Hey all, I’m new to this forum, and have some questions.
Here’s a little background: I’m 33, super active, fit and eat well (low carb - 30-75g/day trying to stick to bernsteins advice but having a really hard time), have been diagnosed as a pre-diabetic for the last 1.5 years and finally ended up getting frustrated with my PCPs and doing research on my own and learned about LADA. I forced my doc to order antibodies and am positive for GAD65 and ZnT8. My latest a1c was 5.9 a few months ago. I have found plenty of posts and articles on the importance of starting insulin early on in the disease course, but haven’t been able to find any concrete numbers on when it would be ideal to start insulin therapy. Any advice would be greatly appreciated as I have my endocrine appointment on Monday and don’t have a lot of faith in the doc.
A simple approach would be that you can start insulin as a therapy to normalize blood sugars as soon as you can identify opportunities for treatment. If you fasting blood sugars are elevated you can use a basal insulin, if you have blood sugar surges after meals you can use a rapid insulin. But it is also true that if your blood sugars are only slightly abnormal oral medications may also enable you to attain good control. And while there is work that suggests starting insulin before your body totally loses control of your blood sugar is best, there isn’t really anything that says insulin is better than other treatments when you can attain really good control with either insulin or oral medications.
The best place to start is to know your 24hr BG profile. Your endo should be able to provide a LibrePro sensor for 2 weeks. The numbers will be blinded so until you go back you won’t know whats going on which is not a bad place to start. Just keep a food log for the analysis.
I suspect your meal time spikes are what will need to be addressed as you have probably lost a robust first phase release but you will know this after the profile is done. The new monomer insulin afrezza is the only insulin which will mimic the pancreas to provide this first phase release to blunt the spike and signal the liver. Its also easy to use and reduces hypos since its so fast.
You can read Gary Scheiner’s review here Review: Afrezza Rapid Acting Insulin | Integrated Diabetes Services
The con Gary lists, afrezza requiring follow-up puffs, since you still have phase 2 release is not really a con for you.
The biggest con for afrezza maybe insurance coverage. The problem with other RAAs is not providing first phase release and they hang around too long. The problem with T2 meds is they will work your pancreas overtime which is exactly the last thing you want.
If your endo can’t do the LibrePro you can buy your own Libre sensors on amazon or ebay and download the reader app.
See what happens as you may/will still want your own Libre so you can see real time results yourself.
I found your response intriguing. I am a Type 1, diagnosed 4 years ago. I am trying to keep my BG’s under tight control with Low Carb and MDI with Novolog and Levemir. I do not have insurance, so a CGM and a pump are out of the question. In your opinion would the LIbrePro be a good idea to give me more information than I have testing 10 times a day? If so, are these available in the US on Ebay?
It would be pointless for me to try to discuss any of this with my doctor, he thinks all adults have Type 2, and that testing more than 3 times a day, each time before meals is all that should be done. I have tried to explain that hospital diagnosed me Type 1, but he changed diagnosis to Type 2, stating there is no way to distinguish between types. I gave up trying to talk to him, just go there to get insulin prescriptions.
Sigh. My endo doesn’t much care for my consults with Dr. Google, and sometimes goes overboard evaluating pretty benign issues, but has done all the right stuff as far as recommending and supporting things I adamantly resisted–like my now beloved CGM and insulin pump! I’ve found patience and honesty work both ways. If I don’t agree, I can ask for a second opinion. I am fortunate, I have terrific insurance, and I have had zero/bad coverage in the past. I empathize for those with limited choices for caregivers but encourage requests for a second opinion–the doc might be annoyed, but you might be a winner!
Agree. We are the ones with skin in the game, and we are the ones who must live with the consequences of choices made. If a doc’s ego is uncomfortable with the idea of a second opinion, that’s his problem. Don’t let it be yours.
That’s great advice for the 24 hour bg profile. I’ll look into getting it from my doc or from Amazon. I’ve done postprandial bg checks before and know more or less how I respond. If there’s minimal carbs I stay in the 120-130 range like a normal person but as soon as I add in any grains I shoot up to 180. My morning fasting bg is generally above 100 so I’m curious to see when it starts going up over night.
I already have the name of a different doc who’s not on my insurance plan but who is very well recommended so I’ll get a second opinion if this endo doc isn’t helpful.
Hi Mary: You are in the Type 1 diabetes phase called pre-symptomatic Type 1. According to Dr. Bernstein, early insulin therapy and a low carb diet is the way to preserve remnant beta cells. I write about early insulin therapy in adult-onset Type 1 in this blog Adult Onset Type 1 Diabetes: Early Insulin Therapy in Adult-Onset Type 1 Diabetes
JoAnn - The LibrePro and Libre are different. I am assuming you are in the U.S. The Pro is FDA approved and has great Medicare and Medicaid coverage but it is for “doctor” use only. The profile is taken over 2 weeks in 15 minute samples but it is blinded from the PWD. Doing a first profile with the doctor its a great option. Here is a write-up on the differences. diabetesviews.com/2016/11/difference-between-freestyle-libre-and-libre-pro/
The Libre is EU approved and should be approved “any day” by the FDA. I think Abbott expected it to be approved by ADA 2017 but that did not happen. The sampling on this is 1 minute and Abbott is trying to get it approved for dosing. Again like the Pro the sensors are for 14 days. Today, you can buy the sensors on amazon and ebay or other internet sites. You can also download the official Abbott LibreView" app if your location is set to UK. It is free and there are other free apps available too.
For self management you want the Libre. There is no way I was doing 10 pokes a day so I got the reader a few years ago from England before the apps were available for download. You can shop around for the best price on sensors but they run around $70 or $35 a week which is not much different than 70 test strips. They are available on amazon, ebay and a few other places.
As far as your doctor and T1 vs T2 what matters is was the beta cell attack due to an autoimmune issue or something else and is your pancreas still producing some insulin. If it is “something else” there is a chance you can stabilize your beta cell loss. I have file cabinet filled with study after study and some over 40 years old which show how important early insulin intervention is.
When you say “tight range” that means a lot of different things to different people. If you say the ideal range would be 80-120, I would consider a tight range 80-140 getting back under 100 in 3 hrs after eating. Anything over 140 for a period of time - about 2hrs causes microvascular damage. Some think 80-180+ is a tight range.
As I suggested above, the first step is understanding your 24hr BG profile which is different than managing time in range. The Libre will collect and store at 15 minute samples which is ideal to understand your profile. Get a 2 week profile. Once you understand your profile then you can put a plan together to maintain time in range and this is were the 1 minute scanning with the Libre will also work. You will need to log medication times and food and see how they are affecting the profile numbers.
Mary - that’s great you already have a pretty good feel for how you respond. The 24hr profile will fill in the gaps and give you insight into how long its taking to recover from 180+ and whats going on when you are sleeping. It could very well be you are under 100 until an hour or so before you wake.
If in fact you are losing that robust first phase release a puff of afrezza with the higher carb foods will blunt the spike for you. If you are LADA there is pretty good evidence that the immune attacks happen when the beta cells are secreting. If these studies are correct you will want to minimize the load on your pancreas. All T2 meds place load on the pancreas.
