Update: First HbA1c Result

An update with my first HbA1c result since starting Afrezza and the FreeStyle Libre.

My previous HbA1c results have been around 6.5%, which is inline with the recommendations from the Australian Diabetes Society, who recommend “a general target HbA1c of ≤7.0%” for Type 1 diabetic patients.

My latest test result, which reflects the average glucose level over the previous three months, was likely somewhat affected by the basal mix-up I described previously. The result of 6.0%, although a lifetime best, was therefore a little disappointing – especially with some incredible A1c results being posted online by other users.

If I continue with the same level of control as I have now, my next A1c test is likely to be better – as it will not be impacted by the basal mixup. It’s also worth noting that unlike most users posting great A1c results, I do not have a continuous glucose monitor, and therefore do not benefit from alarms when my glucose is going out of range. The FreeStyle Libre samples blood every minute and provides CGM-like historical data, but requires a manual scan to view this data.

I suspect that using a CGM might change the way I use Afrezza, and would provide a further reduction in my HbA1c due to alarms notifying me earlier than my manual scanning with the Libre.

Although I am a little disappointed, the author of the Crick, Tech, Munch blog gave me some encouraging words that put the result in context: Only 7% of Type 1 diabetics in the UK reach an HbA1c result of 6.0% or better.

The HbA1c test is also limited in that it can potentially reward poor glucose control, by being lowered through periods of hypoglycaemia. A supplementary test —1,5 Anhydroglucitol — is a historical indicator of hyperglycaemia only.

Coupling the HbA1c result with this GlycoMark 1,5AG test gives a far better picture of glycemic control than HbA1c alone. Together, they can show whether an HbA1c result is being artificially lowered by hypoglycaemia and give an accurate indicator of glycemic variability.

I hope to have another HbA1c test in about two months. I have also found Australian laboratories that can perform the GlycoMark 1,5AG test and hope to have that conducted around then too. I am looking forward to seeing these results.

-Matt

HbA1c 6.0%

First HbA1c since Afrezza. Historical results are also shown on document.

Simple Sugar Surfing

A new technique of using insulin is causing quite a buzz within the T1 community. Some think it will become the new standard of care, replacing DAFNE. Read why Afrezza greatly simplifies this method.

Also called Dynamic Diabetes Management, Sugar Surfing is an intensive glucose management technique for tight glucose control that requires a continuous or flash glucose monitor. It de-emphasises the traditional insulin-to-carb and correction ratios, and introduces a whole new lexicon derived from surfing such as shove, nudge, drift and flux.

Timing is the most important part of Sugar Surfing, more important than dose size. The technique involves learning the lags of your insulin and each type of food and taking into account the delay of the glucose monitor. The goal is to optimally time more frequent interventions. High glucose is treated immediately, rather than waiting until the next mealtime. In practice, the approach tends to result in about 9 pump boluses or injections of mealtime insulin in a typical day, which the author compares to the 11-12 waves of insulin each day in a non-diabetic.

Afrezza users who are posting the amazing A1C results have most likely mastered a simplified variant of Sugar Surfing without realising it. Although I’ve only recently discovered Sugar Surfing, I’m amazed how it resembles how I have ended up managing my diabetes, using Afrezza and the Freestyle Libre…. except the Afrezza way is, again, far simpler.

At first, the technique looks quite daunting. It involves a lot of trial and error – and “low expectations” are advised for the first 12 months. However, Afrezza greatly simplifies Sugar Surfing, and precisely addresses some of its weaknesses. Surprisingly, this means that less doses of Afrezza per day are needed to achieve the same glucose control.

When using injected insulin, the technique requires “pre-empting” dosing as long as 45 minutes before every meal, then waiting to start eating at the optimal time for each meal – once a curved pattern appears on the glucose meter display.  With Afrezza, pre-dosing isn’t required with any meal, which greatly reduces the scope for timing errors.

The frequent dosing of injected insulin brings the challenges of stacking doses, that increase the likelihood of hypos. Sugar Surfing introduces the “i-chain” concept to deal with this problem, but the lack of a long tail of action makes Afrezza so much easier.

With Sugar Surfing, in addition to interventions triggered by CGM alarms, the next intervention decision is to be made 2-3 hours after dosing insulin at the latest. At this point, a decision whether additional carbohydrate “nudges” or additional insulin “shoves” is to be made. Additional injected insulin at this stage is problematic, as additional carbs will be required later to avoid hypoglycaemia. Afrezza eliminates this problem, as it is finishes its action so much sooner. Post-meal lows requiring “nudges” seem non-existent with Afrezza, presumably for the same reason.

