Paradoxical insulin reactions?

[epepke]

I'm posting this here, because there are a lot of good medical minds on this board (such as ThirdTwin).

I had acute pancreatitis in January and February and spent about a month in the hospital on two separate occasions. Upon my release, I was given some Lantis insulin, which I think is a form of lente insulin, of which I have taken 10 units once a day at night. My blood sugar levels have not been so good, hovering around 200 mg/dl. I noticed that hydration seems to have a lot to do with it, so I've been drinking a lot of water, but it's been hard to get them below 150. Oddly enough, waking blood glucose levels have been usually over 200, but after I have something to eat or drink, have gone down. I started on an exercise program, which had no immediate effect.

Last weekend, an odd thing happened. I went out of town. I also dropped my vial of insulin and couldn't get another. Previously that day, I had broken diet and eaten a meal with a lot of white rice. So I was worried for a bit.

The next day (Saturday), my blood glucose levels had dropped like a rock and have been consistently down. They're now well within the normal range, even when I eat like a pig. There have been other improvements: on Monday, I was able to double the amount of aerobic exercise that I had been able to do previously without significant effort.

I'm wondering if the Lantis insulin was paradoxically responsible for keeping the blood sugar levels high. I'm wondering if there was some sort of feedback mechanism, such as how people who take anabolic steroids see their testosterone level drop.

The only other possibility I can see is that it took a while for the exercise program to have an effect. However, the correlation between the loss of the insulin and the improvement was quite dramatic. I know that correlation does not necessarily imply causality, but it was still dramatic.

 

[Rolfe]

I give Kumar about ten seconds before he pounces on this as absolute proof of the very first of his wacky theories he aired here. (That insulin causes insulin resistance.)

(I'll leave this for the human medics, but comment that my first guess is that the β cells recovered from the insult caused by the pancreatitis and the cessation of the insulin was coincidental. Happy to hear of the good outcome.)

The rest of the world that is not Merika and therefore not still in the dark ages, should multiply epepke's figures by 0.056 to obtain glucose values in the univerally-accepted SI unit of mmol/l, by the way.

By the way, epepke, it doesn't sound as if you were being very closely monitored by your diabetologist or diabetic nurse - could you give a bit more detail about what level of supervision and support you were getting?

Rolfe.

 

[epepke]

The rest of the world that is not Merika and therefore not still in the dark ages, should multiply epepke's figures by 0.056 to obtain glucose values in the univerally-accepted SI unit of mmol/l, by the way.

That's why I specified mg/dl. Thanks for the conversion factor, BTW. I've been writing a Palm program to keep track of and graph blood sugar levels, and I want to support the SI units as well. Although I wonder why it's expressed in mmol/l instead of mmol/mol. Probably because it's easier to measure a volume of blood.

By the way, epepke, it doesn't sound as if you were being very closely monitored by your diabetologist or diabetic nurse - could you give a bit more detail about what level of supervision and support you were getting?

I probably wasn't. I've seen my GP, my gastroenterologist, and my surgeon (who just removed my Hickman catheter) within the past two weeks, but none referred me to a diabetologist. This whole thing has been a bit of a cluster**** (and I don't mean "bomb"), and I've found it quite difficult to extract information from physicians.

The latest thing I heard from my GP was that hydration levels might be significant. I empirically verified that; once I had a reading of 240 (13.4). After drinking a liter and a half of water, 20 minutes later it was down to 117 (6.55). Also, I had a high level professionally tested, which was probably because I interpreted the ambiguous instructions as NPO rather than no food. I inherit a family trait of perspiring a lot.

Coincidence does seem more likely. However, I'm going to do an experiment. I have another bottle of lente insulin, and in a week or two, if my glucose levels remain normal, I'm going to try using the insulin for a day or two and see if it has an effect either way.

 

[Dr. Imago]

I'm posting this here, because there are a lot of good medical minds on this board (such as ThirdTwin).

Wow! Thank you. I'm not even an intern yet and you're giving me some serious props. Much appreciated.

I had acute pancreatitis in January and February and spent about a month in the hospital on two separate occasions. Upon my release, I was given some Lantis insulin, which I think is a form of lente insulin, of which I have taken 10 units once a day at night. My blood sugar levels have not been so good, hovering around 200 mg/dl. I noticed that hydration seems to have a lot to do with it, so I've been drinking a lot of water, but it's been hard to get them below 150. Oddly enough, waking blood glucose levels have been usually over 200, but after I have something to eat or drink, have gone down. I started on an exercise program, which had no immediate effect.

