# Scary advice from GP



## Michael12420 (Nov 21, 2014)

I apologise in advance if this post is too long but I am really confused and cannot hope for people to understand or help if all of the facts are not covered.

I joined this forum in July 2013 after having a really frightening hypo - the information and support I received was unbelievable and I am still grateful.

Over the past 2 weeks I have had 5 more incidences, no warning, passing out at about 6.30 pm each time and remaining unconscious until about 1 or 2 the following morning.  On each occasion I am battered, bruised and bleeding.

The last one was on the 14th November, out at about 18.30 and woke up at 00.45.  Tried to stand  but could not, fell over and hit my head on the log burner - out again.  A few hours later woke up and crawled on all fours to the kitchen and the jelly babies.  They work really fast and I managed to get up the stairs and to bed.

My chest, shoulders, head and neck were a mass of bruises and I went out to an early dinner on Sunday with some friends one of whom is my pharmacist and speaks excellent English.  I explained the circumstances and they all pleaded with me to go to my doctor, the pharmacist was even prepared to book a couple of hours off work to go with me to ensure that my doctor fully understood the problems. She also told me that she now dispenses so many different types of insulin that it was probably time for a review of mine.  I take Novorapid and Lantus.

We went to see the doctor this morning.  He told me that my practice of only eating once or twice a day was bad. I was to eat at least three times a day, preferably 5 times as is the norm in Spain, or at least this part of it.  I was told to reduce my Lantus from 22 units to 20 and to cease using Novorapid altogether.  I was to look at my evening meal and mentally divide it up into 5 'portions' of equal size and eat this 5 times during the day.  I am gobsmacked.  No Novorapid at all!  No decent meal in the evening!  I simply cannot envisage eating the equivalent of 'nibbles' 5 times a day, no more decent meals to look forward to?  I can only walk with the aid of crutches but I do go out 3 times a day with my dogs for walks that last a total of about two and a half hours.  I also do one walk a day to the local shops - about 30 minutes.  One of the reasons that I only eat once a day is to stop weight gain as I cannot exercise apart from the walks, the other is that I really have no great appetite.

I am to keep a chart as follows.  BS before breakfast (which I don't eat) and 2 hours later on the first day.  I only eat a breakfast if my morning BS reading is below 3 m/mol, which is about 3 or 4 times a week. On the second day repeat the procedure but before lunch (which I definitely don't eat) and on the third day repeat the procedure but before dinner. Then start all over again.  On the 27th November go and have bloods and urine taken for analysis.  A week later go back for the results.  So, between now and December 4th/5th no rapid acting insulin.  It's really scary.

Has anyone ever been given this type of solution or advice?  Somehow I doubt it.  I am prepared to give it a try but I will test far more frequently and at the very first signs of high BS readings I will start using Novorapid to bring it down, after all, in my amateur opinion, hyper is as bad as hypo.

Thanks for reading all of this.  -  Michael


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## Northerner (Nov 21, 2014)

Really sorry to hear this Michael  It sounds like you are having some very serious hypos, and have lost your hypo awareness. Ideally, you should never let your levels drop below 4, although you are probably safer in the 5s as a minimum - bear in mind that your meter may be showing you as higher than you actually are, so you may be living 'on the edge' for much of the time. When you are so used to lower levels your brain no longer sends out the distress signals it would normally do until you are much lower - in your case it seems that nothing flags up the problem and you fall unconscious 

What your doctor proposes sounds drastic, but it may be worth following his advice for a while so that your levels are generally higher and you regain your hypo awareness. It doesn't have to be forever, just whilst you gain better control, and obviously monitor to make sure your levels are not going too high.

If you are not eating much, and only taking novorapid when you eat carbs, then it is likely that your lantus dose is set too high, so hopefully a reduction in this will lead to safer levels and less risk of hypos. Can you think of any factors which might be causing the hypos to occur at that particular time? How long after injecting/eating would that be?


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## Michael12420 (Nov 21, 2014)

I usually eat at 6 pm, inject before eating and the hypos happen at about 6.30 to 7.00.


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## Northerner (Nov 21, 2014)

Michael12420 said:


> I usually eat at 6 pm, inject before eating and the hypos happen at about 6.30 to 7.00.



Do you test before injecting? If so, what sort of levels do you usually see, and how do you work out how much novorapid to inject?


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## Michael12420 (Nov 21, 2014)

I don't - or haven't - tested before injecting.  I know what is in the food I am going to eat because I have prepared and cooked it.  I try to think of the carbs in the food and inject accordingly.  For example, I eat a lot of pasta, a plateful of pasta with meat and sauce and a slice of cake afterwards usually leads me to injecting 16 units of Novorapid.  If I am having a steak and salad it is usually about 12 units.  I did tell the doctor that if he is going to expect me to test as often as he wants he will have to authorize more test strips for me.


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## Northerner (Nov 21, 2014)

Michael12420 said:


> I don't - or haven't - tested before injecting.  I know what is in the food I am going to eat because I have prepared and cooked it.  I try to think of the carbs in the food and inject accordingly.  For example, I eat a lot of pasta, a plateful of pasta with meat and sauce and a slice of cake afterwards usually leads me to injecting 16 units of Novorapid.  If I am having a steak and salad it is usually about 12 units.  I did tell the doctor that if he is going to expect me to test as often as he wants he will have to authorize more test strips for me.



