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Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar?

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Hi, I am a type 1 diabetic for 6 years and I take human mixtard 30/70. I have been working out in the gym for the past one month. I work out intensively in the evening but still wake up with high blood sugar in the morning. I also take a protein supplement after work out. This has started to happen since the past 10 days only. During the day time my blood sugar is normal. I generally desist from increasing my evening insulin dose because it sometimes causes hypoglycaemia during the night. Can you suggest something?
Posted Sun, 26 May 2013 in Diabetes
 
 
Answered by Dr. Om Lakhani 32 minutes later
Hi XXXXXX

First and foremost I am very sorry to hear you are taking Mixtard for Type 1 Diabetes. MIXTARD IS NOT USED IN TYPE 1 DIABETES. Mixtard is premixed insulin designed for Type 2 Diabetics. If you are a type 1 Diabetic you have absolute insulin deficiency that means you need to use basal bolus insulin.

Basal bolus insulin is combination of One long acting insulin (Like Lantus or Basalog) which has 24 hrs action. This is taken once a day either in morning or at night and DOES NOT CAUSE hypoglycemia. The Hypoglycemia you experince at night is because of NPH component of Mixtard which can be prevented by using long acting insulin.

The second component of Basal bolus therapy is Bolus insulin. This is taken before meals. This consists of short acting insulin like Actrapid, Apidra, Humalog or Novorapid. This acts for a short while to help you control your post prandial sugars.

Mixtard unfortunately would neither give you a good glycemic control nor would it avoid hypoglycemia which you are experiencing. Also there are rules of insulin intact that have to be followed which exercise that depend on your pre-workout sugar levels and your intensity of exercise. You need to do the following during work out

Monitor Blood glucose (BG)
- Pre-exercise (BG must be >100mg/dL before starting and <250 before starting)
- Every 30 minutes during exercise
- Post-exercise (periodically, until BG lowering effect of exercise has subsided)

For intense endurance exercise, you typically need to consume 15 grams of carbohydrate for each 15-30 minutes of activity.

I would advice you to consult a good diabetologist or endocrinologist with your reports to have a Basal bolus setup for you based on you insulin requirement. Like I said previously I am actually surprised that someone has prescribed you mixtard for type 1 Diabetes which is wrong line of initial Management. We use Mixtard in those type 1 diabetics who donot understand anything about the disease and can under no circumstance afford or accept any other form of diabetes management , for them since something is better than nothing we use Mixtard, otherwise Basal bolus insulin is the norm in type 1 Diabetics worldwide.

Hope this helps

Regards
Dr. Om Lakhani, MD
Consultant Diabetologist.
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 56 minutes later
Hello Doctor,
I totally understand what you are saying. When I was diagnosed, I was 19 and had just entered college. Adjusting to the new college life away from home was tough and the trauma of taking multiple insulin shots was also there. May be that is why the doctor initially recommended me Human Mixtard. And the reason that he never asked me to switch could be that I have had good HbA1c reports all these years. My first 2 HBA1c reports (1st being 6 months after being diagnosed) were 7.5 and 7.2. Other than that I have never had an HbA1c greater than 7. Believe it or not I had once achieved an A1c of 5.9(while only on Mixtard) when I was at home for 2 months during a summer break. And also I would like to mention that my condition is type 1 diabetes only, other possibilities like pancreatis(forgive my spellings) have been ruled out with a CT scan of my abdomen during the initial stage of my diagnosis. My last HbA1c was 6.7 (which was taken about 4 months back). I am by nature a fanatically disciplined person. I follow the advice of the doctors to the word.

But I totally get your point. Despite having a good control, I have had quite a lot of hypoglycaemic episodes. And those have frustrated me at times. My lifestyle has also undergone change in the past 9 months when I started my job after college. I am aware of the basal bolus insulin therapy and was seriously considering switching to it. Your advice here has only reinforced my decision.

