Might take a pump break, need some advice on MDI

[Oradev]

Hey all. I am currently on an Animas 1250 Insulin pump. I am considering getting off it for a while because of my infusion site problems (i've always had problems with the sets).

Now, I have a few questions about MDI. If you guys could tell me what you do to control these issues I will be able to assess my situation a little better. I will obviously use Lantus as my basil and Novolog for my boluses.

- How do you handle a high fat or high protein meal?
- How do you control the dawn phenomenon?
- When I used to be on Lantus I had many lows, how do you prevent that?
- Lantus not lasting the full 24 hours. Obviously you have to split it, but how? 50/50 split? What times?

[Oradev]

Sorry guys, the Subject line should read "Might take a pump break, need some advice on MDI."

[Subby]

Hi Oradec, I haven't taken a holiday from my pump yet, but am looking forward to a small one at some stage. Here's a few responses to get you started:

- High fat/high protein: you mean high fat/protein with substantial carbs that you would normally square/dual, I assume? Can't slow bolus on MDI, it hardly needs to be said. One option to spread it out, may be taking a split bolus (say half before, half 1.5 hours later).

- DP: can be really hard, may need a high basal rate in evening and snack to counteract the excess basal effect for the next 5 or so hours, so that by the time the DP comes around there is more basal to deal with it. Alternative method might be needing to wake very early to take a correction bolus in the morning. What kind of DP do you get?

- Lantus lows: if your lows were caused by long acting "bunching up" in the system and "rushing in" at times of activity (I got this problem a lot), then I don't know of much you can do, except work to condition your metabolism, and work to lower your basal reqs. If your lows were caused by a mismatch between your basal profile through the day and Lantus, there may be some adjustments can be made to minimise the issue. For example the split dose. Usually seems to be 50/50 12 hours apart, but no reason these can't be modified to suit your needs: for example, if you have much lower basal reqs as night, could try 40% evening, 60% morning.

Obviously adjusting your basals on the fly to avoid lows from the likes of exercise, is not an option on MDI. You gotta use the other tricks to try and counteract the lows from activity, if you get them. Such as food.

What basal rates are you on at the moment?

[Cielo]

Does anyone take a mixture of MDI and pills (the ones used by Type 2s)? For the past few months, Adam has used a combination of his pump and MDI (pump for basals, MDI for boluses) and it has worked great. But now his sites are becoming a problem again and he's considering getting off the pump for a while and I was curious if anyone uses the pills to help control dawn phenomenon? Just a thought...who knows, it might work.

Also, what does everyone do about their scar tissue? Is there anything out there that gets into the skin and breaks up the scar tissue? His stomach is the only place where his sites are comfortable and so it's building up scar tissue quickly, which makes sites trickier to use.

[Subby]

Forgot to say, with long acting, it's completely possible to at least profile what's going on with basal testing. Bluesky wrote up a handy guide: Basal Testing for MDI - Diabetes Daily (http://www.diabetesdaily.com/forum/articles/16675-basal-testing-multiple-daily-injections#post148668)

[Subby]

Hi Cielo, not sure about the pills, will be intrigued to hear of any type 1 controlling the likes of DP with pills. As DP is a pretty natural response of the body, to use meds to the degree to suppress those hormones may be quite an unnatural and disruptive thing to do... but I don't know for sure.

Also can't help much with scar tissue in itself. I just leave it alone. I imagine a time will come it's more of a problem for me. What areas of the body have been tried? Have a range of set types been trialed? Do sets get painful over the 3 days?

[jenb]

Hi Oradev. I'm on MDI and really don't mind injecting as many times a day as it takes to keep my BG under control.

To handle the high fat / high protein situation (usually about 15 minutes before eating. I then test every 45 -60 minutes and take additional boluses as my BG starts to rise. Usually end up taking 3 small boluses.

For dawn phenomenon I tried increasing night basal but didn't want to snack to keep from going low. So now I take a small bolus (1/4 unit to 1 unit) at 6:00 a.m. depending on what my waking BG is. I also take a.m. basal at that time.

For regular meals I do 1 or 2 small boluses prior to eating - 1 about 20 minutes prior and 1 around 5 minutes prior or at the start of the meal. After weeks of testing I found this really reduced any post-meal spiking.

Concerning basal insulin - I use Levemir and found that with my relatively small daily need it was more effective to break it into 3 shots at 8 hour intervals. With 2 doses my BG consistently rose between 8 and 12 hours after an injection. The 3 shots has flattened this.

Lots of shots, I know, but it seems to work for me. Good luck!

[xMenace]

If I was to MDI right now I'd take enough Levemir (flatter than Lantus) to cover my lowest basals: midnight to 4am and 11am to 4pm. I'd then get up every day at 5am or 6am and shoot around 4 to 6 units of Novarapid to cover my DP. I'd shoot the same with dinner. I'd split my Levemir into two equal doses, when I take my Novarapid basal. If a dose runs out during my low period, great, but this may cause me to be higher than desired during these times. I'd probably adjust my Levemir up and my Novarapid down until my low basal periods were good. Everything validated with basal tests. Make sense?

It's the getting up at 5am to inject that's the hard part, but DW is up then anyway chasing the cats. I think I could get a 6.0 A1C with MDI this way.

