Update on Me- Lots of Small Annoyances

 I got new glasses in June (I'm near sighted). My prescription changed a lot in one eye, and I decided I wanted totally new glasses. A couple of days after I got my new glasses, I walked past a door and did a double take- it looked totally warped into a C shape. When I looked at it head-on, it was fine. After that I couldn't stop noticing that everything in my peripheral vision was warped. I use my peripheral vision less than most people do (sensory processing dysfunction- had an OT work with me for a long time trying to get me to track things and look at things without turning my head- I feel safer when I don't see things in my periphery). I went to the optometrist, who did something to my glasses and told me to give it a few days. It's still just as bad.

A few days after I came from my vacation, I started walking into things a lot, and kept injuring myself. In one day, I racked up four scrapes, one bruise, and one burn. The rate of injury has dropped off since then but I'm not doing so great.

A week ago Friday, in the evening I wanted to lie on my side and tried to prop myself up with my left hand. There was an excruciating pain across the top of my hand and I fell. I thought it was yet another stupid joint issue and didn't think too much of it, tried to just use my right. Kept hurting the left everytime something bumped it. Monday night, the hand started feeling the way it did when I had an IV infiltrate- tingly and swollen. So on Tuesday I went to see an orthopedic surgeon, figuring I had a sprain or a fracture. But he took a look at my hand and said, "Interesting- this is acute tarsal carpel tunnel syndrome".  He says his tentative diagnosis is diabetic neuropathy with carpal tunnel syndrome. That is really depressing. I think he's wrong though- I wouldn't be surprised if I do have neuropathy (both  hands and feet have been tingling in a non-painful way) and there's clearly some nerve involvement. But it's the wrist that's really been hurting and it's across the top of my hand, and it's as much on both sides of the hand (thumbward and pinkieward) and plus, I'm only 23 years old.

I'm now wearing a splint and applying a topical NSAID. My Dexcom has been performing pretty erratically and I wonder if it's the NSAID, which is Voltaren Gel (diclofenac sodium topical gel). I'm having a little difficulty in doing shots- I can easily do an injection one-handed, the hard part is drawing up the insulin. And taking the caps off the syringe. Tips welcome.

I'm also having an issue with extreme, sporadic, dizziness. Like everything around me is spinning, but I'm not hypo.

Also, on Friday morning I woke up a little high (218 mg/dl) and tested urine ketones, which were moderate. I tested blood ketones and got a 2.0!!! Unfortunately the strip was a month past the expiration date and I don't have anymore of them, so I couldn't confirm or disprove the result. I took a lot of insulin for breakfast and supper, and my urine was ketone free by evening.

My computer, a little Eee PC, is also having some issues and was giving me blue screen deaths. It works okay as long as I keep it in safe mode (with networking) but the sound won't work and if I go out of safe mode, it restarts.

Despite all that, I'm feeling okay. Have been enjoying finding work arounds, but hoping to return to the state my body was in a month ago.

Side Effects

 A while back, I got a comment on here asking if I'd accept guest posts. I said yes, if the guest post was relevant. This is the article written for this blog from drugwatch.com, a website that focuses on the risks in medications, and especially those that have been recalled. Although us type 1s do not really have much choice about taking insulin, I sometimes think we can use the reminder that it's not always a good idea to take other medications, or to advocate the use of medications in type 2 diabetes, even when it lowers blood sugar- there are worse things than high blood sugar. Anyways, here's the article. Please leave a comment if there's something you think somebody who is calling attention to the downsides of medications should know about diabetes.

