False hypo food advice

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Quizzical

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Type 2
I’ve been a T2 diabetes controlled diabetic for years, but started on insulin (Lantus) just under a week ago. I saw my GP yesterday and he told me to up the units from 10 to 14. However, my fasting bg this morning was 6.2, so I decided to leave it at 10. I had my usual low carb breakfast, but an a hour or so later had what I think was a false hypo with shaking. Checked bg which was 5.7. It would normally have been around 9. My question is: should I eat more carbs at breakfast, and is it OK to fast after supper (at about 6.30pm) until morning or should I have a snack later in the evening.

Sorry if this is all a bit confused!
 
An increase of 10 to 14 units is significant and general advice is usually to increase or decrease by 10% and see how that goes for a few days if it appears that an change in dose is actually necessary. Were the majority of your readings significantly higher than 6 for the Dr to suggest such a big increase? Probably just as well you didn't follow that advice!

Lantus is what we call a basal insulin. It is designed to deal with the glucose trickled out from the liver when we are not eating. It is not there to cover the food you eat, so you should not have to change your diet and eat more carbs in order to have stable BG levels if the dose is correct. You might see your BG levels rise after eating and if that rise is significant, then they should be providing you with a fast acting (bolus) insulin to deal with the carbs from your meals. But taking Lantus should not mean you need to eat more carbs. If you wanted to have the flexibility of eating more carbs then you could do that but they should prescribe you a fast acting insulin as well to cover the carbs in your food.

It may be that now you are using Lantus it has taken a bit of the strain off your failing beta cells (which produce insulin) and having had some of their workload removed by the Lantus, they felt invigorated enough to produce what might ordinarily be a normal insulin response to your breakfast, but because you are used to a less efficient response and less insulin being produced, so your BG levels dropped quicker than usual and your body detected that and panicked a bit causing a false hypo. They can be really nasty and I remeber my first one felt like I might be dying and wiped me out out for the rest of the day. Now even with a genuine hypo, I can usually just munch on a jelly baby or two and continue what I was doing, so even though you weren't genuinely low, it is a really nasty feeling!

Hope your levels settle down a bit soon. I am now off to read some of your other posts because it occurs to me that you might be LADA (Latent Autoimmune Diabetes in Adults) rather than Type 2, which is essentially a slow onset Type 1 diabetes.
 
Thanks for your very helpful reply. I guess that my GP didn’t wait long enough for the Lantus to kick in before deciding to up the dose. I should have added that my diabetes is steroid induced - although I suspect that I may have been going in that direction anyway. I’ve been on prednisone for many years.

The false hypo wasn’t too awful, but I decided to eat a biscuit anyway - I now understand that that might have been a mistake and I should have waited for it to wear off.
 
It is even possible that you may need to reduce the Lantus dose as your beta cells get more help from it and the strain on them is relieved. Early introduction of insulin can preserve and revive flagging beta cells, particularly if you were prescribed Gliclazide previously. which would have put them under increased strain.
My advice would be to play it by ear with the Lantus but go very cautiously if you do feel like you need an increase and always keep hypo treatments with you wherever you are and in particular by your bed so that you don't need to wander the house looking for something when you are sleepy and hypo, perhaps in the bathroom (hot baths and showers can be a prime cause of hypos particularly after exercise) and in the car if you drive is essential as well as whilst out exercising etc.
Good luck and keep us posted with how you get on.
 
Those warning signs at bottom-end-of-the-healthy-range numbers are unpleasant, but not dangerous in themselves.

Something small to eat, with a moderate amount of carbs in it can help to reduce them, but you are wise to be cautious, because you don’t want to overdo it. The urge to eat everything within reach can be pretty overwhelming. o_O

Hopefully it won’t take long for your glucose thermostat to reset itself as you spend more time between 4.0 and 8.5.

Have a chat with your Dr or nurse about your BG improvements, and the symptoms you have been experiencing to keep them in the picture. 🙂
 
Just as well I didn’t increase the Lantus - at 4am I was incredibly hungry and BG was 5.3 rising to 5.6 at 7am. Following the titration guide I was given, I have reduced the Lantus to 8 units this morning. Tried to contact my GP this morning to update him, but he’s on a day off. I’m going to drop a letter into the surgery in case I can’t get past the receptionists tomorrow (yes, I know that they have a challenging job, but grrr!)
 