Yes, you should certainly insist on more strips Michael. I suspect that the doctor's advice is aimed at giving you a smaller carb load throughout the day so your levels are not too badly affected, but of course you need to be able to monitor this closely. I can see that this will be quite difficult for you to follow, given that you are used to eating just once a day, but think of it as a temporary thing whilst you regain your hypo awareness. Once you are getting hypo symptoms at safe levels then I see no reason why you can't return to your normal eating regime - your lantus should hold you steady through the day and the novorapid with your evening meal should cope with the carbs eaten then.

Bear in mind also that insulin requirements can change over time - mine can vary considerably, so only testing before and after eating for a while can help you determine if a change in doses from what you would normally inject is required.

Let us know how things go, and if we can be of any more help


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## AlisonM (Nov 21, 2014)

I have to say Michael that I think your doctor's advice makes sense. It should, in theory, spread the 'fuel' more evenly through the day and make you less susceptible to hypos. With all the walking, you may be using more energy at times than you have fuel on board to cover. IMO, it would be worth trying at least.


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## Michael12420 (Nov 21, 2014)

your lantus should hold you steady through the day and the novorapid with your evening meal should cope with the carbs eaten then.

Thanks, BUT - I am told not to inject Novorapid at all, not even before my evening meal - it is this instruction that causes me worry and trepidation.


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## Flower (Nov 21, 2014)

Hello Michael

I'm sorry to hear what a frightening time you have been having. I received similar advice from my diabetes consultant when I was having a lot of hypos resulting in a loss of consciousness. I was told to graze on small amounts of carbs spread over the day although as I use a pump I still bolused small amounts of quick acting insulin for the food. It removes the need for one larger amount of quick acting insulin. I still follow this method although I have cut down as I don't eat breakfast. It certainly helped reduce serious hypos and circulating insulin but I can understand your worries as it is a very different approach for you if you only eat in the evening.

Like you I have needed crutches to walk for years, you can expend up to 2 to 3 times more energy walking on crutches than normal walking - even if you are weight bearing on both feet. That does have a big knock on effect on blood sugar levels after walking for any length of time.

I hope you can work out a system that will help you overcome your problems. Good luck.


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## Redkite (Nov 21, 2014)

Sorry to hear this Michael, how scary for you . I must say you really need to up the frequency of your BG testing.  My type 1 son tests about 12 times in a 24 hour period, but as a minimum you need to test before each meal, mid-morning, mid-afternoon and bedtime, which would be six.  Otherwise you are flying blind when it comes to taking the correct insulin doses.  Since you've been having these hypos at a similar time of day each day, why not start checking your BG level hourly from 4-8pm for a while, to see when you are starting to drop?

I don't know why your doc has said no novorapid, as without BG test results, how does he know what you need and when?  Do you take your Lantus in the morning?  Because if you're taking it in the evening I'm surprised there would be much of it left to cause you problems the following late afternoon.  And I'm assuming you're not taking any other medications which could affect your BG?

Definitely agree that it helps to have regular meals, even if you just have the standard 3 spread across the day, that's better than missing breakfast and having the lion's share of your insulin at night.

Finally, don't continue to suffer - if these hypos keep happening despite you taking measures to prevent them, ask to be admitted to hospital for observation for a day or two.  Or perhaps for a CGM?


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## Michael12420 (Nov 21, 2014)

Thank you.   I had not realized that walking with crutches was more energy consuming, one lives and learns.

I have just had my first 'lunch' for many months, a very small piece of baguette with cream cheese and smoked salmon - it took some getting down I can tell you.  I am intending to have a small pork chop and some fried potatoes for dinner - and no Novorapid - I ain't gonna get any sleep tonight and that's for sure - I'll be testing every hour and worrying myself sick that I'm going to expire - and then who'll feed the dogs?

Upwards and onwards - and thanks again everyone.


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## Northerner (Nov 21, 2014)

Michael, please don't be too afraid of getting levels higher than you would normally like. A week or two won't have any effect on your long-term health as long as the levels don't go too high. I would say if they stay below 12 mmol/l or so, then that is fine. The severe hypos are much, much more dangerous to your health in the short term.

Good luck, and let us know how you get on


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## DeusXM (Nov 21, 2014)

> I don't - or haven't - tested before injecting. I know what is in the food I am going to eat because I have prepared and cooked it.



To be blunt, this is REALLY bad practice.

Knowing what is in your food in front of you has absolutely no bearing on what your blood sugar level is before eating.

Say you have a meal containing 50g of carbs in front of you. How much should you inject? That actually depends on what your reading is before you eat. If it's 5-7 mmol, then you probably want to inject amount x. But what if your blood sugar is actually 3.5mmol? Then you'll want less insulin. What if it's 12mmol/l? Then you'll need more insulin. You can't effectively dose your insulin without knowing what your blood sugar is at the time.  It sounds to me like you're assuming it's always going to be a certain level before you eat regardless of whatever happens. That is a very dangerous and wrong assumption. 

