When do you know it’s time to start insulin?

Just last month my diagnosis of LADA was confirmed with a GADA65 of >250 IIU/ml and C-peptide of 0.8 ng/ml. This was after 3 years after a Type 2 diagnosis. I have been on a keto diet for the last 3 years, was able to bring HbA1c down from 9.2 to 5.4 within a few months of Type 2 diagnosis, but despite being strict with diet and exercise, my HbA1c has drifted up to 6.1 over the past year. Hence the testing for LADA. My GP doesn’t do any treatment until HbA1c hits 6.5, so she thought I was doing great. I requested referral to an endocrinologist, but he said he would not know how to prescribe insulin for someone like me since my diabetes is so well controlled.
So, I’m wondering if I should push for an insulin prescription at my follow up visit in a few months. Is there anyone who has been in a similar situation and found that starting insulin made a big difference in how you feel? I have been feeling low energy lately and wondering if it is because I am at the end of the “honeymoon period”. Any advice?

As far as I know, I’m type 2, but I couldn’t get my A1c under 6, so I requested insulin and had no trouble getting it. If you’re LADA, you need it even more. Keep pushing. The insulin didn’t make a difference in how I felt, but it did lower A1c to 5s.

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I would push for it. I was misdiagnosed too for years, medications were making me sick and not working very well. I was first put on long acting insulin and then they added fast acting.

But I thrived on insulin, I felt much better.

There are some theories out there too that if you take insulin it will help protect what you are making for longer. And maybe at first an endo gives you guidelines to follow but you are better off learning how to carb count and dose appropriately. The sooner you learn to do that the more control you will have with your levels and what you eat.
Just always keep a quick hypo treatment (glucose tablets, gummy bears etc) with you at all times, it happens to the best of us that we will need it.

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If your doctor believes no insulin until 6.5, then I suggest to find endo. Or stop doing keto for awhile to raise BGs and get current md to prescribe.

In my opinion, having insulin and knowing how to use it gives you most flexibility in food, exercise, lifestyle choices, and more flexibility to influence your A1C.

However, if you like keto, insulin can also work for that, but with lower dosing.

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+10

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Thanks all for your replies! Still figuring out how this forum works. I guess my original post wasn’t clear. I did go to see an endocrinologist and he didn’t think I would need insulin for possibly 5 years. I chose that endo because he was young and at a well known teaching hospital. I expected him to be on board with the latest I had read (and what several of you said) that starting insulin early would benefit preservation of beta cells. He seemed more concerned that I would have problems with lows, especially with exercise. The thought of having to deal with lows and the complexity it will add to my life is discouraging me. Life has been easy just avoiding carbs and not taking any medications for diabetes.

A CGM would be a good tool to help decide. It’s possible that you are having some high BG’s even with an A1c in the mid 6 range. High BG after meals could be causing that fatigue you mentioned.

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Insulin might make you feel better.
However, insulin brings risks for new insulin users.
This might not be an ideal time to start insulin because of external events.
Do you live alone? Are you working?
If you live alone and are working full time, I would be comfortable with you going as high as 7 and waiting until adequate resources are available to smooth your transition to insulin. Increased risk of hospitalization during this time makes me uncomfortable. Since you can hold off, I would recommend that.

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@mohe0001:

Thank your for making that point to @GoldFinch. I think that everyone, not only us diabetics, needs to do everything possible to avoid trips to the ER … both for our own safety and to try to minimize extra load on a medical system already in crisis.

Very solid recommendation!

John

Yes, now is definitely not the time to start insulin. I’m just thinking ahead to my next (July) appointment. I have used a Freestyle Libre on 4 occasions and have graphs from those weeks and also from my finger stick results for over 3 years using Glooko. I am an engineer, so I collect lots of data😉. I go over 140 fairly infrequently. Mornings after a late (low carb) breakfast are my worst times and when almost all of my >140 readings occur. Interestingly, my readings after noon have not really changed much in the last 3 years, but my fasting numbers have gone from less than 100 to sometimes as high as 130. Most of the rise in the morning comes before I eat. Maybe if I figure out how to use this forum better, I can post some graphs.