I also want to know one more thing. If I start the bolus basal therapy, and as you said that basal insulin does not cause hypoglycaemia, does that mean that in case I skip an evening snack it will not cause my blood sugar to drop below 70? (Assuming that my sugar levels 2 hours after lunch were say 150)?
Would you also be able to tell whether the cost of basal bolus insulins is more than the mixtard or actrapid or is it more or less the same?

 
 
Answered by Dr. Om Lakhani 50 minutes later
Dear XXXXXX

I am proud of your HbA1c achievement . Believe me HbA1c <7.0% is difficult task to achieve in type 1 Diabetics, but it is good that you have achieved it.

If you HbA1c is fine with Mixtard, it is good news. However Basal bolus therapy will give you flexibility which a young person of your age would require. The switch would be seamless and we can have the same dosage you are using now with mixtard for basal bolus regimen so that your HBA1c is not affected.

As far as skipping evening snack is concerned this flexiblity can be provided by basal bolus therapy. Basal insulin like Lantus will not cause hypoglycemia and if you skip the snack all you have to do is avoid a basal dosage. However, not for sake of hypoglycemia but for the sake of keeping proper nutrition I would recommend you to take small frequent meals. This will provide proper intracellular nutrition concentration which is compromised in diabetics. (Diabetics have high blood glucose but glucose doesnt reach the cell because of lack of Insulin and hence cells are deprived of nutrition).

Hope these recommendations helps

Take good care of yourself. And like I said, as a Diabetologist I am proud of your glycemic control.

Regards
Dr. Om Lakhani
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 37 minutes later
Thank you doctor. Just for my information, before I go and see a doctor in person, can you tell me what is actually the regime of insulin shots of basal bolus therapy. I mean which shots will I have to take and how frequently?? Also will it solve my problem that I mentioned in my very first question? i.e. High sugar values in the morning? Also, is my exercise routine causing this elevated blood sugar in the morning?? its like I take 6 units of human mixtard before dinner. when I go to bed my numbers are 150-180 and in the morning they get to 250. This only happens when I start going to the gym regularly. It has happened in the past also when I used to work out in college. At that time I left the exercise for the sake of blood sugar control and every thing came back to normal. But now I want to continue going to the gym because hours of sitting in front of a computer in office is causing deposition of fat at my abdomen, and I don't want to look like a pregnant lady in a few years.
 
 
Answered by Dr. Om Lakhani 26 minutes later
Hi XXXXXX

Basal bolus regimen would be 4 shots of insulin minimum. One shot of Lantus (long acting) at bedtime and three shots of short acting before breakfast, lunch and dinner. What the doctor would do is you take you total dose of Premixed insulin and divide by half. One half would be Basal insulin (long acting) and other half would be divided into three and given as three time bolus dose. The dose adjustments would be done for your fasting, prelunch, 2 hr post lunch , predinner and post dinner sugar values.

What you are experiencing is what is known as Somoyagi phenomenon. What happens is since you workout, about 6 hrs post workout your muscles crave sugar and they take up all the blood sugar. Plus there is action of Mixtard so there would be transient hypoglycemia at about 2-3 am in night. To counteract the body would produce more counteracting hormones that would increase your blood sugar hence your fasting sugars are high. This is classical action of NPH which is component of your Mixtard. By using Lantus we would prevent this nightime dip of sugar and hence prevent Somoyagi phenomenon. We would adjust the dose of Lantus based on your fasting sugars without causing hypoglycemia at night.

No problems with working out, but just follow the rules I mentioned previously. Also if possible I would recommend morning workout instead of evening as it would be better for getting controls of sugars.

As far as cost is concerned basal bolus therapy would be costlier than Premixed but I guess cost is secondary to the benefit you will get.

Regards
Dr. Om Lakhani.

Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 8 hours later
Hi doctor,
I went to see a diabetologist today. He has recommended me novorapid and Levemir. The thing is that I have two insulin delivery pens. one is novopen 3 and the other is Insupen. I will get the novorapid cartridge for the novopen. But I will have to buy a new pen for Levemir. Can you tell me if there is a basal insulin available by this Insupen brand which can substitute for Levemir?
 
