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Suggest Treatment For Fluctuating Blood Sugar Levels And Continuous Shoulder Pain
Question: i have got blood sugar swings from 60 - 250 in a normal day, even sometime hypo. i am 48.male. 6ft. 80 kgs. LADA . got diabetes 4 years back. started insulin shots after 1 year. Humalog 17 units before 3 meals and Lantus abt 40-42 units everyday. Though HbA1c is 7.2-7.7. i have thyroid problem and i take 150 mcg daily. have continuous shoulder pain inspite of physiotherapy.
how to minimise swings or this would continue in lada type1 ?? diet is as good as it can be with wholewheat flour, raw veg, fruits,nuts etc. no potato,white rice etc.. exercise is less - walk 25 min - 4 times a week.
how to minimise swings or this would continue in lada type1 ?? diet is as good as it can be with wholewheat flour, raw veg, fruits,nuts etc. no potato,white rice etc.. exercise is less - walk 25 min - 4 times a week.
Brief Answer:
SMBG may help.
Detailed Answer:
Hi Mr. XXXXXXX
Thanks for your question.
Noted your concern.
In view of hypoglycemic episodes, I may suggest to continue current insulin doses along with it do SMBG (Self Monitoring of Blood Glucose).
In SMBG blood sugar tested by home glucometer.
One should do at least 2 to 3 reading daily from following 7 readings -
Fasting
2 hours post breakfast.
Before Lunch.
2 hours post Lunch.
Before Dinner.
2 hours post Dinner.
3 am (occasionally) once in 3 to 4 weeks.
Additional readings if there are symptoms of hypoglycemia. Along with it note down time, any variation in meal content or timings, physical exertion.
Depending upon weekly chart appropriate changes in insulin doses can be made for better blood sugar control without hypoglycemia.
Along with this continue diabetic diet and regular exercise.
After going through other test reports I may suggest -
- Continue Thyroid supplement as you are taking.
- Oral Iron supplement as there is Iron deficiency.
- Statin treatment (cholesterol lowering drug) as there is dyslipidemia.
You should discuss this with your treating diabetologist.
Hope this helps you.
I will be happy to answer your follow up question, if any.
Otherwise close the question and rate the answer.
Regards,
Dr Abhay Mali.
Diabetologist.
SMBG may help.
Detailed Answer:
Hi Mr. XXXXXXX
Thanks for your question.
Noted your concern.
In view of hypoglycemic episodes, I may suggest to continue current insulin doses along with it do SMBG (Self Monitoring of Blood Glucose).
In SMBG blood sugar tested by home glucometer.
One should do at least 2 to 3 reading daily from following 7 readings -
Fasting
2 hours post breakfast.
Before Lunch.
2 hours post Lunch.
Before Dinner.
2 hours post Dinner.
3 am (occasionally) once in 3 to 4 weeks.
Additional readings if there are symptoms of hypoglycemia. Along with it note down time, any variation in meal content or timings, physical exertion.
Depending upon weekly chart appropriate changes in insulin doses can be made for better blood sugar control without hypoglycemia.
Along with this continue diabetic diet and regular exercise.
After going through other test reports I may suggest -
- Continue Thyroid supplement as you are taking.
- Oral Iron supplement as there is Iron deficiency.
- Statin treatment (cholesterol lowering drug) as there is dyslipidemia.
You should discuss this with your treating diabetologist.
Hope this helps you.
I will be happy to answer your follow up question, if any.
Otherwise close the question and rate the answer.
Regards,
Dr Abhay Mali.
Diabetologist.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Doctor XXXXXXX
obviously, i check 2-3 times a day at different times- thats why i know that there is a wide fluctuations. Same - similar meal,exercise and insulin units is giving different results two hours after. it i becoming unpredictable. Pls Remember i am a knowledgeable LADA insulin dependant patient for the last 3 years so i know a lot abt know carbs, GI, GL,exercise, insulin doses etc. what i want to know are suggestions from your side - HOW to keep stability of sugar readings ?? Any specific food or medicine or any other ?? And whether exercise actually affects sugar readings in type 1/LADA.??
