Recent LADA diagnosis

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Daffodil63

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Type 1.5 LADA
Hello and Good afternoon!
I have found this site and the forum very helpful in these first 3 months since starting insulin following diagnosis of LADA in June. One of the main things I have learnt is that everyone is different with regard to their management of diabetes and the key is to find what works for you. Three months in and I feel I am still in the ‘trial and learn’ stage, currently waiting for a hospital appointment with the dietician, management so far with help from my GP practice which is at the moment without any diabetic nurses. So I have a few questions and would appreciate any thoughts from the kind people on this forum.
background: type 2 diagnosis Jan 22, started Metformin and low carb diet in an attempt to improve things. Diet successful, lost 20kg over 10 months, improvement in Hba1c initially. Relaxed diet a little, still losing weight, next Hba1c raised again. Took Dapagliflozin for 4 months, still didn’t feel right so I asked GP for antibody test. Positive for GAD and LADA diagnosed. Oral medication stopped and insulin started in June.
Currently take 9u Lantus once a day and 7 to 8 units novorapid per day split between the 3 meals.
I have worked out my insulin carb ratio to be between 1:15 and 1:30, depending on the meal. I have not yet done a formal carb counting course but have done the Bertie on line and have read quite a lot! I feel I have a good grasp on the carb counting concept but need practical help. It seems I still have some insulin production of my own so on some days I find the carb counting does not always work and I end up with either low or high BG post the meal. I keep a diary on most days and have used this to look at insulin carb ratios.
I am self funding a libre CGM and find this very useful to reduce anxiety and keep an eye on BG. Hopefully I should be able to have this prescribed once I have the hospital appointment.
so a few questions…
How do we keep BG within range, is it normal to have the odd blip up or down post meals….happens 2 to 3 times a week for me.
Should I be concentrating more on keeping morning, pre meal and bedtime within range and not worry too much about the BG readings in between?
If BG remains higher than 10 two hours post a meal, is it wise to give a correction dose? As I need a relatively small amount of insulin, I worked out my correction dose of 1 unit would bring BG down by 6 mmols which is quite a lot, so I am wary of doing this. Have resorted to exercising but that’s another story….
My basal dose is about right as overnight levels are in range.
I have asked if I can have a half unit novorapid pen but asked to wait until my hospital appointment . Do you have any suggestions how I might improve the mealtime dosing?
I feel sometimes that I am restricted to 1, 2 or 3 units per meal, tried 4 units when I had a starter too and that took BG below 4. I read on a post here that when considering the insulin dose using carb counting,take into account the pre meal BG and if it is on the low side, round the insulin dose down, but if it is on the high side, round the insulin dose up. I also read that some of you split the mealtime dose rather than take it all up front to get better control. Any advice on this would be welcome.
Exercise….I have found that both gardening and walking the dog can bring my BG down quite quickly especially within 2 hours of the next meal. Conversely, sitting at a computer after lunch at work can keep my BG high and I seem to need more pre lunch insulin in this situation than when pottering around at home. I am just getting back into playing tennis so let’s see what happens there. I gather these situations are fairly ‘normal’?!
lots of questions….I think I am doing OK, but any advice welcome, especially before my hospital appointmen. I would really like to reduce the peaks and troughs, but I am aware it is early days and the LADA diagnosis may complicate things.
Thank you
 
Welcome to the Forum @Daffodil63!

First and foremost it really sounds like you’re doing a great job in managing your sugars. You’ve done lots of reading and the Bertie online course which seems to have given you a lot of confidence.

You’ve asked really sensible questions and we’re sure there are many here on the forum who will have similar experiences to share.
 
Daffodil63 said:
How do we keep BG within range, is it normal to have the odd blip up or down post meals….happens 2 to 3 times a week for me.
Should I be concentrating more on keeping morning, pre meal and bedtime within range and not worry too much about the BG readings in between?
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It’s certainly normal for the odd blip up or down post meal as there will be varying factors impacting the sugars. For example, the meal itself and how much activity you have done on that day.
You say it’s happening 2 to 3 times a week for you. Have you noticed any particular patterns when this has happened?
Sounds like you’re managing really well if the blips are happening as few as 2 or 3 time a week. You’re privy to a lot more information with the Libre and your BG readings in between meals are of course important but you only need to be concerned if you’re going too low (below 4) or too high with symptoms.
 
