Need Advice on Helping a Fellow Type 2 Who is on Insulin

Type 2
1

I moderate a Diabetes group, on Facebook, to help out the owner who had a tragedy in her family, and now has no time to keep up with it. It’s a neat experience, as all kinds of people come together… and I can usually share some of the wisdom I have learned in here, from so many of you… even if it’s not from my own experience, or if I can point them to a link, or a discussion, etc.


Now, I was asked a question which I really don't have any first hand experience with, and don't know where I could point the person: A fellow Type 2 Member who has had Diabetes for about a year, and has recently gone on insulin and I think another oral med, is having some real troubles controlling her numbers and wrote me this message:

"If you don't mind I'd like to ask you for your opinion. Keeping in mind that managing our diabetes, heres my question.
I've been on levemir(long lasting insulin) for about 7 or 8 weeks. On June 1st. my doctor added novolog (fast acting insulin). You know, where you figure your carbs, figure your units from bs number and carbs. give yourself a shot before eating and all that. After these 2 weeks my after meal numbers are still too high (even though I have my meals real tight. I also exercise 50 minutes every single day. So my question is should I call my doctor after these 2 weeks to see if we can alter the calculations on my insulin? or should I wait the 5 weeks until till my next appointment? I really think I should call but wonder if its just to soon."

I know that getting one's treatment with insulin down, takes all kinds of tweaking, and time... but I don't know any ideas to give her, except that book "Think Like a Pancreas." Any thoughts, encouragement, and suggestions I can pass on are much appreciated... :)

Addendum....

I added to replies in this discussion that her blood sugar post meals was 281, and her A1C was 9%. Sorry if some of you missed it, and thought there was no other additional info.

Today, she also added this message about yesterday:

"This is some extra info from my friend:

"Here was yesterday: am(fasting) 149-5units novolog. breckfast 2hrs later bs-331. 9:00am 28units levemir. Lunch: before lunch bs-115, 4 units novolog, lunch, 1hr later, 50minutes exercise, after lunch bs-180. dinner: before dinner bs-264 (talked to my doctor this pm. changed novolog from 1unit per calculation to 1 1/2units per calculations. 16units novolog. after dinner bs-383."

Thanks for your help.
2

It would be helpful if this person’s A1C was available. It wouldn’t hurt to call the doctor for a formula to follow regarding tweaking either the long term or short term acting insulins. I am in similar circumstances. However; what works for one person won’t necessarily work the same way for another. I am loath to provide more advice without more information. There are books and sites with advice out there and there is also the problem of information overload. A person can assimilate only so much information in a given time frame.

3

I’m not sure what all more information you need, David, or how knowing a person’s A1C would help in tweaking her insulin formula… but I’ll go ahead and ask her. :slight_smile:

4

Her most recent postprandial was 281 mg/dL, and her most recent A1C was 9.

5

She should call her doctor & not wait five weeks.

If she’s had very high BG, her doctor may be lowering BG slowly for her body to adjust. But 281 is obviously way too high.

It must be difficult for a T2 on insulin to arrive at doses because of insulin resistance.

To avoid hypos, doctors usually start patients on a conservative insulin:carb ratio of 1:15 & then adjust up or down. This woman needs a different ratio. Many people on insulin have different ratios for different meals. People tend to be most carb sensitive/insulin resistant in the morning. (I eat very few carbs for breakfast because of this & dawn phenomenon). The ratio for breakfast may be lower than for other meals. Afternoon, when we’re more active, usually has a higher ratio. Dinner tends to also be a time when ratio is lower. Hormones, illness, stress, other meds can effect ratios.

To learn I:C ratio, start out with no insulin on board, other than basal. Eat something that with a known carb count. Start at something with 15 carbs, not a huge meal & not one with a lot of fat. Take a reading. Take meal insulin 15 minutes before eating. Test two hours after. If before & after readings are pretty close (without major highs or lows), then the dose is accurate. She should do this for several days at the same time with the same number of carbs & write it down to see patterns.

Timing of injecting 15 minutes before eating is a general guideline & needs experimentation to see what works best.

She should start by testing I:C ratio with one meal & adjusting insulin from there. Then, move on to the other meals & keep logs of everything. Insulin changes should be made by only 1-1.5 units & this dose kept the same for three days.

Lows or highs between meals indicates basal insulin dose needs tuning. Raise or lower by only 1-1.5 unit at a time & use this dose for three days to get a good idea of what’s happening. Making wild changes won’t give a handle on what to do.

The other thing she needs to learn is her ISF (insulin sensitivity factor) so she can correct highs safely. This means how much 1 unit of rapid acting insulin will lower high BG. Everyone is different & dose is based loosely on weight.

Another good book:

Using Insulin, Everything You Need for Success With Insulin By John Walsh

6

Here’s what I did as a type 1. To find my base(long lasting insulin) I did a few 12 hour fasts and checked my bs every hour, when my bs didn’t go up or down more than 20 mg/dl I had my base. For me that’s 30 units of Lantus in the morning. Gerri is right on for I:C ratio. mine is 1 unit for every 7.5 grams carbs… My last a1c was 5.7. Wishing them and you the best!!!