More importantly, you can't know your insulin doses are effective unless you test before and after. Say you test 2 hours after a meal and you've a reading of 10mmol/l. That tells you nothing. You might interpret that as needing more insulin for that type of meal. But what if your reading before eating was 15mmol/l? That means the insulin you took was too much by a magnitude of 5mmol/l, technically. So what happens the next time you eat the same meal, and increase your insulin because you ran high the previous time...but instead of your start reading being 10mmol/l, it was actually 4.5 but you didn't know because you didn't test? Not only do you have the baseline of way too much insulin for the meal anyway...but you've also added way more, which compounds the issue.

You absolutely need to test before AND after a meal. 

I suspect you're going to find that your ratios for carbs to insulin are 'off' quite considerably. I find it very hard to believe that for a steak and salad (no carbs) you need 12 units, yet for a bowl of pasta followed by cake (130g of carbs?) you only need another 4 units to stay level.


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## Michael12420 (Nov 21, 2014)

Thank you DeusXM - that is very thought provoking.  I am only practising at the moment the information that I was given from 1991-2005 when I left the UK.  You know, or maybe you don't, 'Always carry a Mars Bar'.  Think of carbs all of the time. I know from reading this forum daily that things have changed considerably, most of the stuff on here I can't understand as we have no specialist nurses, doctors, consultants etc here. I do thank you for the information and will now test more often and, as you suggest, both before and after eating.  Thank you again.


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## DeusXM (Nov 21, 2014)

Glad to help - it is NOT your fault if you haven't been given the right support. Even the Mars Bar advice is out of date now, they're a bit too slow-acting for treating hypos. I think most of us here are on the 15:15 rule and jelly babies!


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## trophywench (Nov 21, 2014)

Michael

Example of basal insulin changing - me.  Before pumping when I was taking Lantus and at work - 18u a day, or rather at night.  Changed to Levemir 14u morning. 4u at night.  But sometimes I needed 15u morning and sometimes 5u at night - which was 19u but the two never coincided.  By this time I'm retired.

The only time (in 42 years) I have ever had consistent BG for a week, I was in hospital in bed and on an insulin sliding scale, being 'fed' by drip. (I was between 5 and 6 ALL that week, marvellous apart from the fact I couldn't even get to the loo!)

Anyway now pumping and that does tend to reduce your basal requirement but ...... I'm now on 8 point something units a day.

When I was diagnosed the 'old, old' advice for all diabetics was to watch the amount of carbs so you don't put weight on and 'eat little and often'.

The first part of that's still correct - so why shouldn't the second be too?

The object of the exercise is to level off your BG all day and all night - by not dumping a lorry-load of carbs into you in one go (which you have been doing) it prevents our body from going  so you have more chance of success with amending the regime after that, to suit your own lifestyle.

I don't actually think the man's gone bonkers after all !  I think you'd rather us say he had.

Sorry.


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## Michael12420 (Nov 21, 2014)

You see what I mean?  What's 15:15?  The jelly babies, now that I can understand - have already included several bags on my Christmas wish list as I can't buy them here.  Strangely enough every other Haribo product is available - just not the jelly babies. It's a conspiracy I tell you - a conspiracy.


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## Michael12420 (Nov 21, 2014)

I don't actually think the man's gone bonkers after all ! I think you'd rather us say he had.

Ermm - sorry, not as quick thinking as I should be - what man are you talking about - my doctor?


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## Michael12420 (Nov 21, 2014)

OK, I'm in the process of preparing dinner, simple and smaller than normal  My BS reading is 10,2 after having a minuscule lunch and no Novorapid.  So according to my doctor I should now eat a pork chop and some fried potatoes without injecting any Novorapid. I'll do it, but I ain't happy.  Watch this space - tomorrow.


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## Northerner (Nov 21, 2014)

Michael12420 said:


> OK, I'm in the process of preparing dinner, simple and smaller than normal  My BS reading is 10,2 after having a minuscule lunch and no Novorapid.  So according to my doctor I should now eat a pork chop and some fried potatoes without injecting any Novorapid. I'll do it, but I ain't happy.  Watch this space - tomorrow.



Test a couple of hours after and before bed Michael  Hope all goes OK and you get a good night's sleep


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## trophywench (Nov 21, 2014)

Yes your doctor Michael - I wasn't referring to you!  Is she a lady?

15:15 is standard hypo treatment advice from when I was first diagnosed, take 15g of fast-acting carbohydrate preferably glucose - and test again 15 mins later.

How many g of CHO in the fried pots?


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## Michael12420 (Nov 21, 2014)

I've absolutely no idea - 2 small potatoes less than the size of an orange.  I musn't inject any Novorapid so I don't have to think about it.  If I was injecting I'd reckon on 8 units for the potatoes and 2 units for the pork chop.  It's all go!


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## Northerner (Nov 21, 2014)

No carbs in a pork chop Michael (it's meat=protein), so it's only the potatoes you'd normally inject for 

Jelly babies are about 5g carbs each.