Quizzical said:
Just as well I didn’t increase the Lantus - at 4am I was incredibly hungry and BG was 5.3 rising to 5.6 at 7am. Following the titration guide I was given, I have reduced the Lantus to 8 units this morning. Tried to contact my GP this morning to update him, but he’s on a day off. I’m going to drop a letter into the surgery in case I can’t get past the receptionists tomorrow (yes, I know that they have a challenging job, but grrr!)
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Hi Quizzical

What you are trying to do at the moment with trying to get your dosage right is one of the most common topics on the forum.

I like to use the analogy of the captain of the ship (doctor) and the deck hand (you, the patient), do you just follow what the captain tells you or do you think and act for yourself? Ultimately, it's finding the right answer and finding patterns; which may be a combination of the doctors/nurses advice and your own input, or the doctor may be wrong and you are best making some changes yourself. Self management is particularly important for Type 1's (like myself) where changes are required regularly and it would be impractical to seek a doctors guidance at every step of the way. It's having the confidence to make some changes yourself to your diabetes management, be it food, carbs, exercise or insulin and testing etc. It's not easy, but this forum is where many people go for answers.
 
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Thanks Amity, that’s very helpful. My FBG this morning was 8.2, so maybe I reduced a bit too far. Although I guess other factors come into it.

I am disappointed with the lack of easily accessible support in this very early stage of my insulin journey; I have no doubt that in time I will be able to self manage, but right now the care all seems a bit perfunctory. I would be much happier with a DSN I could go to with small queries.

I’m not sure how reactive I should be with my FBG - for instance, if it is 8.2 today (but 5.6 and 5.3 yesterday) should I up or reduce the units on one reading or wait several days? My GP didn’t want me to go below an FBG of 6.

I have a titration guide but it isn’t very helpful on the small details.

Thanks again to the forum - glad I found you!
 
Advice is never to alter doses based on an individual occurrence due to the fact that so many things can have an impact on BG so always look for a pattern before considering changing anything xx
 
Quizzical said:
I’m not sure how reactive I should be with my FBG - for instance, if it is 8.2 today (but 5.6 and 5.3 yesterday) should I up or reduce the units on one reading or wait several days? My GP didn’t want me to go below an FBG of 6.
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If your GP is not wanting you to go below 6, then I think a waking reading of 8.2 is really good. The standard guidelines of 4-7 don't apply if you increase the lower limit, so I would say a waking reading under 10 is absolutely fine at the moment.

Many people have a false sense of what is achievable with BG control using insulin (including medical professionals) and some times this leads to unreasonable expectation. It is a very complex balancing act and there are something like 42 factors which affect BG levels and many of them you don't have any control over. Add to that basal insulin injected once a day which may provide too much at some times of the day and not enough at others when a healthy working pancreas trickles out tiny bits throughout the day and night which it adjusts to meet your body's needs and keep things reasonable balanced.
The general guidance is to give any changes in basal insulin 3 days to see the full effect before making more changes. There are exceptions to this if you were hypoing regularly particularly through the night despite a reduction in basal, then it would be prudent to make another reduction sooner and if you are using Levemir which is a shorter acting basal and gives you a more real time response. I regularly change my evening Levemir doses consecutive evenings to get a better balance.

Balancing your basal insulin with your body's needs can be a bit of a dark art. There are elements of educated guesswork and intuition involved. You will find that you are the person who is best placed to make those decisions because you will develop the intuition, whereas the doctor or nurse can only offer an educated guess. Human bodies are very individual and complex. Don't be fooled into thinking that you can "control" your BG levels. The best that you can do is manage them well, but you are never totally in control so aiming for unreasonable targets is setting people up failure, which can negatively impact your mental health.

Not sure if any of the above makes as much sense as I would like, but what I am trying to say is that you are doing really great. It's a huge learning curve and neither doctors, nurses or yourself will get it right all the time. The best you can do is empower yourself with knowledge and learn from any mistakes you make. You have already shown that you have good intuition by not doing the increase the doctor suggested. Don't set yourself unrealistic targets or let clinicians make you feel like you are failing as sadly sometimes happens. Do the best you can and accept that you won't get it right all the time. Most of the time is good enough.
 
