My wife is a 46-year-old female of 5.4 feet and weight of 80 kg. She has diabetes for around four to five years and hypertension (after medicine 130/80), hyperthyroid (after 150 Eltroxin well controlled) for a similar period. She had a hysterectomy done around four years back.
She is on diabetic medicine since seven years, and however, control has not been good with HbA1C around eight to nine and fastings around 200 and PP around 260/250. Since seven years ago, she has been on 24 hours Insulin Lantus (starting from 20 IU to now 48 IU every morning daily). After two months, she also started having three-time rapid-acting Insulin Humalog Lispro (beginning from 16 IU per three times to 20 IU). After all this, her levels are around 150 fasting and 200 PP. Some time PP is about 160. We have also tried 50-50 mix Humalog for short, and medium acting results are a little better with only short term insulin.
She is good at exercises (two to three kilometers walk every day, average household activities), and eats healthy food – salad, srown food, no fried, no sweets, and low fat. Once a while, maybe two times a week, there can be fatty meals from the restaurant, which will typically change readings from 150 fastings to around 200 or even above 200 PP and change accordingly to 250/260.
Along with insulin, no medicines are helping like Glimepiride, Metformin, Pioglit, Januvia. Metformin controls her sugar well, but side effects are very severe with diarrhea (10-15 times a day), especially after using this medicine for few days to few weeks on high doses of 1000mg morning and evening.
Current diabetic medication are,
Lantus 48 IU daily at 9 PM, and Humalog Lispro 20 IU three times per day.
Please suggest what is the best way to go forward. Can a dose of Insulin be increased further? What are the maximum recommended doses for Insulin, both short and long term? What happens as her age increases? Would the dose of Insulin increase even further?
Please help; I can provide any more information you need.
Welcome to icliniq.com.
Thanks for your query. I would initially like to know her TSH (thyroid-stimulating hormone) levels since my target is to maintain TSH to around 1.0. Further, your wife's Insulin is resistant, whereby her dose of Insulin is likely to go up with time. Insulin dose and age do not correlate. The correlation is between the number of carbohydrates (sugars in different forms) in each meal and Insulin dose. The more the carbohydrate content in the food, the more is the Insulin requirement. Reduction of carbohydrates (such as rice, potato, sweets, cold drinks, junk food, confectionery, etc.) will automatically reduce the dose of Insulin. Stop restaurant food completely. Dietary discipline is a must. For the time being, increase the night dose of Humalog Insulin to 22 units and keep on increasing the night dose by two units until your wife's fasting sugar comes down to around 100mg/dL. The morning dose of Lispro may be increased to 21 units and keep on increasing the morning dose by two units after that, till her PP (postprandial) comes down to around 130mg/dL, no change in afternoon dose or that of Lantus (Insulin Glargine). Finally, there is no maximum recommended dose of Insulin. I hope you find my response helpful, informative, and enlightening.
Thank you, doctor, for your reply.
This is a follow-up to your earlier reply (history is already with you). She is on 48 IU Lantus at night and Humalog Lispro 20 IU x 3 times and cannot tolerate any medicine, especially Metformin. Even after all this, her FF was 180-200 and PP 220-250 for the last two months.
However, for some reason, in the last one week with almost the same routine of exercise (three to four km walk daily in two chunks), healthy food, Insulin as above, her sugar levels have shown perfect changes where fasting coming in a range of 90-120 and FF also from 90-150. We reduced Lispro from 20 to 18 x 3 times, and the results are similar. Thank you for your efforts to bring this on the positive side.
My query is like this:
• What X factor could have changed last week that did not change with the same routine for almost two months? Three factors, exercise, food, Insulin, are virtually the same. The point is IF we can identify, we can improve even better on working that X factor
• Is there some standard/average sugar values for quantity/type of food one eats, quantity/type of exercise one performs, quantity/type of InsulinInsulin and medicines. E.g., suppose one eats two chapattis, sabzi, yogurt, salad in lunch, generally for average diabetic persons. In that case, the sugar level will increase by about 40 points, or if one takes 20 IU of Humalog, the sugar level will fall by 60 points and so on.
