God’s Country

I wanted to be prepared. I didn’t want to go to my appointment with lofty expectations, so this morning I downloaded my Dexcom to see what the latest numbers said. The 14 day average was 154 mg/dl. The 30 day average was 166 mg/dl. Both of those numbers indicated that my A1C would be somewhere in the lows 7s. Better, but not quite all the way to where I’d hoped it would be.

This was my second attempt at finding an endocrinologist in Minneapolis. Although the first endo put me on Victoza, which has been working swimmingly, I didn’t mesh as well as I’d like. Another local D-friend, who just gave birth to her first baby, recommended her endo so I decided to give it a try.

I was very anxious when I arrived at the clinic because I really wanted it to go well with the doctor and I wanted a good A1c. On top of that, I had left my insurance card at home, and I was nervous the receptionist was going to lecture me or give me a hard time. But she was actually very nice about it and it worked out just fine. I had to wait quite awhile for the nurse to come get me, but she was also very nice. She didn’t ask me any silly questions about my diabetes, which was a relief.

My blood pressure was taken, and it was surprisingly on the low side. I had expected it to be a little higher because of the appointment but I was taking a lot deep breaths! She took the blood sample for the A1C and my Dexcom and PDM to download the data. Unfortunately their Dexcom system wasn’t working, but I wasn’t too bothered this time because my last sensor was a little on the wonky side and I didn’t think it would have been that valuable anyway.

Eventually the endo arrived, and she was very cheerful and smiley. We started off talking about where I was from, what I did, school, my previous work at DiabetesMine, my blog, that sort of thing. We started talking about my management, and then she realized that the nurse hadn’t brought back my A1C reading, so she went off to get that.

“It’s 6.6. Are you cold in here?” she said when she returned, adjusting the thermostat.

I couldn’t believe it. No, really, I couldn’t believe it.

“Wait, what?”

“It’s 6.6.”

“Really?”

“Yeah.”

“You’re sure?”

“Yes.”

“Wow… Are you sure your machine is accurate?”

She laughed. “Yes, it’s very accurate. It’s calibrated every day.”

“I’ve never been below 7% before…”

“Well, welcome to God’s country!”

I just about fell out of my chair. My A1C in June was 8%. Today, 6.6%. That’s a drop of 1.4%! Holy crap!

Of course, I attribute most of this to Victoza. I don’t know why it took me so long to start using it! Be ye not so stupid! Having Victoza has smoothed out a lot of my postprandial spikes, and I think that was the biggest reason why my A1C dropped so much. I also think it has made me more sensitive to corrections, so I don’t stay high for as long. I don’t really have any proof of this, but it’s a theory.

I also know that working with Jenny at Integrated Diabetes played a huge part in it. Even with Victoza, I still struggled with getting my rates settled. There were a lot of adjustments in the beginning, and I’m still making a lot of adjustments. As I lose weight and as my activity increases, my insulin needs change too. Sometimes it’s hard to keep up!

However, because I’m working with Jenny, the endo and I didn’t talk that much about my blood sugars. Jenny helps with a lot of my little tweaks, and lately things have seemed okay. Sure, there are a few highs and lows, but nothing that screams trend.

We did talk a lot about pregnancy and diabetes. She explained how their system works, and that since I don’t already have an ob-gyn, it would be good to have one in their network of clinics. She gave me a couple names of providers who she think would be good for me, which was super helpful. I hate having to find a doctor!

We also talked about my previous labs showing low thyroid and low Vitamin D. She decided that it would just be best to get new lab work done because it’s been over a year. I’m also getting tested again for celiac. It’s been a couple of years and from what I’ve heard, it’s good to get tested regularly for it because it can appear suddenly.

victory_cat_by_oman96-d3kzkd2I felt very comfortable with this endo. There weren’t any warning bells as far as anything she said, and she was very nice and personable. She reminded me a lot of my New York endocrinologist, who I saw for six years. Despite having diabetes for 20 years, I’ve only had a handful of endocrinologists and the whole process of finding a new doctor is something I completely dread. I can definitely see myself walking through a pregnancy having her on my diabetes team. I’m really glad the second time was the charm!

