Can I have your thoughts?

Status
Not open for further replies.
D

DancingStar

Active Member
Relationship to Diabetes
Type 3c
I had a diabetic check with the nurse at my GP surgery. My Hba1c check came back as 40.

The nurse thinks this is too low. She asked me about hypos, I said I get 1 or 2 each week. I think these are usually when I've been physically active or have misjudged my bolus - eg. not finishing a meal because I'm full or similar. I don't have "bad" hypos, I'm pretty good at spotting the signs and a couple of jelly babies put me back on track. I don't have hypos in the night.

The nurse told me I shouldn't be getting any hypos at all and that I need to reduce my Lantus from 20 units to 15 units. Which I've done. Now my Libra2 is giving me readings of 12 and above regularly - several times a day. Before the adjustment it would sometimes go up to 10 or 11, usually when I'd had a biscuit or something when out visiting but not really above this. Never to 14 or 15 which I'm seeing now.

Is Hba1c of 40 too low?
Is 1 or 2 hypos a week 1 or 2 too many?

Can I ignore the nurse and go back to 20 Lantus units?

I also see DSN and consultant at hospital and they were fine with my routine last time I saw them when Hba1c was 41.
 
GP surgery nurses don’t usually know much about Type 1 or Type 3c, they are more used to dealing with Type 2s. (if mine is anything to go by). A 25% reduction of basal is an awful lot on one go, I’ve never been advised to cut basal by more than two units maximum at a time, and I normally do it in steps of a half or one unit at a time. Some hypos are inevitable, I think, but if they happen around exercise, with my Libre, I tend to set my low alarm to around 5.5 if I'm going out for a walk, or doing heavy gardening, because it alerts me in time to take action before I hit hypo territory, which should keep your nurse happy.
 
My HbA1C is also 40 and my DSN is not concerned because my time in range is greater than 70%.
Any hypos is “too many”. However, no hypos is unrealistic when living an active life unless you are running your BG high.

In my experience, the DSN at my GP knows very little about anything apart from type 2. Mine asked me if I had ever had a hypo … in twenty years.
It does not sound to me as if your DSN is very experienced in insulin dosing,

Dropping your basal by 25% due to a few not bad hypos, sounds like a large drop. Especially when you suggest the reason is due to miscalculating bolus. It seems overkill of the wrong insulin to me.

You can do what you want with your insulin dosing. Maybe meet your DSN halfway with a basal of 18 units? Or maybe splitting your bolus so you take some of it when you finish your meal? And maybe consider techniques for avoiding activity hypos such as sipping/drinking fruit juice instead of water or raising your BG a little higher when you start.
 
Last edited:
DancingStar said:
I had a diabetic check with the nurse at my GP surgery. My Hba1c check came back as 40.

The nurse thinks this is too low. She asked me about hypos, I said I get 1 or 2 each week. I think these are usually when I've been physically active or have misjudged my bolus - eg. not finishing a meal because I'm full or similar. I don't have "bad" hypos, I'm pretty good at spotting the signs and a couple of jelly babies put me back on track. I don't have hypos in the night.

The nurse told me I shouldn't be getting any hypos at all and that I need to reduce my Lantus from 20 units to 15 units. Which I've done. Now my Libra2 is giving me readings of 12 and above regularly - several times a day. Before the adjustment it would sometimes go up to 10 or 11, usually when I'd had a biscuit or something when out visiting but not really above this. Never to 14 or 15 which I'm seeing now.

Is Hba1c of 40 too low?
Is 1 or 2 hypos a week 1 or 2 too many?

Can I ignore the nurse and go back to 20 Lantus units?

I also see DSN and consultant at hospital and they were fine with my routine last time I saw them when Hba1c was 41.
Click to expand...
It doesn't sound low to me, as long as your hypo awareness is good and you don't spend your days below 3.9 you should be fine.
 
