I live in Namibia where diabetes management resources are not the best. I was diagnosed with LADA 16 years ago aged 50 which makes me 66 now. I started on basal bills insulin 12 years ago. My GP says I should continue with metformin 1000 mg/day and a Dipeptidyl Petidase 4 Inhibitor called Galvus 50mg/day. I believe my pancreas stopped producing insulin completely many years ago which basically means I should now be treated as a Type 1 as I understand it. Can I stop taking the metformin and DPP-4i?
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LADA treatment with insulin + metformin + DPP-4i?
- Thread starter Piers
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SB2015
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Welcome to the forum @Piers
If your pancreas is no longer producing insulin, which is the eventual outcome of the antibody attack, then you are as you say effectively Type 1. I was also diagnosed in my 50s and have been happy with the T1 label from the start.
Idint know the Ned’s that you are taking and uncertain what benefit the Metformin will be having. We’re you given reasons for continuing with these?
If your pancreas is no longer producing insulin, which is the eventual outcome of the antibody attack, then you are as you say effectively Type 1. I was also diagnosed in my 50s and have been happy with the T1 label from the start.
Idint know the Ned’s that you are taking and uncertain what benefit the Metformin will be having. We’re you given reasons for continuing with these?
Thanks for yours SB2015. My GP here is my only medical support and he doesn't really know much about diabetes - I think I'm his only diabetic patient. So no, he hasn't given any reasons for continuing with metformin and dipeptidyl peptidase 4 inhibitors (DPP‐4i) other than that they probably won't do any harm. I'm wondering if T1 diabetics take other meds such as metformin and dipeptidyl peptidase 4 inhibitors (DPP‐4i) or do they just go with insulin. Those pills are expensive here, especially the dipeptidyl peptidase 4 inhibitors (DPP‐4i), and I'd much rather stop if possible.
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I have no medical qualifications, but from what I understand of DPP-4 meds they don’t seem likely to be helpful for T1 or LADA where there is little or no insulin production.
www.diabetes.org.uk
Have you had a cPeptide check to assess how much insulin you are still producing?
LADA is mostly treated as a form of T1 in the UK.
Some people with T1 find it helpful to take Metformin (especially if they have some insulin resistance) as it can make them more sensitive to the insulin they take.
Are you getting side effects from either of these meds?
DPP-4 inhibitors (gliptins)
DDP-4 inhibitors are a type of medication you might need to take if you have type 2 diabetes. They are also known as gliptins.
Have you had a cPeptide check to assess how much insulin you are still producing?
LADA is mostly treated as a form of T1 in the UK.
Some people with T1 find it helpful to take Metformin (especially if they have some insulin resistance) as it can make them more sensitive to the insulin they take.
Are you getting side effects from either of these meds?
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Ah that puts it in a different light.
It is uncommon, but not unknown for a T1 to be offered Metformin in the UK.
But I would not expect a T1 to be offered a DPP-4, especially if they have little or know insulin production to be stimulated by the drug.
Thank you everydayupsanddowns. I've just found a place where I can have a C-peptide test here and will do so in the coming days. Having quickly googled it I understand that should definitely be my next step. I reads that C-peptide levels <0.3 nmol/L: a multiple-insulin regimen is recommended. And from you I've learned that I can probably do without DPP-4. You say that metformin can benefit people with insulin resistance. What is that? How does it exhibit?
Sorry I didn't answer your question: Are you getting side effects from either of these meds? No, no side effects except to my peace of mind and wallet.I have no medical qualifications, but from what I understand of DPP-4 meds they don’t seem likely to be helpful for T1 or LADA where there is little or no insulin production.
DPP-4 inhibitors (gliptins)
DDP-4 inhibitors are a type of medication you might need to take if you have type 2 diabetes. They are also known as gliptins.
Have you had a cPeptide check to assess how much insulin you are still producing?
LADA is mostly treated as a form of T1 in the UK.
Some people with T1 find it helpful to take Metformin (especially if they have some insulin resistance) as it can make them more sensitive to the insulin they take.
Are you getting side effects from either of these meds?
I've just read on the Diabetes UK site that both metformin and DPP-4i reduce the amount of glucose released by the liver. But how important is that? I have pretty good blood glucose control - last HbA1C was 6.3 - but I put that down to insulin. Probably I should just stop the pills and see what happens - subject to the C-peptide test result?
