Monday, February 28, 2011

Sick Day Insulin Resistance

Yesterday I was congested and sneezing and sick. Also running high. I went to bed early, around 10 PM, taking 12 units of Lantus instead of the previous night's 10. I also took three units of Novolog because I was around 220 heading up.
I woke up at midnight with a blood sugar of 260 and took three more units, went back to sleep.
I woke up at three with a blood sugar of 250, took three more units and went back to sleep.
I woke up at five with a blood sugar of about 250, took three more units and went back to sleep.
I woke up at 6:50 with a blood sugar of 156 (Hallelujah!).

My breakfast ratio these days is around 1 unit Novolog to 12 grams of carbohydrate. I figured that given how my night went, I should expect to need about twice as much insulin. I injected 14 units of Novolog, which seems like a lot to me. I had a cup of pedialyte (6g), and a bowl of cereal (25-29g carbs of cereal plus 10g of soymilk). Total carbs: 41-45g.

Then I felt really sleepy. My blood sugar was already spiking upwards, so I went to rest on the couch. I set the low alarm on the Dex to 100, and hoped I'd wake up soon.
I didn't wake up until 10:30. I was drenched in sweat and figured I'd gone low. My Dexcom disagreed- it said 150. But in the following twenty minutes, it showed me dropping to 90. I checked my meter. It said 98.

So, assuming that 14 units lowered my blood sugar about 60 mg/dl and covered 45 grams of carbohydrate, I figure that gives me an insulin: carb ratio of about 1:4. Maybe 1:3.

I tried an early lunch at a 1:4 ratio and so far it looks like I'm gonna need some more insulin.


And on an unrelated note, a nurse from the gastroenterologist's office called today. She says the endoscopy showed inflammation of the duodenum and the stomach, but that the biopsies didn't show any bacteria. She says there are multiple possible reasons for the inflammation, including some medications I don't take and some foods I started avoiding a long time ago because they make my stomach hurt.
She says she left a note for the doctor to see if he wants me to take anything for it and she expects he'll get back to her this afternoon.
So, I'm not sure what this means other than that my stomach hurts.

Thursday, February 24, 2011

The Problem With Ketone Testing

is that it's nonspecific.

On Friday morning last week, I woke up with a blood sugar in the upper three hundreds. I was a bit surprised, but corrected and moved on. Had breakfast, etc. I was about to leave for work when I spotted the syringe with my dose of Lantus still in it from the previous night- OOPS! I squirted out half of it, and took a normal dose that night.

Later I tested for urine ketones- trace.

I tested for ketones again after a spike Sunday night- trace.

I tested ketones for the heck of it Monday night- trace.

I tested ketones Tuesday night- small.

I tested ketones Wednesday night- negative!

I had the most perfect blood sugar today. I've been under 200 and over 70 for about 29 hours now (range = 73-184), most of it between 80 and 140. My Dexcom's been spot on. I've eaten lots of carbs. My urine ketones are small.
Even though the color doesn't match the vial perfectly, it's very clear that the ketones are positive because I have yesterday's negative strip and the two are extremely obviously not the same color.

I bought up the matter to my mother, who suggested that my ketone strips had gone bad, since I am eating carbs, drinking water, and keeping blood sugar below 240. I also seem to be digesting at least some of the carbs, seeing as how I haven't had any crazy hypos and I am prebolusing.

I haven't tested blood ketones since I'm clearly not in DKA and my blood sugar is excellent.

I was told, at diagnosis, to test for ketones when I peed if I'd had two readings over 240, one reading over 300, or was sick, or if the previous test had not been negative. I stopped testing ketones for blood sugars over 240 pretty quickly because they were always negative. I tested after blood sugars over 300 since I rarely had blood sugars over 300, but those were also always negative. Even as the high blood sugars became more common, I never got high blood sugar ketones. I would get positive ketones if I vomited, but not for any other illness.

Last summer I tested my ketones after a high blood sugar and found small urine ketones. The high came down and the next day I tested ketones to reassure myself- but they were positive. They took days to come down. That was a different vial of strips.
Since then, I've been testing urine ketones more often and I keep finding results of trace-small (except when ill or fasting- I got large ketones on Yom Kippur and also when I threw up in December).
When I got a blood ketone monitor a few months ago, I had one slightly elevated reading that matched the urine ketone reading, and I had one normal reading at the same time as a large urine ketone reading.

My doctor points out that urine ketones often take longer to go back to normal than blood ketones do. And indeed, after my diagnosis in DKA, my urine ketones took almost two weeks to normalize. But I remain puzzled.

