Diabetes Update March 2021

My last blog was a few years ago. Covid is still with us, but seems more manageable for society as a whole, but as of yesterday, I have a new health problem. 

I got a new adult tricycle. It has a big basket on the back so I can go shopping. I have to strap my prosthetic leg onto the pedal, so a fall would be disastrous.

11 days ago I fell while getting off of my new Tricycle, and my right shin landed on the pedal. There were many cuts and bruises on my right shin. 

I treated them all, and a week later they were all healing well, excepts one small wound. Then a few days later, the one unhealed sore started hurting. It was sore to the touch, hot, red and swollen.

On Friday, I went to my local, favorite Dr. She looked at my leg, and immediately nodded, and started asking questions. She asked about my Blood Sugar levels and whether I had been able to control my BG lately. I told her that my BG seems to go high easier, and comes down slower. I hadn't thought about my sore leg being Diabetes related.

She diagnosed Cellulitis. A Diabetes web site said this, about Cellulitis: 

"Cellulitis affects the two deepest layers of the skin—the dermis and the subcutaneous tissue. It often appears as a swollen, red area on the skin, and feels tender and hot when touched.

Cellulitis typically develops in areas where the skin has been broken, such as near ulcers, bruises, burns, or recent surgical wounds.  While many types of bacteria can cause cellulitis, Staphylococcus and Streptococcus are the most common culprits.

If the cellulitis spreads to your lymph nodes and bloodstream, it can become life-threatening. Seek medical help immediately if you suspect you have this infection."

OK. Now she had my full attention. She said the plan was to hit it hard now, with the two strongest antibiotics possible. Then if there was not a distinct improvement by Monday morning, I was to go to the big hospital casualty and get admitted for about 3 days. She said that Penicillin was the best treatment, but I am allergic to Penicillin. At least I was allergic in 1971. She decided to test me to see if maybe I was no longer allergic by taking a blood test. She said that information would be needed by the hospital staff.

Cellulitis is a major cause of amputations amongst Diabetics. My poor brain imagines the worst. I am almost 70 years old, and live alone, in a small house. How do I transfer from the bed to my wheelchair with no legs? Toilet? I can't even reach my spices for cooking without at least one good leg. What about driving? My new Tricycle? 

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Saturday morning...

I had a poor nights sleep. Quite a bit of pain. Of course after Cancer, and the amputation of my left leg, and the phantom pain afterwards, this is just "toy pain". But enough to keep me awake. I have lots of powerful pain pills on hand if the pain gets worse.

I now see small blisters all around the wound.

I am following the antibiotic pill schedule the Dr gave me to the letter. I am keeping the leg elevated, and I have packed a hospital bag. I see no improvement after 12 hours of antibiotics. 

Parkrun effect on BG

June 30 2019

 I seem to comprehend the details of carb counting, and insulin injection, but am having trouble with the big picture.
I downloaded an app for my phone called "mySugr". It really helps with turning all the details  and data into usable information. It does require many entries a day to give the app enough data, and this is a PITA. But then I guess that having diabetes is also a PITA...and having one leg is a PITA.... and worrying about cancer is a PITA, and being 68 years old is a PITA.

Yesterday was Saturday, and Parkrun day. I awoke to 6.8 BG. I made my standard breakfast of oatmeal and blueberries, and put it in a Tupperware box for later. I spent an hour getting the leg on right, and blister pads in place, and allignment of the ankle versus the knee perfect, and walked around the yard in the dark for a while making sure all was working OK.
I arrived at the Park run an hour early. This allowed me to walk lots at speed to get warmed up, and make sure the stump was seated all the way. I walked fast for about 1.5 kms, then stopped at the car and ate breakfast a half hour before the start. The oatmeal seems to peak the BG at about one hour, and because it is low GI, the BG will stay high for another hour.
So hopefully I'll not go low BG for the run, and the hour after.
All my planning seemed  to work. I finished the Parkrun in 1 hour 3 minutes, and BG was 8.3. The oatmeal usually pushes up the BG by about 5 mmol/L. A 5 km fast walk usually reduces the BG by about 4 mmol/L. I was expecting a BG of  about 7.5 at the finish. It was a bit high at 8.3.

Before bed, mySugr shows my data for the Saturday at Carbs=95, average BG=7.4, bolus=0, basal=10ui.

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This morning BG was 8.5mmol/L. I don't know why so high.
My calculations for breakfast went like this:
Target BG is 6.5, so I am 2mmol/L high. 1ui of Novorapid should lower BG by 2.7.
A nartjie=11g carbs, oatmeal =30g carbs, and blueberries= 8g carbs for a total of 49g. 3.2 ui of Novorapid should correct that.
So in total I need 4.2ui of Novorapid.