Please suggest exact iron supplement and dosage and should i start Rosuvas 10 and if yes - how many and for how long ??
obviously, i check 2-3 times a day at different times- thats why i know that there is a wide fluctuations. Same - similar meal,exercise and insulin units is giving different results two hours after. it i becoming unpredictable. Pls Remember i am a knowledgeable LADA insulin dependant patient for the last 3 years so i know a lot abt know carbs, GI, GL,exercise, insulin doses etc. what i want to know are suggestions from your side - HOW to keep stability of sugar readings ?? Any specific food or medicine or any other ?? And whether exercise actually affects sugar readings in type 1/LADA.??
Please suggest exact iron supplement and dosage and should i start Rosuvas 10 and if yes - how many and for how long ??
Brief Answer:
LADA Insulin is the only treatment option.
Detailed Answer:
Thanks,
I really appreciate your efforts to know more about your diabetes.
To avoid fluctuations in blood sugar levels I may suggest-
Considering the fact that you are very much aware of Glycemic index, Glycemic Load, how to titrate insulin doses you can individualize dose of Humolog before each meal depending upon before meal blood sugar level, carbohydrate content of meal, Insulin to Carb ratio & Correction factor.
Along with this clinical examination is also important including that of insulin sites.
In this process constant involvement of your diabetologist and dietitian is required.
Also use of AGP (Ambulatory Glucose Profile) may help, as it provides blood sugar level pattern over 14 days graphically using almost 288 readings per day.
You are also aware that LADA has only treatment option and it is insulin.
Some time change in type of insulin may help depending upon blood sugar level pattern.
Like Lantus contains Insulin Glargin it is also called as once a day insulin as it act over a period of 24 hours to control before meal blood sugar levels.
But in certain individuals it may not work for complete 24 hours and it may be difficult to control before meal blood sugar levels usually before dinner.
In such cases additional dose of short acting insulin like Humolog or twice a day Lantus or changing lantus with Insulin Degludec may help.
Exercise helps in any type of Diabetes.
During exercise muscle utilizes blood glucose with very minimal use of insulin and decreases blood glucose level ie. decreases insulin requirement.
If one of my patient present with similar scenario I may have suggested -
* For Iron Deficincy-
Tablet containing iron like Tab Orofer XT started with once a day and may have increased to twice a day according to patient’s tolerance, as tolerance with oral iron may be issue in many patients.
Duration of treatment may be 3 to 6 months depending upon response.
Along with it increase intake of iron containing food like green leafy vegetable.
* For Dyslipidemia-
Tab Rosuvastatin 10mg at bed time for almost life time if there are no side effects or contraindications to its use in future. Also in future doses may need to be revised according to lipid profile and other scenarios.
Hope this helps you.
LADA Insulin is the only treatment option.
Detailed Answer:
Thanks,
I really appreciate your efforts to know more about your diabetes.
To avoid fluctuations in blood sugar levels I may suggest-
Considering the fact that you are very much aware of Glycemic index, Glycemic Load, how to titrate insulin doses you can individualize dose of Humolog before each meal depending upon before meal blood sugar level, carbohydrate content of meal, Insulin to Carb ratio & Correction factor.
Along with this clinical examination is also important including that of insulin sites.
In this process constant involvement of your diabetologist and dietitian is required.
Also use of AGP (Ambulatory Glucose Profile) may help, as it provides blood sugar level pattern over 14 days graphically using almost 288 readings per day.
You are also aware that LADA has only treatment option and it is insulin.
Some time change in type of insulin may help depending upon blood sugar level pattern.
Like Lantus contains Insulin Glargin it is also called as once a day insulin as it act over a period of 24 hours to control before meal blood sugar levels.
But in certain individuals it may not work for complete 24 hours and it may be difficult to control before meal blood sugar levels usually before dinner.
In such cases additional dose of short acting insulin like Humolog or twice a day Lantus or changing lantus with Insulin Degludec may help.
Exercise helps in any type of Diabetes.
During exercise muscle utilizes blood glucose with very minimal use of insulin and decreases blood glucose level ie. decreases insulin requirement.
If one of my patient present with similar scenario I may have suggested -
* For Iron Deficincy-
Tablet containing iron like Tab Orofer XT started with once a day and may have increased to twice a day according to patient’s tolerance, as tolerance with oral iron may be issue in many patients.