Monday, February 21, 2011

Armbands on sensors?

I put in this sensor 8 days ago, on a Sunday. That Monday, the receiver broke. That evening I was moving furniture for my mother and the sensor caught on something, and came up a little- the adhesive on one side came off- but the sensor stayed in. On Tuesday, the new receiver came and I spent over half an hour trying to get the transmitter out without pulling the sensor off my arm. I got it off, entered the transmitter number into the new receiver and it started working.
The accuracy has left something to be desired, although actually the last two calibrations were good (but earlier ones had differences like 81 v 188). I suspect that this has something to do it having come part out.

Back when I wore minimed sensors, which required extra adhesive all the time, if my skin was too itchy at night, sometimes I wrapped and tied a shirt or bandage around the sensor in my arm to keep it on. This mostly worked fine at night but twice it failed and if it wasn't tight enough, it would pull the sensor down with it. I had some suspicions about whether the extra pressure on the sensor might affect its usefulness.

Somebody recently posted about keeping an omnipod on with an armband, and I started thinking about using it for sensors. Here is the website:
The armbands here are customizable by size and are intended for pumpers.
I'm going to send an email to the people who make them because I have some questions (in particular, I suspect that they may be too long for my upper arms) and I think I might buy one (or two, since they're running a sale).

Have any of you tried armbands on sensors or pump sites? What was your experience?

Sunday, February 20, 2011

Type 2 Risk Factors

I'm getting poor accuracy from the current sensor, and especially after I recorded great accuracy from the previous sensor, I'm debating with myself about whether or not to pull this sensor early.
When minimed had to replace my receivers, it would also send me a sensor, since the time after the receiver broke was obviously time that the sensor wouldn't be working. Dexcom didn't do that.
Dexcom tells me that the reason I don't have insurance coverage yet is that my doctor hasn't sent them a particular paperwork item - a CMN which I'm guessing stands for certificate of medical necessity. I'm not sure I believe them that he didn't send it, since I once faxed them stuff they claimed not to have gotten. But I need to call his office again anyways.

I was thinking the other day about risk factors for type 2 diabetes that don't get much publicity, and why. Since the risk factors that do get publicity are the ones we blame people for- eating and exercise habits in particular- the ones we don't talk about are important in terms of guilt. They're also important because of who causes those other factors.
Whether or not type 2 risk factors contribute to type 1 diabetes is an open question. The acceleration hypothesis suggests that maybe if a person has insulin resistance plus antibodies, they're more likely to develop diabetes more quickly. A large study of children in California found that obese children were about 10% more likely to have diabetes antibodies. Children diagnosed with type 1 diabetes are typically smaller at the time they are born. My take is that the accelerator hypothesis has some merit but that insulin resistance does not contribute to more than a small portion of cases in the development of type 1 diabetes.

Anyways, some risk factors for type 2 diabetes that affect a significant portion of type 2 diabetics include:
- antipsychotic medication usage, past or present
- some antidepressants, such as lithium
- corticosteroid medication usage over a period of time (those of you who've seen insulin dosage changes in a type 1 on steroids shouldn't be surprised). This may be for asthma, cancer, immunosuppression (for transplants and/or autoimmune diseases), as well as other diseases
- bisphenol A consumption, which comes from food and drinks that are in plastic. Food from plastic contributes significantly to the metabolic syndrome
- genetics (alright, that one's not a secret)
- some mineral deficiencies, such as zinc
- liver disease, particularly hepatitis C
- antiretroviral HIV treatment (one video about HIV that I watched suggested that heart disease and diabetes are becoming the largest causes of deaths in young men with HIV)
- alcoholism (although alcoholic diabetes is kind of a hybrid between types 1 and 2 as it tends to cause damage to the pancreas)
- smoking
- polycystic ovarian syndrome (10% of women overall have this, although it's more like 9% of straight women and 35% of lesbians)
- hypogonadism in men
- some types of oral contraceptives
- maternal diabetes during pregnancy, of any type
- heroin, methadone, probably marijuana, and high doses of anabolic steroids
- smoking (past and present)
- sedentary life style (past and present)