Last weekend, an odd thing happened. I went out of town. I also dropped my vial of insulin and couldn't get another. Previously that day, I had broken diet and eaten a meal with a lot of white rice. So I was worried for a bit.

The next day (Saturday), my blood glucose levels had dropped like a rock and have been consistently down. They're now well within the normal range, even when I eat like a pig. There have been other improvements: on Monday, I was able to double the amount of aerobic exercise that I had been able to do previously without significant effort.

I'm wondering if the Lantis insulin was paradoxically responsible for keeping the blood sugar levels high. I'm wondering if there was some sort of feedback mechanism, such as how people who take anabolic steroids see their testosterone level drop.

The only other possibility I can see is that it took a while for the exercise program to have an effect. However, the correlation between the loss of the insulin and the improvement was quite dramatic. I know that correlation does not necessarily imply causality, but it was still dramatic.

Short answer: could be the Lantus. I'm not making a diagnosis here and I have no idea if this is what's happening, but there is a very interesting thing that sometimes happens called the "Somogyi phenomenon". If you are consistently having high blood sugars in the morning, it could be that you are getting too much evening long-acting insulin. What happens essentially is that your blood sugar crashes while you are sleeping, but you don't know it because... well... you're sleeping (i.e., the normal cues such as sweating and panicky feeling are blunted because you're asleep). Your body's other intact compensatory mechanisms (such as the release of glucagon from pancreatic alpha cells) kick in and bring your blood sugar up, mostly through gluconeogenesis in the liver, to seemingly paradoxically high levels. The fix is to either lower the dose of evening long-acting insulin, or to have a light late night snack consisting of complex carbs before going to bed.

Now the disclaimer: I have no clue if this is actually what's at work here. It's just an idea. I'm not offering you any advice on what you (or anyone else) should or should not do. If you (or anyone else) change(s) your regimen and/or construes anything here to be medical advice, you are taking your health into your own hands. I'm not suggesting you (or anyone else) should do anything before talking to a physician qualified to treat hyperglycemia/diabetes. Futhermore, you had a major pancreatic assault not too long ago, and your pancreas is likely not functioning properly still (hence the need for the insulin in the first place). Could be that you are also recovering some normal pancreatic function as well, which would be a great thing. But, I can't work you up on an Internet forum, and I'm not licensed to do so besides. Best bet is to talk to your physician and see what he/she thinks is the next best step. Some tests should be run (including C-peptide levels) to see what's really going on.

-TT

P.S. Just so we're clear, this is not a diagnosis and I'm not recommending any changes to your treatment. Talk to your doctor.

 

[Rolfe]

However, I'm going to do an experiment. I have another bottle of lente insulin, and in a week or two, if my glucose levels remain normal, I'm going to try using the insulin for a day or two and see if it has an effect either way.

I would strongly advise against taking any insulin if your blood glucose is normal. Much better to do as ThirdTwin advises and talk it over with your doctor.

I don't know how it's done in Merika, but here a newly-dignosed diabetic would be assigned to a diabetic nurse for support and guidance. These people are real specialists and know more about diabetes than most non-specialist doctors. They also have more time for each patient. (One of my staff suddenly crashed with type I diabetes a few years ago, and his diabetic nurse was a real lifeline.) Each case needs to be considered as an individual, and experimenting with insulin without medical giudance can be dangerous.

Rolfe.

 

[epepke]

Re: Re: Paradoxical insulin reactions?

Short answer: could be the Lantus. I'm not making a diagnosis here and I have no idea if this is what's happening, but there is a very interesting thing that sometimes happens called the "Somogyi phenomenon". If you are consistently having high blood sugars in the morning, it could be that you are getting too much evening long-acting insulin. What happens essentially is that your blood sugar crashes while you are sleeping, but you don't know it because... well... you're sleeping (i.e., the normal cues such as sweating and panicky feeling are blunted because you're asleep). Your body's other intact compensatory mechanisms (such as the release of glucagon from pancreatic alpha cells) kick in and bring your blood sugar up, mostly through gluconeogenesis in the liver, to seemingly paradoxically high levels. The fix is to either lower the dose of evening long-acting insulin, or to have a light late night snack consisting of complex carbs before going to bed.

Hmmm... That might explain some more things. I did have some night crashes in the hospital, but I didn't have the high glucose levels in the morning. But I think I didn't have much glycogen in my liver at the time. I was losing fat at an alarming rate, and I was walking a mile every day when I was in the hospital. Also, it's possible that my pancreas wasn't working well enough at that point.

