Got questions about life with diabetes? You know where to turn (hopefully).  That would be our weekly diabetes advice column, Ask D'Mine, hosted by veteran type 1, diabetes author and community educator Wil DuboisAsk DMine column.

This week, Wil gets two questions on out-of-control blood sugars. Remember, no one here at the 'Mine is a doctor and we don't pretend to be. So take what you read as an honest amateur assessment in non-doctor speak, and some great info to bring up with your doctor if you happen to be in these patients' shoes.

Here's what Wil has to say this round...

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

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Lexi, type 1 from New York writes: Hey Wil, I've had T1 for 2.5 years and have been in very good control of my blood sugars since the beginning: consistent A1Cs below 6.0, college athlete, relatively healthy eater. However, about a month ago my blood sugars skyrocketed into numbers I've never seen since diagnosis. I found out that I have Grave's Disease and have been on 30mg of Methimazole for about three weeks, but the blood sugars are not getting any better. I've just been told to increase my insulin doses and am now taking 3 times the amount of insulin I used to take to no avail. So here's my question: should I just keep increasing the amount of insulin I take? I'm terrified to do so because if the medication kicks in suddenly, giving myself so much insulin would drive me dangerously low! Is it worth the risk?

Wil@Ask D'Mine answers: Remember, I'm not a doctor. But from the perspective of an experienced patient-educator, I'd say it is worth the risk, for two reasons. First, the risk is not so great as you suppose it is, and second, there is a much greater shadow risk you may be unaware of.

But before I get into either of those, I want to make sure you and all our other readers get that whole chicken-and-egg thing straight when it Chicken and Eggcomes to high blood sugar and Grave's Disease. Sometimes medical teams get in a rush and don't take the time to explain everything to their patients, so I want to make sure that you know that the crazy-high blood sugars you're seeing are thanks to the Grave's, not to the drugs you're taking for it. Methimazole boasts an impressive array of side effects, but hyperglycemia isn't one of them. Instead, it's the high levels of thyroid hormones in your body, which is what Graves causes, that drives blood sugars upwards. (The leading theory on why this happens is that the half-life of insulin is reduced by a combination of inactive insulin precursors.)

So you're not out of your mind to worry about what might happen if your meds "suddenly" kick in. In theory, once the hormone imbalance is fixed, your insulin needs should return to normal, but most things related to thyroid happen in slow motion. I doubt that the med will have a sudden impact.

Now, on to that dark shadow I was talking about. Too much thyroid hormone super-sizes your DKA risk. You, my Dear, are at a huge increased risk of revisiting your diagnosis, assuming you were dx'd in the intensive care unit at the friendly local hospital.

Remember the first rule of survival: Address the clear and present danger before you worry about the danger on the horizon. You've already told me your blood sugars are crazy-high. I know that you are at increased DKA risk from even mildly elevated sugars. Don't screw around with this. Take whatever amount of insulin you need to get your sugar back down to normal. When the slow-working thyroid med eventually gets your hormone balance fixed, you can reduce the insulin again. I suspect you'll play a game of increase, increase, increase followed by decrease, decrease, decrease. But meanwhile, you need to keep upping the insulin until you get your sugars in check—nullifying your DKA risk—then, as the thyroid gets reined in, you'll likely need to start dropping your insulin again until you reach a happy medium.

Remember, the maximum dose of insulin is the amount that will fit in a syringe, and you can use as many syringes as it takes to get the job done. Insulin is unique in this fashion. Every other medication I can think of has a toxic dose, a level at which the curing elixir becomes a lethal poison instead. Not so of insulin. Yes, if you take too much, your blood sugar drops below target. But it can't poison your body.

Oh, and on another dicey and politically sensitive topic: If you are not already doing so, please take birth control pills. Methimazole is a Category D pregnancy risk med, which means there is "positive evidence of risk" to your baby, should you become pregnant.

So up your insulin, take your birth control, and tuck your terror away. I believe you are going to be fine.

 

Liz, pre-diabetic from New Jersey, writes: Wil, I'm a 32-year-old female who has been diagnosed as pre-diabetic & hypoglycemic.  I work rotating shifts (12 hours between days & nights) and try to eat a healthy diet.  There is a strong family history on both sides of type 2 diabetes and on one side of type 1 diabetes.  I'm also a paramedic part-time and hate seeing low numbers and wondering how I'm not on the floor or convulsing yet. My question is: why does stress cause me to go low?  I'm talking LO/20s/30s sweating, shaking, glass-eyed LOWs.  Based on everything I've read/discussed with/asked doctors, family members, and others, stress should make my blood sugar rise, so why do I end up low?  I treat the low, wait the 15 minutes, and repeat until I see a 70 or 80 or 100 and 1-2 hours later I'm back at the same number or lower than I started.  How do I break this cycle? My doctors just say treat what you feel and the number, but what on earth is causing this?  If it's an extremely stress-filled week or I'm extra stressed due to other things I end up sick of tabs, juice, etc. Currently I'm using diet to control everything (or trying to), not on any outside medication (other than birth control), and my doctors are taking a wait-and-see-what-happens attitude.  Due to insurance reasons, I'm very limited on who I can see, and what I can do. 

Wil@Ask D'Mine answers: Like dead celebrities, diagnoses come in threes. You got the pre-diabetes and the hypoglycemia, but I think they might have missed a third diagnosis You're describing a textbook case of Adrenal Fatigue.

Here's what's going on: You (and your doctors, family members, and others) are correct that stress generally raises blood sugar. But that assumes that everything in your body is working as designed. The classic fight-or-flight response to stress is a complex ballet of hormones throughout your body, including glucose from the liver, insulin from the pancreas, and the three horsemen of the adrenal glands: epinephrine, norepinephrine, and cortisol. It gets a little more complex than we have time for here, but having low levels of that trio of hormones sets you up not only for epic hypos, but for after-shock hypos as well. In simple terms, you've lost the counter-balancing mechanism that keeps your sugar in check. Insulin is soaring, the cells are sucking too much glucose in, and with nothing to inhibit the process your blood sugars tank when you get stressed. Oh... and having a hypo is stressful, too, and that can restart the whole process. So on and on and on it goes, and where it stops nobody knows, but it might be with you lying on the floor.stress

How can adrenal glands get fatigued? Just like the rest of us, they get worn out by working too hard. Interestingly, adrenal fatigue is on the rise. Physician and author Dr. Jacob Teitelbaum believes that adrenal fatigue is a modern plague. His rationale, which makes sense to me, is that back in the caveman days our flight-or-fight response was triggered relatively rarely. I mean, really, how many times in a month was it likely you'd encounter a saber tooth tiger? But he points out that in today's world, stress is omnipresent, firing off our adrenal glands like Studio 54 strobe lights, effectively wearing them out from overuse. OK, Dr. T didn't compare it to Studio 54 -- that was just me waxing poetic. But you get the idea.

And looking at your life... rotating shifts, part-time paramedic, family full of D-folks... yeah. I'm thinking there's some stress there.

You need to get with your medical team and have them look into Adrenal Fatigue and see if that is the root cause of your hypo adventures. If so, treating it might be accomplished by diet modification. The fix could be as simple as adopting a pattern of frequent small meals and snacks to keep your body fueled up at modest levels that avoid sugar spikes. But the reason you need to prioritize a doctor's visit, even though your resources are scarce, is that's it's also possible that you could be suffering from the more serious Addison's Disease, which can also cause hypos under stress.

Ya' need to get this sorted out, as the treatments for Addison's and Adrenal Fatigue are different. You can't eat your way out of Addison's. It's a serious autoimmune disease that needs to be medicated.

 

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 

 
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