Wednesday, February 16, 2011

Well, That's Over With

The endoscopy was performed today in the early afternoon. There weren't really any problems, diabetes wise. I took less Lantus last night, and corrected a couple of times in the morning. I think it might have been my fault (calibrations at the wrong times) that the Dex was being kind of inaccurate in the morning, but it was spot on by the time I went in.
I ran blood sugars around 160-210 during the afternoon. The anesthesiologist was kind of disdainful about that. He also asked me about diabetes complications, which I've never had an anesthesiologist ask about before. He was like, "Have your eyes been checked?" and I thought he was talking about in a pre-operative kind of way, but he clarified that he meant, had my eyes been checked for diabetes. I resisted the impulse to tell him that yes, my whole body has diabetes, and instead I told him that my eyes were last checked for retinopathy over the summer and they were fine. And I've had a couple of bad urine samples but not in a row (I actually didn't even think to mention the out of range kidney bloodwork), that I have some loss of feeling of vibrations in my feet (he was disgusted that I didn't know exactly how much), and that as far as I know, my heart is fine.
There were some other interesting moments in the preparation. For instance, I was promised sedation with an anesthesiologist by the GI doc. But the nurse who did intake was under the impression that it would be without an anesthesiologist. She went and checked with the doctor and came back and told me if I wanted an anesthesiologist, it would have to be rescheduled. I prevaricated and then said, eh, let's go ahead sans anesthesiologist, let me tell you all about my diabetes management. Then somebody came in to say that the doctor said my endoscopy would be under general anesthesia. So, okay. Again not what I was told, but fine. We called the person picking me up to let her know that it would be an extra hour because of the general anesthesia.
Getting me ready was a big deal. There were the gowns, which I think I tied on wrong. There were the socks, which I finally got a correct fit for. There was the IV, which took a zillion attempts, a blown vein, a local anesthetic, and pushing past a valve, to get in. There was the taking of the vital signs, in which I was not happy with my weight. There was the rash on my back which hopefully wasn't an allergic reaction but which freaked out the nurses. There was a frantic attempt to find the records from my last endoscopy. There were way too many consent forms, and a local anesthetic for my mouth that came in a spray rather than mouthwash form (BIG improvement, IMHO). And then, there was sleep.

I woke up feeling very dizzy and a little tired, quite oriented and a bit restless. So I started trying to figure out what I was still attached to. They'd apparently put an EKG on me while I was asleep.
I didn't get to speak to medical people as much as I would have liked to after the procedure, but my understanding is that nothing bad happened or was seen while I was under. They did biopsy my stomach and I should hear from the doctor about those samples sometime between Monday and Wednesday of next week.

My friend and I left the hospital around 3 PM and walked around for the next three hours, talking. It was nice. Then we went our separate ways home.

The two affects of the sedation (or anesthesia?) that persisted after leaving the hospital were an extreme sense of dizziness, and difficulty retrieving words. Both are problems that I have some of the time anyways. The dizziness went down to safe levels around 4:15 PM, and the word retrieval became normal before that. I'm not sure what time the procedure began but it was scheduled for noon.

In sum: it was a bigger deal than I expected, I'm kinda wondering if it was really worth it, and I feel fine.

Monday, February 14, 2011

Death Knell For Dexcom

Last night I took out sensor 14. It was working fine, but it was itching fierce, possibly because the adhesive was off enough that the sensor was probably able to move a bit.

I took a bath, I put in sensor 15. It was the first sensor that I put in all by my self, and I'm kinda proud of it. It's in my right arm. It was giving kind of weird numbers, had some ???s overnight and in the morning, then seemed to be settling down to something like accuracy.
Around noon, it made a little beep sound. One single beep. I pressed a button, it didn't turn on, so I held down all the buttons until it said Initializing... and it started back up again (with readings).
It gave a beep and did that again around 2:30. It did again at 4:00. At 4:15 I heard a beep and looking down and it said Initializing... and then it said Err with a triangle, and the code HWRFT. I called Dexcom, they said it's a hardware error, and I should have a new Dexcom tomorrow by 4:30.

So I'm leaving the sensor in and will "start" it tomorrow after I get home from work. I really want to have a working sensor for Wednesday's endoscopy day.

So in case you wondered what the death knell sounds like... it's a single high pitched beeep.

Sunday, February 13, 2011

Under the Influence of Big Pharma

As is probably clear to anybody who knows me, I'm a big reader. I read at the rate of roughly one non-fiction adult book per day (like half a book on weekdays and three on Saturday). I also read a fair number of children's books because I volunteer in the children's department of the regional library. I also a lot of medical journal articles, mostly but not entirely culled from pub med.