Daffodil63 said:
If BG remains higher than 10 two hours post a meal, is it wise to give a correction dose? As I need a relatively small amount of insulin, I worked out my correction dose of 1 unit would bring BG down by 6 mmols which is quite a lot, so I am wary of doing this. Have resorted to exercising but that’s another story….
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If 1 unit brings your BG levels down by 6mmols it doesn’t sound like you would need to be doing this often. What sort of results have you noticed 2 hours post meal?
Sounds like something to mention at your hospital appointment too.
 
Hi @Daffodil63, I’m very new and in pretty much the same situation as you (including insulin doses/ratios!) except I was diagnosed in August. I’ll let other more experienced people chime in here, but my GP surgery is prescribing my Libre 2. I believe they can now do this, whereas previously only the hospital could? I would ask your GP about this - I hate to think of you paying for the Libre if you’re entitled to it on prescription. I haven’t had a hospital appointment yet either. Good luck and I’ll be reading all the responses to this with interest!
 
I use excercise to keep my bs lower after eating. I eat, Eait for bs to start to rise, then normally take a 20 min walk until the cgm shows bs have finished spiking and started to go down. But then they can go down quite quickly so have to be careful...i would use exercise to lower bs up to 5 hours after a bolus injection (on novorapid too)
I used to split bosules etc but, to be honest, now i don't bother.
As for your diavestes doing different things on different day...it just does that
I'd focus on total time in range (4 to 10) but not be too hard on yourself about it, just see if you can get a wee bit better week on week
One thing it took me a while to realise is just how much quicker juice is to get working than glucose tablets or jelly snakes.
Re improving meal time dosing, i found getting ths carn count up tp what i wanted with a course of cheese, fruit and biscuits...outcakes are around 5 carbs and with grapes can be used to get your carb count up to a good number for your insilin dose
 
I agree that you are doing brilliantly for such a short time on insulin and no formal support and being limited to whole unit pens, particularly when you are insulin sensitive.
I really would not worry about highs at this stage unless you are going up to mid teens or above and not coming down by the next meal.

The NR has a max 5 hour profile of activity, so don't be tempted to make a correction until at least 4 hours after you injected it, definitely not after 2 hours as the chances are it will bring you back down by your next meal.

Try not to get sucked into the BG targets for dietary controlled Type 2 diabetes. ie. 4-7 before meals and less than 8.5 2 hours after a meal. The insulin we use has a longer profile of action than naturally produced insulin and we inject it into the wrong place (ie subcutaneously rather than belng secreted into our blood stream), so we can't expect it to match home produced insulin and balance things quite as well as that. We will get more rise and fall and in some respects the data Libre provides can cause us to assume that we are not doing well, when by the sound of it your are doing fantastic, but yes you will have wobbles and spikes which longer term and with more refined tools like half unit pens and learning how long in advance of each meal to prebolus, to allow the insulin you have injected to hit the blood stream at pretty much the same time as the glucose from the food you ate and generally it is this which prevents the spikes unless your carb ratio is out. However, in these early days, your own pancreas is still producing some insulin but it can be unpredictable, so you have to play it safe and use less insulin than you might need and give it longer to work, rather than get impatient, inject more and then the tail end of the insulin you already injected or a bit of home grown insulin kicks in and drops you like a stone.
There will be plenty of time to fine tune your diabetes management when you have half units and perhaps your own insulin production has more or less run out, but in the early months it is really just about keeping things on a reasonable even keel, but perhaps slightly higher rather risking lows.

Do be aware that exercising during that 3 hours after a bolus injection (ie with active insulin in your system) can cause your levels to drop quite dramatically and some people reduce the number of units they inject for the meal before exercise to counter this. Also, the effects of exercise can last up to 48 hours and will have a cumulative effect, so exercising 2 or 3 days in a row can make you more prone to hypos. My levels usually drop at night whilst I sleep after exercise and I have to reduce my evening basal insulin to try to prevent nocturnal hypos. Just to be aware when you start playing tennis again that it can have this longer term knock on/cumulative effect, which can have implications during the night and the following day and night.
 
