Insulin resistance

[MBuck]

I have had diabetes for a long time since my twenties. The condition was induced by a prolonged period of talking steroids because of a rare illness. I wasn't classified as either T1 or T2, actually the classification system wasn't there over fifty odd years ago. To cut the story short. I am now on NovoRapid and Toujeo. The control isn't brilliant with HbA1C about 8. I am allergic to many drugs including Metformin. I have insulin resistance too. I started Toujeo about three months ago hoping the reduced amount of injection helped. Unfortunately not as expected.
It would be lovely if anyone who would like to share your experience. Thanks.

 

[Proud to be erratic]

Hello @MBuck and welcome to the Forum,

I can't particularly share a specific experience on steroids damaging one's pancreas and causing diabetes - but the condition was recognised during an International Conference not many years ago when the nomenclature of Type 3 (a-k) was developed and you would fall into the proposed Type 3e. Some extracts below:

​

Secondary diabetes occurs as a consequence of another medical condition. For example, cystic fibrosis, hemochromatosis, chronic pancreatitis, polycystic ovary syndrome, Cushing’s syndrome, pancreatic cancer, glucagonoma and pancreatectomy. There is also drug induced diabetes which is caused by taking certain medications. For example, corticosteroids (steroid induced diabetes), beta-blockers and thiazide diuretics.​

Usually secondary diabetes is a permanent condition, however in some cases there might be the potential to reverse the effects of hyperglycaemia. The management of secondary diabetes will depend on the condition or medication that has caused it.​

​

Then followed the listing for each T3 type, including:​

​

Type 3e diabetes. This form of diabetes is any diabetes that has been induced by chemical or drugs. For example, high doses of steroids, taken for an extended period of time, can lead to diabetes developing. Steroid-induced diabetes is therefore a form of type 3e diabetes.​

​

Today those diagnosis descriptors were not wholly adopted, since the World Health Authority didn't endorse the proposals. But in UK Type 3c has been taken into NHS vocabulary and there is a general increasing awareness by Health Care Practicioners that not all Diabetes is simply T1 or T2.

This vocabulary matters, since I (as a T3c after surgery to resolve my Pancreatic Cancer) is treated as if T1 and I get all the breadth of support that is available to T1s, ALONG with support from Hospital based Diabetes Teams and for over 3 years the associated Surgical teams for Upper GI, plus continued Oncology support.

And that wide ranging support is a great help, starting with recognition that my D originates from radical surgery and I continue to have issues that affects my D management, originating from my Surgery (a Whipples Procedure).

So returning to your unique circumstances:

Do you have some form of CGM, such as Libre2 or 2+? If not, you should and that will help enormously with daily management.

Are you under any other Specialist Teams, including for your original rare illness and now your Diabetes? If not, then that ought to be resolved. Notwithstanding any GP's best intentions as a General Practicioner your condition is outside their normal experiences.

There is a vast amount of experience on this Forum, who will certainly be able to help with "tips and tricks" for daily management of anyone's D, so do ask questions; any question; there will be someone who can point you in a good direction.

Look forward to hearing more from you.

 

[Ivostas66]

Sorry to hear you're having issues with insulin.

Not long after my diagnosis, I was put under the care of a new DSN who immediately moved me onto Toujeo. She had the most up to date training in the centre (this was back in 2018) and said the Toujeo was amazing when compared to other Basal insulin. She said that during the extensive testing prior to it 'coming to market', it had proven to be the most stable and effective in almost all metrics. She warned that my doctor would not be keen to prescribe it and would most likely say that it was 'too strong' for someone who required relatively small doses, which was me at the time. However, the real reason she said that it would not be prescribed was due to cost. Sure enough he questioned the request, claiming it would be too strong for my needs and that I should be on a more recognised basal. She pushed very hard and I was moved to Toujeo. My control in terms of time in range improved significantly.

I was moved from Novorapid (Notveryrapid for some of us) to FIASP a few years ago and also saw improvements - the dreaded post prandial spikes were less frequent and much lower.

 

[MBuck]

It sounds like you’ve been managing a very complex case of diabetes, and it’s impressive that you’re staying proactive. Since Toujeo hasn’t worked as expected, it might help to revisit your insulin dosing and timing with an endocrinologist. Exploring options like continuous glucose monitoring (CGM), other insulin types, or medications that tackle insulin resistance could also make a difference. Dietary tweaks and light exercise might improve insulin sensitivity, but these should align with your overall plan. Sharing experiences in support groups could also bring fresh ideas. Stay strong—you’re doing great by seeking solutions!

Thank you Kristin for your kind words and wishes. Insulin resistance is a hot potato that so far no definite solution for it. I often have surprises with the injection results. They could be satisfactory readings, or disappointingly high or low readings. Sometimes readings stay level through out the day. All these results depend on the injection sites more than what I eat or how much exercise I have done. I have a feeling that the Diabetes team is somehow abandoning me because of the barriers. Perhaps I should say the diabetes care in my area needs improvement.