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## Copepod (Nov 21, 2014)

Injecting 10 units of short acting insulin is way too much for 2 orange sized potatoes. It's worth weighing them and checking carbohydrate content either in a book or online. Sounds like that's been the cause of your 6.30pm hypos. 

By the way, it's wise to always carry a few jelly babies or other sweets in a pocket, or beside bed at night, in case of hypos, instead of having to go to another room.


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## Michael12420 (Nov 21, 2014)

Thank you.  I have not injected any short-acting insulin this evening, following the advice of my doctor.  I carry jelly babies in a container in my pocket most times.  I have jelly babies on the side table by my bed.  Not having them in the episode described in my first post on this thread was due to the fact that I had changed from my day clothes into my night clothes - in any event there was absolutely no warning that I was to have such an horrific attack - just passed out and that was it.  I am grateful for your advice.  Another hour and I can take a BS reading and then go to bed and hope for the best, a peaceful and hypo-free night.


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## Michael12420 (Nov 21, 2014)

OK, two hours after eating my BS reading is 20.4!  20.4 - I am supposed to go to bed happy with a reading of that size with the 'Ketones' warning flashing away?  I am not  a happy bunny and I doubt if I'll get much sleep - I worry too much.


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## Northerner (Nov 21, 2014)

Michael12420 said:


> OK, two hours after eating my BS reading is 20.4!  20.4 - I am supposed to go to bed happy with a reading of that size with the 'Ketones' warning flashing away?  I am not  a happy bunny and I doubt if I'll get much sleep - I worry too much.



That is higher than I would have hoped Michael  If it was me, I would see how things go overnight, but get in touch with your doctor as soon as you can to see if he would refine his advice about having no novorapid at all, having a reduced amount instead. You will still have your lantus, so you will not be without circulating insulin. Might be worth setting your alarm and checking during the night to see where things are at.


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## trophywench (Nov 21, 2014)

So what was your BG already, before tea?

I mean it may only have raised your BG by a smaller amount, but if it was already too high.......


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## DeusXM (Nov 21, 2014)

trophywench said:


> So what was your BG already, before tea?
> 
> I mean it may only have raised your BG by a smaller amount, but if it was already too high.......



Think he said it was 10.2 beforehand, so already too high, then even higher.

I think the problem with the hypos here comes from inaccurate carb counting and not having an insulin ratio - all of which come from not knowing pre-meal blood sugar. I personally don't agree with the doc's idea of not taking any Novorapid for now but I can see how that conclusion could be come to.


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## trophywench (Nov 21, 2014)

Well I don't necessarily totally agree with it either but like you I can see where he's coming from.

Thing is, the doc hasn't any resources other than himself and I shudder to think what might happen with a newly diagnosed T1 in that location.  Certainly no carb-counting training - but hopefully Michael can teach himself to do this using BDECs online resources.

I dunno what lists of carb values (exchanges) are available online now - you used to get about 4 typed pages from your hospital here before they started labelling things.

What are carbs in Spanish?  But it's not on fresh stuff not bought in packets, so you do need some things to refer to.


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## Michael12420 (Nov 22, 2014)

Good morning everyone.  Now I am totally confused.  I went to bed just before 9 pm reading 20.4.  I injected 22 units of Lantus, following the doctors advice.  As you may have gathered I was not too happy, in fact I was a wee bit scared.  I woke up 20 minutes ago - 08.37 - feeling very strange, almost as if I was having a hypo. I was somewhat disorientated, bedclothes were wet from sweat.  My reading was 7.1 - just don't understand it unless the Lantus is more potent than I ever thought.  Got to have breakfast now, and no insulin.  Carbohydrates in Spanish is* los hidratos de carbono*. Not much different.  My doctor is male - I went to bed before I read the latest posts so sorry didn't answer yesterday.


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## Redkite (Nov 22, 2014)

Sorry to hear that - it sounds like you went really low in the night.  If I were you I'd set an alarm to check your BG at 2 or 3am.  And it really might be a good idea to get a CGM so you can see exactly what's going on.


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## Northerner (Nov 22, 2014)

Michael12420 said:


> Good morning everyone.  Now I am totally confused.  I went to bed just before 9 pm reading 20.4.  I injected 22 units of Lantus, following the doctors advice.  As you may have gathered I was not too happy, in fact I was a wee bit scared.  I woke up 20 minutes ago - 08.37 - feeling very strange, almost as if I was having a hypo. I was somewhat disorientated, bedclothes were wet from sweat.  My reading was 7.1 - just don't understand it unless the Lantus is more potent than I ever thought.  Got to have breakfast now, and no insulin.  Carbohydrates in Spanish is* los hidratos de carbono*. Not much different.  My doctor is male - I went to bed before I read the latest posts so sorry didn't answer yesterday.



That is quite a steep drop Michael - although your levels were still above hypo, your brain would have reacted as though it was a hypo, hence the symptoms you experienced. It looks like your lantus dose may be still on the high side for it to drop you so much overnight - ideally, there shouldn't be more than a 1-2 mmol/l difference between your bedtime and waking levels.

