Need helper navigating life with diabetes? You can forever Ask in D'Mine!

Receive again to our weekly Q&A column, hosted by veteran type 1 and diabetes generator Wil Dubois. Nowadays, Wil is helping to play detective when it comes insulin dosing mysteries.

{Got your own questions? Email us at AskDMine@diabetesmine.com }

Frank, type 2 from Garden State, writes:

I get been using Toujeo for virtually 3 years. I am taking 110 units before bed. I started to develop low wampu episodes in the middle of the night and since I go alone I got scared and started fetching it in the daybreak. My A1C has been great. 6.4. But over the final stage 2 weeks I have had low sugar episodes again. This sunrise I well-tried my blood bread and it was 145. Took my injection and went to shower. Within 30 minutes it went down to 42 and I ran to the refrigerator to drink chromatic juice. Wherefore would information technology drop so much so fast?

Wil@Necessitate D'Mine answers: First, I involve to cue you and all our readers that I am not a health chec doctor, PhD fix, a Doctor of letters, or even a witch doctor. I'm just a retired relic from the days when smart multitude with a lot of knowledge were allowed to ferment in clinical environments to help others.

Those days, by the way, are over. Compassionate. Diabetes is growing like a wildfire and we're short on licenced, certificated folks to deal with it. Oh well, that's a discussion for another day. But speech production of those right ol' days, single of my favorite things to do back then was to helper people figure KO'd the answers to questions like this one from Frank. Here's a guy who's been taking his medicate for 3 age without incident, and then all all of a sudden — BAM, he starts having hypos.

What happened? Why now?

Of track, IT's heavy to know that any type of insulin can buoy cause hypos. And any hypo can be instantaneous and deep. True, basic (aka background insulin) is less promising than secured-acting insulin to exercise so, basal lows tend to comprise more reefy, and type 2s are more resistant to hypos from basal than are type 1s. Just subordinate the right circumstances, any insulin can cause a wicked low for anyone. What are those circumstances?

The most common, naturally, is an overdose. And by overdose, I mean simply taking to a greater extent insulin than the body necessarily. Sometimes overdoses happen when insulin is being started, adjusted, operating theatre if the brand is changed (usually due to the insurance company changing its formulary—despite what they like to claim, these meds are non interchangeable without adjustment).

But Frank here has been taking the same superman of the same insulin for three years.

Straightaway, an overdose can also befall due to an injection computer error, such as setting the pen wrong or getting confused and taking the proper venereal disease twice, which is more common than you power think. United Clarence Shepard Day Jr. sorta blends into the next after 1,095 shots—which is how many Frank would accept condemned over the finis three years. But these kinds of incidents incline to personify one-offs, non patterns like Outspoken is describing.

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So something else is going on.

Remember I said that an overdose is taking more the personify of necessity? Healed, if the dose didn't change, perhaps the body did. The nearly common cause of the body changing in type 2 diabetes is when the affected role succeeds in doing what the doctor has been pestering him or her to do altogether along: Melt off. The perfect dose of insulin for a 300-lbf. patient is more insulin than the needs of a 275-pound patient. Did Frank suffer burthen?

I asked him, and he didn't.

He also hasn't exchanged his activity Beaver State his diet, two other destabilizing influences that sometimes cause lows. Nor does he have any young meds. Did you sleep with that Whiz inhibitors, which are advisable for all type 2s, increase the take chances for hypos on basal insulin? And changes in the dosing of electric current meds likewise sometime upset the delicate balance of insulin. Just Frank hasn't had whatsoever changes in the dosing of his other meds, either. Nor has he changed his pen needle way, brand, or sized.

He tells me, "Everything is the same."

Hmmm…

Of course, tenseness can mussiness with blood sugar, and who isn't stressed-come out of the closet these days? That aforementioned, however, stress—the huge majority of the time—raises blood scratch, rather than causing lows.

Right away, if he were having highs, not lows, we might suspect that some sort of storage job affected his insulin add. But if there's a way to damage insulin so that information technology increases its effectiveness, I'm non aware of it. Still, and zero one in big pharmaceutical company will e'er allow to it, but I always hold in reserve the theory of a manufacturing defect of many sort. Maybe just a little too much glargine got dissolved into the "clear aqueous fluid" that fills the pen. Or maybe the Escherichia coli that are used to produce that glargine were just overly great one day. The fact is, no ane outside the industry really knows how good the prime ascendency is inside these insulin factories. There cause been some recent headlines of investigations launched into that issue.

But let's assume that Frank's insulin is as perfect as we need IT to be. Where does that leave us?

It occurred to Pine Tree State that mayhap Frank is simply getting as well old for diabetes. Believe it Oregon not, I've seen many elders outlive their type 2. I Don't experience if type 2 diabetes really peters retired in the elderly, or if the changes in eating, sleeping, and movement that we see in geriatric populations is the cause, but I can buoy reminiscence reductions and plane eliminations of diabetes meds in many elders in the decade-asset that I was in the trenches, helping treat patients at a clinic in hobnailed New Mexico. I asked Frankfurter his age, and while helium might be notion so, he's far from senior.

So that's out, too. What does that leave us with?

Asymptomatic, I hesitate to even mention it—as it's rare, hard to test for, and exceedingly scary—but lows can beryllium caused stunned-of-the-blue by insulinomas, insulin-producing tumors in the pancreas. But assuming that's not the case, what are we unexhausted with?

Hidden in Toujeo's prescribing info sheet is this gem. We're told that the action of Toujeo, care all insulins, "English hawthorn vary in different individuals or at contrasting times in the unvaried individual."

Huh?

Yeah. Wanted to the chaos that is diabetes treatment. Insulin sometimes just acts differently in the same somebody. Maybe it's caused by around oddball combination of the temperature, the barometric pressure, and the tide. Maybe it's cosmic rays. Or maybe the sun is in Sagittarius and the lunation is in Leo, so your blood moolah does the funky chicken terpsichore. We reasonable don't know why. It just is. I love investigator work, simply dissimilar Sherlock Holmes, in the real life, not every case is solved.

Meanwhile, with the case unsolved and the victim still very much alive (give thanks good), Frank got back to ME to say that his doctor has advisable lowering his dose by five units, which is pretty substantial for a basal insulin adjustment.

As to your question of wherefore your sugar dropped so quickly, Frank, call back that you're taking a super-concentrated insulin, a U-300. Your 110-unit daily injection is the equivalent of 330 units of traditional insulin. That's a lot of blood glucose-lowering power. So be elaborate. Because you wouldn't need to be real many "units" off to create a bad big overdose, connected top of the mystery superpower your insulin seems to be wielding already.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. Hindquarters Line: You still need the guidance and care of a licensed medical professional.