Getting frequent lows after meals!

Getting frequent lows after meals. (37,42,47,50 etc). I am taking humalogmix50 insulin 20 units before breakfast and 12 before dinner. What should I do. It seems like an emergency. I am getting shaked. Doctor isnt replying. Whether I am type 1,2 or 1.5 it is not sure. But I have been put on insulin since I was diagnosed(May 2013).Should I decrease the units?

You should absolutely decrease the units if you are getting those kind of lows. Do you use an Insulin:Carb ratio? I really don't know anything about the mixes; they are an old-fashioned way of dosing insulin. You are much better off with a bolus (fast-acting) insulin for your meals (dosed according to an insulin to carb ratio). and a basal (long-acting) insulin once or twice a day for your background insulin. Your doctor doesn't seem to be helping you very much. Do they have endocrinologists where you live? That is the specialist in diabetes. They can also determine your type.

For now, I would just lower your doses until you stop getting those lows. Then worry about getting a more appropriate treatment. When you are ready, you might get the book Using Insulin by John Walsh.

With reduced insulin the lows should stop; that is not scary, I know!

Thanks. I did not use Insulin-Carb ratio. My doc, he is an endo, prescribed me these doses. That might be the problem. Amount of carbs I am taking may not match insulin amount I take. In humalogmix50, there is 50% long acting and 50% rapid acting insulin.
My doc has not been able to tell me clearly what type I am. Everytime I ask he says its merging between 1 and 2 and its very common. Although one other diabetologist once said I am definitely type one. On diagnosis I also had subclinical hypothyroidism(based on TSH>normal range,now it is wihin range),also I had Thyroid Peroxidase Antibodies(>600, not tested after that). So autoimmunity is there, that is why he said type 1. But I am not sure 100%. I mean, I am about to decrease insulin units which means pancrea is still making some insulin. I would look for this book and will also try to know about insulin-carb ratio which may by the reason behind the lows. Thanks again.

You sound like you will do a good job on figuring things out mostly on your own the way many of us do. Yes, you are right, that set doses don't take into account what you eat. Your insulin needs vary with the amount of carbs you eat which is the reason for an insulin to carb ratio. That means that, for example if you ratio is 1:15 you take one unit of insulin for every 15 carbs you eat. Many of us have different ratios for different meals. Mine, for example are 1:6, 1:10 and 1:16. The way you find them out is basically trial and error. 1:15 is a safe place to start and then you change it one point either way depending on results of a couple days.

The mixes are hard to dose, though because you can't alter your bolus depending on food without also altering your long-acting. Hopefully your pharmacy stocks one of the fast acting brands (Humalog, Novolog and Apidra) and one of the long-acting brands (Lantus or Levemir).

You are right, having another autoimmune disorder makes you more likely Type 1, as does being thin and being sensitive to insulin.

The standard of care with insulin is to use intensive insulin therapy (sometimes called MDI) which uses separate injections of basal and bolus insulin. Using a mix may be more convenient, but it really does not do well and can cause the kinds of problems you are having. If you blood sugar levels are reasonable before meals and upon waking that suggests that your basal insulin levels are pretty close, but with a 50/50 mixture you may just be getting too much bolus insulin at meals. I would really recommend that you push to use separate injections of basal and bolus. But in the meantime, if you are getting too much bolus at meals you could switch to a Humalog 75/25 mixture with a reduced dose which would allow you to keep a similar basal insulin level but drop the amount of bolus you are getting at breakfast and dinner.

My upon waking levels are around 150, so basal insulin levels should be higher. Poast-meals are low,so bolus has to decrease. Humalog 75/25 may be the solution where basal portion in 75%.
Actually I used to have humalogmix75/25, 4 months back. But I started getting low blood sugar levels at midnight daily, so doc changed it to humlogmix50,which worked till now. I wonder, what will be the right combination to avoid lows at any time.

I will start with 1:15, before that I also have to know about the carb counting. I have not yet found a way to easily count the carbs in meals. There are many books for this in market but dont know which one is really the one. Is there any book or web source available for this.

I had a very similar situation. Injecting enough 'mix' to cover meals was giving me an excess of the intermediate component, leading to frequent, severe lows.

What worked better for a while was switching to two injections (AM and bedtime) of Humulin N and three or more of Humalog. This worked great, almost completely resolving my lows. worked until it didn't (sort of my life story).

So now I've elected to start using a pump due to the flexibility & customization benefits.

As Type 1 diabetics occasional lows are unavoidable. But on MDI - basal and bolus it's easier to be in target more often. You are right, you need more basal and less bolus, but the mixes are a rough way to do this.

There are lots of different carb counting sources. I have one printed from an old book I use but also like I cook a lot at home so I measure and then count all my ingredients. Vegetables I count all as 1 cup cooked=10 and 1C raw = 5. I put carb counts in my recipe books and then I have them for the next time I make that recipe. It's harder when you eat out.

The use of the pre-mixed insulins tries to make life simple but can create more problems than it solves. I think you'd be better off with separate basal and bolus insulins. You need to understand the onset, peak, and duration times of each insulin. You also need to understand insulin to carb ratios and how sensitive you are to each insulin.

Lows can be very dangerous. This is nothing to fool with and you should sort this out with your doctor ASAP. Maybe the premixes are more suitable to insulin resistant T2Ds.

