Yikes, lows

Type 1 and LADA
1

Curious how often people on this site with good/excellent control go low?

I've recently improved my control a lot with a change in infusion set which seems to work much better for me. No more crazy red, itchy, hive-y sites and random spikes up into the high teens and 20s (300s and 400s). A few times now my site has "fallen out" (it does not stick well at ALL, I need to get some skin tac or something) and I've gone up into the low teens (around 250) and figured it out after an hour or two of not coming down. I'm not sure I've seen a high teen since changing infusion sets, actually, which is awesome.

But with this new-found control has come a new problem in the form lows, lots and lots of them. I'm pretty sure if this keeps up my endocrinologist will freak out when I see him in November, even if my A1c is better. Plus, I think it's getting pretty unsafe, especially because I live alone and recently had a scary morning low where I didn't wake up for my alarm and was an hour and a half late for work.

So I'm curious how often you all who have an A1c in the 6% range or lower go low?

According to my meter, I've gone below 3.9 (70 mg/dl) 48 times in the past month! (And 28 times in the past two weeks, and 14 times in the past week.) If I lower that to readings below 3.3 (60 mg/dl), then I've hit that low a total of 21 times in the past month, 14 times in the last two weeks, and 9 times in the past week. If I lower it even more to readings below 2.8 (50 mg/dl), then I've had six in the past month, four in the past two weeks, and two this week.

I heard somewhere that more than two lows per week was getting to be too much. And mine certainly seems to be too much. It seems lows are my new problem rather than highs, especially because I don't get many symptoms which makes them very hard to avoid, and they seem to be associated with "normal" activities like walking to the bus stop or shopping ... Tonight I went shopping, got home and put the groceries away, and then felt sort of low so tested and found I was at 2.8 (50 mg/dl) with 1.5 units of insulin still on board. I tried lowering my I:C ratio last week and starting getting readings of 10 (180) after meals. I'll try lowering my basal rates and see if that works, though.

2

Sure happy to read, that your " new type " of infusion is working !! Lowering basals maybe your clue . As an for instance : I had 2 lows yesterday ( one big rebound for the first one )followed by a walk with SPCA at least 5 k ...and my A1C is definitely not in the low 6 ; last one was 6.9 ... I don't pay too much attention anymore to A1C's results ...I am much more concerned about my day to day living with d ( no complications after 30 plus years , at age 73 ) I am in training for my 8 km run in Amsterdam , Oct 20 ...that seems to be added to the low challenges ...always more to learn !!!

3

I reduced my basal rate today so we shall see if that works. I'm not even exercising so that is partly why I'm concerned about so many lows! I want to get back into swimming soon ...

First have to solve the issue of my infusion sets literally falling out whenever they get the least bit wet. It's happened four times in the past six weeks or so, and other times where it hasn't fallen out but I've had to tape it down (which I hate as my skin hates the tape). The adhesive does not stick to my skin well at all. This morning my set (which I put in last night) came unstuck and I tried taping it down ... Lasted until tonight when the tape was so itchy and sore I took it off and changed the site, my skin was very red and itchy/sore underneath the tape. So I'm going to get some Skin Tac when I call Animas (have to order a new clip and screen protector) to see if that helps. The adhesive patches on the contact-detach gets a bit itchy on the second day and I really don't want that developing into an allergy so hoping the wipe will help that as well.

Anyway, got a bit off topic .. Good luck on your run! When I am done school (hopefully end of this year) I'm planning on setting an awesome exercise-related goal to accomplish. :)

4

Hi Jen - I just prepared this low report for my endo a few weeks ago. This is using CGM data for a 14-day period late May to early June. My last three weeks have similar numbers.

% time Low 60-69 4.1%
% time Very Low 50-59 0.7%
% time Dangerously Low<50 0.1%

Number of episodes < 70: 25

Average number of episodes/day: 1.8

Average time per episode: 34 minutes

I use an average of 1.8 Dex4 tablets per day to correct low BGs.

It's important to realize that gluco-normal people spend 5% of their day < 70, usually in the early morning hours. (Bergenstal, et al 2013, Ambulatory Glucose Profile)

Your low exposure seems similar to mine. I'm happy with these results. It's not perfect but quite livable. If I can keep 2/3 or more of my lows in the 60s then I can live with that.

