What type of insulin should I ask for?

#1

I am going to meet my endo in December and want to make sure I make the most of the appointment since it is tough to get in appointments. My endo believes I have LADA due to a low c peptide (0.6) and high postprandial even though I was negative for GAD, IA-2, Insulin and ZnT8 antibodies. She said that not everyone has antibodies and so will treat me like a LADA patient. I did retake my c peptide test because I was curious since I didn’t have antibodies and the first time I fasted for 15/16 hours and also exercised that night - so with an 8 hour fast I got a 1.3 (range is 0.8 to 3.85) but my endo said that to her a 0.6 and 1.3 were the same and considered low so it was still LADA. My glucose at the time of the cpeptide were both mid 90s.

I read that LADA patients can prolong beta cell function with insulin so would like to start if it can be done safely. My endo gave me some fast acting insulin (novolog) samples to use with meals but didn’t explain much to me so I’m a bit hesitant to use it since I don’t even know what I:C ratio I should expect. She just told me if I go over 60 carb meals then use a unit or two and I don’t feel comfortable with that right now since even though I can spike to 180/190 I do come back down to 80-100 at two hours. I am okay keeping up my low carb meals (I aim for 15-20g a meal except breakfast I try to do less than 10g). I did have a 130 at one hour when I splurged and had a higher (not high but higher than I’m used to) carb dinner - (I walked on my treadmill for 15 minutes after the meal so I assume without that it would have been in the 150/160s if I didn’t exercise) - is that when I should use the fast acting or is that still risking going too low? I got back to 94 at two hour with that meal.

My fasting numbers were trending in the mid 80’s to mid 90’s but for the last week or so are in the low to mid 70’s so I am not sure if I should ask for basal or that will just send me too low.

So in summary - what sort of insulin should I ask for? Just keep the fast acting meal ones? At what level is fast acting appropriate? Should I use it when I assume I’ll get to 150 at one hour? How do I safely test if one or two units is appropriate for me when I do eat higher carbs? Should I ask for basal too to protect beta cells or the risk of lows too great right now? I have so many questions and my endo is a bit hard to get information from so I want to make sure I have a well thought out plan before I see her. I am going to discuss all of this with her as well but want to have a better idea of things to think about/ask.

#3

I personally would not be considering insulin use with the patterns and history you’ve described. I would seek a second opinion. I’m not a doctor but in my estimation neither one of those c-peptide levels is meaningfully low when taken with normal fasting levels. I also wouldn’t find spiking to 180 at one hour and back down to <100 at two hours particularly concerning or worth medicating. But again, I’m not a doctor… but if mine told me those things in that case I’d be seeking a second opinion…

#4
  1. I’d be asking for a CGM–even if a temporary loaner. (Since she’s coding you as type 1/Lada, you should be able to get one.) You will have much more info about your condition with CGM.
  2. If/when you do go on humalog, you can ask your endo for a “Jr. Pen” that doses 1/2 unit increments. My endo gave this to me, as I’m LADA & insulin sensitive.

Good luck!

#5

Let’s say I agree with asking for a second opinion.
Your numbers and testing look every similar to mine when I was diagnosed 10 years ago with an unconfirmed LADA or possible. Type 2. A1c of 12.0 Fasting test was 325
But I was 63 (T2?) but thin, a runner and extrememely good, but not lowbcarb diet.

My doctor gave me a choice, first choice to start insulin now, or second choice take intensive training in low carb eating and exercise plus one pill of metformin.
She gave me two months and if my numbers did not come down, we would start insulin.

Well I consume 30 to 50 carbs aday now age 73. Run three times a week etc.
Still thin. My last A1c was 5.7. I have been 6 or under since year two. No meds

If I eat bread, pasts or rice etc. I can easily spike to 180, but if I dont , then I don’t spike. I return to normal after about 2 hours on low carb . Typical fasting 95-105
So I am still producing insulin.

Obviously I am not LADA. My thought pattern was if I went straight to insulin I would never know if I had another option.
Not a doctor, but what every kind diabetic I am I can be well controlled with out meds.

Not medical advice just someone else’s experience. The odd part is that many of my friends at my age were diagnosed with LADA, so it does not scare me.

#6

Except she’s describing normal fasting levels, hasn’t mentioned an elevated a1c, and is back to optimal levels less than 2 hours after eating… a modestly elevated bg temporarily 1 hour after eating doesn’t make someone a diabetic… that can be perfectly normal, so unless there’s a lot more to her story than she’s shared I’m really not understanding where her doc is coming from, particularly with zero antibodies—- although they’re not definitive, basically it sounds like she’s described zero symptoms of diabetes except temporary elevated post prandial levels, and is antibody negative/— so I don’t understand where her doc is coming from.

I was diagnosed with LADA with fasting levels at 400, a1c at 12 and gad positive at age 29. My c peptide was 0.6 with a fasting level of 400. Low c peptide at a normal blood sugar level isn’t meaningful.

#7

With blood glucose returning to normal range levels at two hours and no insulin I would personally be happy (Overjoyed actually) but I understand your desire to preserve beta cells and extend your honeymoon period. With no antibodies present you are still too early in the process to determine what type of diabetes you may have.

My best advice is to listen to your doctor. None of us have the knowledge to advise you on this. If you feel that insulin will be best for you let the trained professional decide which kind.

#8

My A1C is 4.9 right now (taken a few weeks ago).