 
Answered by Dr. Om Lakhani 25 minutes later
Hi XXXXXX

Absolutely. Insupen is from Biocon which have BASALOG as long acting insulin. You can use that. Infact it is similar to Lantus. I would prefer Basalog and Lantus anyday over Levemir because they are true 24 hr insulin which Levemir is not.

Hope that helps

Regards
Dr. Om Lakhani, MD
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 40 minutes later
That's a relief doctor. Because Levemir is almost 4-5 times expensive than other types of insulin like actrapid and all. I have a few more questions.

1.) What is the difference between Actrapid and Novorapid? The doctor said that Novorapid acts immediately and there is no half an hour lag period like Actrapid. I prefer to have a gap between my injection and my meal because it allows me to take the injection privately and give me time to go to the place where I am supposed to eat. The doctor has recommended me Novorapid. But if there is no other difference between the two accept the one mentioned above, can I use Actrapid?

2.) The doctor has asked me to take lavemir 18 units after dinner. Can I use BASALOG directly? I mean is it ok to change brands without altering the number of units I take?

3.) Doctor asked me to take Basal Insulin after dinner. Does that mean immediately after finishing my dinner or 2 hours after dinner?

3.) Since I have used Human Mixtard for so long I have observed that the rate at which the NPH component of human mixtard lowers blood sugar is around 50 units per hour. I want to know how does BASALOG behave in this regard. I mean suppose my blood sugar after dinner is 160 and I take BASALOG 18 units immediately after dinner, will it not cause my blood sugar to dip low during the night during sleep?
 
 
Answered by Dr. Om Lakhani 23 minutes later
Hi XXXXXX

Lets answer your questions

Q1 difference between Actrapid and Novorapid

Novorapid is a analgoue insulin. It gives more flexiblity to you. You can take it immediately before meal. Actrapid you have to take 30 min before meals. Also the dose requirement to get the same control with Actrapid will be higher. It is like old technology actrapid which still dose the purpose which it is supposed to while novorapid is fancy new technology, better action at lower dose. But if cost is an issue and you do mind planning your meals, Actrapid is fine.

Q2. Dose of Basalog

How much were you taking Mixtard total in the day ? Based on this I can tell you the dose of Basalog you require. switch to levemir to basalog in same unit is fine but depends on what parameters your doctor used for calculating the dose of levemir.

Q3. Dip in sugars

Basalog/Levemir is not like NPH. It will not cause hypoglycemia or sudden dip in your sugar like NPH. So it will not cause hypoglycemia at night. It has a flat profile. You can click on the following like to see the profiles of various insulin

WWW.WWWW.WW
FYI: Detemir in the above image is Levemir and Glargine is Basalog/Lantus.

Hope this helps

Regards
Dr. Om Lakhani
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 7 minutes later
And what about the timing of the BASALOG after dinner? Is it immediately after dinner or 2 hours after dinner?
 
 
Answered by Dr. Om Lakhani 3 minutes later
You can take it either time. I prefer bedtime or 2 hr after dinner. The only concept here is not meal timing but to take it same time of the day everyday because it has 24 hour action so if you take same time everyday it will have a more even action.
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 2 days later
Hi doctor,
I have started taking Basalog and Actrapid and I am trying to adjust the dosage of each by constant monitoring of my blood glucose levels. But I still have some confusion about the behavior of Basalog. Consider the following observations and let me know if there is an explanation for that.
One night my blood sugar 2 hrs after dinner was 127. I took 16 units of Basalog and as per my routine I took one glass of skimmed milk. I checked my blood sugar again after 1 hour. It was 130. But in the morning I woke up with a sugar level of 151.
Now my sugar levels before breakfast were 151. I took 16 units of actrapid, after two hours by sugar level was 228. After almost about 2 hours(during which I ate nothing) my blood sugar was 208.(Human Mixtard on the other hand would have reduced it to about 128 in two hours)
2 hours after lunch my blood sugar was 130. and after two hours of that it dipped to 49.

