pretty advanced, so I'm curious about you. Some kinda rock star with 7 basals. Thats serious stuff. My hat is off to you.

#12

The 7 basals were begun with Georgetown Hospital Endo team and me. We all agreed that a flat basal wouldn't work for me because of the fluctuations that occur in my BG regularly during a 24 hour period. I have heavy duty DP, and I used to be lower at night than I like. Also the 4-5 pm time frame has always been problematic for lows, so I have different basals at 12, 2:30, 4:30. 9:00, 3:30, 8 and 10. I have been using this method for years, and most of the time it works great. But then some shift occurs in the universe, like a weather change, high altitude, etc., and it all goes down the drain.

I have taken her up on only correcting at meals, except over 200 overnight. If I mix an overnight high with DP, my day is all highs, which I fret over and am miserable. I was just curious about others ideas.

Can feel a low at about 50. Thanks for the kudos. Been dealing with T1 over 50 years and a pump for over 12.

#13

Yes, I correct between meals. I do factor in the insulin on board (IOB) number. Sometimes I fully respect it and sometimes I deliver a bit more correction insulin than the IOB computation calls for.

I don't usually ever correct during the first two hours after a meal. During that time it's hard to tell how the metabolism is reacting to the mixture of the food and insulin.

When's the last time you did a basal rate test? Perhaps the fasting that that involves will be an added bonus to pulling down your highs. BG control all starts with the accurate basals and eliminating hypos.

You mention that you recently spent 4% of your time on average each day below 55. That's 56 minutes. How many episodes make up that 56 minutes? Is it one or two or is it spread across four?

I'm sorry your doctor is adding to your stress instead of reducing it. It should not be an adversarial relationship.

#14

I suspect these endos would fire me immediately. I stack correction boluses all the time. If I see a 120, even with IOB, a lot of times I redline my basal to 200% to cover it. This is sort of a weird time of year to be making big changes as I, and perhaps many other folks, are flying all over the place with holidays of one sort or another, eating different things. The midweek shutdown isn't helping much. With junior getting herself to school and, on vacation, sleeping in a lot, nobody gets up much before noon or one except me and I'm sleeping in a lot of the time. I've seen quite a few higher BG but am also eating crap, taking huge corrections and eating more crap to get it back up. I presume everything will fall into place. Even if you don't have craziness, it's winter in the northern hemisphere, short days, colder temperatures and sort of endemic societal stress probably don't help BG.

That being said. I wonder about these docs. Part of me would like to get some feedback from the doc occasionally but if it were this sort of absurdity, I'd consider firing them. The current doc, who I told I fired the last doc b/c they screwed up my A1C at an appointment, screwed up my A1C too. A local buddy (hi Wiffy!) has a doc that I'd scoped out previously but I might move on but it's such a hassle. Although the new doc is actually closer to my office, another plus.

During the holiday mayhem season, I'm overriding the pump's cutting correction boluses. If it's up, I figure I missed some carbs so I check out and pump 1/2 the "correction" amount on top of whatever IOB is floating around.

One thing you've mentioned Spock is needing help with hypos, either from Mr. Spock (ha ha, I had to say that!) or maybe even EMTs? Mrs AcidRock reported the EMTS at my last big hypo (2011 I think?) to have been quite handsome but I still prefer not to see them. To me, if that's still happening for you, the doc may be onto something but I've been lucky enough to handle my own stuff most of the time these days. If you're records show that whatever sort of help is needed, one way to fix it might be to nudge higher? I don't like running higher that much as I feel like I have more crazy, nosediving lows when I do that than when I'm running flat. I hope you can get the doc trained sooner rather than later!!

#15

Sounds like you have an Endo that needs to learn how modern insulin pumps work. Or how a reasonable individual with an IQ slightly higher than a potato can work out the math!

#16

Mine says the same thing! I try for 6 and now mine is 7.5 and they said good work. NO.

#17

Yep

#18

My endo has never once talked about trying to balance bolus and basal insulin. Some days I am 50-50%, other days not. It usually depends on how many carbs I eat. Most of the time I eat moderately low carb, but if I have a lot of carbs, of course it is going to affect my ratios. Frankly my body doesn’t know the difference between basal and bolus…

The only time she has ever suggested that my A1c might be too low was when I hit 5.0, but then didn’t say a thing when the next one was 5.2. As long as most of my lows aren’t below 60, she is OK with that. My Dexcom CGM has been extremely instrumental about warning me of lows before they hit the cellar. Also because of mostly eating low carb, I don’t get as many crashing lows because I just don’t have that much insulin on board. I have a lot of BG readings that hit the 70’s. Some people would argue that the 70’s are normal, but I usually have one or two glucose tabs depending on IOB or a couple of apple slices.

I often wonder “how good” our BG control needs to be. Dr. Bernstein would say that we should aim for completely normal with A1c’s in the 4’s. Most GP’s and many endo’s would say 6.5 is a great target. IMO there are many healthy numbers between those extremes. My personal aim is to eliminate extreme highs and lows and spend as much time as possible in my target range. I do a lot of mini-corrections during the day and also use a lot of temporary basals. I think that it is very easy to start obsessing over every number and that can be unhealthy from a quality of life issue. At this point in my life, I don’t think that a half point change in my A1c will make much difference.

I feel lucky to believe that my endo is on the same page as I am. So many of us who live successfully with Type 1 are self-managers. I think that is one reason that we are successful. I would have a difficult time dealing with an endo who wanted to micromanage my care. At the same time if I am making decisions that are unhealthy or even dangerous, I want my endo to be willing to stand up to me.

Good luck getting things figured out, Spock.

#19

I avoid endos and am mad at myself for seeking help this time. Unfortunately medicine and the reality of T1 are different. I was a little desperate when I saw her...

Mr. Spock, as many of you know from my posts, is fantastic. Last EMT visit was 3 years ago---and they are cute! I also know a lot of them through community work, so..... STAY AWAY!

And LOTS OF SHOTS, I agree. New plan is needed and after holiday will probably help.

#20

OMG, your the most amazing diabetic I have ever met. 50 years? 7 basals? Just amazing. Blows my mind.