My endo said “normal” folks don’t go to 180/190 with a single shrimp tempura roll or a half of a sugary muffin (this was in the morning though and I’ve learned I have issues with eating carb heavy things in the morning and have stopped since the same thing in the morning can give me a 150 but a 110 at lunch). I did go to <100 with both meals at two hours. I also have had one reading at 142 for two hours when I had a ton of carbs (small sub sandwich, chips, ice cream and a cookie) and both her and my GD dietician told me a “normal person” would never be over 140 at two hours (my one hour for this was 170 so reading more I assume the fat in the meal made it not spike so high but then also delayed me coming back down) and I was back to the 80s by three hours. So based on all this she said I was pre-diabetic/headed towards type 2 until she ran my c-peptide and said my levels are too low to indicate type 2. She said that she has LADA patients that don’t have antibodies and I may have antibodies that aren’t discovered yet which is why I’m negative for the common ones/may not have high enough levels to show up on the labs.

She said she has LADA patients that do diet only but they were diagnosed much older than me (in their 60’s) and so don’t need to protect their beta cells as much as I do since I’m 34. So she advised starting insulin - she wanted to give me samples with the child’s pen with 1/2 units but didn’t have any so just gave me the Novolog samples. I didn’t have much discussion about this and it was a lot to take in at the appointment so that’s why I was curious how to safely take insulin.

My BMI if it matters is 24 (I am trying to lose some weight) and I did have GDM that was easily controlled with diet. I honestly thought I was headed towards T2 since I know GDM has a strong correlation with T2 but she disagreed based on c peptide levels and said that pregnancy can trigger LADA so she suspects that’s what happened to me. If it matters I do have slightly higher TSH (around 3.5) normally and was put on 50 mcg synthroid about 2 years ago to bring it down to about 0.8 a months ago - no thyroid antibodies.

#9

Yep I will listen to my endo (so not asking for medical advice) it’s more of figuring out what to ask her/talk to her about since the appointments are like 5 minutes and I want to make the most of it and be better able to ask and discuss what to do. When she told me to take insulin it went really quick - she handed me the pen and said it is super easy take a unit or two with carb heavy meals and that’s was all the information I received. This was pretty overwhelming as a few moments before she said I have LADA/Type 1 rather than the previously suspected type 2. So next appointment I want to be in a better position to ask her questions since I felt incredibly lost/confused at my last appointment.

#10

Ah okay I didn’t realize they had loaners - I hope she one so I can better see how things go since I can go through test strips like crazy (luckily I have a ton from my GDM time). I do test at 45/60/90/120 minute if I’m curious how things go and my spikes are typically at that 60 minute mark unless protein heavy then it can be at the 120 minute mark. She gave me Novolog because that’s all she had as samples - she said she wanted to find the child one with the 1/2 units but didn’t have any in the office.

#11

Ask to talk to a CDE (Certified Diabetes Educator) they are the professionals that have the time to help you. 5 minutes is not enough time. If you are to inject insulin you MUST be properly trained.

#12

Thanks for your reply - I am apprehensive starting insulin so will listen to my endo and also trying to make sure I take it safely. I didn’t think of having glucose tabs available - are these https://www.amazon.com/Glucose-Tablets-Assorted-Fruit-Count/dp/B000SDRKMU the ones? I did have some capri sun juice packs in my fridge from July 4th holiday when we had nieces/nephews over so was planning to use that.

#13

I would still get a second opinion. The c peptide is not meaningful imo when taken with normal bg level. The reason that’s the case is because even if it was a moderately low value, it was still ~enough~ to be perfectly regulating your bg levels. Testing with a home blood glucose meter is not accurate enough to be determining if a spike to 180 or 140 at 2 hours etc is actually cause for alarm.

My best advice is to get a second opinion. I am not a doctor, but what you’re describing sounds nothing like my own experience with lada, and why they’d jump to that assumption with no evidence of antibody activity makes no sense to me (it’s true they’re not always present, but in the lack of other evidence it strikes me as a bizarre assumption to make…

#14

Ashley, I think the first questions I would ask your endo is why she thinks you have diabetes. With numbers like you’re describing, it doesn’t actually sound like you have diabetes.

When I was diagnosed with LADA I had a fasting glucose level of 356 and an A1C of 13.4. You’re a long way from those numbers. I’m sure we’re not getting the whole story here, but I would agree that maybe you need a second opinion on your diagnosis.

#15

David, Sam, With her prior history of Gestational Diabetes I believe her doctor is warranted to consider diabetes. Her numbers are not alarming but they’re not exactly normal either.

#16

Yes, I agree, but a history of GD is not associated with LADA… which makes it seem even more strange that this is what they’d be telling her with these factors at play and with this presentation

#17

GD can be related to T1, A co-worker and good friend of mine experience GD. after delivery all returned to normal for her, months later she found herself in the hospital in DKA.

#18

It can happen, coincidentally, but they’re not believed to share the same etiology.

Lacking elevated fasting levels, lacking elevated a1c, lacking symptoms, lacking antibodies, I strongly suggest a second opinion before considering insulin.

#19

What Gary mentioned - I was told to track my numbers after birth and when I got the 142 at two hours my GDM nutritionist told me that was not normal under any circumstance and I needed to go to my OBGYN who told me to go to an endo (I’ve been seeing her for my thyroid). So based on this I was instructed to track my meals and report back - if it wasn’t for the 142 I would never have looked at my numbers.

There does seem to be a set of women who get T1 after GDM (either a trigger or GDM revealing it). I did think I was on my way to T2 though since that was drilled into my head that I was at a much higher risk for it. At first my endo was just going to put me on metformin but she said insulin now.

#21

Not a bad suggestion. Insulin is no walk in the park, if you need it or are certainly going to need it I say go for insulin, starting it before you really know is questionable.

#22

A turkey mini sub, chips, a good portion of ice cream and a cookie. So definitely a carb heavy meal. However the GDM nutritionist and my endo both agreed if nothing was wrong with me then I would never go over 140 at two hours. This is when my endo started to question and more tests were run.