I've read many disquieting things about diabetes in the past few years. I've read studies whose evidence didn't agree with the conclusions authors took from them. I've read media articles promoting "cures" when the research they cite didn't support their conclusions, or there was already a reason to know it wouldn't work. I've read studies that were clearly biased by design, intended usually to show the superiority of a more expensive treatment. I've read studies in which the set up wasn't biased but the data collection was.
I've read studies showing that NPH-Regular users have A1cs as low as Lantus-Humalog users, many studies showing that drops in A1cs for people switching to pumping are typically not sustained for more than a year. I've noticed over and over a bias in that things wanting to show evidence of helping diabetes pick only people with elevated A1cs, so that even the control group, if there is one, has a reduction in A1c.
I've followed the media as it reports on wonder drugs, and I've followed the downfalls of numerous diabetes medications (mostly for type 2s).

Despite all this, I am aware that there are many conditions, type 1 diabetes among them, for which medication is essential.

Yesterday I read a book entitled Mad In America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill by Robert Whitaker. I picked it up because it was a snazzy looking paper back. It chronicles the treatment of those with mental illness- schizophrenia in particular- in the United States. It makes an extremely strong argument that taking "antipsychotic" medications WORSENS schizophrenia outcomes, and that the evidence of this has been there for all to see since the 1950s, and that the modern medical establishment has turned willfully away from the evidence.
I hoped, as I read the book, that after I finished it I would find some criticism explaining why the book was wrong. What the flaws in the arguments were.
The criticism I found was... well, it was nit picking. They complained he left out a study. Big whoop. They complained some of his analogies were simplistic- yes, but so what? None of them truly could argue that he was wrong.

Reading about the sins of companies that make some of my medications makes me scared. Reading about the willingness of doctors to do experiments clearly not in the interest of patients, ditto. It also gives me pause regarding clinical trials. Whitaker talks about clinical trials in which the trial was clearly misrepresented to patients. There have been at least a couple clinical trials for diabetes products in which patients were hurt, and it has not escaped my notice that clinical trials for diabetes often target the very newly diagnosed, who just happen to be more vulnerable to false hopes, and less aware of how livable diabetes is.

I don't know what to end this post with. I don't have a resolution. I'm just becoming more and more aware of how public perception of disease is molded by big phama, and I don't like it.

Sunday, February 06, 2011


So I'm wearing this sensor on my stomach and it's been in for a little over four days and it's performing fine. For the most part, a comparison between the meter and the Dex gives very similar numbers.

But the adhesive! It seemed to stick on just fine all around when I put it in, but merely four days later, and one side of adhesive is all the way up! I have the uneasy suspicion that it is going to get yanked out by accident when I'm adjusting my shirt or pants or something.

Also! I finally figured out how to get the alarms to persist and wake me up at night. I set the snooze time to half an hour. That gives it way more chances to wake me up. I also set the high alarm all the way up at 200 instead of a lower number; that way when it alarms I know that it's actually at a number I for sure will want to correct.

Wednesday, February 02, 2011

Gallbladder Disease and Diabetes

Note: I refer to cholesterol gallstones exclusively in this post. Pigment gallstones have separate risk factors entirely.

One thing I've been saying, that I thought I was told by a doctor, was that my gallstones and diabetes were unrelated.
I mean, that makes sense. I've had these stomach aches since I was 10 years old, and we certainly didn't notice any diabetes symptoms at that time. If the gallstone symptoms predate the diabetes symptoms, they shouldn't be related, right?
And the four major gallbladder disease risk factors are: family history, female, fertile, over forty, and fat. Since female, over forty, and fat are risk factors for type 2 but not type 1 diabetes, I figured it would make sense for diabetes to be listed as a risk factor without type 1 diabetes actually being a risk factor, and I figured that my diabetes was not related to my gallstones.

So I asked the GI doctor, why did I get gallstones? I don't fit any of the risk factors. He said that type 1 diabetes was a major risk factor, and that many of the atypical cases he sees- cases in people who are non-obese young men- are type 1 diabetics.

I wasn't sure I believed him.

So I started looking on pubmed and now I believe him. 20% of people with diabetes who have their gallbladders removed are type 1s. Since less than 20% of all diabetics are type 1s (about 10% of people diagnosed with diabetes have type 1 diabetes), that means that type 1s are at a higher risk of having a gallbladder removed compared to type 2s, and since type 2s tend to be high risk because of having the same profile that is high risk for gallstones... type 1 diabetes must be a major risk factor for gallbladder disease.

The next question is, why would diabetes be a risk factor for gallbladder disease? I had already read two possible answers. Celiac disease is known to affect some of the muscles that are supposed to keep the gall moving and prevent gall stones, and celiac sprue is a risk for gallstones. Hypothyroidism, even subclinical hypothyroidism, is also a known risk factor for gallstones, for similar reasons.

