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RE: [IPk] Definition of a hypo

Just for info, Gareth, I'm T1 and also on metformin to reduce insulin
resistance.  I still have occasional hypos - especially if I skip or have a
lighter meal than usual mid-day - I tend not to eat much then normally so
don't bolus for it.

But still my consultant says no-one on an insulin pump should have a hypo.
Animas were stunned when I told them this yesterday!

I always thought that the BDA had set the "normal" parameters as 4 mmol
being the floor and 10 mmol the ceiling.  Perhaps the DSN is taking a rough
guide as 3.3 being a hypo... Why not 3.5 or 3.6?  I don't know...

I woke up on Wednesday am at 2.2.  My own fault as I'd only had a banana for
lunch, an early light meal - couldn't face food and obviously did not eat
enough for a snack in the evening.  

The only reason I've heard of giving metformin to T1's is to reduce insulin
resistance thereby making insulin more effective.  It's been used this way,
to my understanding, for several years, so unsure why it is only now being
researched?  Melissa et al, have I missed something here?


-----Original Message-----
From: email @ redacted [mailto:email @ redacted] On Behalf
Of Gareth Hicks
Sent: 05 December 2013 22:05
To: email @ redacted
Subject: [IPk] Definition of a hypo

My wife Jean is the T1 in our house, it's now been 48 yrs - and a pumper for
last 5yrs.

She's now almost a year into a 3 yr  trial (Removal) which I understand is
to assess how metformin might be used in T1 treatment (as against T2) to
mitigate diabetic complications (and make insulin more effective?).
It's a blind trial so we don't know for sure whether she's on metformin or
not, but have a suspicion that she is.
That's because we've seen many more 'technical hypos' since she started on
it, sometimes daily.
These are virtually ALL between 2 and 3, her hypo setting is 3.3
I said 'technical' because she has no really obvious symptoms these days,
not above 2 anyway.

Aside from the administration of the trial itself, Jean's diabetic
consultant and GP are now concerned about hypo frequency and are suggesting 
some more fasting tests.
Whilst this is OK in theory, our experience is that we can fiddle about with
basal settings to out heart's delight but historically have eventually ended
up roughly where we started.
That's an over simplification, and we did make some 'trial and error' basal 
shortly after the Removal trial started,  but you get my point.
I'm not saying we resist fasting per se, just wondering whether the hypo 
related criteria for doing so is 100% relevant to her.

We are in fact already more actively using temporary basal reductions when 
BGs are
edging downwards, especially last thing at night.
And using longer acting carbs when sorting out a hypo, something we haven't
been too good at admittedly.

Her latest HbA1c is 6.3 compared with 7.5 - 8 in pre pump days.
Considering Jean's age, the advice we have received from our consultant in
the past, and listened to,  is not to consider a  much lower HbA1c than say 
7 as
a target in any sense.
Implying that avoiding hypos is now more relevant for her.

We have, about 6 months ago, adjusted the bolus settings and the insulin 
sensitivity factor  and I am (fairly)
happy they are Ok where they are.

I have no idea now where the 'under 3.3 qualifying line' for hypos came
from, perhaps set by the DSN when Jean first had a pump.

My question, do  other pumpers use a different definition of a hypo, and if
so does anyone know how these are worked out?
Or is a standardised  definition being used?

My growing and uninformed, concern, despite there being no obvious
symptoms, is that frequent hypos (as currently defined) are causing longer 
underlying harm, unnecessarily.

Gareth Hicks 
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