LADA new diagnosis

[Leo]

Hi everybody!
I hope you are all keeping well?
I have a question re starting insulin when on a low carb diet.
My diabetes nurse has prescribed low dose Glargine (4-6) and Humalog (2-4) even though I was already on a low carb diet for weight loss purposes. My bloods are in range for I’d say 95% of readings as long as I stick to the diet. I explained to her that I would be happy to start injecting once my bloods trend upwards whatever I am or am not eating and she agreed that would be ok.
I have also read that when diagnosed it is probably a good idea to start injecting low dose as it puts the Pancreas under less stress to produce.
I should probably be asking the nurse this question but I’m not due to see her for a couple of weeks but I just wonder if any of you lovely people out there have experience in this?
As things stand at the moment I seem to be in the “honeymoon period” but at the same time I don’t want to have to eat carbs just to ‘soak up’ injected insulin to avoid hypo’s. I saw on a conversion chart that each unit of insulin seems to reduce glucose by 2.8mmol or 50 mg/dl. This chart doesn’t seem to differentiate between long acting/fast/rapid acting insulin. Please educate me! Thankyou in advance.

 

[TheClockworkDodo]

Hello Leo, if your glucose level is in range 95% of the time without injecting insulin, I'm not sure you should be injecting any insulin at all.
If you can provide a few more details it might be helpful. Are you presently taking any other meds? Can you share your latest hba1c, or some of your recent daily finger prick results.
If you are underweight then a Dr might prescribe insulin to help build you back up, but if your weight is good, and your glucose level is in range, then I don't understand why, for now, you cannot keep doing what you are doing.

Yes, I agree - I can't see why you'd need insulin at the moment either - you'd need to eat more carbs, and if you're trying to lose weight it wouldn't make sense.

I'm afraid I can't help with starting with low doses - I always understood we need as much insulin as we need, but I was diagnosed type 1 when hospitalised with DKA, so it may be different with LADA. I can tell you though that the amount each unit of rapid-acting insulin reduces blood glucose is different for different people - one unit reduces mine by about 5 rather than by 2.8. The chart you saw is presumably referring only to rapid-acting insulin - long-acting is "background", to keep your blood sugar steady, rather than to balance your food.

 

[leonS]

The number that you refer to is called the sensitivity factor and is defined as the drop in BG that will occur after two hours as a result of injecting one additional unit of insulin. The sensitivity factor can be estimated from:
SF = 100/TDD
where TDD is the total daily (insulin) dose in units.
The TDD can be estimated from
TDD - weight * factor
where weight is the person's weight in kilograms and factor is a number usually between 0.5 and 0.7. About half of the TDD should be in basal insulin and the rest as bolus.

To find how much bolus insulin to use you need to know the carb to insulin ratio. This is about:
10 g carb : TDD/50 units.

All of these are for a diabetic who makes little or no insulin of his own and only give, at best, a rough guide to the numbers to use, as we are all different .

It is impossible to comment on the number that you found on the net without knowing the context in which it was given, but all the factors certainly differ from person to person. It might be that that number was used as an example to show how calculations are performed.

I don't think that stress has a deal to do with it. In type 1 and type 1.5 it is the body which is killing the cells that produce insulin, this causes the problem, not the lack of the cells' ability to make insulin. No matter what you do, if type 1.5, you will eventually need insulin.

Important questions to ask are "How was the diagnosis of type 1.5 made?" "Was it based on a test?" and "What was the test?" or was it a iust wild stab in the dark!

 

[Leo]

The number that you refer to is called the sensitivity factor and is defined as the drop in BG that will occur after two hours as a result of injecting one additional unit of insulin. The sensitivity factor can be estimated from:
SF = 100/TDD
where TDD is the total daily (insulin) dose in units.
The TDD can be estimated from
TDD - weight * factor
where weight is the person's weight in kilograms and factor is a number usually between 0.5 and 0.7. About half of the TDD should be in basal insulin and the rest as bolus.

To find how much bolus insulin to use you need to know the carb to insulin ratio. This is about:
10 g carb : TDD/50 units.

All of these are for a diabetic who makes little or no insulin of his own and only give, at best, a rough guide to the numbers to use, as we are all different .

It is impossible to comment on the number that you found on the net without knowing the context in which it was given, but all the factors certainly differ from person to person. It might be that that number was used as an example to show how calculations are performed.

I don't think that stress has a deal to do with it. In type 1 and type 1.5 it is the body which is killing the cells that produce insulin, this causes the problem, not the lack of the cells' ability to make insulin. No matter what you do, if type 1.5, you will eventually need insulin.

Important questions to ask are "How was the diagnosis of type 1.5 made?" "Was it based on a test?" and "What was the test?" or was it a iust wild stab in the dark!

