HIGH BG with Insulin, Metformin and Invokana

Hi all! I've been a T1 for the past 14 years and always managed good control, my last A1c was 7.0. I'm on a t:slim pump and wear a Dexcom religiously. The past year, however, my blood sugars have been out of control. My blood would be high, I'd correct, my blood would go higher, I'd correct more, higher, more, higher more- then I'd just get out a syringe and give too much and naturally, my blood would come crashing down.

My body is essentially immune to all drugs and insulin is no exception. My carb to insulin ratios were 1:5 and my daily basal was about 30. Not wanting to continually increase my insulin intake, I discussed other options with my Endo.

I started with Symlin but that didn't quite work out for me- too intense with the timing and calculating how much I'd be eating and I didn't like an additional injection. I then tried Metformin, 500mg a day. That was wonderful but soon I saw my BG creeping up again. I increased to 1000mg a day, one in the morning and one in the evening. That worked for a little, but then my BG began to rise again. I then increased to 2000mg of Metformin a day. My Endo gave me samples of Invokana to take as well. I began taking 100mg of Invokana with the Metformin in the morning and, as usual, that worked for a little while but did not last. Keep in mind, throughout all of this I've unfortunately had to increase my basal rates to try to fight the highs.

I am currently taking 1000mg of Metformin and 300mg of Invokana in the morning and 1000mg of Metformin at night and my BGs are still out of control. For example, I woke up this morning with a BG of 175 (after waking up throughout the night to correct highs). Less than 1 hour later, with nothing to eat or drink in the meantime, my BG was 275^^ (rising rapidly).

I DON'T GET IT!!! Any insight would be greatly appreciated.

Wow, I'm so sorry. That sounds very frustrating. Do you work out at all? I've found that when I start adding more exercise in my routine I become more sensitive to my insulin, and I usually have to readjust my pump settings. I don't know how much this would really help you but it popped in my head and I thought I'd share that with you.

Good luck, and please keep us updated.

Two thoughts come immediately to mind: You seem to have developed a fair degree of Insulin Resistance and are taking meds for that. Have you gained significant weight? If so, working on slowly losing would help reduce the IR.

Second, I don't know how much you tweak your own numbers, vs rely on the endo, but I would go back to square one with basal testing, or adjusting basal rates for the different time zones based on problem times. Then I would reevaluate your I:C and ISF. Finally, I would promptly correct highs so they don't build to higher levels that are harder to get through the resistance.

I'm sorry to hear you are having such difficulty. It just seems like you are doing the right things but your body isn't reacting as expected. Have you been checked to see if you have active inflammation or infection?

ps. I have a wicked case of Darn Phenomenon, if I awake high and don't eat it just gets worse and worse.

pps. Disturbed sleep gives me insulin resistance and blood sugar problems

Thank you for the responses!

Jamie - I have a horse and ride 6x a week for about an hour at a time. I'm sure more exercise would be helpful but working 2 jobs and having a horse doesn't give me too much free time :(

Zoe- I have actually lost weight recently so weight gain/insulin resistance isn't a possible factor, unfortunately. I have discussed with my Endo doing basic basal testing to tweak those numbers and the I:C and ISF, however, we have decided to try to get my numbers under control with the Metformin and Invokana so that I don't have to increase my insulin intake (even though I am still continually increasing it.) When I take more insulin, I gain weight and it's just a downward spiral from there.

Brian- no such infections and I'm past my Dawn Phenom stage. I had a very extensive blood screening to see if anything was wrong... Nothing.

Strange that you've developed Insulin Resistance without gaining weight! I understand about wanting to keep insulin doses reasonable not to gain weight, I worry about that too. But basically it takes what it takes to control blood sugar. Someone can correct me if I'm wrong, but I think those other medications are for controlling IR which will hopefully lower your need for insulin somewhat, but for better or worse it still takes sufficient insulin to control blood sugar. Perhaps in time your resistance will be diminished by the oral drugs but for now you obviously need more insulin if your numbers are so high. Just my take on it.

Six times a week for an hour already sounds like a lot of exercise to me, I would imagine it would be difficult to add anymore. I really hope you find a solution to your problem soon I know it must be extremely frustrating at this point. Try to stay calm and don't get to worked up about it though eventually you and your doctor will find a solution, maybe stress is contributing?

One thing that pops out to me is that corrections via the pump don't do much but injections do.
What kind of a sets do you use, straight vs slant, auto vs manual? How many sites do you rotate through?

