Type 2 and Insulin

[Caterham Driver]

I have been a diabetic for 37 years and apparently a Type 2. I have been reasonably successful in my diabetes management. However, recently I have been becoming more concerned with my diabetes control especially in the mornings despite many test during the night.
My current medication regime is as follows:-
Glargine 28 units at 18:30
Humalog as per my carbs intake but using a 2:1 ratio.
Sukkarto (Metformin) 1x1000 mg per day
Ezetimibe (cholesterol) 10 mg per day
Amlodipine (blood pressure) 10 mg per day
Irbesartan (blood pressure) 300 mg per day.
I have attended a full DAFNE course many years ago (best thing ever) and have recently been on a DESMOND course after I was complaining of no support to to my GP's Practice Nurse.
I have not had a blood test since October 2019, but never seen the results!
The last blood test I have (September 2018) the results showed my HbA1c to be 6.9%
I have not seen a consultant since November 2018 and I am due only a telephone consultation with him on Tuesday 7th July.
I was under a specialist Diabetic Nurse though Virgin Care, but this programme was cancelled and I was cut adrift, no communication, nothing.
It was under this specialist nurse that she queried whether my diagnosis was correct (after all this time).

What advice to people have for my telephone conversation?

 

[grovesy]

I am confused as though you are saying you are Type 2, but you are Insulin and regime more akin to those who are Type 1. You have also done a DAFNE course which again suggests Type1, even Type 2 on Insulin don't usually get on such a course. You then say you recently have done Desmond course which is a Type 2 course.

 

[rebrascora]

I would be asking if you have in the past had C-peptide and GAD antibody tests to clarify your diagnosis because it sounds to me like your Health Care Professionals are/have been hedging their bets with your diagnosis, rather than actually trying to find the correct Type of diabetes you have.

You seem to be on a basal bolus insulin regime which is what you would prescribe for a Type 1 and the amounts of basal you are taking would be more consistent with a Type 1 diabetic as most Type 2 diabetics usually need significantly higher doses to overcome insulin resistance.... but they also have you on Metformin, which is obviously a Type 2 diabetes medication.

Can I ask how old you were at diagnosis and if you were overweight at the time? Being a mature adult and overweight at diagnosis usually leads HCPs to assume you are Type 2. If you were slim and fit at diagnosis, it might be more likely to flag up a possibility of Type 1 .... but ..... you can get slim Type 2s and overweight Type 1s so it is not easy to categorize purely on that basis which is why the C-peptide and GAD antibody tests are so relevant, but not generally performed on your average Type 2 diabetic who responds to dietary changes and oral meds in the first instance.

It is also unusual for a Type 2 diabetic to be under a consultant as their management is usually undertaken by a GP or more often a practice nurse with some diabetes training. As @grovesy says, DAFNE is a Type 1 diabetes course and DESMOND a Type 2 course, so it is not surprising that you are querying your diagnosis...

If they have not done Type 1 testing (C-peptide and GAD antibodies) then I might be inclined to ask for that testing to be done although I am not sure if you will still have the antibodies this far from diagnosis.

You mention that you are struggling with your control in the mornings.... what problems are you having with your levels?

 

[Caterham Driver]

To try my best to answer some of your questions:

I was diagnosed at 29 years old and at the time was extremely fit, visited the gym 4 times a week, and was about to go on a 2 week skiing holiday. It started when i could not get rid of an abscess on my arm. My blood sugar was 27.

To start with I was put on a diet, high fat, no or low carbs, but this did not prove successful and I was then put onto tablets.

After 18 months there was still not much improvement, so was put onto an insulin regime. This was modified over the years, until it became similar to a type 1 regime, with both background and fast acting insulins.

Due to this regime it was suggested I attend at DAFNE course, 1 week long. This was the best thing that ever happened to me for my diabetes. All of a sudden I could see why I could not get my bloods under control. Since then they have been good to very good.