Of course, pregnancy is not exactly right around the corner. We’re thinking it’s probably about a year away, maybe a little more. But having an A1C of 6.6% makes the whole becoming a mom thing seem a lot more real. For so long it’s been something that was in the far off future, because I didn’t know how or when I could ever get an A1C below 7%. Especially last fall when my A1C climbed from 7.2% to 7.7%, I felt like it was impossible. I was never going to figure it out. And now that I’m here, it’s like wow. This is really going to happen!

 

The Countdown

I made my second first appointment with an endocrinologist in Minneapolis. As you may remember, I had my first appointment at the beginning of June and while the appointment was okay, I didn’t feel that I really jived that well with the doctor. Although he did put me on Victoza which has since gone swimmingly (more on that in a minute), I felt that since I’m getting ready for pregnancy, which is a pretty emotional time, I really needed to make sure that my endocrinologist was someone that I felt completely comfortable with and who I felt really understood me and was on my side instead of feeling like my diabetes was a battle of the wills. I’ve never had that experience, thankfully, but I know enough people who have and it’s not something I’m looking to sign up myself up to.

Anyway, I crowdsourced again to see who might be a good second appointment. I decided to make an appointment with an endo at the International Diabetes Center at Park Nicollet for Thursday, September 18. So I have about six weeks until my next A1C. I’m really looking forward to seeing how the Victoza ends up affecting my A1C overall.

A couple weeks ago, I noticed that my blood sugars were getting harder and harder to stay in my target range. I thought it was because my period, but it didn’t really end when the period stopped. In fact, I had two days of solid high blood sugars which was infuriating. I emailed Jenny, completely convinced that the Victoza affect had suddenly stopped working and I was back to square one. Jenny suggested that perhaps I just increase the dose from 1.2 to 1.8. She said that some people need to titrate up to the higher dose after a few weeks. And as it would happen, it worked! This last week has had some of the best blood sugar (except for the epically awful day) that I’ve had in a long time. Definitely an A1C in the low 7s.

But maybe, possibly, an A1C in the 6s.

45 days…

Valentines-day-hearts-number-6-at-coloring-pages-for-kids-boys-dotcom.svg

 

Victoza, Visually

I took my first Victoza shot on Friday, June 6. Before starting on Victoza, my control was not good. I’m not going to say it was awful, but it was pretty meh.

When I look at my stats on Dexcom Studio, this is what the 14 days prior to starting Victoza looks like:

Glucose Average: 195 mg/dl
Standard Deviation: +/- 77 mg/dl
High: 68%
Target (70-150): 30%
Low: 2%

Visually, you can really see how up and down I was:

beforevictoza

Basically as long as I wasn’t actually doing anything (read: sleeping), I did okay! But even then, many of my nights were spent at least partially out of range.

So let’s fast forward two weeks, shall we? Here’s what the past 14 days have looked like:

Glucose Average: 151 mg/dl
Standard Deviation: +/1 47 mg/dl
High: 47%
Target (70-150): 51%
Low: 2%

And now my Dexcom graph looks like this:

aftervictoza

For those who struggle with mental math (like me), here are the differences:

- 14-day meter average has dropped by 44 mg/dl

- standard deviation has dropped by 30 mg/dl

- time spent in range has jumped 21%!

!!!!

Ideally, standard deviation should be less than 1/3 of the mean. Pre-Victoza, my mean BG value was 195 mg/dl, which means my SD should be under 65 mg/dl, and it was 77 mg/dl (12 points higher). Now, my mean BG value is 151, which means my SD should be under 50 mg/dl, and it’s 44 mg/dl. Bam! Now that’s what I’m talking about!

We’ve also started learning the importance of time spent in range. Gary Scheiner talks about it in the new edition of his book, Think Like a Pancreas, and Dr. Irl Hirsch recommended that we start looking more at “time in range” and less on A1C at a session I attended at the ADA Scientific Sessions. Well, my time in range also went up!