The Benefits and Risks of Diabetes Medications


People with type 1 and type 2 diabetes have similarities and differences when it comes to their medications. People with type 1 diabetes rely mostly on insulin injections, and people with type 2 diabetes are usually prescribed oral medication to help manage the insulin their bodies still produce.
Type 2 patients may require insulin at some point, as well. And people with type 1 diabetes might use an oral medication like an alpha-glucosidase inhibitor to slow the flow of sugar into the bloodstream after a meal.
No matter which medication they take, people with diabetes must be familiar with the drug and possible side effects.
Many diabetes drugs are effective at controlling blood sugar. But they may be too effective, causing hypoglycemia. Both type 1 and type 2 patients need to be on the lookout for low blood sugar. Symptoms include:
* Hunger
* Shaking or trembling
* Blurry vision
* Rapid heartbeat
* Tiredness
* Nervousness
* Headache
* Sweating
* Tingling
If left untreated, hypoglycemia can lead to fainting, seizure or coma. When blood sugar drops, the best thing to do is to eat a piece of candy or drink some regular soda.
Many patients require insulin, which is one of the most powerful reducers of blood sugar. But when it is used in higher amounts than it should be, it can lead to hypoglycemia.
If a person fails to take enough insulin, however, their blood sugar levels can rise dangerously high — a condition known as hyperglycemia. Symptoms include: thirst, tiredness, frequent urination and an upset stomach. It is often treated by exercising, but a doctor would know the best treatment.
Actos is one of the most popular type 2 diabetes medications, and can lower long-term blood sugar (measured by glycated hemoglobin) by about 1.5 percent. It does this by making the cells more receptive to insulin.
Unfortunately, Actos (pioglitazone) also has been linked to serious side effects, including congestive heart failure, bladder cancer and liver disease which has led some patients to begin to file lawsuits. It has carried a black-box warning from the Food and Drug Administration (FDA) since 2007.
The positives and negatives of diabetes medications aren't always clear cut. It's important for people with diabetes to look at medical studies about diabetes drugs before they begin taking them. Look on FDA.gov to find a drug's warning labels to fully understand its risks.

William Richards researches and writes about prescription drugs and medical devices for
Drugwatch.com.

I was on vacation July 1-8; left on the first and came back to Chicago on the 8th. I reduced my Lantus from 8u (which I'd been taking for the last week of June) to 6u, which I took on the evenings of July 1-6. I took 4 1/2 u Lantus on the evening of the 7th because the 8th was a fast day.
This was my first vacation with diabetes in which I managed to avoid severe, symptomatic, scary hypoglycemia. I did run a lot of lows in the 40s, but I didn't have any lows that made me woozy, panicky, or disoriented, and I didn't go lower than the 40s.

This was also the first time I tried packing a sensor. I've had two vacations in the past where I had been wearing a CGM; in one, I just left the CGM at home and took a sensor break, and in the second I changed sensors right before leaving. This time I took a sensor in the bag but not the box and put it in with my clothes. When I got where I was going the bag looked pretty beat up but the sensor looked okay, and two days later I changed sensors. It performed beautifully. Unfortunately, I'd forgotten to bring scissors to cut my hairs before applying the sensor, and it was a really hot week, so after a week I pulled the sensor because I didn't think it would stick on much longer. But it worked just fine. I will be less hesitant to pack sensors in the future.

One thing I must've done a bad job packing: pen needles. I currently use syringes for the Novolin R and testosterone and pen needles for Lantus. That means that on an 8 day vacation, I expect to use 7-8 pen needles and anywhere from 20-50 syringes. So I packed a box of a 100 syringes and counted out ten pen needles which I put in the box. Well, I guess that's not a good place to put them, because I had trouble finding the darn things. In the end I only could find five pen needles. I reused one of them and did the last Lantus shot by syringe. I guess if you have enough syringes, not having pen needles isn't really such a big deal.

I recently read a study that's made me think about how I store my insulin, even those vials in use. This study looked at Regular and 70/30 insulins made my Novo, Lilly, and Biocon (Biocon insulin is not available in the US and is a U-40 insulin for sale in India). So that's 6 types of insulin. They stored them in unopened vials in 5 different storage conditions (now we're looking at thirty different situations). They wanted to compare how the storage conditions affected degradation of the insulin over a period of two weeks, and over a period of one month.
They injected the insulins into rabbits to see how much the insulin lowered rabbits' blood sugar after being stored in different ways. The rabbits started out with blood sugars in the range of 100-108 mg/dl (apparently that's normal fasting blood sugar for rabbits). The insulin then made them hypo. It lowered blood sugar into really tight and predictable ranges with little standard deviation. It lowered blood sugar significantly less when the insulin had been stored at temperatures of 32 and 37 degrees Celcius (89.6 and 98.6 degrees Fahrenheit), as compared to when it had been stored at temperatures of 5 to 26 degrees Celcius (41 to 78.8 degrees Fahrenheit).

This strongly suggests, at least to me, that a person who carries around his short acting insulin during hot temperature days should carry it in something that will keep it at a temperature that is at least below 89 degrees Fahrenheit, lower if possible, unless the insulin will be used up in less than a two week time period. The Frio may be a good idea.

The full text of the study is available here: http://icmr.nic.in/ijmr/2009/august/0910.pdf

Public Displays of Injection

I was on the bus, drawing up my pre-breakfast insulin. I considered my body, wondering where to inject, when from two rows behind me I heard "Isn't he cute?!" I held on to the syringe, wondered if she could be talking about me, thought, "Nah...", and turned around anyways. There were two women staring at me. I turned back around, pocketed the syringe, and stared forward for the rest of the ride. The other woman agreed that I was cute, they were silent for a few moments, and then moved on to other topics.