Quizzical said:
Thanks Amity, that’s very helpful. My FBG this morning was 8.2, so maybe I reduced a bit too far. Although I guess other factors come into it.

I am disappointed with the lack of easily accessible support in this very early stage of my insulin journey; I have no doubt that in time I will be able to self manage, but right now the care all seems a bit perfunctory. I would be much happier with a DSN I could go to with small queries.

I’m not sure how reactive I should be with my FBG - for instance, if it is 8.2 today (but 5.6 and 5.3 yesterday) should I up or reduce the units on one reading or wait several days? My GP didn’t want me to go below an FBG of 6.

I have a titration guide but it isn’t very helpful on the small details.

Thanks again to the forum - glad I found you!
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Quizzical,

You seem to be on top of things and the readings you are getting are very good indeed, certainly nothing to panic over at such an early stage. I am not type 2, but a type 2 diabetic getting single figure readings is excellent, be it early on or later on.

I agree and "perfunctory" is the perfect description, I've also found this to be common in healthcare, hence why I came to the forum.

For me as a type 1, in the early days it was easier to keep everything the same each day, eating the same foods, amounts, timings etc to enable the insulin doses to be changed, this gives one the knowledge of what affect this is having on blood sugars. The key is like any experiment, only changing one thing at a time and giving things time to take effect.

You are essentially building up a data base, once you get doses right, then you can move on to food types, carbs, timings, amounts of food, exercise, stress etc. For type 2's it does seem it's the carbs that need attention to help lower blood sugars into range, although easier said than done, so many factors involved.

You're off to a good start and you've made an effort to come onto the forum to try and make things easier for yourself.

It pays to put the effort in.
 
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What I am hearing from you makes really good sense and I feel quite reassured. Thank you - it’s a better day already!

My FBG levels and Hba1c results have never been really high, but enough to compromise my general health, so I am playing with quite small adjustments. With steroid-induced diabetes there isn’t much choice of treatment and I react badly to oral meds. Hence the insulin. I can already see the FBG levels coming down a little so that’s really encouraging.
 
Quizzical said:
I’m not sure how reactive I should be with my FBG - for instance, if it is 8.2 today (but 5.6 and 5.3 yesterday) should I up or reduce the units on one reading or wait several days?
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Sounds like you are working hard at bringing your BGs into line @Quizzical

Lantus has a bit of a reputation for being a bit ‘laggy’ when it comes to dose adjustments. Many people find it can take a day or two for it to settle into an adjusted dose.

Waiting a few days to see if there is a pattern in results, and then being patient while the dose changes settle over a day or two can help stop you feeling like you are chasing your tail and going round in circles 🙂

(though it can also make the process of adjustment feel like it’s going on for ages!)
 
Thank you for the encouragement! Yes, I think that it was a false start with the Lantus. My GP clearly thought that it wasn’t working enough. I will be more patient now and stop panicking. FBG today was 6 (8.2 yesterday). My AgaMatrix app gives me averages and I’m quite happy with those so far.
 
Is there any reason why units seem to be recommended to go up or down in twos? I would like the choice of changing one unit up or down. I don’t mean that I want to change from day to day, but maybe after a week, depending on FBG results.
 
Quizzical said:
Is there any reason why units seem to be recommended to go up or down in twos? I would like the choice of changing one unit up or down. I don’t mean that I want to change from day to day, but maybe after a week, depending on FBG results.
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Hi, I think it depends on the pen device. My Tresiba pen gives 1 unit increments.
 
Back in the day I had to ask for a Lantus-suitable pen that had single unit increments - the default blue Autopen24’s they seemed to issue only did 2u divisions
 
I change by half units sometimes. If you are using small doses then single units or half units are fine for adjusting. Once doses get larger then 2 units is more standard. So for me on Levemir, I use 26 units on a morning and anywhere from 0-6 on a night depending upon how active I have been in the previous few days. I usually change my daytime by 2 units if it needs adjustment, so I will occasionally drop it to 24 but my evening dose can sometimes just need half a unit and sometimes if I have been really active it will need as much as 3 unit reduction, or anything in between.
I think 10% is the recommended standard adjustment and then give it 3 days to see how that worked out.
 
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