Stick with it, keep testing regularly and let us know how you get on


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## DeusXM (Nov 22, 2014)

I'd agree - it sounds to me like there's a combination of things going on here, namely too much Lantus, and incorrect dosing of Novorapid at mealtimes for the reasons discussed before.

The good news is all of this is (relatively) easy to fix, even on your own. This might be a bit much to take on right now but I think you should look at 'basal testing' - this is where you do quite a lot of tests to make sure your Lantus dose is right. As Northerner says, your Lantus shouldn't really change your blood sugar, just keep it level when you don't eat. 

Basal testing takes a few days. What you do is set aside certain times of the day where you don't eat, and then test regularly. For instance, say you wake up at 7am. You could then 'fast' until 1pm, testing every hour. Because you haven't eaten, and because you won't be taking any Novorapid at this point, the blood sugar battle should just be between your body and your Lantus. If your Lantus is right, your blood sugar should stay roughly the same between 7am and 1pm. Then at 1pm, eat and carry on your day as normal. 

The next day, eat in the morning but then don't eat from 1pm to 7pm, do the same. This will then show you what your blood sugar does throughout the day. That then will help you to tweak you Lantus dose. Once you Lantus dose is right, then you can start tackling your insulin ratios!


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## Michael12420 (Nov 22, 2014)

Thank you for the advice - it sounds eminently sensible and my gut reaction is to try it right away.  It would however go against the advice my doctor has given me with regard to eating at least three times a day. What I think I will do is follow the regime the doctor has given me, ie. divide the week up into 3 day cycles, test before breakfast and then 2 hours later, the same for lunch and then the same for dinner over the three day period for the next 12 or 13 days before  I see him with the results of the analyses which will take place on the 27th November.  He will then work out (hopefully) a plan for my future injections.  Once that is done I will convey what he recommends to all of you. Once your reactions are in I will then consider the basal plan outlined by DeusXM and if it is at all possible I will carry it out.  Fasting for me is not a problem - I'm not used to eating lots and I am certainly finding this business of breakfast/lunch/dinner difficult.  As always, I am very grateful.


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## Michael12420 (Nov 22, 2014)

I am going to reduce my Lantus tonight to 20 units.  I had a chocolate chip biscuit with my mug of tea this morning, I had two small slices of baguette with smoked salmon and cream cheese for lunch and I'm going to have some more toasted baguette with baked beans (good old Heinz) for dinner at 6 pm.  My reading a few seconds ago was 13.9.


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## Redkite (Nov 22, 2014)

Good plan Michael, and please also set an alarm to check your BG in the early hours (2 or 3am). x


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## Hanmillmum (Nov 22, 2014)

Good luck with it all Michael  - (very sorry to read about your recent problems)


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## qwertyfan (Nov 23, 2014)

Good luck Michael, I've read this thread and feel your worry and confusion. I hope you get the balance you need just as soon as possible.
Take care,
Stephen


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## AJLang (Nov 23, 2014)

Hi Michael how are you getting on today? I hope that you had a good night.


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## Michael12420 (Nov 23, 2014)

Good morning.  I went to bed reading 13,9.  The baked beans on toast was a VERY bad idea.  I was violently and continually sick from about 2 am onwards for about an hour.  I don't think my ancient body is able to cope with stuff like that any more - but it was quick and easy both to prepare and eat. Indigestion and the results have been a problem for me for some years now. After that I slept really well.  No signs of hypo like the night before.   BS this morning 8.1. I'm going to have a proper Sunday meal this afternoon. I did set the alarm, but it didn't go off and after the sickness incident all I wanted was to go to sleep.


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## DeusXM (Nov 23, 2014)

You ate a baguette when you had a reading of 13.9, had no bolus and woke up at 8.1? That would suggest your Lantus dose is too high but I'm concerned by the vomiting as that can be a DKA symptom. What are your ketones like?


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## Bloden (Nov 23, 2014)

trophywench said:


> What are carbs in Spanish?  But it's not on fresh stuff not bought in packets, so you do need some things to refer to.



Hidratos de carbono. 

I was dx in Spain. They gave me a book on carb counting before I left hospital, and I've been counting carbs right from the start. And, in defence of the Spanish NHS, there are specialist nurses and consultants. I'd hate for you all to think it's the dark ages over here!

Anyway, I hope you can get back on track asap, Michael. We're all here to help. Why not buy some Gummy sweets (made by Chupa Chups). They have the same effect as JBs.


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## Michael12420 (Nov 23, 2014)

No Bloden, It isn't the dark ages at all.  As you know healthcare provision in Spain is decentralised, not only does each Junta decide its priorities but provinces within the Junta adjust accordingly.  Jaen is one of the poorest Provinces in Spain and facilities provided by it in all of life's spectrum - health - education - etc are cut to the bone.  I am informed that my nearest specialist diabetic professionals are in the capital city - Jaen - some 42 km away.  My doctor is doing  his very best and I am grateful. I shall keep an eye out for Gummy sweets although I have put in my Christmas order for Haribo JB's to be shipped out.