I ask this because I have found through personal experience that straight sets don't work as well for me as a shallow insertion slant set. When I use auto straight sets I need as much as 30-40% more basal than I do when I'm using a manual slant set. I've tried auto slant sets and am some where in the middle. I think it has to do with the length of the canula, and angle of insertion. Also the harder impact of auto sets can cause tissue injury/irritation that can decrease absorption.

One other thing I find is that the higher the volume of insulin pumped the more frequent I need to change sites. Rotating through a variety of sites so there is at least a week between insertions within an inch or two of each other also helps me to maintain good absorption and good numbers.

I have a bit of DP as well but I have used the patterns my dex shows me to set an increased basal rate at about 3 AM, which is around two hours before the rise starts to happen. Has been helping me keep it under control.

If you don't want to redo basal testing at this point have you thought about checking your carb ratio, correction and possibly more important your Duration of insulin activity.

With a dex it should be fairly easy to check. I have found that for me personally that novolog does not work for the 4-5 hours listed in the literature. For me it more like 3:45, since I changed my DIA and then worked on my correction factor, I'm have better results with corrections, and have not had issues with insulin stacking.

I also went back and revisited my carb counting skills, and readjustment my I:C ratios. Has made a big difference in my control.

One other maybe weird tidbit that may be related to my pump settings, may be quirk of the dosing algorithms, or may simply be my weirdness, but for me on the tslim when I used 100 as my target I would have trouble getting to 120 without big swings through the day. Now that I'm using 85 as my target I get numbers around 100 with much less variability.

It may not work for you, but something to consider.

Interesting info about infusions sets, 2hobbit. I am finding that fthe quick sets that I have been using for 10 years seemto be causing tissue injury. Although I rotate the sites, it takes 2-3weeks for the irritated hard site lumps to go away. Perhaps this is why I am appearing to need more insulin for better control, though I have lost a tad bit of weight( 4-5 lbs). I also have been taking more insulin because I went down South to see my the family twice this summer : And yes, the soul food with big accompanying bolusses was partaken of.
I have some sample Sillhoettes( sp?) that have an inserter.. Were they the ones you were referring to as a "manual slant set'"? Tell me the names of some more. Maybe I can get samples from MM.

to mmr5020,the OP,this has to be so frustrating, as you have had decent control. My DP has gotten worse as I age. I have to up my basals from around 4;00 a.m. and keep them higher until I return to a standard basal at 9;30. I need more insulin in the am. Always. Hope you can find a solution. Praying for you.

I'm using Comfort Shorts. It's pretty much the same as a Silhouette but is manual insertion. I use the 13 mm canula. The Silhouettes have the sillserter but you can choose not to use it and do a manual insertion. I have tried the Cleo 6mm and 9mm auto insert straight sets but need higher insulin and tend to get poked by the canula if I roll over and sleep on my site. Have tried the Inset-30s, if I follow the insertion instructions I get results better a bit better than using the Cleo. But if I change the angle to match my manual insertion get numbers that are very close to the Comfort Short.
I'm using a tslim so I can use any set that has a leur lock. All the sets I've used are soft catheters.

Like the idea of the Contact Detach but it's a straight set so not sure if a metal set would be different. However have been hearing about issues with seperation of the metal needle from the adhesive patch, with the needle being left behind when site is removed. Not wanting to have a bunch of needle tips left behind!

mmr5020: your morning numbers look like Dawn Phen riot with liver sugaring you up.

Did you check bg numbers from 3:00am thru 5:00 am. Typically some add extra basil insulin if on pump usually around 4:00am to tell liver to shut up.

I see you are on metformin. Is that standard met. f it is that 1000 mg dose will wear off in 1 to 3 hours. Typical up to dose times are about 2.5 hours.

I run a dose 500 to 750 mg at 10:00 pm and second dose at 12:00 am midnight. That helps tell liver to shut up from 12:30 am to 5:00 am.

I do not take single large dose as I find that useless while the two timed doses seems to keep liver shutup! The numbers you have; remind me of battling liver dawn phen in past!

Something to consider is low grade site infections- aka pump bumps. I use generic chlorhexadine scrub on BOTH new site and on the site I just pulled when I do a change. Then do generic neosporin on the old site twice a day for two to three days. With the combo I heal up quickly with out a bump. If I forget to do either, then I get a red mark/bump/scab/ect that takes a while to disappear.