Insulin and blood sugars increasing?

Hi everyone,

I was seeking some advice. I was diagnosed type 2 DM back in November 2013. I had gestational Diabetes in 2012 and I think it never event away. The antibody tests were done for type 1 and I am negative for that. So after some diet and exercise change I went on metformin. When I was diagnosed, I was 115 lbs and 5’2". I was able to keep my post meal blood sugars within range but my fastings were almost always over 100.

My doctor wanted me to try victoza but I didn’t end up using it since I’m still breast feeding and the side effects were awful. So last week, we decided that a small amount of lantus is good to bring my fasting bs down. He said to start at 3 units at bedtime for 3 days, increasing by 1 unit every three days until my fastings are below 90. I’m on day 5 of lantus so I used 4 units last night and my fastings are higher that they ever were on metformin. Yesterday morning my bs was 116!

Does it take time for your body to adjust or is this a sign that insulin will not work for me?

Thanks for any responses.

Insulin works for everyone. It takes time! If you are truly Type 2, 5 units of Lantus is a very low dose. Keep working on it, though you might in time find that a split dose works better.

Have you read Think Like a Pancreas? Great book - it is written so everyone can understand how it. Is a great reference and will help you know what to ask. As well as provide plenty of answers.
You can get if for ereader from Amazon if you want it quickly.

Your doctor's instructions to increase by one unit every three days is a cautious ramp. There's nothing wrong with that. It may take you some time to discover a dose that works for you. Insulin is very potent stuff. It will work. I've found that insulin does not always work in a linear fashion. Sometimes doubling the dose can produce four times the effect.

A blood sugar of 116 is not doing you any harm, so patiently following your doctor's instructions is probably your best course. Don't be surprised if all of a sudden, with just a small increase, you get the desired effect on your BGs. That's much better than driving your BGs into the hypo range and suffering with a rebound hyper.

While you're doing this, it will help to remain as consistent as possible with any evening snacking. If it were me I'd try to eliminate any eating after dinner just so the basal insulin (Lantus) is only metabolizing your liver's glucose (glycogen) output.

At the time you were diagnosed your weight was in the normal range. I see that you have been tested for antibodies but I would not dismiss a T1 diagnosis on those results alone because not all T1s will test positive in the beginning.

That being said not all T2's are overweight. I think your doctor has chosen a good approach to treatment and I'm surprised that he has introduced insulin so soon. Like the others have said the best way is to start with a low dose and increase it gradually. I am wondering if you are continuing with the metformin because most T2's will remain on it even after insulin is introduced because it helps with insulin resistance and helps to control liver releases of glucose.

Gail, do you have any data to know if you have insulin resistance or not? Most T2's do.

If so, your ICR is probably between 1:4 - 1:8, and your CF is probably in the 1:10 - 1:20 range.

I'm 1:4 in my carb ratio, and 1:10 in my correction factor. I'm on a pump now, but back when I started insulin last June, I was doing MDI using lantus for a basal (which I really don't need), and humalog for bolusing. For comparison, I was taking 40U of lantus at bedtime, and it didn't really seem to make any difference whether I took it or not. With IR, that relatively low-level of background insulin (40/24 = 1.67U/hr) didn't seem to dent the blood sugars.

The only thing that does, for me, is fast-acting insulin, calculated and bolused based on the correction I need. THAT is very reliable.

Also, I seem to have a wicked Dawn Phenomena. Because I have a pump, I have a basal rate program that goes from 0.05U/hr to 4U/hr starting at 2:30AM, then drops back to 0.05U/hr at 9AM. This wiped out DP, and I wake up with BG in the 90s. Often, depending on how my BG is tracking, I'll stop the high rate basal before 9.

So, this may be an issue with DP, and there's little control you can have over it without fast-acting insulin. Trying to compensate for DP with Lantus is like trying to hit one nail among many on a board with surfboard. The resolution's too poor.

That's not to say the Lantus won't help at all, but you also have to watch some other things that affect DP:

  • Do not eat late -- eat around normal dinner time.
  • Eat light for dinner, low-carb, low-cal overall.
  • Get in some light exercise after dinner when possible -- nothing more than just a nice evening walk or something.
  • Take the Lantus even if your BG is borderline before bed (70-80). Have a very modest, well quantified snack (like a graham cracker) to get a little something flowing in slowly from your stomach while you sleep.
  • If BG over 100 at bed, do not have a snack!

As a T2 -- and one not as far along as me in beta cell exhaustion -- your pancreas can probably handle holding your BG level, so what you really need is a way to get it back down there as fast as possible, and with repeatable certainty. There are three words that fit that bill: Humalog, Novolog, Apidra.

You've already stepped over that line of taking injections -- the psychological hard part's over. Talk to your doc about starting a regimen of correction bolusing when neccessary.

Well, I was educated on this by no less than David (dns) that one can have T2 and not be insulin resistant. Stimulated me to do some quick research on the net, and indeed this happens! It's relatively rare, but not unheard of.