DeusXM, you have me a trifle worried.  I had to look up what DKA stood for and was shocked when I read the information provided by Diabetes UK.  Reduced or no insulin injected - well that's true considering the regime I have been handed down. Having to breath deeply -  yes it happens, but only during the night.  Nausea and vomiting - yes that takes place - not often  but more often that I would like.  Tiredness and lethargy - yes, but I put that down to my age and the amount of walking I do.  The Ketones warning  comes up on my little strip machine when I test - but usually only in the recent past because of my stopping the Novorapid.  Oh dear - I don't know what to do next.  My review is due around 5th/6th December.  Can I hold out until then I am asking myself, and can I ask my pharmacist to book another 2 hours off work?  Oh dear!


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## Bloden (Nov 23, 2014)

Don't you ever get to see your specialist? Mine's a half-hour drive away, but I see her 3 times a year, for HbA1c, etc. 

If you're at all worried about DKA, go and see your dr before Dec. There's no point worrying. You'll just make yourself feel worse. Good luck, Michael.

PS JBs are nicer, but Gummy Jelly sweets are cheaper! I couldn't believe how expensive JBs were when I last bought them!


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## Michael12420 (Nov 23, 2014)

I've been here 9 years - no specialist.  I did ask about 2 years ago because I was not satisfied with the once-a-year analytic tests.  I was told that there were none, except in Jaen city and that there was a waiting list - a long waiting list.  Hey Ho!


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## Northerner (Nov 23, 2014)

Do you have any ketone test strips Michael? Bear in mind that you are not totally without insulin - you have the lantus which you are continuing with. I feel nauseous with high blood sugars, so it could simply be that which is making you sick.


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## Redkite (Nov 23, 2014)

Michael, I think it would be well worth you getting a referral to the consultant - 42km is no distance at all (25 miles).  We travel out of area to my son's consultant because the local hospital was hopeless.  It's a 90 minute journey each way by car and train, but well worth it!


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## Michael12420 (Nov 23, 2014)

Do you mean that there are separate test strips for Ketones?  In which case - no I don't.

I use a machine which was given to me when I first lived in Spain in 2005.  It is an Optium Xceed. I use test strips that are named 'Freestyle' and, on occasions, a warning 'Ketones' flashes at the top of the screen. I assumed that this was triggered when my blood sugars are high - or is this a dual purpose strip?  I have no idea.


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## Michael12420 (Nov 23, 2014)

Redkite, thanks, I think that you are right but I am, at this moment, willing to wait until such time as this recently suggested regime is over and done with.  No, 42 km is not a great distance but we have no trains, in order to get a 'bus I would have to drive to Baeza and there are only 2 'buses a day.  On a good day, given my blood sugars are under control and my legs work somewhat near normal and the wind is behind me, I could drive without too much trouble.  It is certainly something I am definitely going to have to consider.  Thank you again.


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## Northerner (Nov 23, 2014)

Michael12420 said:


> Do you mean that there are separate test strips for Ketones?  In which case - no I don't.
> 
> I use a machine which was given to me when I first lived in Spain in 2005.  It is an Optium Xceed. I use test strips that are named 'Freestyle' and, on occasions, a warning 'Ketones' flashes at the top of the screen. I assumed that this was triggered when my blood sugars are high - or is this a dual purpose strip?  I have no idea.



That meter can also use a different kind of strip, specifically to test for ketones. The test strips are expensive though (£20 for 10 here), so given how you describe your healthcare the doctor probably would resist prescribing them. There are some cheaper strips which can test the urine (around £5 for 50), so you might be able to get some of them. The ketone warning is because your BG levels are high, but if ketones are low then there is no worry about DKA.


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## Bloden (Nov 23, 2014)

Michael12420 said:


> I've been here 9 years - no specialist.  I did ask about 2 years ago because I was not satisfied with the once-a-year analytic tests.  I was told that there were none, except in Jaen city and that there was a waiting list - a long waiting list.  Hey Ho!



Mine's in the nearest city too - I'd get your name on that long waiting list if I were you. It's not right to cope with what you've been thru alone.


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## Bloden (Nov 24, 2014)

How you doing today, Michael?


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## Michael12420 (Nov 24, 2014)

Good morning, thanks for asking.

Last evening I was extraordinarily tired and went to bed just after 8 pm with a reading of 20.2.  At 9 this morning I was 9.1. Once again I only injected 20 units of Lantus.

Had a very good nights sleep although I did have to drink a lot of water at times - and then had to get up later to 'pay the bill'. I also had a craving for something sweet, a real craving, so ate a Twix bar.


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## DeusXM (Nov 24, 2014)

I think it's becoming pretty clear that your Lantus dose is way too high. I can understand why you were tired at 8pm if your blood sugar was 20.2, but to have it drop by 11mmol/l overnight with no bolus insulin should not be happening. You Lantus shouldn't actually lower your blood sugar but keep it steady.

Also, next time you have a craving for something sweet, you MUST test before. A craving for something sweet could be because of a hypo. Equally (and confusingly), it can also be a symptom of high blood sugar - and adding a Twix to high blood sugar is not a good move! You must test before you eat, without fail, even if it's just a snack.