I'm not shy about injecting in public. Even when I meet new people, if I want to do a shot I draw it up and then I say "lemme do my insulin", inject, and am back in the conversation in under 15 seconds. But I have a hard time injecting when I notice strangers are looking at me, from too far away to talk to. Sometimes I don't care what they think - let them think this is heroin or whatever. They're not the cops. But sometimes... it's hard to witness reactions to what I do, to what I am, when people are too far away for me to really influence their reactions. I dunno. Also, I get flustered when people say I'm cute.

Traveling With Diabetes

On Sunday, I'm going on vacation and won't be back until the following Sunday. I'll be taking a Greyhound bus from Chicago to Pittsburgh, then transfer to an Amtrak train to a rural area of Pennsylvania, where I'll spent Monday-Friday at a retreat for autistic folk. I'm still trying to figure out arrangements for the sabbath- if I have any readers in Pennsylvania or thereabouts who might want to host me, let me know.

I'm kind of stressing out about hypoglycemia. I have had some of my most predictably unpredictable lows while traveling.  I don't know if it's the excitement, disturbance to my sleep schedule, different foods, or what. The swimming doesn't help.

I read recently a post in which somebody said that when she was a kid at D camp, she and other kids spat on some of the urine glucose test strips and found that spit also made it change colors depending on blood sugar level. I have been testing this out and am sorry to report that so far, all three of my ketodiastix strips (at blood sugars of 260, 200, and 190) did not change colors for glucose or ketones. I am certain that my pee would have shown sugar when my blood sugar was 260, and it probably would have for the other two.

Novolin R Lot BZF0116 Exp 05/2014

I opened a new vial of Novolin R nine days ago. I noticed almost immediately that my blood sugar wasn't doing what I was expecting... but it doesn't always. About three days later I had a strange high in the night. I was right around 300 and stable (had been right around 300 for three hours) when I woke up at 4:30 AM. I took five units of insulin. This was based on the theory that each unit of insulin lowers me by 50 mg/dl but only over the course of four hours, and that it does so at a roughly steady rate. So I expect each unit to drop my blood sugar by about 12 mg/dl/hr for four hours. And I figured I'd be getting up in another two hours, at which point I'd have dropped about 120 mg/dl, to 180 mg/dl and everything would be cool. Instead I woke up three hours later to find that by my CGM, I'd dropped 200 points in the first two hours after injecting and had been really stable for the previous hour. I was very surprised but diabetes is full of surprises so I let it go. Then a few days ago I had another night time high. This time it was 2:30 AM, but my blood sugar was once again looking stable around 300. This time I took 4 units, and went back to sleep. I woke up at 6 AM, expecting to see blood sugar still dropping. Instead, again, I saw a flat blood sugar that had dropped rapidly and dramatically after my injection, but which had dropped only about 10 mg/dl in the previous hour. Well, one time is just diabetes weirdness, but twice in a week after opening a new vial of insulin makes me think. I'd been noticing that it didn't seem like my insulin was being active as long as I was expecting and that it was having more punch in the hour or two after injection than I'd been expecting, but I hadn't been sure because those times when there was food complicating things. Now I'm feeling pretty sure. Which leads me to the question... is this really regular I'm injecting? As I see it, either I'm imagining patterns that don't exist, or my body has changed the way in processes insulin (and coincidentally did this after I opened a vial from a different lot), or this batch of Regular is different, or this isn't Regular. It's the last theory I'm thinking about. This insulin isn't acting like the Novolin R I've been using for a year. It's acting a lot more like Novolog. Novolog is sold for twice as much but doesn't actually cost more to manufacture, as far as I know (there's no reason why it would). Is it possible that, on purpose or by accident, one was labeled as the other? I don't see why not. I've been puzzling it over and puzzling it over and I'm not sure if I should contact the FDA. It's not like I have an adverse event to report, and besides, how likely are they to trust my impression of the duration of action of insulin? Most people probably don't really know their DIAs. Contacting Novo Nordisk has some of the same issues, but I think I'll contact Novo Nordisk all the same. Just in case other people are having the same issues with insulin from this lot.