Why is basalog behaving differently during different times of the day? in the morning it could only reduce my sugar from 228 to 208. And in the evening from 130 to 49 in 2 hours. Whereas my morning numbers are about 30 units greater than my bed time numbers.
Kindly explain.

Also I would like to mention that I am not going to the gym since the day I have started the basal bolus regime. So there is no major physical activity that I am doing these days.

 
 
Answered by Dr. Om Lakhani 2 hours later
DearXXXXXX

Like I explained to you Basalog will not cause the Dip in sugar like your mixtard. It will only maintain a constant level of Insulin in the Body. The Dip of your sugar to 49 was not a result of Basalog , rather it was a result of a delayed action of your Actrapid. Since 2 hrs post lunch you sugar is 130 and post dinner 127 I would ask you to reduce the Lunch time actrapid by 2 units each time. This will prevent the dip you observed. Post prandial sugar <180 is enough, we dont need it to dip. Your morning actrapid on the other hand is not enough and we need to increase the dose of it.

The morning time dip you explained is also not due to Basalog. It is because of the morning's actrapid. Like I said XXXXXX, BASLOG WILL NOT CAUSE SUGAR TO DIP LIKE NPH IN MIXTARD. Baslog will just MAINTAIN your sugars in normal range when you are not eating.

As far as action of Basalog is concerned, Basalog is still not adequate. I think there is a little error in the dosing that is made for you. I think the prandial insulins given to you are higher dose than they should be and Basalog is lower than it should be. I think you need to visit you Doctor again and give him this suggestion if mine.. Increase Basalog, increase morning actrapid dose, reduce lunch and dinner actrapid dosages.

This should solve the issues.

Regards
Dr. Om Lakhani
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 2 hours later
Ok, I think I got your point. If Basalog will not cause a dip in my blood sugar, does that mean that I should not have snacks between meals?? because if I have a small snack(say 15 gm carbs) it will make my blood glucose high for the next meal. Is that right?
 
 
Answered by Dr. Om Lakhani 29 minutes later
Hi

Yes. If you take a small snack you can take additional rapid acting insulin like actrapid or novorapid before that. But basalog will not control your sugar during snacking.

Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 2 days later
Hi doctor,
My blood sugar seems to be on track. I am particularly relieved that I neither have noctoral hypoglycemia nor my morning numbers are high.

Right now I am not going to the gym. But I plan to monitor my glucose levels for this week and then start working out again in the next week. I just want to know, how do you advice to go about it? I mean, I need to have some carbohydrate before going to the gym. so should I also take a small dose of actrapid??

Also, for how long does act rapid work after taking the injection? I have observed 3 hours. Tell me if that is right.
 
 
Answered by Dr. Om Lakhani 15 hours later
Hi

Yes. Actrapid works for 3 to 4 hours. For work out dont take any Actrapid. Let Basalog do its action. Also you need to follow these rules


Monitor Blood glucose (BG)
- Pre-exercise (BG must be >100mg/dL before starting and <250 before starting)
- Every 30 minutes during exercise
- Post-exercise (periodically, until BG lowering effect of exercise has subsided)

You may or may not take carbs before workout however in either cases actrapid is not required unless you sugar is very high.

Regards
Dr. Om Lakhani.
Above answer was peer-reviewed by
 
Follow-up: Diabetic, taking human mixtard. Working out , take protein supplement. Reason for increased blood sugar? 48 hours later
Hello Doctor,
One last question, If I take more actrapid than I need I will experience hypoglycemia. But since Basalog does not cause hypoglycemia how would I know ever in future that I might be taking more Basalog than I need?
 
 
Answered by Dr. Om Lakhani 39 minutes later
Hi XXXXXX

Yes if you take actrapid more than you need you will get hypoglycemia. Basalog we always titrate based on youe fasting sugars and keep the mimimal dose that maintains your fasting level. So once your fasting is in range using basalog, we would not be required to increase or reduce its dose. That means you will be mostly sticking to the same dose hence there is no point of excess dosing.

Hope that helps

Regards
Dr. Om Lakhani.
Above answer was peer-reviewed by
 
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