[Oradev]

Forgot to say, with long acting, it's completely possible to at least profile what's going on with basal testing. Bluesky wrote up a handy guide: Basal Testing for MDI - Diabetes Daily (http://www.diabetesdaily.com/forum/articles/16675-basal-testing-multiple-daily-injections#post148668)

I can't find the guide on the site.

[Subby]

The linked post IS the guide.

[notme]

I fixed the title for you Oradev. ;)

[Scratch]

DP is handled by injecting a rapid insulin like Novolog or even R if the DP lasts for a number of hours. When I wake up in the mornings, I have to inject 1 to 2u of Novolog to help keep me flat if I don't eat.

Meals that have slow carb uptake are handled by splitting the bolus injection up, I've got some meals that I handle by injecting about 2/3s up front, then the last 1/3 about 1.5 hours later.

[Gary_W]

Hi Oradev,

Just taking a step back here, what are the problems you've had with the infusion sets that make you want a pump break? Have you tried different sets etc.

I've been on the Inset 2's, and whilst these are fantastic when they work I've certainly had more than my share of little issues of late (bent canulas, weird absorbsion issues etc). I'm nowhere near touching MDI with a bargepole at this point :) Not disparaging your choice, just trying to understand it :)

I've actually tried one of the Inset 30's now. Absorbed fine, but was nowhere near as comfy as the Inset 2's and the site was really sore for a few days afterwards. But I'm game for a laugh and will have another go.

On MDI, splitting Lantus didn't work. One shot didn't work either (bad lows in the middle of the night OR ineffective coverage all day. Happy medium did not seem to exist). If you are going back to MDI, remember that any changes you make to Lantus take 3 days to settle down, so change things slowly in response to your basal tests.

Back on MDI High fat meals would involve multiple injections. And an alarm to remember!

Gary

[fairyblood]

It is nice to read that other people wake up at 5am to stick needles in themselves. I do a shot at 5am of 5 units novalog on most days (sometimes I don't need it).

I split my Lantus 70% for the day and 30% at night. This works best for me.

I believe if you are running low with Lantus that most likely you need to take less. It should hold you steady when you don't eat.

[Oradev]

I know this might be a stupid question, but has anyone ever gotten off the pump and did better on MDI? Or felt better on MDI?

[Oradev]

It is nice to read that other people wake up at 5am to stick needles in themselves. I do a shot at 5am of 5 units novalog on most days (sometimes I don't need it).

I split my Lantus 70% for the day and 30% at night. This works best for me.

I believe if you are running low with Lantus that most likely you need to take less. It should hold you steady when you don't eat.

What times do you take your Lantus?

[DanG]

- How do you control the dawn phenomenon?
- When I used to be on Lantus I had many lows, how do you prevent that?
- Lantus not lasting the full 24 hours. Obviously you have to split it, but how? 50/50 split? What times?

I know nothing about DP.
However, that does not leave me without ideas about DP.:o
I wonder if DP may be caused in part by the lantus? I am thinking that as the metabolism needs close to nothing, as it is doing close to nothing during our sleep time, perhaps the basal is enough to trigger the mighty islets to try and save the day? I find good reason to continue with my lantus in the AM rather than lantus in the PM as originally prescribed. i.e. the metabolism is not doing anything and hence needs little or no assistance in sugar management. You might think about that potential method to manage the lantus not lasting 24 hours and the many lows that lantus sometimes seems to cause. My one trial with split lantus was my last, as the paramedics came to visit. Lantus as I take it now at breakfast is a cakewalk with no lows. I recommend that scheme.

[lorilei]

i was thinking the same thing regarding the lantus and the dp...perhaps it is too much at night causing a liver dump...i have never thought about splitting a bolus for 1/2 before and 1.5 hrs later..something to consider down the road..now i just call it a correction and do it a bit later...you guys are way too skilled for this gal!

[Subby]

I know nothing about DP.
However, that does not leave me without ideas about DP.:o
I wonder if DP may be caused in part by the lantus? I am thinking that as the metabolism needs close to nothing, as it is doing close to nothing during our sleep time, perhaps the basal is enough to trigger the mighty islets to try and save the day? I find good reason to continue with my lantus in the AM rather than lantus in the PM as originally prescribed. i.e. the metabolism is not doing anything and hence needs little or no assistance in sugar management. You might think about that potential method to manage the lantus not lasting 24 hours and the many lows that lantus sometimes seems to cause. My one trial with split lantus was my last, as the paramedics came to visit. Lantus as I take it now at breakfast is a cakewalk with no lows. I recommend that scheme.

i was thinking the same thing regarding the lantus and the dp...perhaps it is too much at night causing a liver dump...

Dawn phenomenon is a natural rhythym of the body to help activate for the day: a rebound effect is a seperate phenomenon. They can have similar consequences in the morning, ie, being high when you wake. DP and rebound require almost directly opposite tactics to deal with, which is why it's so important to know specifically what's going on. Which is another reason why basal testing through the night to reveal what's going on is recommended so constantly here at DF about such problems.


i have never thought about splitting a bolus for 1/2 before and 1.5 hrs later..something to consider down the road..now i just call it a correction and do it a bit later...you guys are way too skilled for this gal!

For myself there is no way I could correct for such a meal myself with much success in keeping things acceptable, I'd need to be aware the food is likely to be slow release and get the insulin in before problems are apparent. A correction would be far too late too save the day... for many people it's probably worth considering this as a separate tactic to correction, which is usually more of a reaction to an existing high.