And another one, and another one bites the dust

It started Sunday, when my sensor glucose reading was 171. It alarmed: beep gr crunk. Sounded like gears that weren't perfectly aligned, grinding. Over the past couple of days, the alarms have sometimes vibrated, sometimes beeped, sometimes made a grinding sound, and most often hasn't alarmed at all. I called Dexcom and they're sending me another receiver. I used my first Dexcom receiver for five and a half months, until on Valentine's Day it gave me sensor errors and quit. RIP Dexcom I 9/1/10-2/14/11 I used my second Dexcom receiver for less than three months; the beep stopped working. RIP Dexcom II 2/15/11-5/6/11 I used my third Dexcom receiver for five months; then it gave me sensor errors and quit. RIP Dexcom III 5/8/11-10/10/11 My fourth Dexcom receiver, I've been using for seven and a half months, but this sensor session will be its last. Goodbye Dexcom IV 10/15/11-5/31/12 (I hope it makes it to the 31st- the sensor will need changing then). I have read numerous people's claims that their Dexcom receivers are still working well after two or three years. I wonder if I'm just putting more wear and tear on mine by checking them frequently, or dropping them (yes, I admit to dropping mine), or if there's something in the Chicago heat and humidity, or the living in the basement humidity, that's an issue.

I just saw a blurb on nocturnal hypoglycemia in type 1 diabetics recently. The study it describes had thirty seven type 1 adults wear CGMs and heart monitors for three nights. During those three nights, a total of 18 hypoglycemic episodes were recorded, where hypoglycemia means a blood sugar of less than 63 mg/dl. For each episode of hypoglycemia, they took data from a period from the same time of night and same patient when blood sugar was at least 72 mg/dl. Then they compared data between the hypo periods and the non hypo. I was interested to see that heart rate was essentially the same. The average heart rate during hypoglycemia was 62 bpm, and for non-hypoglyemia, 63 bpm, with a standard deviation much larger than 1. This was interesting to me because I like to lie in bed, waiting to fall asleep, watching my clock, with my Dexcom receiver over my heart, and counting my heart beats. The receiver acts a little like a stethoscope; it really magnifies the sound of my heart. Also I can feel it through the Dexcom. When I go hypo, my pulse tends to feel faster, but I count the same number of beats, which I think says something interesting about my perception of time when I'm hypo. On an unrelated note, all of my labwork from Monday's visit came back normal. My blood sugar on the labwork was 129 mg/dl; my Dexcom at that moment was showing 108 with an up arrow, and I didn't test my blood sugar on my meter because I'd treated a hypo about an hour earlier and suspected my blood sugar was moving fast.

Gangsta Diabetes by Adam Cole

I first wondered what the lyrics were to this song more than three years ago, soon after it made its internet debut. I even wrote and asked what the lyrics were, didn't get a reply. My attempt at transcription is below the video. The song begins about 45 seconds in:



Type 1 diabetes mellitus

it goes

yo type 1 diabetes really does suck
takes the insulin right out of us
now there's way too much glucose and fatty acids
 in our blood from what the basal secretion
of what epinephrine and glucagon does

basal secretion y'all, that's the trick
when insulin's gone,
what's going on...

with insulin gone, glucagon got the Glock
it be popping and locking up to make it stop
so when in the liver glucagon
 turns a lot of things on
like ketone body synthesis and fatty acidation
fats burn down to acetyl CoA
which in the normal condition turns to the TCA [Kreb's Cycle]
but with insulin missing ya gotta find another way
to make ketones descend from the sexy bod-ay

yeah yeah right here angelina wiki wiki

glucagon isn't gone
there's two more on its list
like gluconeogenesis and glycogenolosis
making way more gluc than you need to exist
that's why type 1 diabetics have sugar in their piss

gluconeogeneis is also low acid
so using it up kills the TCA
to regress, it's a mess when acetyl CoA
don't have any other option than ketone bod-ays.

yo an maybe some other stuff, but like what's important is it forces it down

now listen, this gets tricky:

I think I know why,
with our insulin gone,
there's so many ketones and glucose inside our circula-shon
but there's another component I'll take a moment to address
our adipocytes think our body is under stress

with insulin gone, glut4's MIA
we really got basal glucose and glucose plasma in the brain
you know how many more glucose to make,
glycerol 3 phosphate
which adipocytes use to know our energy state

above it all cortisol kills neoglucogenesis
so without glycerol kinase we can't make that shit
now the adipocyte is out of glycerol 3p
so it's thinkin' that the body really needs energy

what, un, even though we're swimming in it.
Got all kinds of glucose
yeah right skeleton man

so even though we're swimming in glucose
from the basal secretion
keepin glucagon and epinephrine
I don't give a beatin
now epinephrine's a player, insulin's out of town
so we've got a bottle of henessy, with the hsl [hormone sensitive lipase]