A single basal rate is recommended for Sugar Surfing, making Tresiba the perfect basal for it. Tresiba is equivalent to a pump set to a fixed basal rate all day, and takes out a whole host of variables, further simplifying management.

As the technique requires taking into account the lag in the glucose monitor, the FreeStyle Libre is brilliant – with changes showing six minutes before the Dexcom G5. Although the Libre lacks alarms, Sugar Surfing highlights how its factory calibration is not just for convenience. Each calibration required every 12 hours with the G5 introduces variability and often reduces accuracy.

If you’re considering using Afrezza, it’s worth checking out the book. It will introduce you to the mental leap that you will have to make with Afrezza – that timing is more important than dose size. You can begin applying the principles with your existing regime – and see how labor-intensive the technique is. I would think that after a few months Sugar Surfing with injected insulin, it would be obvious why you would want to upgrade to Afrezza.

Users with a background in Sugar Surfing would hit the ground running with Afrezza, without the learning curve and “unlearning” that I encountered. A simplified Dynamic Diabetes Management protocol would serve as the best protocol for Afrezza use in Type 1 diabetics. Most users would eventually figure this out themselves within 6-12 months, as it becomes quite obvious when using Afrezza with a CGM.

However there’s no reason to keep new users in the dark. Unhelpful in-box instructions fixated on unit conversions to injected insulin should instead introduce basic dynamic management techniques. I hope to develop a simplified set of these principals for those starting Afrezza.

-Matt

Sugar Surfing with injected insulin brings you closer to normal glucose levels, but further from a normal life. (Source: Stephen Ponder)

From the sample chapter of Sugar Surfing:

“Did you know that when you use your insulin pump to bolus 1 unit of insulin it can be off by a range of plus or minus 30% – 200%? “

“Personally, I found this obsession with ultra-precision in insulin dosing a bit unnerving since I didn’t usually see any improved control in patients who practiced it. “

“Stuck on the idea that you are only going to inject X number of times per day and no more? As I said above, the pancreas of a non-diabetic is known to unleash 11 internal insulin bolus events per day How can you expect to have the blood sugar profile of a non-diabetic if you’re not even open to the possibility of giving yourself half that many injections? “

“the human body produces on average 11-12 waves of insulin from the pancreas each day. This is actually consistent across all persons without diabetes. I’m not advocating 11-12 insulin doses a day, but if non-diabetics produce insulin between meals but if non-diabetics produce insulin between meals, then maybe learning how to do that properly isn’t a bad idea “

FreeStyle Libre: 8 Weeks On

Here’s a video update about the FreeStyle Libre glucose monitoring device that I’ve now been using for about eight weeks.

Unfortunately three sensors have failed early. One gave some odd readings the day before and then gave an error saying the sensor needed to be changed.

The other two sensors kept saying I was dangerously low when I felt fine, but the system’s self-diagnostics didn’t detect the malfunction. I applied a second sensor and used a second reader, which showed a higher reading by about 2.0 mmol/L by the time I removed the sensor. It may have had something to do with the adhesive coming loose on the sensor – which hadn’t happened before.

Since recording the video, a third sensor has failed early, and underneath there was pronounced skin irritation (pictured below). This may be responsible for it becoming unstuck. Other users online have also found that their initial sensors worked fine, but their bodies seem to attack sensors applied later on. It’s happening in almost half of FreeStyle Libre users, and some are experimenting with a Compeed barrier between the skin and sensor. I might try this next time.

It’s also worth noting that the sensor applied most recently caused bleeding out of the hole immediately after application (also pictured below), but it hasn’t caused any issues so far.

Notice the skin irritation that may have caused the sensor to become unstuck. Also note the bleeding from the newly-installed sensor.

The skin irritation that might be linked to the sensor malfunction. Also note the bleeding from the newly-installed sensor, which did not seem to affect its performance.

Fortunately the incorrect Libre results are in a safe direction, and wouldn’t have resulted in an unsafe insulin dosage decision. However for the first time in six weeks, I have had to supplement the Libre with finger testing, as I need to be confident in my results while switching my basal to Tresiba.

Overall I still really like the Libre, but it would be amazing if it had the ability to transmit a high glucose alert (say, at 6.0 mmol/L) like a CGM. The Dexcom G6 coming in 2017 sounds like it might be a great (but expensive) alternative to the Libre. However, I’ve already got high hopes for a future Libre that might transmit via Bluetooth to an Apple Watch.

Also check out my video of applying the sensor.

FreeStyle Libre Sensor Application

If you’re wondering how the Libre sensor is applied, I made this video showing how it works.

The applicator is like a stamp that fires it into the skin and sticks the adhesive in one action. The application looks much friendlier than the Dexcom, and isn’t particularly painful.

Also check out this post which sums up my experience using the Libre for 8 weeks.