It's great you made a breakthrough on the infusion set/allergy front. You're on a roll now!

5

Interesting, I'll be interested to see what others may say. I don't have a CGM and I also live alone and I think that's partly why I think my endo will freak out. I don't mind so much the minor lows like 3.7 or 3.9, but I do think those might predispose me to not feeling lows at lower levels. I had hypo unawareness almost from the time I was diagnosed all through my childhood and teenage years, and I'm also nervous of that coming back. (I think as an adult I can feel lows better partly because I pay attention, but also because my A1c and blood sugars have been running higher than they did as a kid.) The lows I'm catching are just when I happen to test, so who knows how often I go low overnight or during the day and don't even know. That also freaks me out. At the same time, if I try to avoid going low I just end up going high ... I'm planning on getting the Vibe as soon as it's approved in Canada (right now our only CGM is the Minimed pump-integrated one), if I can afford the sensors, but I think that's still a ways off.

6

I run pretty low pretty regularly but I don't have a lot of "plunging" lows, more drifting lows. Usually it will run 5-10% of the test results on my CGM although right now, it's a bit crazier than that. I've had some busy weeks and it's been some adjustment to high school, not for me (ha ha) but my daughter so, in the week since I got the new pump, it says 23%!! I have an appt w/ a new doc so I'd better fix that this week so my data will look more handsome...

7

I am really pleased to hear that your new sites are working. I think you are prudent to be concerned about the lows. I really think that nel's suggestion of lowering your basal and perhaps increasing your target may help. Just the improvement of not having all those pesky highs should give you a real decrease in your A1c. And then over time as you figure out how to further minimize your swings, then you could tighten things up.

8

i go low pretty often, sometimes i can't even understand why.
this is an extreme example, but this weekend i went hiking. i usually do about a 4 mile hike.

before starting, my BG was 178, so I thought that was perfect. Within 45 mins, i had dropped to 43.
i ate a plum, and had a juice box. this was 30 carbs at least.

so, i was up to 73 before 15 minutes had passed and I began to walk again.
I then dropped again to 66. At that point, all I had on me was 4 glucose tablets.
WIth 2 miles left to go, I opted to jump onto the main trail back to the parkin lot & was lucky to come across a family who had an apple to give me.

talk about scary. that was a lot of lows in a short period of time. That night, i went to bed in the mid 100's, and woke up at 2 a.m. @ 44.

i go low almost on a daily basis. most of the time it is at night, but there are days where i'll have several lows in the 50's.

i hope lowering your basal works!

9

Yes, I would go with the lowered basal rates, making sure to note any patterns in "time zones" and lower only two hours before the periods you're regularly having lows. That is definitely too many lows, Jen! Perhaps now that you've solved some problems you need to do an overall reevaluation of doses? (Such fun!).

To answer your question, I only had 7 lows in a three week period - but I only count as low numbers below 60. Now highs, that's another thread!

10

I lowered my nasal rates so we will see what happens. I woke up at 6.1 but was then 15. I still go high every day, I probably hit 11 (200) on a daily basis … but now most highs only last a few hours, and I’m not spending entire days out of range. :slight_smile: I think your idea of reevaluation my pump settings is a good one.

11

Jen - I apologize for missing the gist of your original post. You are concerned about lows and rightfully so. I assumed that your frequency of lows, although similar to mine, were qualitatively like mine as well. My lows tend to drift down, like AR's, and do not usually plunge quickly.

Adjusting your basal rates sounds like a good place to start addressing your concern. Sorry for the overly-optomisitc response.

By the way, I fingerstick test a lot and find that my meter average and standard deviation correlates well with my CGM data. I don't know how often you use your meter but if you use it enough, the trends it reveals are quite good.

12

I know I have too many lows, but I am aware of them & correct with glucose tablets, sometimes I am a bit confused as to how many to take but I always manage it. I don't live alone & my husband is a very good low detector & makes sure I test & correct, but usually I know without his prompting.

For the last 6 years since I started pumping my A1C has been between 5.7 & 6.3, usually near 6.3.

I count lows as 60 or below & looking back at my records I see that for the last couple of months I've had about 9 to 14 a week, for the 2 months before that it was fewer 5 to 8 a week.