7

I am a Proud Type 2 Diabetic taking lots of pills and Levemir.

I want to talk you for monitoring this website on facebook! I am sure you are doing a good job.

If she feels she needs to contact the doctor then by golly do so. If she feels she is not getting the correct response then she needs to let her doctor know this so they can at least establish some form of pattern to a baseline. the doctor will probably take her serious if she takes this very seriously. If she is daring she can adjust it herself like I did and told my doctor afterwards. the worse thing that could happen is low numbers which can be cured with a cup of orange juice.

I am wondering if she is exercising/walking and watching her food intake. We can’t always expect medication to be the sole answer to everything.

I would have to agree with the other folks that have answered this question with the advise of getting some education. I have mentored several newbie diabetics and the first thing I tell them is to educate themselves on the meds, the disease, and nutrition. Don’t just depend on the doctor.

8

Thank you ----sorry i am up all night working the grave yard…words slip by sometimes.

9

Thanks all, for your great, and thorough responses, and book suggestion. :slight_smile: I have passed on all this info to her, and I hope it truly does help. I think the consensus so far seems to be that:

  1. Her I:C ration needs tweaking, and perhaps her basal.

  2. She should call the doctor.

  3. She should do more to learn her I:C ration in the way of experiments, with her meals and her routine (exercising), and perhaps getting some reading materials.

  4. She should perhaps consider lowering carbs.

The help is soooo much appreciated. :slight_smile: Diabetes is such a pain.

10

This person is type 2? So with all that Insulin resistance, she sounds like she needs help with the oral meds. When I was diagnosed Type 1 , Insulin brought my BGS down immediately. So if Insulin isn’t doing that, maybe her oral meds need to be changed or increased.

11

Not enough information. We’d need to know how high the BS is after eating, how much time after eating and the BS before eating. If the doctor knows what she’s doing, she’ll ask these questions - so call.

Terry

12

I also wanted to ask is she taking any metformin. Sometimes doctors will give insulin and metformin. Metformin will get the pancreas to work a little more. I think she needs to have her meds tweeked. Ask her to ask her doctor about an injectable called Byetta. This alone will drop your BS quickly…I have experienced some lows with drug.

Dump question…

My Endo hasn’t really sugested doing a whole lot with the I:C ratio or basal with me. Is this normal for a Type 2? I know Type 1’s are normally concerned with this.

13

Some docs insist that they be in charge of every dosage change.

But when I was diagnosed as a kid with T1 30 years ago, they made it clear that I was going to be the guy who tweaked my doses up and down in response to urine tests (and then later bg tests). They made sure that I knew what my expected test results were and how I should tweak things to correct for hypos and too-high numbers. It wasn’t quite the MDI or pump regimen expected today but the idea was that I was in charge of my numbers, not my doc.

Today, with good basal-bolus thinking and frequent bg testing, our ability to respond to bg numbers is vastly superior to 30 years ago. Yet they seem to be sending patients out with bg meters and insulin but without the knowledge to turn bg numbers into changes in doses. That doesn’t really seem like progress.

If the only complaint is “too high” I have a hard time seeing how I can help someone else tweak their doses. For some people here “too high” is 105, for others it might be 405. Dose tweaking principles are the same for each although the delta numbers will probably be very different.

14

I did reply to someone at the very top of this thread that her high was 281, after her meal. Her last A1C was 9%. You just had to dig a little more for the info. :slight_smile:

15

I have added more info about her fasting and post prandials at the top of the discussion.

16

1unit per calculation to 1 1/2units per calculations. 16units novolog. after dinner bs-383." What does “per calculation mean”? How does hse correct and does she count carbs What did she eat for dinner ? How many carbs ? Even with 16 units of Novolog,that 383 post prandial is very high. \ difficult in saying just where to start:We do not know her weight, what she ate, or when she took the post prandial reading 1 hours after, 3 hours after? Please have her to print out a lg book from online sources ( maybe someone on this forum has a ready link); and use it. If you are close to her, maybe you can help her with logging and understanding what to write down… I know this is a lot of work for someone who is already under a lot of stress, and maybe you can just help her out with correc tfood management , and a CDE can help her adjust one aspect of insulin dosing at a time.

God Bless,
Brunetta"

17

I don’t think I expect everyone to answer 100% what to do for her, to correct her highs… But others have given general pointers, and direction, as to how to tackle all these things, and learn how to make insulin calculations… She is just, again, a friend on another Diabetes group. She’s not near me, nor do I have access to every single little detail of her person. Just some generalities into how all those variables play into calculating for things would be good… I have already referred her to contacting her CDE, and getting books on the matter. Her doctor seems to not be doing much to help.

18

Ask her if she has a Diabetic Clinic in the area or near the area where she lives. Has she gone to any diabetic classes? It is a shame when doctors don’t want to help out too much…

19

Well, she has an Endo, and a CDE (that she’s been trying to get a hold of, all day, and not been able to…) I don’t know about a specific clinic. Where I live, there’s no specific clinic just for Diabetes (as in most smaller areas), and I know she has mentioned her area has limited staff, before… but’ll mention it anyway. Thanks.