You’re doing great @Daffodil63 🙂 After safety, the most important thing to remember about Type 1/LADA is that perfection is impossible. 70% Time in Range is considered very good control. Yes, 70%. Striving to be in range every minute of the day is not only the way to madness and burnout, it will also impact your life practically. When people are diagnosed, this often isn’t pointed out. People are given the impression it’s Do This, Do That and once you’ve got used to it all, you’ll achieve perfection. That’s not true - and knowing that brings mental peace.

I don’t see why you can’t ask your GP for a half unit pen - I would. It would make dosing for meals a hell of a lot easier. Also, when you have your proper appointment, I’d consider changing to a twice daily basal. You say your basal is ok because you’re in range overnight, but what about the day? Perhaps your basal is contributing to highs or lows? The best basals IMO are the twice daily ones where you can adjust the day and night doses separately according to your needs. Very few people need a flat rate of insulin 24 hrs a day.

Again, well done on getting a handle on so much 🙂
 
Daffodil63 said:
How do we keep BG within range, is it normal to have the odd blip up or down post meals….happens 2 to 3 times a week for me.
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We don’t keep it in range all the time. Especially if like you and me we have insulin production of our own. The target for fantastic bgs is 70% or more 3.9-10.0 and up to 4% below that.
 
Tdm said:
I use excercise to keep my bs lower after eating. I eat, Eait for bs to start to rise, then normally take a 20 min walk until the cgm shows bs have finished spiking and started to go down. But then they can go down quite quickly so have to be careful...i would use exercise to lower bs up to 5 hours after a bolus injection (on novorapid too)
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This sounds to me like diabetes is controlling your life. Waiting around for BG rise and then walking for 20 minutes after every meal.
We have better tools for managing diabetes that allows us to get on with our lives. It is called insulin. Yes it takes some getting used to in terms of timing and dosing but, unless everyone with Type 1 instantly retires, the option of doing exercise every time we get our insulin timing and rising wrong is not viable.
I love exercise but that is not because I have to and definitely not because I have diabetes. I exercise on my terms not when my diabetes dictates I must. Doing a stressful full time job means I often eat at my desk whilst working (I agree it is not perfect) and unable to take a break at that time. Or I eat late in the evening (often because I am busy exercising) when I would not go out walking alone.
It is important for me that diabetes fits around my life not that my life fits around my diabetes. Without doing so, I would be at very high risk of diabetes burnout.
 
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Tdm said:
I use excercise to keep my bs lower after eating. I eat, Eait for bs to start to rise, then normally take a 20 min walk until the cgm shows bs have finished spiking and started to go down. But then they can go down quite quickly so have to be careful...i would use exercise to lower bs up to 5 hours after a bolus injection (on novorapid too)
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Well that sounds way too much hassle, why not just learn to use insulin better instead? I do none of that i just bolus and get on with my life, checking and correcting between meals if needed and knowing what foods need different timings, and have a time in range well over 70% (83% last 30 days, 76% last 90 days). I don’t low carb and have limited exercise due to CFS/ME
 
Hi @Daffodil63

Well Done. You have got your head round things so quickly and you are using the information that you gather to make decisions about changes. None of us will ever get our levels perfect, since it is impossible with our use of artificial insulin, rather than natural production. We just do the best that we can. So the blips you describe are absolutely normal, and unavoidable.

With regard to the Libre sensors your GP should now be prescribing these. They should be available to all that are T1. Do press for this as you should not need to self fund the Libre. I am pleased that you find it so useful. Don’t worry that you get post meal rises at present. There are some strategies that you can look at later to reduce the size of these once things settle, and a half unit pen will definitely make life easier. There is no reason why your GP cannot prescribe that now as well. It gives you more flexibility with your meal doses.

I remember being amazed at the impact of normal activities such as gardening and simply walking into town. I found that I either needed to reduce the meal dose (easier with a half unit pen) or eat an extra snack for activities. Another thing that you will gradually work out.

As @helli says it is important to make your diabetes fit round your life, rather than the other way round. Having said that it takes time to get your head round things, and as your body is likely to still be making some insulin, things are less predictable. After 15 years I am still learning, tweaking, and recognising that how ever organised I am my Diabetes just doesn’t behave itself all the time.

You are doing brilliantly and this forum is a great place to ask questions, and nothing is considered silly. Just ask. I look forward to reading of your continued progress.
 