Inka
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A basic way to see if you’re insulin resistant is to look at the amount of insulin you’re taking. Can you give a little more detail eg insulin name, number of units, meal ratios?
rebrascora
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Needing large doses of insulin would indicate insulin resistance.
If you are going to get a C-peptide test, make sure you prepare for it properly. There should be instructions for your BG levels to be above a certain level so that your own pancreas is stimulated to produce insulin. A blood C-peptide test is more useful/accurate than a urine C-peptide but the sample needs to be frozen within 20 mins of being drawn and sent to the lab in that frozen state (which may be even more relevant in Namibia), so generally needs to be done at a larger medical facility or perhaps the lab itself, to ensure the sample is processed appropriately.
If you are going to get a C-peptide test, make sure you prepare for it properly. There should be instructions for your BG levels to be above a certain level so that your own pancreas is stimulated to produce insulin. A blood C-peptide test is more useful/accurate than a urine C-peptide but the sample needs to be frozen within 20 mins of being drawn and sent to the lab in that frozen state (which may be even more relevant in Namibia), so generally needs to be done at a larger medical facility or perhaps the lab itself, to ensure the sample is processed appropriately.
Thank you, Inka. How much insulin I take varies a lot partly because I have a rather unstable lifestyle. When things are quiet I would normally take 17 units of a basal dose of insulin glargine, and about 30-40 units of Novarapid in 5 or 6 doses per day. Sorry I don't know what meal ratios means.
Thank you Barbara. The blood C-peptide test will be done tomorrow morning and I've been told its a fasting test. No other instructions. I am wondering when and for how long BG levels should be above a certain level? And what level? Approximate figures would be much appreciated? The test will be done at an excellent medical facility and I am sure it will be processed properly (in Cape Town. South Africa).
rebrascora
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I am not sure that a fasting test for C-peptide is appropriate but perhaps your system is different. The idea I believe is that you eat something without bolus insulin, so that your levels go high enough to trigger your pancreas to release whatever insulin it can in response to that food. @Lucyr had a C-peptide recently so hopefully she will have more info on actual levels
Actually, I booked the test by phone this morning and they told me nothing. Then I read at C-Peptide Test: MedlinePlus Medical Test
Will I need to do anything to prepare for the test?
For a C-peptide blood test, you may need to fast (not eat or drink) for 8–12 hours before the test. Ask your provider if there are any specific instructions you need to follow before either a blood or a urine test.
So I phoned again and asked about fasting and they confirmed.
This is normal where there is no NHS....
I think I will do as you say: "eat something without bolus insulin, so that your levels go high enough to trigger your pancreas to release whatever insulin it can in response to that food". Makes sense.
rebrascora
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Your insulin doses are not particularly high that insulin resistance would be indicated but your ratio of basal to bolus is interesting. Ie Bolus insulin is almost double your basal. I wonder if you have done a basal test recently to assess if your Glargine dose is holding you steady in the absence of food or if your bolus insulin is having to prop up a basal deficit.
Not saying your Glargine dose is wrong but you clearly have very little support with your diabetes management so it may be that that dose was based on some formula that may or may not apply to your body and has perhaps not been checked or reviewed.
It is also entirely possible that your body is at one side of a broad spectrum and you just need less basal than bolus insulin perhaps due to the climate.... Generally they seem to think that the basal/bolus insulin ratio should be somewhere a bit closer to 50/50 but nothing is set in stone.
It sounds like you don't carb count and just inject set amounts for meals. Do you also add corrections and do you have a correction factor ie. 1 unit of bolus insulin drops your levels by x mmols?...Usually they suggest 1 unit will drop your levels by 3mmols to start you off, but then you experiment to see what actually works for your body. With insulin resistance you usually need considerably more insulin to bring levels down, so you might find that 1unit drops you just 1mmol or perhaps you need 2 units to drop you 1 mmol.. that sort of thing..... If none of that makes sense, just ask me to explain it better because I am aware that you have likely had very little input on using a basal/bolus insulin regime effectively.
Not saying your Glargine dose is wrong but you clearly have very little support with your diabetes management so it may be that that dose was based on some formula that may or may not apply to your body and has perhaps not been checked or reviewed.
It is also entirely possible that your body is at one side of a broad spectrum and you just need less basal than bolus insulin perhaps due to the climate.... Generally they seem to think that the basal/bolus insulin ratio should be somewhere a bit closer to 50/50 but nothing is set in stone.