Duration of treatment may be 3 to 6 months depending upon response.
Along with it increase intake of iron containing food like green leafy vegetable.
* For Dyslipidemia-
Tab Rosuvastatin 10mg at bed time for almost life time if there are no side effects or contraindications to its use in future. Also in future doses may need to be revised according to lipid profile and other scenarios.
Hope this helps you.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Great reply. Thanks. I think AGP is like CGMS. Tell me the cost of AGP. And educate me further on how to calculate insulin requirement based on carbs etc. as per your reply. This would help me.
What is the remedy for lumpiness/coagulation below the insulin sites in the stomach area. Any medicine or ointment ??
It is difficult to fall asleep at night even at 2 pm. There is uncomfortable feeling the feet and legs. I moisturise and massage and take neurobion i feel better. What is your advice on this as i sleep well in the afternoon and use to sleep at will during any point of the day.
How are my HbA1c result - 7.2-7.6 during last 18 months ??? I feel that these nos are misleading as the average of very high 250 and low 70 would give the same HbA1C which is my primary concern. Your idea on this pls.
What is the remedy for lumpiness/coagulation below the insulin sites in the stomach area. Any medicine or ointment ??
It is difficult to fall asleep at night even at 2 pm. There is uncomfortable feeling the feet and legs. I moisturise and massage and take neurobion i feel better. What is your advice on this as i sleep well in the afternoon and use to sleep at will during any point of the day.
How are my HbA1c result - 7.2-7.6 during last 18 months ??? I feel that these nos are misleading as the average of very high 250 and low 70 would give the same HbA1C which is my primary concern. Your idea on this pls.
Brief Answer:
One to one doctor and patient contact is important in your case.
Detailed Answer:
Thanks for your response.
APG is done by using a simple disposable probe which may cost around Rs. 2000 to 2500. Readings are derived by a specific devise compatible with probe and special software. You should check exact cost and its availibilty with your treating diabetologist.
Formula for Calculation of Insulin Carb ratio, correction factors can be easily assessable from google search.
But its application to some one requires high degree of motivation, one to one counselling, knowledge of carb counting.
It will be better for you to consult your treating diabetologist and dietician for same.
It is not feasible to discuss it here.
Lumpiness at insulin site may be due lipohypertrophy, though clinical examination is important before reaching to diagnosis.
Lipohypertrophy resolves at its own but may take variable duration from months to years.
You should avoid taking insulin at these sites.
For prevention of it at other sites, rotation of site of insulin with frequent change in insulin needles may help.
Your symptoms of night time restlessness, numbness in feet is most likely due to diabetic peripheral neuropathy.
It requires detailed neurological examination depending upon it use of medicines like Amitryptillin, Pregabalin may help.
Vitamin D and Vitamin B12 deficiency may exaggerate the symptoms of neuropathy.
With insufficient level of vitamin D, I may suggest oral vitamin D supplement using Cholecalciferol 60K units once a week
Also your Vitamin B12 level is in lower normal range continue taking Neurobion as before.
What you say about HbA1c is absolutely right. With wide fluctuation in daily blood sugar levels we may get similar reading of HbA1c.
But scientifically HbA1c is accepted as important tool to compare glycemic control with development of diabetic complications.
CGMS & AGP may help in resolving this issue.
Hope with this I am able to clarify your doubts.
One to one doctor and patient contact is important in your case.
Detailed Answer:
Thanks for your response.
APG is done by using a simple disposable probe which may cost around Rs. 2000 to 2500. Readings are derived by a specific devise compatible with probe and special software. You should check exact cost and its availibilty with your treating diabetologist.
Formula for Calculation of Insulin Carb ratio, correction factors can be easily assessable from google search.
But its application to some one requires high degree of motivation, one to one counselling, knowledge of carb counting.
It will be better for you to consult your treating diabetologist and dietician for same.
It is not feasible to discuss it here.
Lumpiness at insulin site may be due lipohypertrophy, though clinical examination is important before reaching to diagnosis.
Lipohypertrophy resolves at its own but may take variable duration from months to years.
You should avoid taking insulin at these sites.
For prevention of it at other sites, rotation of site of insulin with frequent change in insulin needles may help.