 

[MBuck]

I am flattered with all the comments. They are really useful . Thank you all .
I have been using NovoRapid for a long time. Perhaps change to another short acting insulin to see if that would work better. I'm seeing the DM consultant coming Friday. Hope to get something positive .

 

[rebrascora]

Hi and welcome.

Sorry to hear you are experiencing unreliable results with your insulin.

Just to be clear, are you needing increasingly larger doses of insulin to keep you in range? This is insulin resistance where your body becomes less responsive to the insulin you produce yourself or the insulin you inject. This can sometimes occur if you become overweight or it can also be caused by changes in other hormones in the body. In this situation you might need very large doses of insulin possibly in 3 figures for your basal insulin and 30 or more units per meal.

Or....

Are you talking about poor injection sites which are not absorbing well. If so Toujeo which is insulin glargine, may not be the best option because it can get trapped in injection sites particularly if the tissue is damaged and then release later, sometimes weeks or months later when you least expect it, causing massive hypos and of course when it is trapped and doesn't release levels will go very high and you will need to fire fight with fast acting corrections.

Which insulins have you tried in the past and what sort of size doses are you currently taking,
Also, have you used the full range of injection sites including buttocks and thighs and basically anywhere you have a reasonable depth of subcutaneous fat and no significant surface blood vessels.

 

[MBuck]

Hello @MBuck and welcome to the Forum,

I can't particularly share a specific experience on steroids damaging one's pancreas and causing diabetes - but the condition was recognised during an International Conference not many years ago when the nomenclature of Type 3 (a-k) was developed and you would fall into the proposed Type 3e. Some extracts below:

​

Secondary diabetes occurs as a consequence of another medical condition. For example, cystic fibrosis, hemochromatosis, chronic pancreatitis, polycystic ovary syndrome, Cushing’s syndrome, pancreatic cancer, glucagonoma and pancreatectomy. There is also drug induced diabetes which is caused by taking certain medications. For example, corticosteroids (steroid induced diabetes), beta-blockers and thiazide diuretics.​

Usually secondary diabetes is a permanent condition, however in some cases there might be the potential to reverse the effects of hyperglycaemia. The management of secondary diabetes will depend on the condition or medication that has caused it.​

​

Then followed the listing for each T3 type, including:​

​

Type 3e diabetes. This form of diabetes is any diabetes that has been induced by chemical or drugs. For example, high doses of steroids, taken for an extended period of time, can lead to diabetes developing. Steroid-induced diabetes is therefore a form of type 3e diabetes.​

​

Today those diagnosis descriptors were not wholly adopted, since the World Health Authority didn't endorse the proposals. But in UK Type 3c has been taken into NHS vocabulary and there is a general increasing awareness by Health Care Practicioners that not all Diabetes is simply T1 or T2.

This vocabulary matters, since I (as a T3c after surgery to resolve my Pancreatic Cancer) is treated as if T1 and I get all the breadth of support that is available to T1s, ALONG with support from Hospital based Diabetes Teams and for over 3 years the associated Surgical teams for Upper GI, plus continued Oncology support.

And that wide ranging support is a great help, starting with recognition that my D originates from radical surgery and I continue to have issues that affects my D management, originating from my Surgery (a Whipples Procedure).

So returning to your unique circumstances:

Do you have some form of CGM, such as Libre2 or 2+? If not, you should and that will help enormously with daily management.

Are you under any other Specialist Teams, including for your original rare illness and now your Diabetes? If not, then that ought to be resolved. Notwithstanding any GP's best intentions as a General Practicioner your condition is outside their normal experiences.

There is a vast amount of experience on this Forum, who will certainly be able to help with "tips and tricks" for daily management of anyone's D, so do ask questions; any question; there will be someone who can point you in a good direction.

Look forward to hearing more from you.

Thank you for the information. Diabetes is such a complex condition that many mysteries remain to be explored.
I have been using Libre2+ for a while. It is convenient for blood sugar test, but I am not too sure if it gives absolutely accurate readings. I compare the readings using my Accu-Chek and Daxcome 1 plus. Daxcome gave the highest reading, Libre2+ second and Accu-Chek the lowest. Each reading is about two units difference. My Libre2 doesn't always record my readings. However, I find Libre2 so far fulfills the basic purpose. I check with my Accu-Chek when in doubt.
I have irregular appointments with the DM consultant, which is not ideal. I wouldn't say the diabetes care in my area is brilliant. They definitely need more empathy and enthusiasm.
I have other conditions too. They rely on a good control of my DM to be stable. Hoping to get support and learn more from this forum.