What does it say at the top of the screen? 'Everybody manages their health differently, pleae be mindful of this'

And i am very happy with my 92% in tight range (3.9-8) and my walks, thank you very much
 
Agree Tdm.
Like you I try and manage it with exercise normally a short walk or just a few weights if I don't want I go out due to time or poor weather.
I really don’t see it as a hassle and in fact am much more comfortable doing that longer term than adjusting insulin doses to compensate.
I understand that there may be situations where an insulin adjustment is preferable such as during the night or if you have a very tight schedule such as in a busy workplace.
It is all about personal preference and choice and no one way is better than anyone else’s imo and it is a question of what works best for our individual situation.
 
Perhaps I should add that the reason why I prioritise exercise is not only as I prefer it but also I can make any adjustments very quickly and almost have an immediate effect ( ie within 5 minutes).
I aim not to use the exercise to come down from a peak high so much but to manage the trend to try and smooth out the highs and the lows ( carb adjustment) to get a much better variance than allowing the spikes to reach their normal level.
 
Tdm said:
What does it say at the top of the screen? 'Everybody manages their health differently, pleae be mindful of this'

And i am very happy with my 92% in tight range (3.9-8) and my walks, thank you very much
Click to expand...

I’m another who finds that a short burst of exercise (even just stumping up and down the stairs lr walking round the block for 5-10 minutes can really help to take the edge off a BG that is rising in double figures after a meal.

From a MH perspective, I find it much easier (though sometimes not without its own frustrations) to hit the stairs for literally 5 minutes, rather than sit there stewing for 2 hours with BG frustratingly in the 10s-teens while Novo-notvery-Rapid dithers about apparently doing nothing. A short burst of activity seems to ‘switch it on somehow.

Welcome to the forum @Daffodil63 - congrats on your excellent start to your pancreas-impersonation career, and glad you have de-lurked. 🙂
 
I understand the desire to "take the edge off" a post-10 BG with exercise instead of insulin corrections.
I understand we can never be 100% on target with our insulin dose and timing and that is why we need corrections (whether they are physical exercise or extra insulin).
But having to always do that exercise suggests to me that the insulin dose and timing is wrong all the time.
Learning how to correctly dose insulin is an important lesson because there are many times when that exercise is not possible.
And it means that diabetes is not taking over more of your life than necessary.
 
I have noticed that a walk or gardening does seem to ‘switch on’ the novorapid for me Post a meal. The problem I have is insufficient time to do this at work and my BG can sit around 10-13 for a couple of hours. But if I up the insulin dose, then I have to eat more food which I don’t want or hang around waiting for the expected dip in BG.
Re the libre on prescription, my area only allows GP to prescribed once initiated by hospital team. I am told via the NHS app that I should hear when my appointment is by this week. If not in the near future then I will chase both libre and half unit pen. Hopefully the half unit pen will help with the lunch at work issue.
It has been useful to learn that many of you still get some highs and lows….I agree that this wasn’t explained fully to me and I have found this aspect the most difficult!
I have been concentrating on bolus dose of insulin around meals. Any tips on how to handle unexpected snacks, eg more than 10g piece of cake offered with tea mid afternoon? I can carb count the cake, but if I have had my lunch bolus within 3 hours do I need to take this into account or just give the correct (best guess )insulin for that amount of carb?
thank you
 
@Daffodil63 if the level of questions is an indication of how much you are getting a handle on this, you are well on the way. Excellent questions.

WRT bolus doses for lunch, are you able to pre-bolus earlier. If you look at the profile of your NovoRapid, you will see that it has a peak. The idea is to time this peak to coincide with the peak of your carb digestions. If your NR peak is later than the carb peak, you will go high and eventually get back down to your baseline level. To overcome this, we need to pre-bolus.
You may find your pre-bolus time will vary at different times of the day, especially in the morning when we have a tendency to be more insulin resistant.
You may also find some threads which describe NovoRapid as NovSluggish and , as a result, some people take their breakfast bolus as much as 45 minutes before eating.
As ever, it takes some experimentation. The usual advice is to move your bolus by 5 minutes at a time and try to eat similar food whilst experimenting. This is easiest for breakfast as most people ahve the same breakfast every day and lunch is likely to be similar if you always ave sandwiches.

You also asked about snacks over 10g. Yes, you can bolus for that and ignore the correction part if you have IOB - active bolus insulin on board. Pretty much as you mentioned
The only thing I would add is to ignore overage corrections but if you are below your target BG, you may want to reduce your snack bolus dose.
 
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