The standard deviation for my BG values is 42 which the Doc says is excellent

13

I'd bet your I:C and correction ratios are off. Also check your DIA -- for humalog, it should be set around 4.5 hours*

I was too agressive with my ratios and was routinely going low bolusing according to what the pump was suggesting. I'm T2, and was set for I:C 1U:3g, correction 1U:10mg/dl.

My CDE had me bump the I:C to 4, and that did the trick... dramatic decrease in lows. Now, my BG seems to settle almost exactly where it should.

This did, however, change the dynamics of my dosing. I've adjusted my pre-bolusing timing, bolusing 30-40 minutes before I eat. This many times results in the insulin peaking just right with the carbs, and I get nothing more than a little 5-10mg/dl blip an hour or so after eating, that takes an hour or so from start to finish.

I used to bolus 15-30m before a meal, and have about the same effect; but then, the BG would keep going down for the next 3 hours after BG peaked, often leading to a hypo.

If I stick to that bolusing strategy, with my higher I:C now, I can easily spike to 150-160 after a meal.

So, work on your ratios and your DIA settings; adjust bolus timing to get that (now smaller) dose of insulin to hit just right, and you'll be fine.

Also, this bears repeating, since we all lose sight of it now and then: The sugar control system is dynamic, and is affected by trends as well as immediate, acute values. In other words, the longer you keep the sugars down and in control, the more stable they will become. So don't get discouraged if at first it's tough to control things as your changing settings and procedures. Give it a few weeks to settle.

Best of luck!

Dave

*I know many people here, particularly the flatliners, have a different (and strong) opinion about DIA, advocating for a much shorter DIA around 2-3 hours. Everyone should do what works for them.

14

I'd be careful with attacking this with basal. That might be the answer, but only if your fasting, 0 IOB trend is downward for hours, heading to hypo.

OTOH, if 3+ hours after eating and no IOB you are flat, hour after hour, the basal isn't the problem -- it's the boluses.

15

I haven't tried sneezing less yet... does this really reduce the lows? :-) :-)

(reread your post carefully :-))

16

Hi Jen -

Congratulations on finding a set that doesn't torture you.

I've been running about 1 low a day for the past couple of weeks. Almost all of them are in the 60s and most to use AR's term are drifting lows. On the other hand I had a crashing low to 45 yesterday which left me wiped for about an hour.

I tend to have bad lows more often when I've been going high and then hitting the roller coaster. As I'm sure you know, the goal isn't to lower the A1c as much as it is to flatten the curve.

Good luck with figuring everything out,

Maurie

17

Yeah I changed my basal and I've spent the entire last two days high, except for one low and three readings in range. But I was waking up low some mornings, so I don't know. I changed my I:C settings as well and that seems to have helped after meals.

I am having a terrible time with infusion sets not sticking at all, I've been holding them in with tape which is itself either getting really itchy or not sticking, either. I ordered some Skin Tac from Animas so hopefully that will help. But I've been wondering if that might be contributing to my problems.

Otherwise, I think I need to get really strict about weighing and measuring every morsel I eat. I've fallen off that a bit in recent weeks and found myself "estimating" if it was familiar food and I had no scale nearby.

My DIA is set to 4.0. I was 3.0 for years until my endo pointed out that stacking insulin leads to lows (particularly one extreme low overnight). Sometime else here mentioned my target. Right now it's 5.5 (100 mg/dl) which I don't think is overly low ... I think this is the only thing I hate about the pump, so many settings and adjustments to choose from. I think I will get stricter about weighing all my food and get the Skin Tac (should arrive in the next day or two) and then go from there.

18

I’m able to essentially never have lows… Which I attribute largely to a very low carb diet and minimal insulin. Also in my thinking a number more like below 60 is a better true indication of an actual low, 70 is well within the normal range for a non diabetic

19

Hmm, well I wish I could lower my nasal rates, I'm currently taking three medications to control my allergies! LOL.

20

Oops... that worked for two weeks, then over the last few days lows have started creeping into the equation again.

Now, my BG control has been miraculous compared to what is was when I was an out of control stupidperson (yes, that's one word :-)). So I'm wondering if, gradually, I'm gaining insulin sensitivity as my systems adjust to being "normal". Also, I'm aware that there is a greater "efficiency" with a pump than with MDI, so that's part of it too, I'll bet.

Thoughts?