Ah, I had presumed Type 1, which is my specialty. Your MD is probably correct in holding off on insulin for now, but she may well progress to Type 1 and need it eventually. See http://www.diabetesnet.com/diabetes_types/diabetes _type_15.php for a description of Type 1.5. This is a good site in general, run by a Type 1 friend who is also a diabetes educator. His book, Using Insulin, is a very good one for Type 1 patients.
I'd be interested to know what kind of med she is on. Without insulin, the only thing that would likely cause rapid hypo would be too much insulin stimulation, which reducing the dose should mediate, depending on what it is.
There is an extreme approach you can find at http://www.diabetes-solution.net/ that it sounds like she is, in effect, using now. For a Type 1.5, Bernstein's "minimize the challenge" approach makes some sense, though I think his reluctance to use Huma/Novo-log with Type 1 patients needless.
A case could be made, once an appropriate basal dose of insulin stimulating meds has been determined, to control glucose highs with Huma/Novo-log, after determining the appropriate insulin/carbo ratio (probably less than the 1 U/10 g I mentioned for type 1 patients). The advantage would be tailoring the dose to the carb quantity, which you can't do as easily with something like glyburide or metformin because the dose acts too long. This would lead to the hypo events you describe.
Most endocrinologists who deal with Type 2 patients are reluctant to think of insulin, though, mostlly because they think patients dont't want to inject. The state-of-the-art is moving toward using insulin sooner as patients move from Type 2 to 1, though, and it is much easier to control glucose with insulin because it does the job and gets out of the way, when administered in a proper basal/bolus regimen.
You don't mention her regimen, but it's easier to control glucose with basal/bolus than with split/mixed. Important thing is to ensure that the basal dose really is. Fast all day (10-15 hours) to be sure, adjusting the basal dose until glucose stays steady-normal all day with just the basal dose.
Lantus and Glargine aren't good basal insulins, because basal need changes during the day. I use NPH, which has a small peak to handle the dawn phenominon [at least if you take it near midnight]. Expect 4 times the morning dose at bedtime (NOT split equally, because you need more for that dawn phenom at bedtime, and less when you're active in the afternoon for the morning dose).
Once you have the TRUE Basal dose down, you can use Huma/Nova-log to cover meals, counting carbs and using a ratio appropriate to her insulin sensitivity; typically 1 Unit/10g carb.
Trick to avoid hypo is to account for previously injected insulin. 25% of Huma/Novo-log used up in first hour, 75% in second hour. Rest goes away by 4th hour. Insulin sensitivity is how much 1 U insulin lowers glucose (over those 4+ hours) absent any food, exercise or other bolus insulin. It usually runs from 30-50 mg/dl/Unit - nearer the low end for large adults, the high end for small children.
Medical causes of instability include an overactive pancreas (negative C-Peptide test can rule that out) and variably delayed gastric emptying (can't remember the term for this just now). I presume her MD has ruled them out.
With a true basal/bolus regimen, however, it should be possible to eat carbs without instability. In fact, it's the one thing that makes Type 1 easier than Type 2: you can eat what you want if you just accomodate it with the right amount of insulin, since you aren't counting on diet & exercise to achieve control.
Slashdot Mirror
Ah, I had presumed Type 1, which is my specialty. Your MD is probably correct in holding off on insulin for now, but she may well progress to Type 1 and need it eventually. See http://www.diabetesnet.com/diabetes_types/diabetes _type_15.php for a description of Type 1.5. This is a good site in general, run by a Type 1 friend who is also a diabetes educator. His book, Using Insulin, is a very good one for Type 1 patients.
I'd be interested to know what kind of med she is on. Without insulin, the only thing that would likely cause rapid hypo would be too much insulin stimulation, which reducing the dose should mediate, depending on what it is.
There is an extreme approach you can find at http://www.diabetes-solution.net/ that it sounds like she is, in effect, using now. For a Type 1.5, Bernstein's "minimize the challenge" approach makes some sense, though I think his reluctance to use Huma/Novo-log with Type 1 patients needless.
A case could be made, once an appropriate basal dose of insulin stimulating meds has been determined, to control glucose highs with Huma/Novo-log, after determining the appropriate insulin/carbo ratio (probably less than the 1 U/10 g I mentioned for type 1 patients). The advantage would be tailoring the dose to the carb quantity, which you can't do as easily with something like glyburide or metformin because the dose acts too long. This would lead to the hypo events you describe.
Most endocrinologists who deal with Type 2 patients are reluctant to think of insulin, though, mostlly because they think patients dont't want to inject. The state-of-the-art is moving toward using insulin sooner as patients move from Type 2 to 1, though, and it is much easier to control glucose with insulin because it does the job and gets out of the way, when administered in a proper basal/bolus regimen.
You don't mention her regimen, but it's easier to control glucose with basal/bolus than with split/mixed. Important thing is to ensure that the basal dose really is. Fast all day (10-15 hours) to be sure, adjusting the basal dose until glucose stays steady-normal all day with just the basal dose.
Lantus and Glargine aren't good basal insulins, because basal need changes during the day. I use NPH, which has a small peak to handle the dawn phenominon [at least if you take it near midnight]. Expect 4 times the morning dose at bedtime (NOT split equally, because you need more for that dawn phenom at bedtime, and less when you're active in the afternoon for the morning dose).
Once you have the TRUE Basal dose down, you can use Huma/Nova-log to cover meals, counting carbs and using a ratio appropriate to her insulin sensitivity; typically 1 Unit/10g carb.
Trick to avoid hypo is to account for previously injected insulin. 25% of Huma/Novo-log used up in first hour, 75% in second hour. Rest goes away by 4th hour. Insulin sensitivity is how much 1 U insulin lowers glucose (over those 4+ hours) absent any food, exercise or other bolus insulin. It usually runs from 30-50 mg/dl/Unit - nearer the low end for large adults, the high end for small children.
Medical causes of instability include an overactive pancreas (negative C-Peptide test can rule that out) and variably delayed gastric emptying (can't remember the term for this just now). I presume her MD has ruled them out.
With a true basal/bolus regimen, however, it should be possible to eat carbs without instability. In fact, it's the one thing that makes Type 1 easier than Type 2: you can eat what you want if you just accomodate it with the right amount of insulin, since you aren't counting on diet & exercise to achieve control.