Also, after coming home, I have noticed some sweat on the pillow and some anxiety. However, I dismissed these, as I've always been prone to sweating a lot (seems to be a family trait, my mother has it, too), and panic and anxiety just come with the territory when one is unemployed and facing significant medical bills.

Anyway, I'll bring up the Somogyi phenomenon with my doc the next time

P.S. Just so we're clear, this is not a diagnosis and I'm not recommending any changes to your treatment. Talk to your doctor.

Understood. I'm not looking for medical advice, here, just exploring hypotheses in an intellectual fashion.

 

[TeaBag420]

Epepke,

I have some thoughts, although I doubt they will be much help. I am not a doctor and have no formal medical training.

Rolfe implied that you are a diabetic, but it seems that you had an episode of pancreatitis that brought on the current symptoms? Do I have that right?

Any idea what the cause of the pancreatitis was? alc: sorry, but it's the obvious question).

Are you a gentleman of larger carriage? For myself, I would consider losing fat at an alarming rate a good thing, albeit curious, and walking a mile a day not worth mentioning, even in the hospital.

How's your creatinine (is that the right term, the one they use to evaluate kidney function)?

It's not surprising that taking fluids would lower your blood sugar, but the drop you mentioned was so large that there was probably some other factor at work.

I like the theory someone mentioned that you had a pancreas problem and then you got better.

 

[epepke]

I have some thoughts, although I doubt they will be much help. I am not a doctor and have no formal medical training.

I thank you for your ideas, anyway.

Rolfe implied that you are a diabetic, but it seems that you had an episode of pancreatitis that brought on the current symptoms? Do I have that right?

Correct. I have not been diagnosed as diabetic. The blood sugar problems seem to have been sequallae of the pancreatitis.

Any idea what the cause of the pancreatitis was? alc: sorry, but it's the obvious question).

Pancreatitis is a poorly understood condition. It may have been due to alcohol consumption, but I was not drinking heavily just before my first admission and none at all before my second admission. However, I did drink heavily for two years about three years ago, when I was living in Atlanta. (Those who have had to live in Atlanta may understand the appeal of anesthesia of some sort.) So I may have done some damage then which took a while to have an effect. I no longer drink any alcohol, of course.

Gall bladder problems have also been suggested. However, I had both an ultrasound and an endoscopic (if that's the right word) examination of my gall bladder, and there is no evidence of stones. The output is a bit sludgy, however. My gastroenterologist thinks I should have my gall bladder removed. I was scheduled to have surgery, but it was canceled because my blood glucose was high. I am of two minds about this one. I currently have insufficient income but am trying to get a job in California. Obviously, the recovery period for even laproscopic gall bladder surgery would make moving impossible. So I'm waiting until I know about the California job for sure before scheduling it. Also, my GP considers it unnecessary.

There was a cyst on/in my pancreas, but it wasn't considered big enough for surgical treatment.

Are you a gentleman of larger carriage? For myself, I would consider losing fat at an alarming rate a good thing, albeit curious, and walking a mile a day not worth mentioning, even in the hospital.

I'm big. Not terribly tall and not terribly wide, but enough of both. My father and I couldn't sit on an English train seat side-by-side because of our shoulders. Before I went in I was obese. This is no longer the case, but I'm still big. When I was in my best shape ever, I had a 33 inch waist and a 47 inch chest and still weighed 212 pounds. Just try finding a suit with those measurements!

As for walking a mile, it seemed to be a source of some surprise to the nurses on the floor. It was mostly to get my gut working again. Normally, I wouldn't consider it much. But now I go to the gym and do fairly heavy aerobic exercise.

How's your creatinine (is that the right term, the one they use to evaluate kidney function)?

Just fine. Some of my liver enzymes are a bit high, but not dangerously so.

It's not surprising that taking fluids would lower your blood sugar, but the drop you mentioned was so large that there was probably some other factor at work.

I think not. Getting dehydrated has been the bane of my existence my entire life. It seems to be very easy for me to do, and the thirst mechanism doesn't kick in adequately. In any event, my GP agrees that I was just dry on that occasion.

I like the theory someone mentioned that you had a pancreas problem and then you got better.

Or, more strictly, am getting better. One of the other reasons I'm putting off the gall bladder surgery is that I want to get into as good shape as possible, as I think that it will make the recovery period easier.