Your symptoms of night time restlessness, numbness in feet is most likely due to diabetic peripheral neuropathy.
It requires detailed neurological examination depending upon it use of medicines like Amitryptillin, Pregabalin may help.
Vitamin D and Vitamin B12 deficiency may exaggerate the symptoms of neuropathy.
With insufficient level of vitamin D, I may suggest oral vitamin D supplement using Cholecalciferol 60K units once a week
Also your Vitamin B12 level is in lower normal range continue taking Neurobion as before.
What you say about HbA1c is absolutely right. With wide fluctuation in daily blood sugar levels we may get similar reading of HbA1c.
But scientifically HbA1c is accepted as important tool to compare glycemic control with development of diabetic complications.
CGMS & AGP may help in resolving this issue.
Hope with this I am able to clarify your doubts.
Above answer was peer-reviewed by :
Dr. Prasad
I have high calcium for the last few years, so i think it is not advisable to take vit D 60k. Pls educate.
Low vit B - which one is better ?? Neurobion forte or methycobal 500
When going out for a drink/ snacks and then dinner after 2 hours, is it advisable to split humalog into 2 shots- one before snacks and one bfore dinner ???
Random checking shiws 250 after 3 hours of lunch/dinner, should i take 6 units of insulin at that point with no plan of food going for the next few hours. Will it help??
Any specific to help in shoulder pain which i have even after 2 months of physio ??
Thanks in advance.
Low vit B - which one is better ?? Neurobion forte or methycobal 500
When going out for a drink/ snacks and then dinner after 2 hours, is it advisable to split humalog into 2 shots- one before snacks and one bfore dinner ???
Random checking shiws 250 after 3 hours of lunch/dinner, should i take 6 units of insulin at that point with no plan of food going for the next few hours. Will it help??
Any specific to help in shoulder pain which i have even after 2 months of physio ??
Thanks in advance.
Brief Answer:
Hypercalcemia may need further evaluation.
Detailed Answer:
Depending upon detailed history taking and clinical examination there may be need for evaluation for hypercalcemia.
Avoid Vitamin D supplement, drink plenty of water.
Methylcobalamin is a form of Vitamin B12 while Neurobion contain small amount of Vitamin D along with other vitamins which may help in neuropathy like pyridoxine, vitamin B1. As you are not deficient in Vitamin B12 you can use Neurobion.
Whether to split insulin dose it will depend upon carbohydrate content of snacks. Again knowledge of carb counting and insulin carb ratio will help.
Additional dose of insulin may be advisable when the blood sugar level is >250. But dose of insulin need to be decided after calculating correction factor.
Take help of your treating diabetologist.
You have long term shoulder pain which may be most likely due to frozen shoulder. But it require clinical examination and if required Ultrasonography or MRI of shoulder joint for better management. You should consult orthopedician for same.
Hope this helps you.
In future you can directly ask questions to me on following link-
http://www.HealthcareMagic.com/doctors/dr-abhay-a-mali/69954
Hypercalcemia may need further evaluation.
Detailed Answer:
Depending upon detailed history taking and clinical examination there may be need for evaluation for hypercalcemia.
Avoid Vitamin D supplement, drink plenty of water.
Methylcobalamin is a form of Vitamin B12 while Neurobion contain small amount of Vitamin D along with other vitamins which may help in neuropathy like pyridoxine, vitamin B1. As you are not deficient in Vitamin B12 you can use Neurobion.
Whether to split insulin dose it will depend upon carbohydrate content of snacks. Again knowledge of carb counting and insulin carb ratio will help.
Additional dose of insulin may be advisable when the blood sugar level is >250. But dose of insulin need to be decided after calculating correction factor.
Take help of your treating diabetologist.
You have long term shoulder pain which may be most likely due to frozen shoulder. But it require clinical examination and if required Ultrasonography or MRI of shoulder joint for better management. You should consult orthopedician for same.
Hope this helps you.
In future you can directly ask questions to me on following link-
http://www.HealthcareMagic.com/doctors/dr-abhay-a-mali/69954
Note: For further follow up on related General & Family Physician Click here.
Above answer was peer-reviewed by :
Dr. Prasad
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