Having celiac and/or hypothyroidism is very common among type 1 diabetics, particularly among diabetic girls and women. But myself, I have neither one (although admittedly it's not unlikely that I've been hypothyroid at some point and in fact I had active thyroid disease when my gallbladder was removed). And the higher risk of gallstones among people with diabetes is specifically seen more in men with diabetes, who are at a lower risk of celiac and hypothyroidism compared to women with diabetes.

So, I am still not clear on whether type 1 diabetes can play a role in CAUSING gallstones and whether it did in my case, or whether it is merely associated with other things that cause gallstones that may or may not have caused my gallstones.

Here is one study on diabetes and gallbladder disease:

Longer Account of GI Visit

I went to the GI doctor on Monday. I had a stomach ache at the time of the visit (ugh) but he didn't even palpate my abdomen. My appointment was for 1:45, I arrived around 1:25. I finished filling out forms at 1:40. I didn't sign all their forms- I didn't sign that they could call me to solicit money (!) and I didn't sign that they had given me a notice of privacy practices because they didn't give me a notice of privacy practices. I felt that the receptionist was not exactly happy with me. Around 2:05 somebody announced, "Patients of Dr. K, attention patients of Dr. K, Dr. K is running 30-45 minutes late."
So I went to the bathroom. I got called in by a nice nurse around 2:30. She said the form that the receptionist gave me was the wrong form, and filled out another patient history form and listened to me and measured my pulse (72). She move to test my blood pressure on the arm that my sensor was in and I remembered just in time to tell her to test the other arm. My blood pressure came in at 120/80. That is the highest I've seen it since March when I had pancreatitis. I'm not sure if it was elevated because of pain or what. Anyways. She weighed me in at 100 lb, asked me my height. I said I'm a little under 5'. She looked me up and down and told me I looked 5' and put my height down as 5', which I thought was a bit unorthodox, but okay.
Then I waited and waited and waited and waited for the doctor, who came in around 3:15ish. He listened to me, typed, drew a picture, and came out with two recommendations: an upper endoscopy (like the type they do to test for celiac) to test for a peptic ulcer or gastroparesis, among other things, and an MRI of the abdomen to see if there's residual pancreatitis (among other possibilities). I asked him some questions about endoscopies- I'm particularly worried about sedation. He says he strongly recommends sedation, and particularly for me. He says there'll be an anesthesiologist there. He said he had mornings available, except Thursday, and it's not a problem that I usually have to work afternoons.
He sent in another nurse to schedule me. She ---- ugh--- got to be the bearer of the bad new that in fact, he didn't really have any mornings available very soon, and that anyways hospital policy is you shouldn't work on the day of the procedure. Also that they don't really recommend afternoon procedures for diabetics because of the NPO bit, and that they require somebody be there to pick me up and drive me home. If you couldn't guess, I don't have anybody to pick me up and drive me anywhere anytime. I said this to the nurse and she gave me the number of the hospital's chauffer thing.
Anyways, I'm taking off of work two weeks from today. The appointment is midday which means I can't even work the morning. Somebody in my queer and disabled support group later that day told me that xe was available to come to the hospital and pretend to be driving me home- hopefully they don't insist on validating a parking ticket. I don't think they will because in the actual papers they gave me about hospital policy, it says that somebody must drive me home or accompany me on the bus. So... I think xe will probably accompany me most of the way home. Or to my evening tutoring gig, I haven't decided yet if I think I should cancel.

I'm wondering if I should do a trial run of fasting since the endoscopy will be around noon and I'm not supposed to eat after 5:30 AM. Unfortunately right around noon is when my blood sugar most frequently takes a nose dive.

The Dexcom was showing my blood sugar as being much flatter than it was on Monday and Tuesday and I really wasn't able to trust the readings so when it hit the one week mark this morning I pulled it. It had gone to ??? in the last half hour anyway. It's my first arm sensor that didn't do so great.
About half an hour ago my father helped me put in a sensor on my abdomen. It's closer to my belly button than I've put one before, in an area where shots usually hurt more and feel kind of icky in a non-hurt way (for me). But it looks more fatty and isn't hurting too much and it's starting up now so I hope it does okay.
The sensor will, if it's still in, hit the two week mark right before the endoscopy. I figure none of the other abdomen sensors were really functioning at two weeks, so I'll probably be wearing one on my arm by the time of the endoscopy, but even if not- they're not really concerned with the outside of me, just the inside. So maybe it doesn't matter.