What type of insulin should I ask for?


#46

She just said it wasn’t very realistic and I didn’t push because I don’t know if it would give me any extra information. She asked me to track my meals and I can go close to 200 at one hour without injestng 75g so I do know that something is up with my one hour readings.


#47

Given your stats I am a little taken aback at your doctor’s fast tracking straight to insulin. It’s not the first line of treatment even with your prior dx of GD. Yes, the GD does put you at higher risk of developing diabetes over time but it seems at this point you’d be a good candidate for diet, exercise, oral meds, and/or perhaps a GLP-1 agonist before traipsing down the path of basal/bolus insulin injections.

As others have said, seek a second opinion, ask for other alternatives to insulin therapy in the interim, keep monitoring your BGs, and get a quarterly A1C test done.

FWIW, I wouldn’t put too much stock in the 1 hour post meal reading as that can be dependent on so many things. The 2 hour post meal reading is more telling.


#48

She seems to truly believe my c peptide results warranted insulin treatment to protect my beta cells. She showed me my cpeptide and told me this meant I had LADA even without the antibodies. She just said if I was a prediabetic/a brand new T2 my c peptide would be elevated which does seem to be true when googling and looking at studies. I did get an appointment for another endocrinologist but that is in April (I called 4 different ones and others were not even accepting new patients). Her absolute certainty has me still leaning on talking to her/considering insulin therapy at the end of December but I do want to talk to a CDE before I start and probably request a CGM as well.

The first appointment when we went over my meals but before my c peptide results were in she wanted to do diet or exercise and maybe metformin but the appointment with c peptide she made it seem like insulin was the only way for me to protect my beta cell function which is why I took the pens then realized I didn’t know what to do with them. So she did start with diet/weight/metformin but once she saw my coeptide she said that wasn’t good for me in the long run.


#49

Agree. Everyone spikes at one hour.


#50

We understand what your doctor has told you… but frankly we find it pretty shocking. You just simply aren’t a proper candidate for insulin therapy based on what you’ve described, and the benefits aren’t even close to outweighing the risks by any reasonable stretch of the imagination. They don’t even start antibody positive people on insulin with numbers like yours. Again I’m just a random guy on the Internet, but I’d recommend not even considering it until you have a second opinion. I’m pretty sure that second opinion will be “they told you what!!!’n???” In the meanwhile I’d just exercise and eat healthy. If you start seeing elevated fasting numbers or a1c it’s time to seek treatment… and any primary care physician should be able to clarify this, it doesn’t need to be an endocrinologist


#51

Yep so I did make a second opinion appointment in April but I still will talk to my current endocrinologist since I want to better understanding her rationale.


#52

I sure do too… but a lowish/ normal c peptide level taken without elevated glucose levels doesn’t mean squat (unless you’re already using exogenous insulin)… and if she thinks it does, if it were my doc and they told me that I’d end the conversation right there and find a new one.

Ask her to explain the diagnostic criteria for type 1 / LADA and how you fit into it.


#53

Also please understand if you’re taking exogenous insulin before you see the next endo for a second opinion it will Change your eval…

Eg your c peptide will be artificially low because you’re taking man made insulin…

So that would heavily bias your eval

Also this is not something that requires an Endcrinologist level of expertise to evaluate they could evaluate you for diabetes had any walk-in minute clinic… certainly any primary care doc would be fine


#54

Okay thanks I will keep that in mind. I just have the samples in the fridge right now and haven’t taken any. Again I really appreciate your thoughts and it has me thinking more - I have been seeing this endocrinologist for 3 years now but only for my slight thyroid issue (I am sub clinical but my OB wanted me to get below 2.5).

My fasting for the last week have been in the 70s (I tested middle of night to make sure I wasn’t too low and they are in the 80s) so my next A1C might be even lower since I used to average 80/90s. My December appointment was really for my “final” GDM A1C.


#55

Your a1c isn’t high, and your blood sugars aren’t high, and your 1 hour post meal blood sugars aren’t alarming, and you’re antibody negativ, protocol is to measure at 2 hours and fasting to look for elevations. Over 200 at 2 hours is a big red flag. Over 126 fasting is a red flag.

If you start seeing numbers like that on a regular basis not just once in a while it starts getting to be time to worry and seek treatment

Your numbers are probably actually lower than an average non-diabetic… Except for possibly 1 hour postprandial but again that is really not a measure of that is used


#56

I agree with @Sam19’s comments. Here is a diabetes diagnostic criteria table from the American Diabetes Association 2018 Standards of Care.

26%20PM

FPG = fasting plasma glucose
PG = 2 hours after eating plasma glucose
A1c = Glycosylated Hemogloblin blood test
OGTT = Oral Glucose Tolerance Test
WHO = World Health Organization
NGSP = National Glycohemoglobin Standardization Program
DCCT = Diabetes Control and Complications Trial (A landmark diabetes study published in mid 1990s)


#57

You don’t need to test in the middle of the night… if you’re not taking insulin or even any oral diabetes meds you’re not at risk of significant hypoglycemia. Can I ask how long ago you had a baby? GD is a whole different animal and I don’t know a lot about it, but I know for GD they do watch women’s post prandial levels more-so… but now that presumably baby has arrived, it’s a different criteria and concerns… you could probably just check your morning blood sugar once in a while for now and as long as your a1c stays below about 5.5 and you aren’t seeing elevated fasting levels, there probably isn’t much to worry about, just keep eating healthy and exercising…


#58

I had my baby around 2 months ago and yes there is a ton of emphasis on checking at one hour with GDM (I had to be under 135 at one hour). I was told though to continue to check my fasting a few times a week and also my two hour meals a few times a week but to let them know if I ever got over 140 at two hour. So when I got it I told my GDM nutritionist who told me this was abnormal and to talk to my OB who also said it was abnormal and to talk to an endocrinologist who also said it was abnormal. Everyone was telling me I was likely pre-diabetic for T2 which made sense to me since I was told I had a 50/50 shot of getting T2 in the next 5 years. So that’s why I have not questioned that I am somewhere on this spectrum but the LADA was surprising since I didn’t even know T1 could affect adults until more recently.