It sounds like you don't carb count and just inject set amounts for meals. Do you also add corrections and do you have a correction factor ie. 1 unit of bolus insulin drops your levels by x mmols?...Usually they suggest 1 unit will drop your levels by 3mmols to start you off, but then you experiment to see what actually works for your body. With insulin resistance you usually need considerably more insulin to bring levels down, so you might find that 1unit drops you just 1mmol or perhaps you need 2 units to drop you 1 mmol.. that sort of thing..... If none of that makes sense, just ask me to explain it better because I am aware that you have likely had very little input on using a basal/bolus insulin regime effectively.
Thank you again Barbara. I've never heard of a basal test. What is it? Can I do it myself? Many years ago I was on a basal dose of about 23 units but after I had a few bad hypos I cut it down bit by bit. That was before I started on Dexcom CGM a couple of years ago so maybe I should try upping the basal a bit now.
I do count carbs, well not exactly count but vaguely estimate if you know what I mean. I do vary meal doses a lot and usually take a bit more carbs or insulin a couple of hours after eating to sort out consequent lows/highs. I don't know what corrections are, so maybe that means I don't count carbs. It sounds as if I must do some reading. I've just discovered this Diabetes UK site so I will have a search. Thanks again.
Lucyr
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There are different ways of doing the cpeptide test so you need to do whichever way you’ve been advised, fasting in your case it sounds.
The more useful way (in my view) is the stimulated view. This means eating a meal with carbs, no bolus insulin but take basal insulin as normal. Have the cpeptide test 2hrs after food and bg must be above something, can’t remember what exactly but think it was above 8-9ish.
The other method is to have a fasting cpeptide test. You take basal insulin as normal but have the cpeptide test in the morning before bolus and before breakfast. Sounds like this is the one you’re having.
There’s a seperate range for each scenario and your dr needs to interpret it against the equivalent range.
The more useful way (in my view) is the stimulated view. This means eating a meal with carbs, no bolus insulin but take basal insulin as normal. Have the cpeptide test 2hrs after food and bg must be above something, can’t remember what exactly but think it was above 8-9ish.
The other method is to have a fasting cpeptide test. You take basal insulin as normal but have the cpeptide test in the morning before bolus and before breakfast. Sounds like this is the one you’re having.
There’s a seperate range for each scenario and your dr needs to interpret it against the equivalent range.
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Inka
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Well, your 17 units of basal doesn’t sound excessive, but without knowing your ratios it’s hard to comment. A meal ratio is how many grams of carbs one unit of insulin covers. As an example, if you had a meal ratio of 1:10g and ate 50g carbs, you’d take 5 units of insulin.
Are some of your 5 or 6 doses of Novorapid for snacks or are they to correct high sugar?
rebrascora
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A basal test is where you check to see if your basal insulin is holding you reasonably steady in the absence of food throughout the day and night. It is done by skipping meals in rotation over several days. So one day you might skip breakfast and not eat until lunchtime and see what your levels do overnight and during the morning. Then the next day, you have breakfast early, but skip lunch and see what happens over that lunchtime/afternoon period when only basal insulin is working, then the next day or a couple of days later you have lunch as usual, but skip your evening meal and go all night without food.
If you have not had any formal education on basal bolus insulin usage, the BERTIE online course is often recommended although I am not sure if it is accessible from outside the UK.
There is a thread about basal testing in the pumps and technology section... I will see if I can find it and post a link.
Getting your basal dose right makes all the difference in the world to managing your diabetes as everything starts to make sense when you get the balance right..... until you need to adjust it again of course. Basal needs don't generally stay the same. Here in the UK many of us see a seasonal change in our needs and for me exercise makes a significant difference so I need to dial my dose down after exercise and increase it again when I am more sedentary.
If you have not had any formal education on basal bolus insulin usage, the BERTIE online course is often recommended although I am not sure if it is accessible from outside the UK.
There is a thread about basal testing in the pumps and technology section... I will see if I can find it and post a link.
Getting your basal dose right makes all the difference in the world to managing your diabetes as everything starts to make sense when you get the balance right..... until you need to adjust it again of course. Basal needs don't generally stay the same. Here in the UK many of us see a seasonal change in our needs and for me exercise makes a significant difference so I need to dial my dose down after exercise and increase it again when I am more sedentary.
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