Metformin can be a very very effective drug for T2's still making lots of insulin on their own. It works on multiple fronts... increasing insulin sensitivity, decreasing gluconeogenesis.

Did your doc have you discontinue the metformin when you started Lantus, or supplement it with Lantus?

Your lantus dose you mentioned is still very small and your bg's are not that much above 100 so a slow tweaking of dose will eventually get you to the perfect place.

Insulin is very potent stuff.
Oh, if only!

With my IR, I feel like an insulin tanker pulls up to my house weekly to deliver the 100,000 gallons I use.

Seriously, though, TDD of 100U. That's low-carbing it at 75-125 carbs/day.

When I had my labs done, the insulin level was on the low side of normal. I think my fasting was over 100 though. The PA I’m seeing thinks I have type 2 based mainly on the absence of antibodies and because I am Asian. It is very frustrating. I’ve lost 9 lbs, exercise 4 times a week vigorously. And my blood sugars are still elevated.

I’m going to try to be patient. He did say that since the metformin didn’t do anything to decrease my fastings (he was very surprised about this) that I could discontinue it. But I think I’m going to add it back in.

I can see how people can be depressed about this disease. On the one hand, taking insulin could help me. But on the other, I could be making myself insulin resistant and need more and more. I feel like a walking pin cushion and subsist on a starvation diet while trying to maintain a vigorous exercise schedule, work, and raise two small kids. Just feeling sorry for myself right now.

that is CRAZY!

Injecting insulin does not make you insulin resistant, type 2 diabetes makes you insulin resistance. Taking insulin will help to preserve your own natural insulin production. It does so by lightening the load on your pancreas. Insulin production in Type 2 decreases over time as your pancreas produces large amounts of insulin to overcome insulin resistance. This over use causes your beta cells to wear out.

You are right that diabetes can cause depression. Its a tough lifelong disease in any of its types. Myself I tend to focus on what I can do to fight this disease instead of dwelling on what it has done to me. It helps me to keep my mind in a good place.

That's insulin resistance!

LOL. Dave, there is another possibility I am exploring. It's a very low probability long shot, but nevertheless a finite possibility: MODY. The profile for that is, exogenous insulin needed (check), little or no IR (check), dx before age 50 (check), and a few other things.

Sticking point is that the tests are VERY expensive, like $6K or thereabouts. There is a prominent research program that will test you for free IF you fit the profile they are looking for, which I am checking into.

A long shot, as I said. But I do know one other diabetic whose profile matches mine almost exactly and who was told he probably is MODY. So it's another avenue to run down. Balance of probability is that this is still T2, but it's worth looking into, and I will.

Interesting, David! Keep us informed! I know nothing about MODY; would it impact your treatment or just be something to make sense of it all for you. (I can understand that, I was so happy to know I was actually Type 1 because it made sense of things - until I stopped and said, "And exactly why am I happy to be a Type 1 Diabetic?"

LOL Zoe. Probably because many of the alternatives would have been worse?

I suspect it would not change what I need to do, although many MODY patients can manage well with sulfonylureas. I did that for years with diminishing results, which is another reason I class this as low probability. But I intend to run it to earth and find out. I'll certainly report what I find.

Dave - That’s a tough one to overcome. My experience with IR was one of my most frustrating episodes with diabetes. Do you get the experience where with ever increasing doses, it doesn’t seem to work at all and then it hits you like a ton of bricks?

At my worst my TDD was about 80. It’s now in the 40-50 range. I’m coming off of a bad cold where my TDD went up and I’m slowly backing off to return it to “normal.”

Actually, John Walsh my PA thinks I do have MODY. He’s trying to figure out which genes to test me for

I actually meant when I discovered that I'd been misdiagnosed as a Type 2.

Do you get the experience where with ever increasing doses, it doesn't seem to work at all and then it hits you like a ton of bricks?

I absolutely despise this phenomena. Only happens when I allow my BG to get too high. Anything over 200 is prone to that problem -- bolus the right amount to correct, little happens for 2, sometimes up to 3 hours, then it crashes, often to a hypo.

As long as I stay tight, insulin works according to formula, and my BG is quite predictable.

Had one of those the other day. Got dangerous (actually, was feeling kinda down) and had two scoops of strawberry Häagen-Dazs right before bed. Bolused properly and everything.

CGM said BG was fine overnight, then a wicked DP kicked in after I woke up. Soared to 220, corrected, was still above 200 2 hours later, bolused another properly calculated correction, then crashed driving to work.

As a result, I have to play this game of watching when those super-highs start dropping, then pop some skittles (usually 12g, approximately 30mg/dl worth for me), then monitor, rinse and repeat as necessary. This way, I always head off trouble at the low end, but sometimes spend the entire day tuning and tweaking insulin and carbs to get back down under 100, where I like to be.