 

[Proud to be erratic]

If injection sites are becoming scarce, have you considered (or has your GP / Surgery Nurse / Hospital team considered and suggested) changing your basal to Tresiba. This would mean only 1x daily basal, which lasts c. 40 hrs; ie today's dose is topping up yesterday. That then provides an ensured steady basal, which once the dosage is adjusted to meet your specific needs leaves me with a very dependable background insulin for the late evening and through the night. I then know that whatever is going on with my daytime BG partying only(?) needs me managing my bolus, activity and food. Whatever my Teesiba basal is also bringing is effectively fixed and dependable for that contribution. No needing to 2nd guess is it my basal or my bolus that's causing today's or caused yesterday's wobble?

That means Tresiba is often described as very inflexible - changes in dosing take at least 48 hrs to show a response. I think that inflexibility and thus dependability is Tresiba's strength. It certainly suits my age and lifestyle, in that I'm fully retired, very active (can walk and hike all day, [but never run for a bus!]) with no 2 days similar in routine.

Answers to @rebrascora's questions would provide more clues for us to better understand your situation.

In respect of using CGM with back-up from fingerprick tests, that is essential. From a DVLA perspective, assuming you drive, you must have a means of verifying your CGM whenever you are driving. If you weren't aware of that there are several threads in the Driving/DVLA section about this conundrum, including a recent and lengthy posting about CGM and driving.

CGM is absolutely terrific for a minute by minute reassurance and brilliant for the direction arrows to inform us of changes in BG direction. I'm fortunate enough to have the Dexcom G7 on prescription and that has some very comprehensive alerts built in to the phone app and the Receiver. These show how inadequate Libre alerts are (alas)! But all the CGMs do have definite limitations, which unsurprisingly the Manufaturers don't tell us about. You can find these, if you haven't already seen them, as the first "pinned" thread in the Pumping and Technology section of the Forum. I've put a link to them below.

H

Thread 'CGM limitations and precautions'

Sep 8, 2023

Moderator Note: This helpful reply was copied from another thread as it details some of the commonly experienced limitations of continuous glucose sensors.

My blood sugar has been in perfect range for days now, but although I haven't changed anything, I'm starting to get very short periods of hypos while I sleep and this morning I had a hypo alarm.

If these are very short periods of lows and occur overnight, they are more likely to be compression lows - when pressure is applied to a sensor, it will report a false low. The reason I say this is more likely to happen at...

• helli
• Replies: 23
• Forum: Pumping and Technology

• 
• 
• 

My G7 can be calibrated to mirror my actual BG. The sensor takes interstitial fluid which lags actual BG by 10 or even 15 mins. If you haven't been made aware of this lag, the Abbott tutorials explain the concept extremely well, with their analogy to a long train on a hilly journey and the engine can be at the top of a hill, while the last carriage is still at the bottom; then you of course get the reverse perspective of train at the bottom with the end carriage still at the top. PLUS the scenario of engine halfway down the hill and end carriage halfway up - both misleading you with their apparently equal elevation, only for that to change and further confuse you about trend direction.

The calibration does mean that if a sensor initially starts lower or higher than actual it can be brought to a state that very closely matches actual for almost the full 10 days of its life. The use of an algorithm built into the sensor data readings and then presentation on a screen will never completely get interstitial exactly matching actual when our BG is changing rapidly. I routinely had to work with Libre 2 being 2 mmol/L (and more) adrift from actual; some times higher, sometimes lower and sometimes starting higher but ending lower (or vice versa). It turned out my body was not compatible with Libre; it certainly is very happy with G7. However I know well how frustrating it can be having a 2 or more mmol/L difference can be. Constantly having to gauge how much to dose without overdosing or how light a response might be and yet still be effective.

My experience has been that there are plenty of folk here in the forum, who will share their knowledge and yet rarely try to impose their thoughts or experiences on you. You've already seen some of that.

You said "I have other conditions too. They rely on a good control of my DM to be stable." I suspect there is also a need for each specialist HCP you encounter to take due note of and help you to find compromises that might be essential between your other conditions and your Diabetes. That necessity for compromises is what can seperate the T3s from T2s or T1s.

 

[everydayupsanddowns]

The side-conversation between @Proud to be erratic and @JITR about various Type 3 classifications has been moved here

J

Thread 'Diabetes Classifications…'

Nov 25, 2024

... the condition was recognised during an International Conference not many years ago when the nomenclature of Type 3 (a-k) was developed and you would fall into the proposed Type 3e. Some extracts below:

​

Secondary diabetes occurs as a consequence of another medical condition. For example, cystic fibrosis, hemochromatosis, chronic pancreatitis, polycystic ovary syndrome, Cushing’s syndrome, pancreatic cancer, glucagonoma and pancreatectomy. There is also drug induced diabetes which is caused by taking certain medications. For example, corticosteroids (steroid induced...​

• JITR
• Replies: 6
• Forum: General Message Board