However, during the last 18-24 months I seem to be having difficulty again getting good results. Mornings are the worst with bloods of around 10-13, but very occasionally, maybe once a month, a 5 or a 6. I have tried testing in the night at all times and they are always high. My Specialist Nurse suggests a bedtime sugar of of no less than 8, but if it is anywhere near to 10 before bed I go hypo about 01:30 ish. I should point out that we eat our evening meal around 7:30 pm. During the day my bloods are fine, well within the boundaries, but do seem to have a very large increase in blood sugar for even the smallest inputs of carbs, e.g.6- 7 units for a cup of coffee, so I have to have an injection of 3-4 units for this. It also takes a long time for my sugars to go down, typically 4-5 hours after a meal.

I measure all my foods where I can off the packets and/or use the Carbs & Cals app all the time.

With regard to the DESMOND course I think this was just a sop because I was asking for more support. I am up for all courses, because i think you can always learn something, but this course wasn't really for me I'm afraid.

With regard to the C-peptide and GAD tests, I believe C-peptide was done maybe 15 years ago, but I never got the results as the consultant left.

As one of you said, they were confused, well so am I.

 

[DaveB]

Hi. As you are under a consultant you should assume you are viewed as T1 as T2s are seldom managed other than by the surgery. If your consultant has left you need to ask your surgery to take control of you and give you a C-Peptide test and a review. You need to ask the surgery to give you online access to your test results. One of the problems with being treated by a hospital consultant is their test results and letters to the surgery won't be available to you even with the normal online access (the surgery could give you access to these but rarely do). You appear to be not managed by anyone so get the surgery to take control.

 

[Ljc]

Hi. I too am really wondering if you have T1 rather than T2 , I suggest you ask to be tested for it again .
I also think you need more professional help than you seem to be getting, perhaps push for a referral to a DSN (diabetes specialist nurse) normally based at a diabetes clinic in a hospital, ( diabetes nurses at the Gp are often not specialists .

Have you tried doing a Basal test recently? , I have often found that when things go out of kilter with my BG, it’s often a problem with my Basal, either not enough or too much
Here is a link to Basal testing

Other things I’ve found is, accidentally using well out of date insulin (guilty) or when its been compromised somehow, possibly before you received it, one if my cartridges got well and truly cooked in my handbag which was in full sun for a few days one very hot summer, it really didn’t like it .

I hope the above helps.

 

[trophywench]

It is not unusual for BG to go higher later on at night, but then it dips down low at approx 2.30 - 3,30 am - what people working in A&E used to call 'The suicide hour' for rather obvious reasons. Dunno what time you take your Lantus jab at night, but anyway, it is not released in a completely smooth manner but builds up to a peak after a few hours (4 5 hours-ish) before tailing off - see graph here
https://www.diabetes-support.org.uk/info/?page_id=408

If the high point happens to be at the same time as your personal natural drop - Yep - hypo city.

 

[everydayupsanddowns]

I echo the feeling of those who suspect you may have been misclassified.

There seem to be a few red flags in your case to me - not least the lack of regular checkups and 6 monthly (or at the very least annual) A1c. Diabetes UK identify 15 healthcare essentials which should underpin your annual review.

I also think you need to look at your basal as a matter of priority. You appear yo be running BG artificially high at bedtime in order to avoid an overnight hypo, which is less than ideal and is advice from 20 years ago. Have you considered taking Lantus/glargine at breakfast time? So that it is tailing off, rather than peaking overnight?

It may be that an insulin pump is the only therapy that will accurately match your basal needs, but an accurate classification will be required for that, if indeed you are T1 or LADA) as pumps are not available to T2s on the NHS.

 

[Caterham Driver]

First of all thank you for all your replies and advice. I had a telephone consultation with my Consultant on Tuesday last (07/07/20)
I raised a lot of the points we have been talking about here and he is in agreement that perhaps we need to do a control/alt/delete and start again from scratch. I am going to have the full spectrum of tests including C-Peptide and GADS.
I also asked if I had had a C-Peptide before and after a lot of paper shuffling he said yes, it was in 2012. This showed that I was indeed a Type 2, but was just about as close as it possibly could be to being a Type 1 and therefore wants to re-do this.
We also changed my basal by lowering it slightly and increased my evening bolus ratio to 2.5:1. This seems to have a a positive effect and my morning sugars are now 6-8 instead of 10-13.
I may try, as has been suggested, having my background at breakfast to see if this improves things.
Once again thank you all for your support and comments. Very much appreciated.