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February 25, 2004

Daily Care, Other

Question from Keshena, Wisconsin, USA:

I am a 29 year old type 1 diabetic who is currently 26 weeks pregnant. I have had diabetes for almost six years. My A1c about six weeks ago was 5.9, down from 7.9 at the beginning of my pregnancy. I have no other medical problems. I have been under the intensive care of an endocrinologist, nurse practitioners, my obstetrician, and a dietitian. However, it seems we are all at a loss as to how to get my fasting blood sugars even close to range. I am writing to see if any of the other professionals have any further ideas or suggestions. Right now, they are hovering at around 200 mg/dl [11.1 mmol/L]. My daytime ratios and blood sugars are working well. I have not gained any weight since becoming pregnant (which I believe is directly related to the better blood sugar control I have now). With the high fasting blood sugars, I am concerned my A1c is going to begin to increase again. I was taking Lantus prior to pregnancy and wish I could go back. At first, we realized I was taking way too much long-acting insulin, NPH, overnight. This was causing lows, some of which I was not waking up from. Whether I woke or not, I seemed to have rebounding blood sugars. So, my NPH went from about 28 units down to 10 units over several months. However, I was still having high fasting blood sugars. I was also having lows really early in the morning (like midnight to 1 a.m.), so we added a bedtime snack. However, I am still waking up with high blood sugars. I have been trying to increase my overnight NPH because I have not been on 10 units since being diagnosed and it just doesn't seem like enough for me. However, last night I set my alarm for 2 a.m., after taking 14 units of NPH at 10:30 p.m. and going to bed with a blood sugar of 208 mg/dl [1.5 mmol/L]. I skipped the snack and did not take any insulin. I woke up with a blood sugar of 38 mg/dl [2.1 mmol/L], treated it and went back to bed about 1/2 hour later with a blood sugar of 70 mg/dl [3.9 mmol/L]. This morning I was then 278 mg/dl [15.4 mmol/L]. I have tried testing blood sugars at all hours of the night. I really want these fasting numbers down, but don't know what else to do and it worries me going into the third trimester as I am told it gets harder to keep your blood sugars in target range. Also, my ketones are almost always negative, even waking with a blood sugar greater than 200 mg/dl [11.1 mmol/L]. Do you have any suggestions?

Answer:

Fine tuning glucose control is difficult by e-mail. It sounds like you are having nocturnal hypoglycemia and then rebounding high. However, I have some suggestions. You may want to consider going back to Lantus and then using Humalog prior to each meal. Anecdotal reports suggest that both of these are safe in pregnancy. Another possibility is switching to an insulin pump. It could also be a matter of timing your evening NPH either earlier or later depending on when you get a peak effect and its duration. This is very general advice, but I hope it helps.

OWJ
Additional comments from Dr. Philip Ledereich:

I would consider asking your medical professionals about the possibility of using pump therapy for this and or for future pregnancies to help fine tune your glucose levels.

Good luck with this pregnancy.

PSL