hormo sensitive lipase, he's without insulin
cut and dry, got the drop on glyceride like oJ simpson
Adipocytes are really out of control
sending free fatty acids like there's no tomorrow

yeah, to the blood, what, that's a triple hit for them
they got no glucose, they got no glycerogenesis
it's over, ba bang, ba bang, ba boom, that's right, it's got nerve yall

to summarize, here goes

summarize, it's no surprise I'm pulling the rap
summing biochemistry like it was on tap
from the med school equations
but never hatin relatin
gotta examine the day but take time to keep ratin'

diabetes mellitus
everything is a miss
it's not just the disease that gives you sugar piss
it's the major terrain of a metabolic state
affectin' both fatty acids and carbohydrates

yo lame dance y'all what
 bring it

Other Statistical Measures

One of the major problems with all of the statistical measures I discussed a few posts back- all of the statistical analyses that the Dexcom software does with my numbers- is that they don't consider the following two hours to be different at all:

Hour A: 90, 100, 120, 128, 119, 104, 98, 92, 88, 84, 79, 81

Hour B: 79, 81, 84, 88, 90, 92, 98, 100, 104, 119, 120, 128

All of us who've had hours like these know that there's a huge difference. With hour A, you don't know what to do- your blood sugar zoomed up 38 points in 20 minutes, then it dropped 49 points in the next half hour or so. With hour B, your blood sugar just kept going in the same direction, a 49 point rise, and you are either injecting to correct it or keeping your finger on the insulin waiting to see if it rises further- you know what you're watching.

But as far as Dexcom is concerned, hours like these- days like these- are the same. Your blood sugar average is the same, your standard deviation is the same, your high and your low and interquartile range and all these supposed measures of glycemic variability- they're the same.

It's no use complaining about these things if you can't suggest something better. Fortunately, I can. I suggested it a few posts back. I suggested looking at the average of the absolute value of the first derivative of blood sugar. This basically measures how far apart any two adjacent sensor readings are likely to be. First derivative, by the way, just means slope. Using the absolute value just means that a rise is counted the same as a fall- otherwise the average first derivative would be very close to zero for anybody with decent blood sugar control, where by decent I mean good enough to stay out of DKA. I suggest as a unit of measure change in mg/dl per five minutes, although you can certainly use any other measures of blood sugar and time that you want.
This probably sounds kind of difficult to compute, but actually it's not bad. You can do it in two ways.

The hard way: look at each data point, compute the difference between each two, add it up, and divide by the number of time intervals. For hour A above, that would mean the differences are 10, 20, 8, 9, 15, 6, 6 , 4 ,4, 5, 2, the sum is 89, there are 11 five minute intervals, so the score is 8. 09. For hour B above, that would mean the differences are 2, 3 4, 2, 2, 6, 2, 4, 15, 1, 8, the sum is 49, and dividing by 11 gives a score of 4.45. That is good; the hour with more variation had a higher score.

The easy way, something you can estimate with just a glance at your 24 hour screen, is to divide the screen into lines of up and down and just add up the differences between adjacent high points and low points. Looking at hour A, that'd mean breaking it into the rise of 90 to 128, the drop of 128 to 79, and the rise of 79 to 81; 38+ 49+2, which fortunately gives a sum of 89 again, to be divided by 11. Looking at hour B is even easier because it's all one line, from 79 to 128, which is a difference of 49, to be divided by 11.

Here is how you'd estimate it looking at a 24 hour screen (and this is much more doable with minimed which lets you scroll through data than it is with Dexcom which doesn't). Here is a 24 hour screen I took a picture of a while back:

We're going to do a very rough estimate- and it's going to be a low ball estimate- of my average absolute value of the first derivative. First, we break it up into trend lines. The first trend line looks like a drop from roughly 300 to roughly 80, the second line is fairly flat around 80, the third is a rise from 80 to roughly 280, the next is a drop from 280 to 150, the third is a rise from 150 to 180, the next is a drop from 180 to 50, the next is a rise from 50 to 210, the next is a drop from 210 to 70, and the last is a rise from 70 to 80. Adding the differences on these trends, I get 220+0+200+130+30+130+160+140+10 = 1020. The number of 5 minute intervals in a 24 hour period is 287, so I divide 1020/287 and get roughly 3.6. If I was using the software to break up the lines, I would get a higher number because there are are more drops and rises than I really accounted for, but 3.6 is a reasonable lowball estimate.

I believe that this measure is a much better indicator of how difficult your blood sugar is to deal with than just standard deviation.