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Re: [IPk] Definition of a hypo



Good Morning Gareth,

 If she wakes up hypo, because her alarm clock goes off & it's time for her day
to start there 2 big problems. I know you know them, but when you are working
with clueless clinicians, it helps to break them down:

1) she must have become hypo whilst asleep.
2) the hypo did not wake her, which suggests nocturnal hypo-unawareness.

That combination is, without scaring you, dangerous.

Have you got "Think Like a Pancreas"? It gives you tips for basal reduction.

 By the way, blood sugars varying widely because of hypos & treatment, is
reported to be associated with less than ideal HbA1Cs. I have read the studies,
but I am not really awake enough to find them again yet.'m

On 6 Dec 2013, at 06:51, Gareth <email @ redacted> wrote:

> Thank you Belinda, Rhoda & Jackie for your input.
> 
> My initial query was made partly out of curiosity as to what the consensus
> might be amongst listers as to what level of hypos we tolerate in practice,
> whatever 'the rules' say
> The Wikipedia article is quite useful for an overview
> http://en.wikipedia.org/wiki/Hypoglycemia
> 
> In my wife's case, a study of the various care link reports indicates to me
> that whether on "live" metformin or not there has been a sea change in her bg
> levels in general - a downward shift of the 'plateau' if you will. Suggesting
 > that insulin is more effective, probably because of the metformin which she
may
> or may not be taking..........
> 
 > There is no single pattern of low Bgs although the first one in the morning
is
> a regular.
 > We today intend decreasing all basal rates by a common percentage which
equates
> with lifting that plateau up in stages to the point where average lows are
> around 4.
> That will inevitably increase her HbA1c, it will be interesting to see where
> that ends up.
> It's still rather early here in the Uk so will leave the actual calculation
> until fully awake!
> 
> For the sake of saying it, we report key data monthly to our Remove trial
> contact person, plus less frequent actual review meetings .
> Speaking generally, we don't feel that we are 'on our own' in any sense
 > although we do seem to know more about pumping than some of the professionals
we
> deal with across the whole piece. Which isn't saying very much !
> 
> Gareth
> 
> 
> On 5 Dec 2013, at 23:15, "Jackie Jacombs" <email @ redacted> wrote:
> 
> While it's great to take part in trails I do have concerns that your wife may
> not have been informed if she is on a medication which can affect the blood
 > glucose levels. Well of course she would have know she was or might not be
but
> I would have thought that she would have someone on the trials who can give
 > advice. Also another thing to remember that if the BG levels are running
lower
 > for longer periods that there will be greater insulin sensitivity and
therefore
> with really good tight control your wife may need to review both bolus and
> basal
> ratios.
> 
> 
> Jackie
> 
> -----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
> adjustments 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 term underlying
> harm, unnecessarily.
> 
> 
> Gareth Hicks 
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