Hello @DancingStar, several thoughts from here:

Personally I would be very cautious about taking diabetes instructions from a Nurse at a GP Surgery. I've just seen @Robin's advice (and now @helli 's advice) and fully agree with both. I go to my surgery Nurse for the routine checks, such as my feet; I happen to have a lot of neuropathy from my chemotherapy so it's useful to have a fresh pair of eyes check that aspect. I also recently took the opportunity to ask the Nurse to check my injection sites, since there are places I regularly use and can't easily see; again taking advantage of the fresh eyes.

I note you had your Whipple in 2019 and only needed to move onto insulin in Jan 23. So while I agree none of us should have hypos, the reality is that sometimes we get things wrong or just get caught unawares. So the Surgery Nurse's remarks are a reflection of how she simply doesn't understand. Can you please confirm that you do have Libre or some other CGM? I couldn't see that from a very brief look at your 34 posts.

Assuming you do have CGM what is your low alarm set at? As a T3c after a Whipples - even if your pancreatectomy was only partial - you are likely to be missing more than just the insulin production capability. Your pancreas used to produce several essential hormones and at least 2 of those play an important part in D management - as well as producing insulin. Without the Glucagon hormone that tells the liver to open the sugar store when needed (ie when your brain knows you are low) or the Somostatin hormone that plays a big part in balancing insulin and glucose there could be a lot more to YOUR D management than might be understood by any Health Care Professional (HCP) - even a DSN at a Hospital D clinic. There is also the Creon and digestion factor for food you have eaten. T3c is complex! I have my low alert (=alarm) set at 6 with my G7 CGM. Frustratingly Libre only allowed low alerts at 5.6 or below, which sometimes was not high enough to allow me to intercept when I was crashing. The essential thing is to get ALERTS rather than alarms and then have the time to assess your situation, make a decision and treat as necessary.

You asked is 40 too low for your HbA1c? I think possibly - simply because unless you live a very sedentary life and have little change in your day to day lifestyle any activity could make you vulnerable to hypos and the HbA1c is picking up on that. But your Time in Range (TIR), which your CGM will be telling you, is a far more relevant guide.

I'd want to know a bit more about when your one or 2 weekly hypos were occurring before deciding if your basal or bolus needs tweaking. Whatever, don't tweak both at the same time! You'll never know which one was wrong. Your bolus at 1unit to 5gm carbs feels strong to me (non-medical background), particularly if yoy use the same ratio for all times of day. But need more detail at this stage. Has anyone ever suggested you do some basal tests? It could be that your body has just altered a little, particularly as autumn slips away and everything might need some review. That would be normal for anyone on MDI; those who've been on insulin for a long time tend to just know both when to tweak and make gentle changes almost automatically.
 
@DancingStar I don’t have too much experience with this but the nurse at my GP surgery told me to expect to have 1-2 hypos per week and this is “normal”. I don’t know how accurate that is (I’ve had 3 hypos in the 3 months that I’ve been on insulin) but that’s what I was told, which would imply that your 1-2 a week is reasonable maybe? I was also told that it’s best to change one thing at a time and only ever by 10% at a time. Then see how any changes go for a few days, and do another change if it seems that it’s needed after that. Again, this isn’t my personal experience, it’s just the information that’s been given to me. I hope it’s of some help though, combined with the great responses that you’ve already received.
 
DancingStar said:
The nurse told me I shouldn't be getting any hypos at all
Click to expand...
That's silly! The target is <4% of time under 3.9mmol/l. Obviously try and get that lower, but it sounds like you're closer to 1% than 4%, so that sounds fine. As others have said, the GP surgery probably doesn't know much about T1, which is why they're still asking about the number of hypos (I mean who cares, so long as they're minor enough?).
 
For what it's worth, I agree wholeheartedly with what's already been said - mainly that a maximum of 10% at a time and that after 50+ years it's usually a lot less than 5% in fact not even 1% usually.
And of course the ONLY way to find out if it works is try it yourself. So that bit doesn't change!
 
Status
Not open for further replies.
Back
Top