@GoldFinch,
Wanted to share my experience, which of course is by nature limited, but may be helpful to you:
I too am Lada, diagnosed about 11 years ago. Endo convinced me to start insulin early to preserve beta cells. That was his theory based on then research. I low carb. Like you, I first tried to control bg’s with only low carb and exercise but could not get control. I went on insulin at Dr’s urging. My current daily insulin requirements (10 years later) are quite low. (Perhaps combo of continued low carb, starting insulin early and low body weight?? I’m not sure.) I did want to let you know that I felt MUCH better once I started insulin, and became sick (with colds, etc) far less frequently. You could also ask about adding metformin. I take that as well and it seems to help with fasting sugars. Finally, Dr. Bernstein’s “law of small numbers”, Diabetes Solution, made sense to me and allowed me to start insulin with less fear of lows–should you decide at some point to begin insulin.
Hope this helps
Karin

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Also, love my Dexcom G6 for arresting potential lows and highs. Good luck!

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@GoldFinch,

You’re having difficulty maintaining control and meeting your treatment goals, so that should be enough. CGM mitigates hypos. You’ll need to get him off of how often/how low obsession. You can try using the International Consensus on time in range to shift the conversation off HbA1C to time in range.

If he still won’t budge, I would be looking for a new endocrinologist and go in with firm statement that your treatment goal will be time in range. Expect a learning curve with CGM and pump, so more hypos starting out. Recommend Dexcom CGM, Medtronics sensors aren’t adequate for the kind of control you desire.

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For getting your body to process blood sugar, there is no substitute for insulin. It’s like a miracle drug! Sounds like you are doing everything right, and your engineering sense is well suited to managing it. When I was early LADA, I was happy for the pen that could do half units, that was when I had some endogenous supply. You’ll get this, and your cgm data is a benefit for that.

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I had that problem because traditionally endo wants to give you a combination of long acting basal insulin and fast acting insulin for after meals. Once I got on to a CGM I proved to my endo that it was the long acting basal insulin that generates ALL my lows at night so gave up the long acting insulin and never looked back. As a numbers driven engineer, I can manage my diabetes with 5.4% A1C, 100% time in range on a tight range. Before CGM my A1C was running in the mid to high 6 all the time. Good control will also do wonders to your cholesterol. I am also small with 19 BMI, 71 year old male, on low carb diet and exercise 5-6 days a week so many similarities. Insulin + CGM will give you food and exercise options beyond your wildest dreams. A CGM to an engineer is like crack to a drug addict.

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Lots of great feedback from you all! Just went through a frustrating time thinking my fasting readings were high, but with a new batch of strips, it is back in line. I wish there was less variability in these meters. On another topic, I have noticed that strenuous exercise raises my blood sugar, but results in lower fasting numbers the next morning. Moderate exercise lowers blood sugar at the time, but doesn’t impact next days fasting number. I wondered which was better for me. Then I listened to a podcast of the doctor who coaches the Novo Nordisk cycling team (all type 1s) and he said that they have to do cool down cycling after racing to burn off the extra glucose they generate from the vigorous racing. I am not an athlete, and I am 63 yo, my vigorous exercise is a slow run/jog or a spin on the elliptical, but now I do a shorter run and follow it with walking to cool down and burn off the excess glucose. It is amazing how much I used to be able to take for granted when my body could modulate itself. Now I have to think about it and compensate. It’s a good thing I am retired so I can focus on this stuff!

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You don’t really give much indication what range of bg’s you are reaching if you eat normally (not super low carb).

But A1C is not the only criteria for beginning treatment and you’ve been trying to hard to keep your bg’s in check.

If you could not stay in check for a morning, instead eat like a normal person (not super low carb), and show up at a doctor’s office blood draw or fingerprick test with a random bg of 300+ I betcha they’d pay more attention.

I’ve read of studies showing that starting insulin has insulin-sparing effects, in that using insulin prevented some people from going into full insulin dependence, preserving some beta cell function. There are others like this.

Additional reasons to start insulin therapy earlier:

Although specialists are slightly more proficient than general practitioners in intensifying diabetes therapy when warranted (7), overall clinical inertia results in the majority of patients failing to achieve, or maintain, adequate metabolic goals from a period of months to several years (8,9). In summary, to improve these suboptimal metabolic outcomes, and reduce the risk of disease-related complications, more intensive management of glycemia is warranted, including the option of introducing insulin therapy earlier than the current widely practiced substandard of care.

One tip that works for me: Taking a “restful sleep” (valerian root + l-theanine) supplement before bed (available from WholeFoods/Amazon). It shifted my mornings of 130 to about 100 instantly.

Interesting! I may give that a try.