[Subby]

As I've said before like a broken record, I get a long, variable delay before boluses tend to work, it's been a long term problem.

I just had an interesting thought. After a day of a set just "giving up" and terrible absorption, my new set finally started to work and I took a 2 hour 60/40 dual wave to cover a large snack that had some fat.

The dual wave was immensely successful, and a few things dropped into place for me.

One was that the previous site suddenly felt very hard like a huge tablet under the skin (not like that before). It's something I would get a lot with injections back with MDI: a big "clump" of insulin under the skin for some time, a few hours to half a day, even.

The second was that dual waves in general have seemed to be very successful for me. I had put it down to better meal correlation, but what if it was something different - the slower release helping to avoid this "clumping" problem, and allowing the insulin to filter through as it should?

My guess being that my sub-q tissue has a particular reaction or way of "trapping" the insulin when it hits in a sudden dose. Anyone have any comments on whether they've had/known of a similar issue?

I'm very excited and I'm going to dual or square more boluses to see if my absorption issues improve.

[BlueSky]

I used to have this problem of insulin "pooling" when I was injecting bigger doses. I think it is quite common. And it is a major cause of absorption/action variability. Bernstein advises his patients to limit injection sizes to 7 units to avoid this effect. I haven't had a problem with since my dosage size fell below this threshold.

Have you tried getting the pump to spread out the infusion of a bolus over 5 minutes?

[REDLAN]

Constantly injecting into a site can cause a condition known as lipodystrophy.

Lipodystrophy - Wikipedia, the free encyclopedia

It can be characterised by dents, but also lumps, and hard patches. Caused by constant injections. It can cause the fat to break down.

Conversely you can get lipohypertrophy, where the body's response is for the subcutaneous fat layer to thicken. Thought to be caused by the stimulating action of insulin on subcutaneous fat. Can present as grape like lumps under the skin. I have this condition.

Lipohypertrophy - Wikipedia, the free encyclopedia

Both conditions cause variation in insulin action - typically delaying onset of action.

The answer is to rotate sites as much as possible, and avoid injecting (or putting a set) into any hard areas.

Bernstein advises his patients to limit injection sizes to 7 units to avoid this effect

I'd be curious to know how you manage your basal dose to avoid injecting more than 7 units in one go?

[BlueSky]

Originally Posted by REDLAN

... I'd be curious to know how you manage your basal dose to avoid injecting more than 7 units in one go?

I split the basal dose between two shots (and two insulins). I inject 6 units of NPH at night and 7 units of Lantus in the morning.

[xMenace]

Originally Posted by REDLAN

I'd be curious to know how you manage your basal dose to avoid injecting more than 7 units in one go?

Since Lantus and Levemir profiles are more-or-less flat, one should be able to inject them many times per day. It's like stacking bricks. Too bad they can't be mixed. Bring back Ultralente!

[Subby]

Originally Posted by BlueSky

variability. Bernstein advises his patients to limit injection sizes to 7 units to avoid this effect. I haven't had a problem with since my dosage size fell below this threshold.

This is sounding very relevant. And another possible factor of mine contributing: as I have high insulin needs, a typical meal would be 10 to 15 units.

And it would go a long way to explain why small basal increments are quite effective for me while boluses are variable as ****.

Have you tried getting the pump to spread out the infusion of a bolus over 5 minutes?

That's a good idea. A quick look and I don't think I can do this with the MM At this stage a square at 30min is the best option I can see to slow the delivery down. I will need to research this when I get home later.

Originally Posted by REDLAN

Constantly injecting into a site can cause a condition known as lipodystrophy.

It can be characterised by dents, but also lumps, and hard patches. Caused by constant injections. It can cause the fat to break down.

Conversely you can get lipohypertrophy, where the body's response is for the subcutaneous fat layer to thicken. Thought to be caused by the stimulating action of insulin on subcutaneous fat. Can present as grape like lumps under the skin. I have this condition.