The weight loss in the hospital, dramatic as it was, at least put me in spitting distance of getting into really good shape. I still have a ways to go. I can only do single arm curls at about 40 pounds and typically use 35 pounds for 3 sets of 8 repetitions. At my best, I could curl 75 pounds single arm. However, I can do more than half the stack on the triceps machine, the press machine, and the fly machine, and nearly the entire stack on the lower back machine. So I'm getting there.

I'll go in for some tests of glucose, triglycerides, and C-peptides in a few days, and I should have a better understanding of how well I'm doing.

 

[Rolfe]

Correct. I have not been diagnosed as diabetic. The blood sugar problems seem to have been sequallae of the pancreatitis.

Well, technically you're diabetic at the moment, or rather you were when they gave you the insulin. However, poor beta-cell function following an attack of pancreatitis may in fact recover, which is my guess as to why your blood glucose seemed to normalise, rather than any effect of not taking the insulin.

Hope you get everything clarified when you next see your physicians. Just don't take any insulin if your glucose is normal without it.

Rolfe.

 

[wolfofgubbio]

When I was first diagnosed as Type II diabetic I suffered from Somogyi Syndrome. My endocrinologist explained that for some people the body senses when it is near time to wake up and raises the glucose level to meet energy needs.

I have mixed experience with Lantus, sometimes my morning blood sugar is low-normal other times it's as if I hadn't taken any insulin before bedtime.

 

[Rolfe]

I don't think that Epepke is describing a Somogyi overswing - the timing doesn't seem right. I often deal with cats which are in the process of recovering from diabetes (cats are like that), and this presentation of being insulin-dependent one day and normoglycaemic without insulin the next is absolutely typical of that scenario.

Having that occur in a patient recovering from pancreatitis makes perfect sense, I think, assuming the beta cells are getting back into gear following the insult.

It will be interesting to hear what his physicians say about it.

Rolfe.

 

[Kumar]

Rolfe,

I appreciate your memory. Something can be there. I have tried to get awnser anout my doubts from almost all most reputed agencies, but I neither got any satisfactory positive or absolute negative reply. It just make me to think no one probaby knows or care to know about it. It is mostly not related to "Somogyi phenomenon" which may be resultant of some acid/base/mucous changes or other body's rythyms triggered during night as i think cortisol. In this respect if we can understand role of mucous & mucous blocks on pancreas , digestive tract, probably we can understand something. Mucous(thick & thin) may effect absorptions & secretions of many fluid, emzymes, harmones as insulin. Probably body/immune system may be controlling all these via mucous & acid/base balances in digestive tract or otherwise--reproduction etc.

I don't know why & how it happens in some case with IR:-

Taking diabetic medicines & insulin causes persistant but constant high BG levels irrespective of any quantity(temporarily it do come down)

Taking Insulin increase triglycride levels (not sure about other lipids & protien).

Taking no medicine/insulin causes lot of fluctuations in BG levels, better immediate low BG & good control for few days, but thereafter again rises (indicating previous high doses/current low doses), good thirst(less thrust when on medications) & good daily input & output of sugar, overall good feeling, improvement in central obesity etc..

It looks sulphur in diabetic medicines is related to mucous & mucous blocks.(important). I am not sure but probably Nacl & KCl are related to thining/thickening of mucous.

Can you assess it as ' non-Kumar indication'?

Best wishes.

 

[Kumar]

"Last weekend, an odd thing happened. I went out of town. I also dropped my vial of insulin and couldn't get another. Previously that day, I had broken diet and eaten a meal with a lot of white rice. So I was worried for a bit. "

continued.......

Going out of town is also important. If new atmosphere with better green cover, no pollution, don't eat much, less mental stress more physical stess, chages in water/food quality---all these can show some variations but dramatic rock fall is bit important to understand--alike fasting of insulin effect.

epepke,

Btw, did you get some other changes like bitter taste as bile/alkaline reflux, aversion & inability to take most foods & likeing for very few foods as cabbage, boiled patotos, light foods, diarria(bilary), vomating, lazyness, better sleep etc.

 

[Rolfe]

Epepke, I warned you....

Rolfe.

 

[Kumar]

Epepke, I warned you....

Rolfe.

OKAY, destructed. DTTTM Kumar

 

[epepke]

Epepke, I warned you....

Rolfe.

Heh. Thanks, but I knew it already.

I am in a quackery, being devoured by the cesspool of my own steaming desires.