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## Michael12420 (Nov 24, 2014)

Such good advice and I thank you.  Although I am anxious about my state of health at the moment it is going to be a superhuman effort to test in the early hours of the morning when all I want to do is go back to sleep. I promise that I will do my very best. Apart from the  JB's I will remove all of the Twix and other chocolate bars from my bedside.  No matter what the craving I ain't going to want to go down some cold marble stairs to find some chocolate!


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## Michael12420 (Nov 24, 2014)

I've just been thinking whilst out walking the dogs.  If Lantus is designed to keep ones levels steady, what is it, considering that I am taking no Novorapid, that is taking me from my bedtime highs to roughly half the following morning? Is it the fact that I sleep for usually about 12 hours at a time?


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## AJLang (Nov 24, 2014)

Hi Michael Lantus is designed to keep you at a steady dose if you have not eaten any carbohydrates and the Lantus level is at the correct does. The Novorapid should be the insulin for dealing with carbohydrates.  Therefore if the only insulin you are injecting is Lantus and your blood glucose is going down overnight your Lantus dose is too high.  Eg if you had no carbohydrates from  c. 6pm and only injected your Lantus that evening your waking blood glucose should be the same as it was from when you went to bed.


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## DeusXM (Nov 24, 2014)

> what is it, considering that I am taking no Novorapid, that is taking me from my bedtime highs to roughly half the following morning?



As I said, it is probably because your Lantus dose is too high. The impact of Lantus on your blood sugar is dependent on the amount you inject and everyone has a different dosage amount required to just keep their blood sugar steady.


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## Michael12420 (Nov 24, 2014)

Oh, I see.  So, as I am taking no Novorapid, if I was to reduce my Lantus then I would wake up to roughly the same BS readings as I went to bed. That means that I would be unacceptably high during sleep.  It gets more complicated, and completely beyond my understanding,  that is, if it wasn't for the information I receive on this forum.  I don't know what to do for the best.


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## AJLang (Nov 24, 2014)

I know what I would do Michael but I wouldn't want you to go against your doctor's advice.  Is it at all possible for you to see the doctor earlier than the appointment that you have or to arrange a telephone appointment? Have you looked at the online advice that I think somebody posted about carbohydrate counting because I think that your problem isn't just with the Lantus but that you are injecting much too much Novorapid with your evening meal - that would explain why you having such a severe hypo so quickly after some of your meals.   Although the high blood glucose levels are not nice in the short term they will cause much less damage than that which could be potentially caused by a very severe hypo.  Do you know how many carbohydrates you are having with each meal?


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## AJLang (Nov 24, 2014)

The online carbohydrate counting course that I was referring to is BDEC http://www.bdec-e-learning.com/


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## trophywench (Nov 24, 2014)

No Michael - it's natural!  For you.

So if you weren't diabetic, your pancreas would just be on tickover, not revving, overnight.  You don't have to move your limbs and stuff so those cells won't need much glucose and ergo not much insulin. but actually your body is constantly busy overnight.  Not only your lungs, heart, digestive system are working away, but during sleep is when your brain mends itself.  The non diabetic's BG can normally differ by roughly 1.7 either way overnight - so say you go to bed with a BG of 5.5, when you get up, you'd be between 3.8 and 7.2.  

A lot of diabetics need more insulin at night - some of us - like me and you! - don't for some reason.

Lantus - which says on the tin  that it releases itself smoothly over a 24 hr period - doesn't actually do that at all.  It starts, builds up to a marked peak at about 4 -5 hours and then descends to a fairly even plateau which tails off at the end.  But when is the end for you?  it may not last a full 24 hrs or it may be active for 36 hrs or more!  We're all different and all we have to go by, is our BG.

Anyway .... back to you.  Clearly - as you now have no fast-acting in your body - the Lantus is dealing with your teatime carbs, isn't it?  But as has already been said - it's not supposed to.  So that must mean (on the assumption in future you'll go back on both sorts) you are on too much of it.  Overnight anyway.  Trouble is of course if you reduce it too much, it may not be enough during the day.

Normally I could and would make suggestions as to what you might like to try next - but that's WITH a fast-acting at mealtimes - so I really don't think I ought to, right at the mo.


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## trophywench (Nov 24, 2014)

Here's the graph of Lantus' profile

http://www.diabetes-support.org.uk/info/?page_id=408

The graph of course stops at 24 hrs but it's perfectly obvious from that, that it doesn't stop.  How long it takes you or anyone else's body for the graph line to reach zero again is individual to us all.


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## Michael12420 (Nov 24, 2014)

AJLang said:


> The online carbohydrate counting course that I was referring to is BDEC http://www.bdec-e-learning.com/



I just joined and completed the questionnaire (last time I was asked to complete something  so complicated, and long, was when I applied to be a Concorde pilot!).  I haven't found the bit about carb counting but I will have another look when I get back from out final  walk of the day, and a bowl of pasta.

Thanks Trophywench - you are a mine of information.


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## Michael12420 (Dec 9, 2014)

I thought that I would let you know the results of the regime that I was asked by my doctor to undergo.