In the meantime, decrease your doses!

It seems like I may have to go for the separate injections for basal and bolus. Other option is to use humalog 75/25 and decrease the dose so that basal portion is same as before, as mentioned by brian.
I tried to reduce the doses of humalog 50 to half and its not working, i m still getting lows, 10 mins after meal.

This site, has a lot of information, will be helpful. My meal-plan is also subjected to schedule and food availability of my mess. For type 1, it is must to learn carb counting, specially in mess scenario.

I may have to follow the same path.

I too think, both insulins should be separately taken, it will increase inconvenience but will give more flexibility in diabetes management. Decreasing doses is not working, I will have to either change insulin mix or go to separate injections. In any case, will consult doc.
I just know that rapid acting works for 5 hrs max and long acting for about 20 hrs. They get their peaks much before that. Insulin sensitivity is another important parameter, I dont know much about it, but will try to look into it.

Is money a huge issue? Generally, people are using separate injections for basal and bolus and we are using modern insulins with much better response rates. Honestly, most people with type 1 (or 1.5) who can afford it are on a pump. Yes, you need to take less if going low, but more importantly you need to take better.

I think the larger issue is getting a better doctor (medical care). Ideally you'd see a endocrinologist and get a c-peptide test as well as antibody testing to determine what type you are, and then you could use diabetes education. A good endo should have a diabetes educator to help you. Additionally, there are 4-5 books people often recommend here.

My c-peptide has decreased from 4 to 0.653 ng/ml(0.48-5.05) in one year. My endocrinologist says, as long as treatment is going good, you should not worry about the type. I told him to do the lab tests any if needed for proper diagnosis, but he keeps getting tensed whenever I ask about the type. So far he has not said about using pump to me. Money has never been an issue. As long as I have other options, I just try to hold on it.
Where I live, My endo. doesnt have educators and he himself doesnt give more than 10 mins on each visit. Although I have met some diabetes educators, they were not very helpful. But the books can help, if you can recommend. Thanks.

The two main books people recommend are "Using Insulin" by John Walsh and "Think like a pancreas" by Gary Scheiner. I always recommend the first one because that is the one I have read and always refer back to. I also have "Pumping Insulin" by John Walsh. If you are able to get a pump at some point that is really the way to go. With a pump you can set your basal rates differently over the day and night to better match your actual needs. You mentioned eating at an unpredictable times and the basal coverage will make it so you won't go low if you have to eat later than usual. It also allows you to more precisely set your basal dose. Like this morning I had 8 carbs for breakfast and my dose based on my I:C or 1:6 was 1.35. When I was on shots, 1.0 would be too little and 2.0 too much. Pumps use only fast acting insulin.

But for now if you get on MDI and start carb counting and using an I:c you will find your problems greatly reduced!

Okay, looking at your profile you are not in the US. A lot of us in the US end up doing quite a lot of doctor shopping. Even here, it can be very tough to get a good doctor/endocrinologist. With those C-peptide numbers I'd assume you are T1. Antibody testing would help confirm, but you aren't producing much insulin and it is crashing. You should also get thyroid testing.

So as a T1 you really want to use separate basal (long acting) and bolus (short acting) insulins. The body (liver) is always producing a baseline amount of glucose and basal insulin injections manage that. Then you take another insulin to counter the glucose/sugar in your meals. Ideally, these would be modern insulins like Lantus or Levemir and Apidra, but a lot of cash strapped people use 2 of the older insulins (acceptable but not ideal). Also, most T1s prefer to use a pump with a fast acting insulin. A pump is putting out a small amount of fast acting insulin all the time (basal), and then when you eat you tell it to put in X units of bolus.

So books...
'Think like a Pancreas' by Scheiner
'Using Insulin' and 'Pumping Insulin' by Walsh
'Your Diabetes Science Experiment.'

A controversial book is "Dr Bernstein's diabetes solution" and I'm pretty partial to it....just don't take everything he says (or his approach as gospel). There is a lot of good information in his book, and while he take an extreme approach to low carb, I think there is a lot of merit (at least for people with weight to lose) in keeping carb intake under 100g per day. Also, I think lowering carbs makes it simpler for people who are starting to learn the ropes of diabetes management.

finally, read through many of the old threads here and keep asking questions.

Zoe and Scott are both giving you great tips. The largest single influence on how well you do with diabetes depends on how much you know and how well you execute your plan.

The doctor's influence on your health will be relatively small in comparison. This is a moment-to-moment disease and doctor's don't have time for that demand. That's your responsibility. Do it well and you will be rewarded with better health. The curiosity you express here is a great sign.

I see pump has lot of advantages and seems the best way of treatment for T1. I will ask doc if I can start using pump or atleast separate injections for basal and bolus. Only question about pump I have, will I have to wear it all the time or just during meals. Wouldn't it affect the daily life more like if I go outside for cycling, any other sport, in a meeting or in a lab or in a train.
I have soft copy of 'Think like a Pancrea'. Author himself is T1D. Its a great book. I will look for other books as well. Earlier I was afraid of using pump, but eventually one day it was going to be the way. Carb counting and insulin based on I:C ratio can be started now.

Absolutely I am getting valuable advices from them. They have lot of experience in this regard. And I have also visited other related threads and I was thrilled to see so much information in this community. For instance, I came to know about importance of C-peptide number after looking at threads related to c-peptide.