• My point is if there are some common values, and maybe we can take the same for my wife (as every person can be a little different than average diabetic). She can be motivated enough to change food, exercise, InsulinInsulin further that her sugar levels are always around near normal.
• Further there can be some micro factors influencing sugar levels like how many time one eat/exercise, stress levels, infection, glycemic index, snoring. The list can be endless, but I think that is where medicine needs to establish clinical results.
• Is one factor is her pancreas have now got rested very well by being on a healthy dose of Insulin for a few months, and they have started working better than before?
• Further worry is since we do not know that X factor. What if that again starts working and sugar levels are back to bad?
Suppose this kind of data is not available from a science background. In that case, it can be prepared for a reasonable group, say 100 patients of different diabetic stages, and control becomes a lot easier. Please suggest if my query is clear, and you can guide me on how to get this data and tweak for her.
Welcome back to icliniq.com.
It is a pleasure to hear back from you. I am happy to know that Blood sugars have come under control. She is undoubtedly a highly motivated lady.
The reasons for better control are:-
1. Improved Thyroid control: This increases the metabolic rate. That is, with normal thyroid hormone levels, more blood sugar is burnt with the same level of exercise. Please maintain her TSH levels between 0.5 to 1 for optimal control of thyroid and diabetes.
2. Energy- consumed due to exercise is produced by burning blood sugar. An increase in activity (from 2 to 3km walk per day earlier, to 3 to 5 km per day) has helped regulate blood sugar levels. Further, I presume that an increase in exercise without a concomitant increase in carbohydrate intake has also helped by reducing insulin resistance.
3. As mentioned earlier, blood sugar depends solely on the number of carbohydrates (sugars in different forms), apart from calorie intake. Golden Rule: low calorie (around 1200 Calories per day); low carbohydrate ( 100 gm carbohydrates), low fat (10-20 gm of MUFA fats), high protein (60gm per day) diet is ideal in people with diabetes. A suggested diet chart is given below.
4. Overdose of Insulin --> hypoglycemia --> instant stimulation of counter-regulatory mechanism which shoots up the blood sugar even beyond ideal levels (called Dawn's Phenomenon).
5. Impending Kidneys' involvement as a diabetic complication. Insulin is excreted by kidneys. Impaired kidneys --> reduced insulin excretion --> increased insulin levels in the blood --> further reduction of blood sugar. Please get her urine for microalbumin levels done. Increased Microalbumine levels in the urine suggest impaired kidneys' function.
An increase in exercise, abstaining from restaurant food, and normal thyroid hormone levels were probably responsible for better diabetic control.
* Try to adhere to the suggested diet plan.
* Increase exercise further, preferably gymming, aerobic exercises, and brisk walks.
* Progressive reduction in body weight to 60 to 65 kg in a phased manner.
* Meticulous, sustained control of TSH between 0.5 to 1.0 for six months --> thereafter, reduce Thyronorm (Levothyroxine) dose so as to bring up TSH between 1.0 to 2.0.
* Five blood sugar estimations on any day (Fasting; just before lunch and dinner (before giving insulin); and, at 3 AM.
* Blood urea, creatinine.
* TSH level.
* Urine for microalbumin levels.
* Ultrasound of kidneys.
* Take the HbA1c index after two months.
Suggested diet plan:-
Tea (without sugar) one cup.
Marie Biscuits two.
Stuffed methi, or palak, or lauki paratha two small.
Curd 50 gm (one cup).
Egg white, or Paneer Bhurji one medium bowl.
Plain roti (no oil ) two small.
Vegetable poha, or upama, or oats, or daliya one soup bowl.
Apple, or guava or orange one.
Salad (10 minutes before lunch) one Medium bowl.
Capsicum with gobhi veg one medium bowl.
Dhal one soup bowl.
Phulka (no ghee) two.
Milk, or green tea, or herbal tea, or lemon water one cup.
Roasted chana with Muri one cup.
Salad (ten minutes before dinner).
Phulka (no ghee) two.
Lauki veg one cup.
Curd one cup.
Skimmed milk (no sugar) one glass.
Lastly, I hope you find my response helpful, informative, and enlightening. Please feel free to revert to me for further queries, along with recommended investigation reports.
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