#59

ah, this makes more sense now… I was assuming the baby had been significantly longer ago… I suspect you’re just seeing some lingering GD effects… but I think it was totally unreasonable for that endo to alarm you the way she did and totally inappropriate for her to just willy nilly hand you an insulin pen…

I’d keep an eye on it and see what’s going on between now and April when you have a second opinion. 140 after a meal at 1 hour is not alarming—- I don’t know enough about it’s effects on a developing baby to offer an opinion on gd parameters, but otherwise your numbers sound fine to me. I’d be alarmed by your c peptide level if it was low while your blood sugars were high—- like over 200+… but it’s not, and the reality that your bg comes back down to normal before two hours shows that your body IS capable of ramping up insulin production when it gets the signal to from elevated glucose.

I think you’re going to be fine. I’m literally almost angry at your doctor. I remember the day I received that diagnosis my life changed forever… it was like a ton of bricks falling on me. I don’t want you to feel that way, and based on our conversation I really don’t think there’s good reason for you to at this point


#60

My understanding is GDM Is caused by the placenta so I should have gone back to “normal” pretty soon after and most women do their follow up OGTT at 6 weeks (mine would have been at 12 weeks but my OB said he will defer to my endo because if I got an abnormal result he’d send me to her anyways). It was explained that high blood sugars can affect fetal development and also contribute to a larger baby which has a host of problems like shoulder dystocia. I do wonder if my OGTT during pregnancy is my “normal” since I failed my one hour at 240+ and came back under 140 at two hours and my other numbers are pretty similar to my pregnancy ones. Since it was so ingrained to keep my one hour under 135 seeing the 180/190 at one hour worried me since I was already being told I was abnormal and these weren’t crazy meals.

Oh I was absolutely devastated when she told me I had LADA and was fighting back tears in her office as she handed me the insulin pens. I had gone from contemplating metformin (which I wasn’t even sure I wanted yet) to a future of insulin dependence and that I needed insulin now or I was going to lose what was left of my beta cells. She said that it was exactly why I was told to track so I could be diagnosed early. It felt exactly like you said - a ton of bricks falling on top of me. I actually have a meeting with a therapist who specializes in long term illnesses in a few weeks since I needed to talk to someone about this. My feelings were compounded since we did IVF for my daughter (after trying for 5 years) and spent well over $40k to get some embryos and then to have to think if we even wanted to use them due to this (both risks of having a T1D pregnancy/potentially passing it down).

I know I didn’t have all the antibodies tested like ICA (but I think that’s been replaced now with IA-2/Insulin/GADA) and IA-2A so that sits in the back of my mind now and I’ve spent countless hours googling things.

I do very much appreciate your thoughts/feedback. I am bringing my husband to my next appointment so he can help ask things less emotionally than I would at this point.


#61

Fantastic idea. Having someone there even just for moral support is great whether they are the one asking questions or you are.

I personally would push for the OGTT. It will give you a definitive answer as to whether or not YOU need to worry right now. As for not being real life I once had a birthday cake that was literally 100g of carbohydrate per serving (most of which was sugar). I obviously didn’t get to actually eat a whole serving but if I were a gluco-normal I wouldn’t have ever even checked the nutrition facts.


#62

Another experiment you can do at home is to actually have a “crazy meal” like a stack of pancakes with syrup, hash browns, and a big glass of OJ and see what your BG does… if its a similar pattern to a less carby meal it probably tells you your body has a lot of ability to kick that process into gear and maybe there’s not much to worry about… if it spikes to 400 or something and doesn’t come down for 6 or 7 hours then maybe we’ve got a problem that warrants pursuing more aggressively


#63

I am honestly too nervous to try anything like that. I have for lunch, since breakfast is another beast, eaten a decent sized pancake with a pumpkin marmalade and cream cheese frosting (paired with eggs/1 chicken sausage) and walked around for about 15 minutes and got a 118 at one hour and 100 at two hour. But I’ve also gotten a 190 from a single lactation cookie but this was during breakfast (back to 80s at 2 hour) so who knows!

I would need to just wait for the referral to do an OGTT since my current endo really doesn’t believe in it also I don’t think it would change her treatment protocol since she’s already suggesting insulin and I think even “passing” one she would still have me take it.

I have been googling like crazy and it seems like Asian women who had GDM have some sort of beta cell dysfunction versus insulin resistance which is what precipitates T2 diabetes in the future (insulin will be needed for this too but I assume it’ll be more gradual than LADA but not sure). So I am now wondering if that’s me.


#64

I am not a doctor, but the “135” restriction sounds like it is related to your pregnancy, i.e. to protect your baby who is much more sensitive to high BGs. That 135 at 1 hour corresponds to a target A1C of 5.5 or less (A1C 5.5 corresponds to average BG of ~114), dependent on where your fasting BGs tend to end up. Currently, the ADA is worried that A1C targets under 7.0 are too aggressive, as you can always lower your A1C by going hypo too often. Of course, the right answer is probably in between, AND dependent on the particular diabetic.

I agree with everybody else suggesting a second opinion, and maybe a third, ike talking to an non-endo CDE.


#65

I just actually went back to check and the first person I told who worked with me during my pregnancy is a CDE (I had to dig around for her business card) and she is the one who told me it was abnormal to get a 140 at two hours and sent me down this path.

I just emailed her and asked her if it was possible to schedule a post partum check with her. Maybe she will be able to give me some insight on things.