Lipohypertrophy - Wikipedia, the free encyclopedia

Both conditions cause variation in insulin action - typically delaying onset of action.

The answer is to rotate sites as much as possible, and avoid injecting (or putting a set) into any hard areas.

Thanks for that info Redlan. I was aware of these conditions over the years, keeping an eye on long term skin/lump problems and rotating a lot. Certainly my belly where I used to iinject still has lipohypertrophy, I don't see going there for over a year. For the last 6 months I haven't reused any one site for my sets.

The issue I'm looking at seems to be an immediate, temporary version, a physical reaction to just one "delivery".

[Tin Ben Dur]

This is all interesting to me. I take 12 units of levimir in the morning and about 4 units of novalog every meal. Sometimes when I take a shot it will bleed and hurt. Sometimes it don't. Certain spots. Hard lumps under skin even with 4 units. I furgure it was going into muscle. I have moved my injections to my arm as of recently. My nurse don't know ****. I have an oppointment with an endo in Aug and hopefully she will get me started on the pump with proper insulin dosages.

[Eddy]

Originally Posted by Subby

At this stage a square at 30min is the best option I can see to slow the delivery down. I will need to research this when I get home later.

Might that be compatible with your pre-bolusing approach?

Originally Posted by Subby

The issue I'm looking at seems to be an immediate, temporary version, a physical reaction to just one "delivery".

Wow. It certainly makes sense. I'd never thought that was possible. I guess I should remember what the first part of "assume" is...

Originally Posted by Tin Ben Dur

This is all interesting to me. I take 12 units of levimir in the morning and about 4 units of novalog every meal. Sometimes when I take a shot it will bleed and hurt. Sometimes it don't. Certain spots.

Interesting. Note that the pain/bleeding could also be the needle you're using. I like an 8 mm, 31-ga. needle.

Originally Posted by Tin Ben Dur

Hard lumps under skin even with 4 units. I furgure it was going into muscle. I have moved my injections to my arm as of recently.

If you hit muscle, the insulin will kick in more quickly. Some of us do that deliberately now and then.

Originally Posted by Tin Ben Dur

My nurse don't know ****. I have an oppointment with an endo in Aug and hopefully she will get me started on the pump with proper insulin dosages.

I'm wondering about your once-daily Levemir. Many people need to inject it twice per day. I've done twice-daily, and now am experimenting with three times.

[joinem]

Blue Sky

My favorite insulin cocktail combo was 1 shot Lente, 1 shot Ultra Lente for basal and humalog and regular for meals. I'm so glad someone else uses a similar cocktail. I am still bemoaing the loss of my Lente at $30 per bottle!

I am currently using three small shots of Levemir (totalling 8 units per day at $116 per bottle) and humalog and regular for meals. I am also experimenting with Apidra but honestly, so far, don't see it worth the 3x copay. I may wait for the insulin currently in testing which is based on Regular insulin and should peak in 45 minutes ish. My goal for the Apidra was to possibly add fruit back in to my meal plan as well as for faster correction. I'm just not seeing the value at this point.

Doris

[BlueSky]

Originally Posted by joinem

... I'm so glad someone else uses a similar cocktail. ...

My use of an insulin cocktail is relatively recent development. And I am surprised that combining different insulins is not a more common practice. The endo wasn't keen, and I basically had to figure it out for myself. I suppose it does introduce complexity that some patients may have difficulty coping with. But I wouldn't be able to achieve acceptable control without it.

[Eddy]

Originally Posted by BlueSky

My use of an insulin cocktail is relatively recent development. And I am surprised that combining different insulins is not a more common practice. The endo wasn't keen, and I basically had to figure it out for myself. I suppose it does introduce complexity that some patients may have difficulty coping with. But I wouldn't be able to achieve acceptable control without it.

+1

Cocktails make it so much easier to match foods to insulin release. Without the crazy mixes, I'd have to put up with frequent highs or lows. Ughh.

[Tin Ben Dur]

Originally Posted by Eddy

Might that be compatible with your pre-bolusing approach?



