Two moms talking about our families' lives with type 1 diabetes
I was at my wit’s end. Blood sugars had officially become out-of-control! My very upbeat, laid-back, fourteen year old son, who typically managed his type 1 diabetes very well, was now heard saying things like “why bother”. Why bother pre-bolusing? Why bother counting carbs? Why bother trying your hardest at managing this stupid disease when your efforts seem futile and high blood sugars are always the result. And to be honest, it wasn’t just him who was feeling this way. I was super frustrated as well. We would try our hardest but I felt like for the first time in 13 years since diagnosis, that diabetes was winning. Puberty is definitely a game-changer!
We had thankfully just received a Dexcom sensor system for Paul right when things were ramping up. This system enabled me to see very clearly and undoubtedly what was going on at all times and it also allowed me to make more confident insulin adjustments. I knew by all the highs he was having that I needed to increase his insulin. I more than doubled his nighttime basals which seemed to finally do the trick but I couldn’t seem to “fix” his post-mealtime BG’s. Anytime he ate anything (and always with a pre-bolus), he spiked!! Breakfast was really crazy though with at least a 15 point jump occurring regularly. I tried everything I knew to do. I increased his insulin-to-carb ratio substantially which stopped the crazy spiking but it was also inevitably followed up with a low blood sugar by lunch. If I adjusted the I:C ratio to where it was bringing him down a few hours later to his target number, then the crazy spiking would happen again. He tried, at the same time, pre-bolusing for longer but even with a 2 hour pre-bolus (!) his blood sugar would just begin to budge (before this all started, he would start to trend downwards after about a half hour). Paul started to get where he didn’t want to eat, especially at breakfast, just so he didn’t go sky-high. I also started to see warning signs that he was feeling like giving up trying with diabetes and that’s when I knew I had to do something different.
I began researching options to stop the spiking. Paul made it very clear that he wasn’t willing to try anything that required an injection. That made sense to me and that eliminated amylin (which might have been a better fit). He said he wouldn’t mind taking a pill so I focused my efforts there. I had heard about people with type 1 using Metformin. Metformin basically makes the body more insulin sensitive and also decreases the amount of glucose made by the liver. The downside to it is that it can cause nausea and vomiting as well as diarrhea and other GI issues while your body is adapting to it. There wasn’t much out there for teens with type 1 but I did find a study in which the University of Chicago Kovler Diabetes Center used Metformin with type 1 adolescent females to aid in reducing weight and insulin requirements. Even though the goals of this study were different than our goals, I thought it was helpful because of the increased insulin sensitivity these girls being studied experienced (which is what we were hoping for). I decided I would approach Paul’s diabetes healthcare team with a request for him to try Metformin.
I sent an email outlining the problems Paul was experiencing as well as his change in perspective about his diabetes care. I asked if they would consider trying Metformin with Paul. They agreed and sent us a prescription (as well as a lab requisition so they could establish a baseline for monitoring purposes). They wanted Paul to start taking it at a very low dose and very slowly increase over time until he reached a dose that was helping to achieve the desired results.
Paul started off by taking 125 mg with supper (I bought a pill-cutter so he could start lower than the usual 250 mg starting dosage because I didn’t want him to experience any of the usual GI side effects). Slower is definitely better with Metformin. The plan was that he would stay on a dose for a week and then move up to the next dosage. If he experienced any problems with the next dose, he could just stay on the previous dose for longer before moving up. The goal was to have him take a pill with each breakfast and supper to a maximum of 1000 mg twice daily. Things were going along smoothly until he reached a 500 mg dose with breakfast and a 250 mg dose with supper. At that point, Paul began to wake up in the morning feeling very nauseous and sometimes vomiting (and vomiting and insulin definitely don’t mix). He ended up stopping that supper dose and we just focused on increasing his morning dose which seemed to take care of the stomach upset. It began to have the desired effect once he reached 850 mg at breakfast (the pills come in 500 mg and 850 mg tablets which is why he jumped to 850 mg). He would still pre-bolus for at least ½ hour to 45 minutes (depending on what his blood sugar was) but now he was only spiking a small amount (no more than a 6 or 7 point jump for a medium GI breakfast). He also started requiring less insulin for all his meals as well as for his basal insulin.
We met with Paul’s diabetes team for a follow up at his next clinic visit. They let Paul know that they were there to support him in taking care of his diabetes which is why they decided to let him try Metformin (even though it’s not typically used this way). Paul was able to report to them that the pills seemed to really be helping control the spikes and that he was feeling much better about dealing with diabetes.
We will have to see what happens with blood sugars in the future but for now this approach is working. I would say Metformin has made a big difference in smoothing out a very bumpy road. I am also very thankful that we have the support of a very caring team of medical professionals who are open to trying out new treatments to make this diabetes journey a little easier.