I am 34 years old and I’ve had diabetes for four years. I was told by my former doctor that I had type 1 as I had to switch from oral medication to insulin treatment due to out of control blood sugars. However, my recent new doctor told me that if I had been a type 1 on oral medication for half a year, I would have been dead. So, what type of diabetes do I have?

My last A1c was 7.8. As I want to prepare for pregnancy, I have asked my doctor to change my treatment from a conventional to an intensive insulin treatment. I used to give myself two shots of Mixtard (30% regular and 70% NPH) consisting of 24 units pre-breakfast and 12 units pre-dinner. Now, I am giving myself three shots of Regular to cover the three meals and one shot of NPH at bedtime to cover the night. My doctor told me to aim for blood sugars below 7 mmol/L [126 mg/dl] one hour after meals. However, if I were to give myself enough Regular to meet the target, I will go low even at the hour that has passed the theoretical peak duration of the insulin, considering I have taken snacks accordingly. My weight is 56 kilograms (123 pounds) and I am a light eater, consuming no more than 40 grams of carbohydrates for each meal. How can I make this work peacefully between my diet plan and insulin treatment?

Recently, my fasting sugar in the morning has raised up to more than 10 mmol/L [180 mg/dl]. I am suspecting a low at midnight as my stomach was empty at bedtime and my bedtime reading was between 4 to 5 mmol/L [72 to 90 mg/dl]. However, when I tested at 3 a.m., my blood sugar was 7.3 mmol/l [131 mg/dl] My doctor told me that it is due to not enough NPH at bedtime. What do you think?

You are going to make me work today! These are all good questions.

The question of type 1 versus type 2 diabetes is a very good one. It is very common to have this dilemma. However, please understand that individuals can have type 1 diabetes and have an insidious beginning to their blood sugar elevations. Transient control of sugars on an oral agent is not a reason to exclude the diagnosis of type 1 diabetes. Your doctor also has the ability to measure antibodies and a test called a C-peptide in the blood. These may be additional discriminators for making the decision. There is a condition called late-onset autoimmune diabetes of adulthood (LADA) that would describe your situation nicely. It is a slow-developing form of type 1 diabetes.

Tight glucose control is the standard for preparation for pregnancy. I usually recommend my patients have a normal hemoglobin A1c on more than one determination to demonstrate durable control. To get there, your physician has recommended one regimen that has been used for “intensive therapy.” There are specific guidelines for blood sugar control during pregnancy that need to be met. The 7 mmol/L [126 mg/dl] level of glucose one hour after a meal is a solid recommendation. The problem is how to get there. You may want to consider using an insulin analog like lispro (Humalog) insulin as these agents have a more rapid onset of action and are more rapid-acting than regular insulin. However, with these analogs, you may also have to take an additional dose of NPH in the morning because they don’t stay around as long as the Regular.

I agree with your physician about using more NPH at night to address the rising fasting glucose level. You will have to check your blood sugar at 3 a.m. to make sure it does not go too low.

JTL