Labile diabetes

Hello everyone,

I work with a middle aged male who, I think, has labile diabetes. His BG starts lowish in the morning at 6 am (anywhere from 70-100), and creeps up from there - before 6 am, he’s tested worrisomely low from time to time. At 12 pm it’s anywhere from 200 to over 600, same in the late afternoon and early evening. I wonder if he has gastroparesis. He is on mealtime insulin (regular) and long-acting too. Some think it is the regular that can send him very low in the early morning (stacking), while I wonder if it isn’t the background insulin. I just want to hear people’s thoughts, whoever would like to weigh in. I know the ideal solution is CGM and insulin pump, but due to $$ limitations, I am not sure how viable an option that is. Thank you.

Does this mean same as brittle diabetes?

What long-acting insulin is he using? When does he take it?

Does he pre-bolus before meals or take his insulin with meals?

Has he adjusted his insulin to carb ratio to ensure that he’s getting the right amount at meals? This ratio may vary throughout the day.

What is his blood sugar level before bed? Has he tried waking up every 2 hours to see if it’s falling throughout the night or if he goes to bed lowish and stays lowish?

I would not consider 80-100 lowish at all. Those are ideal blood sugar levels as long as he isn’t running low during the night. He would need to get up intermittently to test to verify that though.

I don’t find the label of brittle diabetes to be very helpful. It’s much more helpful to evaluate possible causes of the described problems and develop solutions. Assigning a depressing label doesn’t really help anyone…

2 Likes

I have been plagued by massive spontaneous shifts in the intrinsic requirements of my physiology for exogenous insulin all my life, which can make the disease chaotic to control. I have adopted the strategy of weighing all my food and eating exactly the same food every day at exactly the same time and maintaining the same activity every day in an effort to keep at least a few variables constant, but even that isn’t enough. The favorite comment of people watching how my glucose jumps around, with the same insulin dose at the same blood sugar level for the same meal producing vastly different results on Tuesday from what it does on Wednesday is, “That’s impossible!”

I have painful memories of the period when the medical profession used to say, “There are no brittle diabetics, just poorly controlled diabetics,” in their utter and absolute ignorance of the way diabetes operates outside of their narrow-minded theories.

1 Like

He takes insulin about 30 min before meals. His BG is probably highest before bed (sometimes upwards of 600, but lately more like high 300s). He occasionally tests during the early morning hours, and as I say, it is occasionally worrisomely low (40s). I would not say he wakes up every two hours but fortunately he can sense when it’s low. I didn’t use the term brittle diabetes on purpose because I have heard it’s offensive. Thanks for responding!

That is worrying!

It could be a basal problem, but it’s hard to tell without knowing what type of basal insulin he’s using. It could be a bunch of different things, but most likely (IMHO) it’s a combination of timing the bolus insulin right, giving enough bolus, and a basal problem. Most basal insulins aren’t 24 hour insulins. If he’s taking his basal insulin at night, he may have a gap during the day. If he’s taking Lantus, it can be really helpful to split the basal into two shots (one in the morning and one in the evening).

R can take quit a while to reach it’s peak, so he may benefit from taking it earlier. It’s difficult to tell without a little more information about his diet. Do you know how many carbs he eats a day?

It’s helpful that he’s recognizing patterns to his blood sugar levels. Patterns generally indicate that there are specific causes. It’s just a matter of identifying them and determining the best way to fix them.

Labile diabetes is generally used to refer to people whose blood sugar is so unstable that they are frequently hospitalized from hypo- or hyperglycemia. My understanding is that it’s quite rare (about 1% of Type 1 diabetes patients) and that it usually has an underlying cause.

How many shots does this person take each day, and what insulin are they using? If they are using regular, it makes me wonder if they are also using NPH, in which case it’s fairly normal to have blood sugar swing wildly. There are ways of getting tighter control with these insulins. Based on the experiences of people in the diabetes community and research on the subject, things like testing frequently, earing a lower-carb diet, learning to count carbohydrates accurately, timing insulin doses for food intake (pre-bolusing), self-adjusting insulin doses on a daily basis, and getting on a modern insulin regimen of four or more shots per day can all help with tighter control. So can getting a pump or CGM, but these are more expensive optiosn than the others I’ve listed.

It’s pretty normal for someone with Type 1 diabetes to have blood sugar that fluctuates constantly. That’s the challenge of the disease right there. It takes a lot of constant monitoring and work to try to reduce the fluctuations as much as possible, but that work pays off in quality of life and reduced risk of complications (both short- and long-term).

2 Likes

I have been called both a labile and a brittle diabetic. I started Tresiba in 2016 and it has made a huge difference in balancing my blood sugars. It lasts longer close to 48 hours and I use a coupon that helps with the cost, only 25 per month. Maybe a different insulin would be a place to try for better results.

1 Like

Hello again,
He is on Regular insulin at mealtimes and long acting once a day. I’m a bit hesitant to detail his complete regimen for worry over ID’ing it too specifically. Thanks for everyone who has responded so far. What I’m really wondering is if anyone has ever had a diagnosis of gastroparesis? And yes, I understand labile diabetes is a rare dx., nevertheless we feel he does have it. He has been hospitalized for out of control sugars, yes.

Lots here if you search on ‘gastroparesis’, but you probably know that.

If Regular is the main or only option for bolus, you might also consider some dietary modification to try to match its activity curve more closely so as to avoid those really high bg’s. Part of that might be to focus on breakfast, lunch and snacks so that late afternoon and evening are more about fine-tuning than dealing with effects of a main (dinner) meal.

Thanks!

Hmm…what did I do wrong? I feel like I did search on “gastroparesis” yesterday or 2 days ago and came up with nothing, for that reason I decided to post on it. But I just re-searched now and found an entry (depressing) from 2011. Looks - unpromising in terms of docs, I’d say.

But thanks! Will do some reading.

I can’t imagine specifying the long acting insulin would be providing any personal details.

Each long-acting insulin has it’s own quirks. It seems silly to not consider these before gastroparesis.

Best of luck though!

I input “gastroparesis” into the TuD search engine (magnifying glass icon) and it returned 50+ results.

You may have misspelled it. There is an abundance written about gastroparesis on TuD. I live with this diabetes complication.

I think all of us who have had D for over 10 or 15 years have some degree of digestive disorder (gastroparesis). I have heard it said that diabetes is a digestive disorder that affects the entire body.

As to the object of this discussion, if he takes Regular as his mealtime insulin, then he must be taking NPH for his longlasting basal. Both are old insulins that are very difficult to manage. When using them, one gets the best results when on a strict schedule and pretty much the same food every day. Otherwise, a rollercoaster of blood glucose numbers results, which is what he is experiencing. If cost is not an issue, I would suggest that he change to the newer insulins.

1 Like

I think you can use Regular insulin with Lantus or Levemir; I recently read in Dr. Bernstein’s book that you can do that.

Yes, you can take other insulins with Regular other than NPH. But with rollercoasters like his, I believe he takes NPH.

There are people who take the modern insulins plus use Regular to smooth out their Dawn Phenomenon or other problem areas.

But the OP for some puzzling reason won’t tell us what the other insulin is. Frankly, this is coming as second person information and speculation is pointless.

1 Like

Well said.