Wow. It certainly makes sense. I'd never thought that was possible. I guess I should remember what the first part of "assume" is...



Interesting. Note that the pain/bleeding could also be the needle you're using. I like an 8 mm, 31-ga. needle.



If you hit muscle, the insulin will kick in more quickly. Some of us do that deliberately now and then.



I'm wondering about your once-daily Levemir. Many people need to inject it twice per day. I've done twice-daily, and now am experimenting with three times.

Thats what I mean. I don't think my general doctors nurse even knows what she is doing. Its like she is just guessing. She has givin me 3 A1C test since March when I was diagnosed with diabetes. I am just anxious to see a endo. I have an oppointment in August. I am thinking a pump is in my near future.

[Subby]

Originally Posted by Subby

At this stage a square at 30min is the best option I can see to slow the delivery down. I will need to research this when I get home later.

Originally Posted by Eddy

Might that be compatible with your pre-bolusing approach?

Indeed it is, didn't have to change things except to square or dual. And I've just had a promising couple of days where my BG remained constant (but yesterday, constant at a higher area). But today - the most incredible day of BG with carbs involved, in my life. My lunch went so well I got cavalier and started throwing carbs and bad food at myself to dare the whole theory to fail and to go back to my usual "swing up 5 points in an hour" mode.

To summarise, today between 2pm and 10pm I've eaten:
thick, white, carby roll (I guessed 40g) (lunch)
latte with 2 sugars (15g)
3 dim sims (40g)
maxibon icecream (40g)
instant meal pasta (30g) (dinner 1)
3 slices of italian style pizza (guessed 90g) (dinner 2)

An insane list of food (and about 250g of troublesome carbs) for me to pile one on top of the other, of which any one or two alone would have me spiking terribly - every single time (unless 1hour+ prebolusing, perhaps). It's would normally be inconceivable to eat all that and not be fighting the highs for the next 14+ hours.

I'm still pinching myself to believe the BG results I've been getting. They were:
2pm 9 (162) (lunch)
3pm 8 (144)
4pm 7 (126)
5pm 7.8
6pm 7.6
8pm 6.5 (117) (dinner 1)
9pm 7.5 (dinner 2)
11pm 6.5

The actual level I was around isn't that special, it's the evenness is outright alien to me. This kind of carb/insulin tradeoff might be pretty normal to other diabetics but for me it just makes me wonder if I'm in some kind of dream state, after 15 years of spiking a minimum of 2 / 36 (and typically 5 / 90) at ANY carbs (and corrections that take 3 hours longer than they should, often at 2/3 strength). I don't know of a day I haven't gone to double figures (180+) in living memory, and that's with going virtually NO carbs.

The only thing I did different was to keep dual bolusing with a pre-bolus pause of 10 - 30 min, keeping the "now" delivery below about 3u. It stand to reason that it must be to do with allowing the insulin to work effectively: if that wasn't the case you would expect that I would have had worse control than normal (as my problem was definitely slow, not fast response - if all things even, the square would only have made it slower).

I feel like I've just found a stone in my shoe that's been there for years, giving me grief every time I walked.

Well, probably doesn't mean that much to many, but I had to share my strange, almost surreal day of insulin actually doing what it's "meant to" for once. I don't expect (or really want) to replicate the success with high carbs like this, instead I might just get some dependable responses to my normal diet to concentrate on keeping things lower and more even than I ever thought I could achieve with my strange body.

[Eddy]

Here's to hoping that you have indeed removed the proverbial gravel from your shoe. Wouldn't it be something if that's all it took? Wow.

That also would make a very good argument for people who wish to pump, but are denied: I don't see an MDIer holding a needle in for half an hour, gently tickling the plunger every few minutes. There may well be others who need the slow delivery.

[Kendall]

Congratulations Subby!!! I am so glad that you seem to have found some answers. I hope it keeps working for you. I know from lots of your previous posts how inconsistent things seem to be for you even with tons of work. Keep us updated on how things keep going.