My Omnipod PDM doesn’t do a great job at giving total daily dose averages for insulin, but from what I can see scrolling through my history, I’m taking on average 20-40 units less each day than I did before Victoza. The area that’s changed most significantly is my bolus ratio and correction factor. But I think the main reason why I’m taking so much less insulin is because I’m not correcting all the live long day.

Another thing that has dropped? My weight! This morning I weighed in at 207 lbs, five pounds down from my pre-Victoza weight of 212 lbs. And this is without any exercise, too. I have been taking a short break from running while getting adjusted to Victoza (I didn’t want too many variables) and also while traveling to the ADA Scientific Sessions. But I’m planning on returning to running and training for a fall half-marathon this week.

Don’t get me wrong — things still aren’t perfect. I’ve struggled a bit overnight with either rising or fall and I can’t seem to get the right basal pattern. When I was in San Francisco, I continually found myself rising overnight, but of course, with my Dexcom and extra sensitivity thanks to Victoza, I never got too far out of range. I made some changes, but I tend to be a little aggressive with my changes. Sometimes I forget how subtle changes really can make a huge difference in my control, because most of the time my first inclination is to try to beat diabetes into submission with a sledgehammer. But unfortunately, that doesn’t always work in my favor! Which is why I’m glad to have a CDE on my team. I’ll be chatting with Jenny later this afternoon to do some more fine-tuning.

Hopefully some of those overnight drops and post-dinner highs will become a thing of the past…

 

Do you have any specific questions about Victoza or my experience? Please let me know so I don’t leave anything out!

I Haven’t Been Hungry In A Week

fussy-eatersI ran into Natalie Bellini, teen faculty for CWD’s Friends for Life, in the Poster Hall at the ADA’s Scientific Session. We had seen each other from afar for the better part of 3 days, but finally caught up with each other on the last day of Poster Hall was open. She was presenting a poster and wanted to grab a picture of it before the hall closed.

“What’s your poster above?” I asked.

“Victoza in people with type 1.”

“I’m on Victoza!” I exclaimed.

“What do you think?”

“Well, I haven’t been hungry in about a week!”

It’s true. Although nausea has been the side effect I’ve read the most, the biggest change I’ve noticed is the fact that I’m not hungry. Like, ever. Having had a voracious appetite my entire life, it’s quite a strange transition.

For the first few days, I sort of ignored the fact that I wasn’t hungry and ate as usual, but I quickly noticed that forcing food just made me feel sick to my stomach. That’s because one of the effects of Victoza is delayed gastric emptying, similar to how Symlin works. Eating normally was not only not very appealing, but it was physically impossible.

Some of my favorite things, like popcorn, cupcakes and even a freddo from Cali-based Peet’s Coffee & Tea, are things I just can’t finish anymore, which is simultaneously awesome and a little disappointing. Although it’s only been a little over a week since I started Victoza, I’ve already dropped five pounds.

I’ve been eating regularly though in much smaller portions to make sure that I’m getting what I need. Typically I start to feel a little empty after about six hours, so that’s been good, but it’s not really the same hungry sensation that I’m used to.

While I was at ADA, I spoke to the rep on the Medical Information side of the Novo Nordisk book (the folks who make Victoza). She explained a little bit about the impact Victoza was having on my digestion and on the glucagon production.

The liver’s glucagon release is normally blunted in non-PWDs, but that doesn’t happen with us, which is among several reasons why we spike after meals. With Victoza, I’m able to take less insulin at meals. So far my basal rate has not changed a whole lot. I’m down a little during the day and up a little at night, but I don’t think my basal rates have been particularly solid for awhile.

The other main effect, the gastric emptying, has made it a lot easier to enjoy food without worry about the effects. I’ve either gone low or stayed stable after eating most meals. The changes to my appetite and blood sugars have certainly been an adjustment but it’s an adjustment that I’m happy to make!