Hi Leon,
Many thanks for your very comprehensive reply!
So far I’m not that advanced that I’m having to work out doses as I’m currently not using but have been given arbitrary doses to start on when needed. Not yet seen the adult diabetes spec nurse service in my area, booked for Oct.
I was diagnosed by chance when my GP took my BP at a meds’ review and it was raised so ordered a blood test. Zero diabetes symptoms btw. Even now.
Glucose came back the same day at 12.3 and hb1ac of 40. 4 days later a fasting of 7.5 and ketones of 1.8 so had a repeat blood test confirming 7.3 and hb1ac of 44 (this was 2 months ago, no updated hb1ac since). I then had a blood test for GADA, ZnT8 and IA-2 which came back GAD+ only. So for the last 2 months testing varies 4.5-6 am, between 6 and at worst 10 after brekkie, 6-10 after dinner and 3.7-7.5 before bed. Only as high as 12-14 on a few occasions (self inflicted chocolate!). Meds I’m prescribed are low dose fluoxetine, beclometasone & salbutamol inh & montelukast. Btw the conversion chart referenced is on Joslin.org.
I hope this makes some sense?!!
L

 

[Leo]

Hello Leo, if your glucose level is in range 95% of the time without injecting insulin, I'm not sure you should be injecting any insulin at all.
If you can provide a few more details it might be helpful. Are you presently taking any other meds? Can you share your latest hba1c, or some of your recent daily finger prick results.
If you are underweight then a Dr might prescribe insulin to help build you back up, but if your weight is good, and your glucose level is in range, then I don't understand why, for now, you cannot keep doing what you are doing.

Hi Benny,
Thanks so much for replying!
I have put a few boring facts into a reply to Leon above regarding meds, results and how this all came about.
I’m not overweight (5ft2 & 53kg) just want to lose 3 or 4lbs to get back to where I was.
But yes Thankyou for confirming that I’m not being unreasonable in holding off until things become undeniably dodgy!
L

 

[Leo]

Yes, I agree - I can't see why you'd need insulin at the moment either - you'd need to eat more carbs, and if you're trying to lose weight it wouldn't make sense.

I'm afraid I can't help with starting with low doses - I always understood we need as much insulin as we need, but I was diagnosed type 1 when hospitalised with DKA, so it may be different with LADA. I can tell you though that the amount each unit of rapid-acting insulin reduces blood glucose is different for different people - one unit reduces mine by about 5 rather than by 2.8. The chart you saw is presumably referring only to rapid-acting insulin - long-acting is "background", to keep your blood sugar steady, rather than to balance your food.

Juliet, Thankyou for your reply! I think for you it is slightly different, you unfortunately became ill and ended up hospitalised (and I hope things have improved for you since?) but you would of course have been under much more scrutiny as an inpatient and therefore doctors initiated your treatment and you would have been monitored very closely and advised/prescribed with a more tailored approach. The conversion chart I found on joslin.org is obviously only a working document and I appreciate your take on the fact we are all different with differing sensitivity which is only learned through experience but yes there was no mention of which type of insulin used in this document.
Each reply I have received confirms my thoughts on not starting insulin at the moment (I posted a very boring reply to Leon above regarding details!) and I thank all of you because I was genuinely considering starting at least basal at low dose. I will hold off until needed as I agreed with the prescriber.
Much obliged...
L

 

[TheClockworkDodo]

Thank you, Leo - but DKA is very short-lived, I felt wonderful once I started using insulin!

If it weren't for the positive GAD results and the occasional 12-14 I'd say your readings were perfectly normal, they don't really sound in diabetic range at all yet. And with your bedtime and waking readings being so low it sounds to me as though you definitely don't need a basal at the moment - you don't want to start hypo-ing in the night, and Glargine is notoriously unstable in small doses (in that it tends to peak and cause hypos if you're not careful). You might find you need to start having a little bolus once you stop cutting down so much on carbs though.

Did you know that Salbutamol raises blood sugar? - I don't use my inhaler very often, but when I do I have to increase my insulin doses.

 

[Leo]

Thankyou for replying again Juliet! Hypo’ing during the night is particularly what scares me as i live alone but i did not know that salbutamol raises blood glucose. It’s just recently i have increased my Salbutamol dose for increased wheeze but have also increased my steroid ihl too on GP advice. Thankyou again for your advice Juliet.

 

[TheClockworkDodo]

You're welcome. And I suspect steroid inhalers will also increase blood sugar, but you'd need to check the leaflet to be sure. I know some people have steroid-induced diabetes though, from long-term use of things like steroid inhalers.

I found when I was first put on Glargine (commonly known as Lantus) I hypo'd every night for the first week, as they'd guesstimated too high a dose for me (I was on 16 units and I needed about 5 😱 ). But I did wake up, very suddenly, very wide awake, and knowing exactly what was wrong and what to do about it! Even now - when I've lost a lot of my hypo awareness - I very rarely hypo in the night, and on the rare occasions I do, I tend to wake up (I know because I have a Libre, which gives me continuous blood sugar readings through the night), and I've never needed anyone else's help with a night-time hypo. So try not to worry too much about that when you do finally start insulin.

