Tight control

[KookyCat]

This may be a silly question but I'm perplexed because medical types keep saying this phrase in a slightly accusatory manner. Every time I mention my tendency to overnight lows to one of my team they say that I have to expect lows when I'm operating such tight control. There seems to be a slight suggestion that if I relaxed said control the overnight issue would go away. So here's my operating framework (or goals to normal humans). I like to be between 4.5 and 5.5 in the morning, I prefer no more than 7 at the two hour mark and if possible in the 5 range before meals. I manage that 99% of the time but to be honest that's easy in the evening because my carb tolerance is incredibly high compared with the rest of the day. I wouldn't be disturbed by a higher figure btw unless it went into double figures and wouldn't come down (because DKA scares me to death after my experience earlier in the year).

So am I operating too tight a ship? I'm revving up to an assault on the overnight low issue with the consultant later in September. I've ruled out too much basal because if I dial it down any further I get a peak before dinner despite normal 2 hour readings, and the dose I'm on keeps me steady as a gymnast until the magical 3:00am witching hour. I'm after a CGM loan really so I can work out how much the dip is and when to give me more to work with 🙂

 

[Amberzak]

I don't really know what to say. You have much better control than me but I can see you mentioned you were scared after going too high.

I have the opposite problem. Twice I've had very scary hypos. I fit violently when I'm low apparently. Once I was living in London, and my landlord came in because I was making so much noise. I'd ended up on the floor. I vaguely remember him coming in, then the paramedics, an injection, feeling sick, and the hospital. I don't really remember much else of it. Another time my husband had to call a paramedic because I didn't wake up. He didn't take me into hospital, but I remember feeling sick all day from the gluco-whatever it's called injection he gave.

So I am one of those that goes to be slightly higher (a reading of about 8) because until they can get me something that will wake me up before I go so severely hypo, I am too scared of hypos.

I know some people are the other way around though. 🙂

 

[Northerner]

We are pretty similar KC, I'm also in the camp of wanting the best levels I can achieve, being more afraid of highs than hypos. I've had a few bad hypos, but nothing I haven't been able to treat myself (lowest 1.7 😱), the vast majority have been very mild hypos. HCPs often contradict themselves. They want you to achieve a good HbA1c and avoid the risks of complications, but what they seem to misunderstand is that it is extremely difficult to 'just run a bit higher' deliberately, particularly if 99% of your readings are in range. They assume that an HbA1c in the 5s must include lots of dangerous hypos, not true. However, as in your case, there can be problem areas which are extremely difficult to address with the blunt instrument of basal/bolus - only a pump can solve such problems for some people.

A CGMS would definitely be useful in working out just what is going on, so I would push for that 🙂

 

[KookyCat]

I don't really know what to say. You have much better control than me but I can see you mentioned you were scared after going too high.

I have the opposite problem. Twice I've had very scary hypos. I fit violently when I'm low apparently. Once I was living in London, and my landlord came in because I was making so much noise. I'd ended up on the floor. I vaguely remember him coming in, then the paramedics, an injection, feeling sick, and the hospital. I don't really remember much else of it. Another time my husband had to call a paramedic because I didn't wake up. He didn't take me into hospital, but I remember feeling sick all day from the gluco-whatever it's called injection he gave.

So I am one of those that goes to be slightly higher (a reading of about 8) because until they can get me something that will wake me up before I go so severely hypo, I am too scared of hypos.

I know some people are the other way around though. 🙂

Thanks Amberzak, it's so hard to know what the right amount of control is. I have a tendency towards hypos too but I haven't yet had a very severe one, and in your position I'd be scared of them too. At the moment my body reacts pretty violently to anything below 3.7 but I've been warned that might change and in turn my fear might well change direction 🙂.

 

[KookyCat]

We are pretty similar KC, I'm also in the camp of wanting the best levels I can achieve, being more afraid of highs than hypos. I've had a few bad hypos, but nothing I haven't been able to treat myself (lowest 1.7 😱), the vast majority have been very mild hypos. HCPs often contradict themselves. They want you to achieve a good HbA1c and avoid the risks of complications, but what they seem to misunderstand is that it is extremely difficult to 'just run a bit higher' deliberately, particularly if 99% of your readings are in range. They assume that an HbA1c in the 5s must include lots of dangerous hypos, not true. However, as in your case, there can be problem areas which are extremely difficult to address with the blunt instrument of basal/bolus - only a pump can solve such problems for some people.

A CGMS would definitely be useful in working out just what is going on, so I would push for that 🙂

Thanks Northerner, I do find it weird that they push good control then seem to suggest too much control, and honestly I've tried everything I can think of to push up the night readings but as I think I've mentioned before even when my daytime readings were in the 30's and 40's I still woke in single figures. Weirdly I also know my body does correct hypos at night because of the initial problems I had with Lantus. I can't decide if I have an extremely precise liver or if it's just a bit lazy and can only be bothered to shove out a bit of glucose if it absolutely has to 🙄 Let the CGM battle commence!