Sorry about the Frank Zappa reference. But seriously, I am technically in violation of doctor's orders by not taking Lantus insulin, but my blood sugar is normal, so I'd be doing something bad by taking Lantus insulin. So it's a case of damned if you do, damned if you don't.

In any event, I'm not going to worry about it so long as my blood glucose levels are normal, which they still are.

 

[Rolfe]

But seriously, I am technically in violation of doctor's orders by not taking Lantus insulin, but my blood sugar is normal, so I'd be doing something bad by taking Lantus insulin. So it's a case of damned if you do, damned if you don't.

In any event, I'm not going to worry about it so long as my blood glucose levels are normal, which they still are.

That bit about "violation of doctor's orders" is why I worry about your not having proper support. It doesn't seem good just to turn a newly-diagnosed diabetic loose with some insulin to get on with it. Even more so if the diabetes might potentially be a temporary situation as with a recovering pancreatitis patient. Clear guidance as to how to use your blood glucose results to vary the insulin dosage should at least have been given, and that guidance should include a "fail-safe" so that you don't use any insulin if your beta-cells recover as seems to have happened.

You're quite right, if you are normoglycaemic without insulin, don't take it. You could induce a dangerous hypo attack.

If you have been off insulin for several days, are eating normally, and are still normoglycaemic, then I think it's pretty certain that your beta-cells have indeed recovered. That's great news!

Rolfe.

 

[epepke]

That bit about "violation of doctor's orders" is why I worry about your not having proper support.

Yeah, I understand, and I appreciate your concern. But i'm really poor in a country where you have to pay for medical treatment, and I can't get Medicare because I don't have any children. Which is stupid, but it isn't something I can change.

I've put in a call to the local free clinic and have gotten on the waiting list, but a waiting list involves waiting.

It doesn't seem good just to turn a newly-diagnosed diabetic loose with some insulin to get on with it. Even more so if the diabetes might potentially be a temporary situation as with a recovering pancreatitis patient. Clear guidance as to how to use your blood glucose results to vary the insulin dosage should at least have been given, and that guidance should include a "fail-safe" so that you don't use any insulin if your beta-cells recover as seems to have happened.

Well, as I said, it was a bit of a cluster****. And there are many problems with the medical system in the US, not the least of which is the fact that there is no system. My insulin prescription was from one of the odd on-call physicians at the hospital who didn't even give me a phone number.

On the other hand, I'm not terribly impressed with the system in the UK, either. My father had three exploratory surgeries before he could even get scheduled for a CAT scan. Not to mention the bedsore the size of a grapefruit that went through to his intestines. Or the fact that what killed him was probably iatrogenic (I paid $700 for an autopsy.)

I've had two CAT scans and an MRI (the latter cost me $500 in spite of the fact that it would have been $1800 list price; everybody has been going out of their way to make things cheap for me.)

When I get into the free clinic, I'm going to say, "OK. I had pancreatitis. Nobody seems to agree on whether I'm currently a diabetic or not. So do some tests. Glucose, triglycerides, C-peptides, or whatever. Knock yourself out."

I probably should have been a more informed medical consumer, but with pancreatits they give you a morphine pump, and morphine is one of the more unpleasant things with respect to brain function that I have encountered. I can't even imagine how anybody could get addicted to it. It isn't even any fun. I could barely write computer programs on good days. And for me to have a hard time writing computer programs means some serious stuff.

If you have been off insulin for several days, are eating normally, and are still normoglycaemic, then I think it's pretty certain that your beta-cells have indeed recovered. That's great news!

Thanks. I feel just peachy, and my blood glucose has been fine. And I can pump iron. Now, if only I could get a job, my life would be, if not exactly complete, at least a lot better.

However, I disregarded your advice and tried some Lantus. It seemed to have no effect that I could tell.

 

[Dr. Imago]

However, I disregarded your advice and tried some Lantus. It seemed to have no effect that I could tell.

Did you do that just now? Check your blood sugar in the morning and let us know.

-TT

 

[epepke]

Did you do that just now? Check your blood sugar in the morning and let us know.

-TT

No; I did it yesterday. Obviously, it's hardly conclusive, as there's some variation anyway, and one would have to take an average. Besides, I've been eating more carbohydrates. At first, I was really paranoid about them and subsisted on yoghurt, curried dal, and tuna fish, along with a couple of cans of Glucerna a day so that I got some vitamins. But now I'm eating well. Which is good, considering the amount of calories that I'm burning at the gym and the muscle work due to lifting weights.