Novorapid is slow. I don't know why they call it "rapid". It seems to peak in about 2 hours from injection. A few days ago I took it 15 minutes before the meal, and it did nothing to reduce the spike of 13mmol/L. It only reduced the BG after about 1 hour 45 minutes later.
This morning I took 4ui at 30 minutes before breakfast.
At 1 hour after breakfast, BG was 13.7. After 1 hr 30 min, Novorapid has yet to do anything.
At 2 hours after breakfast, (2:30 after bolus) my BG was 10.0. Novorapid seems to be doing something.
At 3 hours after breakfast, BG 7.8.
At 4 hours after breakfast , BG was 6.9.

This is very similar to the profile seen when no bolus of insulin is used. Is Insulin doing anything???

I missed a dose of insulin

June 28 2019

I woke up at 3:30 with the realization that I had missed my supper basal dose of insulin. I got online, and Toujeo says that if you miss a dose, do not try to make it up.

If you have missed a dose of Toujeo or if you have not injected enough insulin, your blood sugar level may become too high (hyperglycaemia):
• Do not inject a double dose to make up for a forgotten dose.
• Check your blood sugar and then inject your next dose at the usual time.

They worry more about  stacking doses, which may result in low BG than they worry about having high BG.

The graph for Toujeo absorption looks like this.

I checked my BG and it was 7.5. I went back to bed. When I woke up I checked, and BG was 7.6. That is maybe a little high, but not abnormal.

I wanted oatmeal for breakfast. I took 2 ui of NovoRapid, 15 minutes before eating breakfast.
I ate a Nartjie, and oatmeal with blueberries. Total carbs was 49g. In retrospect I should have had .8ui for the slightly high BG and 3.2ui for the carbs, for a total of 4 ui.  I need to plan my meals better, so there  is going to be an exact amount of carbs.

I ate lunch at a fish place. I had grilled fish, and a salad. 2 hour after lunch my BG was 6.0.

On line there are many people that say NovoRapid is not rapid. It can take hours until it starts to affect the sugar in the blood. Some people suggest giving the NovoRapid bolus up to an hour before the meal.

I need to stick to my oatmeal, and try different strengths and times for the bolus shots.

Different way to control Type 1 diabetes

27 June 2019

I have been learning about "looping". Looping is when a person uses an electronic CGM (Constant Glucose Monitor) to measure blood glucose about every 5 minutes. This data is sent to a computer that can now watch and predict the trends of your blood glucose. The computer then sends a signal to an insulin pump to inject insulin.
This constant injection of tiny amounts of insulin helps to prevent any spikes. Sort of an artificial pancreas.
The people that build these systems are electronic and computer hobbiests, that have Type 1 diabetes.

This looping should mean that any food you eat, will have it's carbohydrates countered by the injected insulin. This appears similar to carbohydrate counting.
Carbohydrate counting is where you measure the carbohydrates of the meal you are going to eat, and compute the amount and type of insulin needed to maintain the desired blood glucose levels after the carbohydrates are converted to glucose. Carbohydrate counting, and looping can both result in large doses of insulin if it is needed.

The other approach to control is to minimize the carbohydrates consumed, which will minimize the amount of insulin needed.
As an example, if you eat a zero carbohydrate diet. You will still need a basal dose of slow acting insulin to counter the release of sugar by the liver, but you would not need the bolus doses of rapid acting insulin to counter the carbohydrates in the food you eat.

In reality, a hybrid approach is what happens. I try to eat a low carbohydrate diet to reduce the dose of bolus injections, but my carbohydrate input is never zero.

Yesterday I tried a bolus of 2ui that I took at breakfast. Before Breakfast I was 6.7, and an hour later I was 12.6. That 2ui didn't seem to do anything. I found this chart online.

Since my oatmeal spikes me, I need to take my shot about 15 minutes before the meal.

I'll try that tomorrow.

Two weeks later - testing rapid insulin

26 June 2019

All my cancer tests were clean ...whew....No indication of any cancer events.

My prosthetic leg is behaving for a change. I did a 5km Park run in 1 hour 3 minutes.

I am learning a LOT about diabetes.

I get weak and dizzy after an insulin shot, so I tested 30 minutes after, and BG (blood glucose) was high, not low. I don't understand. I'll have to ask Dr.

If I wake up with a fasting BG of just under 7 mmol/L (126 mg/dl), and then eat breakfast of oatmeal and blueberries, my BG will rocket up to about 15mmol/L in 30 minutes, and still be about 12 mmol/L after 2 hours. Obviously my slow release insulin isn't handling that very well.

To really see what my BG levels are doing requires many finger pricks a day. Normally I do one when I wake up, and one about  2 hours after every meal. I have a few timers that I start when I start eating, to warn me 2 hours later.

