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June 4, 2008

Daily Care, Insulin

Question from Bangalore, India:

I am 29 and have had type 1 diabetes for about 19 years. I recently got married and moved from Chandigarh, India to Bangalore, India about six months ago. Since my wedding, my sugars are not well controlled and I am very upset about it. Before that, my sugars were controlled, my A1c was 6.0 and I had no complications. I was on Levemir, nine units in the morning and nine units in the evening, plus Actrapid, eight units in the morning, four units in the afternoon, and four units in the evening. Although my breakfast is always smaller, I take more units of insulin for this meal. I am also taking metformin, 1000 mg in the morning and 500 mg at night. My endocrinologist told that me that I have developed some brittleness in diabetes. When I was in my early 20s, my fasting was continuously between 35 mg/dl [1.9 mmol/L] and 60 mg/dl [3.3 mmol/L]. I have seen gradually higher blood sugars and am now on Lantus, 12 units in the morning with tea and six units at night, plus NovoRapid, 12 units in the morning, five units in the afternoon, and five units in the evening. If my fasting is 155 mg/dl [8.6 mmol/L], then also within an hour, just before pre-breakfast it goes up to around 300 mg/dl [16.7 mmol/L]. Although I have taken Lantus, my 3 a.m. sugars are also normal or higher. I have hypoglycemia unawareness also. What do you suggest? I also want to work as volunteer with children with diabetes. I was working as diabetes educator my last five years at Chandigarh.


My understanding is that you have type 1 diabetes. I am not sure that metformin will help with your blood sugar control if you have type 1 diabetes. You are also on a different regimen than what you were on before. Now, you are on Lantus and NovoRapid. It sounds like you may need to increase the Lantus, as well as the rapid-acting insulin with breakfast. I usually use the Lantus by titrating to the fasting glucose. You are correctly following the 3:00 a.m. glucose so as not to have lows in the middle of the night. I do not like to see values under 80 mg/dl [4.4 mmol/L]. If the two-hour post-breakfast is above 200 mg/dl [11.1 mmol/L], the rapid insulin at breakfast needs to be adjusted upward. Besides your new regimen, I am not sure why your requirements are more. I would say that issues such as stress, weight gain, lack of exercise, and intercurrent illness are all issues that increase your insulin requirements.