 

[Leo]

Hi,
Yes you’re right that Hyperglycemia can be caused by salbutamol and beclometasone as per the BNF cautions. I have seen patients at work with oral steroid induced diabetes but I don’t think it applies to me and I’m not seeing a correlation between taking those inhalers and my bloods increasing fortunately.
Im so sorry you had a bit of a mare in the beginning regarding hypo’s due to being prescribed too much but I’m glad to see you now seem to have some control over this by experience.
My plan to reduce the chance of this happening is to inject basal in the morning so if I have a hypo I’ll probably be at work where I’m surrounded by doctors and nurses who will know what to do even if I don’t!
I’m thinking about asking for a libre sensor when I start insulin but I’m not sure I’ll fit the NICE criteria but I’ll ask anyway... anything to cut down on sore fingers! When I look at cost of glucose strips vs libre with less use of strips it seems libre is slightly more expensive. Libre costs the NHS trust I work for £35 every 2 weeks, glucose strips £24 every 2 weeks so I suppose it depends on how tight fisted my local CCG is but hey, adherence should be the panacea right?!!! Well if you don’t ask, you don’t get!

 

[leonS]

Sorry about my long winded post, but you did say that you wanted to be educated.

The important thing in your not at all boring reply is the GAD test. Sooner or later you will be told that you must be type 11 (your age) and you should be doing all the type 11 things. Point out the GAD+ test and all will be well.

Eventually you will get to the stage where you need insulin as the things that are killing your cells will have just killed too many of them. Because you are older they are not very good at doing this killing, so it could be a long time before you need insulin at all, and then some time before you make no insulin to speak of. This will help you to keep your BG stable as your own insulin production will increase or decrease as needed.

I am not sure of the rules on prescription charges. I know that diabetics on medication are exempt, so you can certainly claim exemption even if you use little or no insulin once it is prescribed.

More good news: when you know how to do it, you can add a drop of extra insulin and have chocks with no huge rise in BG (not too much and not too often).

All the best.

 

[TheClockworkDodo]

My plan to reduce the chance of this happening is to inject basal in the morning so if I have a hypo I’ll probably be at work where I’m surrounded by doctors and nurses who will know what to do even if I don’t!

I'd make absolutely sure of that before it happens, if I were you, unless you happen to work in the diabetes ward. It's surprising how many other health professionals think that the remedy for a hypo is to give the patient insulin 😱

Always worth asking re the Libre - some CCGs are more generous about it than others. My diabetes care is in Wiltshire, which doesn't prescribe them, but as I actually live in Gloucestershire they were sneakily able to arrange it so I got one from there!

 

[Bruce Stephens]

My diabetes care is in Wiltshire, which doesn't prescribe them

I thought we had a nationwide policy now? (CCGs are allowed to also prescribe it to people who don't meet the national criteria, but I thought they were supposed to prescribe it to people who do meet the national criteria.)

 

[TheClockworkDodo]

I don't know - do we? It might have changed since I got mine, but I think it may also be to do with interpretation of the criteria. I got mine because of loss of hypo awareness and frequency of finger-pricking, and the consultant in Wiltshire said he thought I should have one, but there was no way he'd get it approved unless things got very much more serious for me (presumably if I started waking up in an ambulance having Glucagen injections, which has never happened to me). He thought this was daft, that I should have it to prevent that very thing happening, but there wasn't anything he could do about it. It was my surgery diabetes nurse who told me that if he wrote to Gloucestershire saying I should have one they'd prescribe it for me.

 

[TheClockworkDodo]

Sorry, actually I realise I said "which doesn't prescribe them" when I should have said "which interprets the criteria to mean they only prescribe them if you're having regular near-death experiences" ... 🙄

 

[Bruce Stephens]

Sorry, actually I realise I said "which doesn't prescribe them" when I should have said "which interprets the criteria to mean they only prescribe them if you're having regular near-death experiences"

It'll be interesting to see updated statistics on prescribing rates (if they're ever published, that is). I'm sure there's some continuing variation between CCGs!

 

[grovesy]

It'll be interesting to see updated statistics on prescribing rates (if they're ever published, that is). I'm sure there's some continuing variation between CCGs!

From what I have read there is still a variation.

 

[Bruce Stephens]

And here are some graphs: https://openprescribing.net/measure/libre/

Looks like Wiltshire is some way below the national average, whereas Gloucestershire is more average. (Though still a bit below Richmond and Kingston, which are nearby to me.)

(For context, it appears that people think there are about 400000 people with Type 1 diabetes in a population of about 66 million, which works out at about 6 per 1000. I'm a bit doubtful about those figures, though: it looks to me like they're based on things like "about 10% of people with diabetes have Type 1". Seems like somebody, somewhere, ought to know how many people (adults and children) have Type 1 diabetes, but I can't find the information.)

(Presuming 6 is about right, 1 or 2 per 1000 would be of the right order if you're aiming to prescribe to 25% of people.)

 

[TheClockworkDodo]

That's interesting, Bruce, thanks. I actually see a consultant at Swindon (at least I do when they finally find another consultant - I haven't been there since 2017 because they're short-staffed), and that's a separate CCG, apparently, but like the rest of Wiltshire it's some way below average. It looks as though they didn't prescribe any Libres at all before 2018, and hardly any then.

 

[TheClockworkDodo]

PS sorry @Leo for veering a bit off-topic on your thread 😳