Because oatmeal and blueberries are consistent with the BG variations, today I am trying something different.
 A shot of fast acting insulin is called a "bolus" dose. a shot of slow acting is called a "basal" dose. Basal are usually only once a day, while Bolus are before each meal, or when ever needed.
Bolus doses are used for two reasons. One reason is to counteract the carbohydrates you are going to consume, and the other is to lower your current BG.

The fast acting insulin my Dr. gave me is called Novorapid.
Their web site mentions that the "normal" reactions of Novorapid are:
1 ui of Novorapid will lower the BG by about 2.7 mmol/L (50 mg/dl).
1 ui of Novorapid will counteract about 15 mg of carbohydrates that I eat.

Before breakfast (oatmeal with blue berries)  this morning I tested my BG 6.4 mmol/L (115 mg/dl).
If this had been high, then I would need insulin to lower it. I am happy with 6.4 so no insulin is needed to lower it.
The 50g of oatmeal has 30g carbs. The 43g of blue berries have 6g carbs. Total carbs for breakfast will be 36g carbs. This should require about 2.4 ui of Novorapid to counter act the carbs.
I shot myself with 2 ui Novorapid, just before I eat.
One hour later I feel dizzy, and my BG is 12.7. Dizzy usually means low BG. Mine is high. I thought the Novorapid would stop the spike. It didn't.
Obviously I don't understand all I know about this.

Results of Pancreas test.

June 12 2019

The Dr. just called with the results of the pancreas test.
There are two numbers of interest in the results. C-peptides and GAD.

C-peptides are the links between different parts of an insulin molecule. The number of them in the blood is an indication of the amount of insulin the pancreas produced.
GAD is an Anti-body that attacks the pancreas. Sometimes the body decides that the pancreas is a bad thing, and it makes anti-bodies to destroy it.

The range of C-peptides in the blood should be between 350 and 1400. Mine is 450. This means that my pancreas is producing insulin, but near the minimum levels.

The GAD levels should be between 0 and 5. Greater than 5, means there are antibodies attacking the pancreas. My GAD levels are 935.
My pancreas is under severe attack, and will gradually reduce production of all insulin. Because of the high GAD count, my pancreas should stop all insulin production within weeks to a few months.
The term for this type of diabetes is LADA. (Latent Autoimmune Diabetes of Adulthood). It is a Type 2 diabetes that becomes a Type 1.

To help my failing pancreas, the Dr gave me an insulin pen. It has some slow release insulin that helps the pancreas. It is slowly released over 24 hours. I am supposed to give myself a shot every evening at the same time with my supper.
He started me with 6ui per shot. the term ui (Unit Injection) is a standard, but arbitrary unit of insulin.

If my morning fasting BG is above 7 mmol/L (126 mg/dl) for 3 days in a row, I must increase the dose by 2ui per shot.

I see the Dr again in a week. Next week is CT scan and Sonogram and a visit to my Oncologist. I need a prosthetic adjustment also.

First Endocrinologist visit

June 4 2019

I saw the diabetes Dr. today. He prescribed some standard pills, and ordered a more comprehensive blood test to determine if the pancreas was working or not.

The amount of sugar in the blood needs to stay at a very narrow range.
If is to low, then your body cells don't get enough energy from the blood sugar (glucose) to work properly, and bad thinks happen. Like you get dizzy and weak. If it goes to low, the brain quits, and you go into a coma or die.
If it gets to high (like me) then damage occurs to small blood vessels. Like the end of your fingers, legs, and the retina in your eyes. This often leads to amputations, or blindness.

The body tries to control the amount of glucose in the blood by having the pancreas secrete insulin. Your BG (blood glucose) varies for many reasons.
Exercise uses the energy of the glucose in the blood, so BG levels drop.
Fighting an infection uses the BG for energy.
Stress causes a drop in BG levels by using the glucose in the blood..
Eating foods increase BG levels, depending on the carbohydrate levels in the food. A nice cream doughnut will cause the BG level in the blood to go up very high, very quickly. This requires a big dose of insulin from the pancreas to bring the BG levels in the blood down to normal values.
If you now do heavy exercise, which will lower your BG, and you have extra insulin, then there is a chance of the BG levels getting too low. It is a delicate, and constant balancing act by the pancreas.

One of the pills the Dr. prescribed is Metformin. It is the standard go to drug for Type 2 diabetes.
Type 2 diabetes is usually when the pancreas secretes enough insulin, but the cells don't receive it as they should, so the excess remains in the blood. Metformin tells the liver to keep it's store of spare glucose, and don't release it. This helps reduce the glucose levels in the blood.

He said the pancreas tests take a few days because they do them in batches. Only when enough people need the results do they test the blood. Until then I will continue doing the finger pricks, and take the readings when I get up in the morning, and two hours after every meal. I must also eat three meals a day, two snacks a day, and take the Metformin pills twice a day.

Next report will be when the pancreas tests results come back.