I was very unhappy at not being able to take my Novorapid and just rely on the Lantus.  There was one night however when my BS readings were off the scale and I did inject 4 units of Novorapid just to ease the fears that I had.

My average morning readings before breakfast over the 16 day period were 9.9.  Before bed over the same period were 23.9.

My doctor told me that I was worrying unduly over these high readings - hmm.

He also told me that my readings were on an old meter and that these (m/mol) were no longer internationally acceptable and he is arranging that I get a new meter tomorrow morning or the day after which gives the new reading.  I am to continue with the regime once I get the new meter until the second week of Janury and he will then decide whether to swap the Novorapid for one of the newer insulins or adjust the Novorapid doses.  He tells me to measure BS before eating, divide the results by 36 and then inject accordingly, ie if my reading is 300 then divide by 36 which equals 8 and that is the amount of whatever rapid insulin I inject.  Sounds funny to me as it will not take into account whatever I am going to eat.

At least I have not had any more hypo's but with readings as high as those I'm not surprised!

Thanks - Michael


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## Redkite (Dec 9, 2014)

Michael, get yourself another doctor before this one kills you.  His advice on insulin dosing is wrong and dangerous.

 Your BG results show that you clearly have insufficient insulin during the daytime, and therefore you DO need novorapid when you eat carbs.  You need to be taught to calculate the appropriate dose of novorapid based on both your pre-meal BG level AND the carbs you will be eating.


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## Northerner (Dec 9, 2014)

Michael12420 said:


> ...He tells me to measure BS before eating, divide the results by 36 and then inject accordingly, ie if my reading is 300 then divide by 36 which equals 8 and that is the amount of whatever rapid insulin I inject.  Sounds funny to me as it will not take into account whatever I am going to eat.
> 
> At least I have not had any more hypo's but with readings as high as those I'm not surprised!
> 
> Thanks - Michael



Hi Michael, that sounds a bit strange. 300 mg/dl (same as the US units for measuring blood sugar) is about 17 mmol/l (the UK and Canadian units for measurement). 36 mg/dl = 2 mmol/l, so 8 units will (in theory) lower your levels by 16 mmol/l. Presumably you levels will be saved from dropping to 1 mmol/l by the food you consume  As you say, it doesn't take into account the actual carbs in the food you eat - what if it was carb-free?

Also, not sure what 'newer' insulin he is planning on. I would be cautious and do regular post meal testing so that you don't drop too low. Let us know how things go.


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## Michael12420 (Dec 9, 2014)

Also, not sure what 'newer' insulin he is planning on

My pharmacist, Elena, has accompanied me to the doctor on the last two occasions. She is fluent in Spanish and English and took time off work so that she could be with me to translate the more difficult of questions and answers.  I am very grateful to her.  As a pharmacist she explained to me that there are several new insulins now available and a lot of her diabetic customers have been swapped to one of the newer versions.  This information is by way of answering you query.


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## Northerner (Dec 9, 2014)

I'm aware of some long-acting insulins e.g. Tresiba, but can't recall reading anything about a fast-acting one. I think people have seen good results with Tresiba though, perhaps this is what they intend 

Great that your pharmacist helped you out, what a lovely, kind person!


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## HelenM (Dec 9, 2014)

1) yes your new meter will be in mg/dl, that's where the 300 comes from. I also use a mg/dl meter 'next door' in France (it's not just the US that uses this unit )If your present meter is several years old then it will be out of date even in mmol/l 
 (it would confuse you to go into why but they have changed a bit since about 2009)

2) What he's giving you is a  sliding scale (the second method here http://www.joslin.org/info/dosing-insulin.html
 As you can see this  is an accepted way of dosing but it does has a big drawback. For it to be effective, it really requires you to eat the same amount of carbohydrates at each meal. So it only works if you count the carbs and  also if you keep to a fairly rigid regime of when you exercise .
 I don't think that the dose he has suggested is large so is probably not intended to cover large amounts of carbohydrates. Of course I suspect he also wants your levels running a bit higher than usual in order to get your hypo awareness back.

I'll give myself as an example to show how it would work out with me.
My glucose level before lunch was 90mg/dl so that was  within the normal range . The whole dose  would go towards covering my meal rather than part of it being used to correct a  high glucose level 
90/36 =2.5 units which for me would cover about 30g carb, (that's individual for many people it would cover a bit more, others much less )
If my glucose had been at 200mg/dl instead the dose would have been 5.5 U (you really need a half unit pen for this!) In this case 3 of the units would be to correct the high glucose level leaving 2.5 again for the carbs in the food.
If my levels were at 70mg, this would result in a dose of 2units, this would allow for a correction to raise the glucose slightly

With this method you still  really need to learn to carb count so it makes sense to also learn a more flexible method of dosing as described in the last method on the link I gave you. That's what is being taught in the bdec course you signed up for.


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## Michael12420 (Dec 9, 2014)

I am so grateful for this information, though it is a bit daunting (Hawking I ain't) but it does mean that I am going to have to learn a whole new set of regulations, rules and procedures. Oh well, needs must.  Thanks again.


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