 

[Northerner]

They want the Moon on a stick! To be fair, my consultant rarely questions my HbA1c or my control these days as he knows that I know myself well. Really, a consultant should only be questioning your control if you are reporting extremes or if there is a big difference between your latest and your previous HbA1c - they shouldn't prejudge people based on some mythical ideal, they need to look at individual circumstances. Unfortunately, some are too lazy to read your notes, some think they know your body better than you do, and some don't believe what you tell them. Mine is good. Which you get is pot luck a lot of the time 🙄

 

[Pumper_Sue]

Hi KK, re your 3 AM lows would it help or have your tried perhaps 10 or 15 carbs just before bed or even moving your basal insulin to a bit later in the evening?
My experience of the too tight a control issue has varied over the years. GP who is my rock say's 6.4 is the lowest he wants to see my A1c, Consultant ophthalmologist who saw me a few weeks back said my control was excellent and he wished he saw more A1c's at that level and more to the point more people with almost 50 years of diabetes with no eye damage. Yet a few years ago it was frowned on to have anything below 7% just in case you hypo too much. 🙄
Bottom line is it's your condition and you need to treat your diabetes the way you are most comfortable with whilst being safe and it's not interfering with your quality of life.

 

[Flower]

It is difficult to achieve tight control but not too tight control. For the past few decades I have always been told to tighten my control but my last HbA1c of 6.2% was deemed too low by my consultant, I have crossed the invisible line! I'm both terrified of going unconscious and terrified of high blood sugar. It's very difficult to find a happy balance within narrow confines 🙄

Definitely ask for the use of a CGM KookyC, it will show you exactly what is happening in the night. If you aren't able to control the dip with long acting insulin then ask if a pump would be an option for you. It might not mean you can easily solve going low although it does give you a lot more tweaking opportunities. At present I have reduced my basal to as low as possible between 1am and 4am but am still going down to the low 3's. Night time glucose control seems a completely different challenge to daytime.

 

[KookyCat]

Hi KK, re your 3 AM lows would it help or have your tried perhaps 10 or 15 carbs just before bed or even moving your basal insulin to a bit later in the evening?
My experience of the too tight a control issue has varied over the years. GP who is my rock say's 6.4 is the lowest he wants to see my A1c, Consultant ophthalmologist who saw me a few weeks back said my control was excellent and he wished he saw more A1c's at that level and more to the point more people with almost 50 years of diabetes with no eye damage. Yet a few years ago it was frowned on to have anything below 7% just in case you hypo too much. 🙄
Bottom line is it's your condition and you need to treat your diabetes the way you are most comfortable with whilst being safe and it's not interfering with your quality of life.

I take my basal in the morning now because it has a most definite peak in me and it was causing some serious lows. That has helped but it still dips down, if I eat some oat cakes that Usually gets me over the bump at 3am but not always. It's just very irritating, my body seems to love a good carb fest in the evening, but my stomach doesn't 🙄

 

[KookyCat]

It is difficult to achieve tight control but not too tight control. For the past few decades I have always been told to tighten my control but my last HbA1c of 6.2% was deemed too low by my consultant, I have crossed the invisible line! I'm both terrified of going unconscious and terrified of high blood sugar. It's very difficult to find a happy balance within narrow confines 🙄

Definitely ask for the use of a CGM KookyC, it will show you exactly what is happening in the night. If you aren't able to control the dip with long acting insulin then ask if a pump would be an option for you. It might not mean you can easily solve going low although it does give you a lot more tweaking opportunities. At present I have reduced my basal to as low as possible between 1am and 4am but am still going down to the low 3's. Night time glucose control seems a completely different challenge to daytime.

Thanks Flower, CGM assault first, then maybe a pump campaign. I need a full nights sleep before I go bonkers 🙂

 

[PattiEvans]

I take my basal in the morning now because it has a most definite peak in me and it was causing some serious lows. That has helped but it still dips down, if I eat some oat cakes that Usually gets me over the bump at 3am but not always. It's just very irritating, my body seems to love a good carb fest in the evening, but my stomach doesn't 🙄

It does occur to me that maybe with the higher carb consumption in the evenings you may be having reactive hypos, but that's usually only T2s, though if I get very high BGs I can crash.

I have found since having a pump that my body's insulin requirements were completely impossible to meet with MDI. For example in the mornings I need 1u per hour at certain times, but in the afternoons I need no basal at all for 2 hours.

 

[KookyCat]

It does occur to me that maybe with the higher carb consumption in the evenings you may be having reactive hypos, but that's usually only T2s, though if I get very high BGs I can crash.

I have found since having a pump that my body's insulin requirements were completely impossible to meet with MDI. For example in the mornings I need 1u per hour at certain times, but in the afternoons I need no basal at all for 2 hours.

I'm beginning to think it's my basal, where it's at at the moment it keeps me stable, except for that overnight period but if I dial it down two units I get a high just before my evening meal which then persists, but it's down again by morning. I did a bit of experimenting with times of injection too and I can delay my basal in the morning (that might have been a mistake because i forgot 😱) and my morning figures stay quite stable. From my crunching of numbers I'd say I have a low requirement in the morning and evening and then a cracking basal need around 3-5pm, this would also make sense of why the evil mixed insulin just wouldn't work and had me crashing into hypos all morning and evening/night but allowed me to be in he high 20s in the afternoon because the two shots of insulin were happening when I needed it the least. I'm glad you mentioned reactive hypoglycaemia because I want to add that to my list to talk to the consultant about because I have another condition that can cause it so I'd like to rule that out. To think, 8 months ago I had no idea what my pancreas was up to 🙂